NHS Litigation Authority Improvement of risk management
Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013
Source — verbatim from the inquiry
●Inquiry recommendation
The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that effective risk assessments take place when changes to the numbers or skills of staff are under consideration. It should also consider how more outcome based standards could be designed to enhance the prospect of exploring deficiences in risk management, such as occurred at the Trust.
Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The NHS Standard Contract requires providers to ensure sufficient appropriately registered and qualified staff are in place and to have regard to applicable staffing guidance (NHS Standard Contract, NHS England, April 2025).
- NICE published safe staffing guidance for nursing in adult inpatient wards in July 2014, identifying increased risks when a registered nurse cares for more than eight patients (Safe staffing for nursing in adult inpatient wards in acute hospitals SG1, NICE, July 2014).
- An academic review in February 2023 found that while structural changes were delivered, understaffing remained a significant concern for staff (Ten Years After Francis, February 2023).
Sources
How was this evidence gathered?
Response — verbatim from government
●Department of Health and Social Care
The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Department of Health and Social Care · 19 Nov 2013 Written response →
Evidence trail — what's actually happened since
- 1 Apr 2025 DHSC and NHS England implementation update provided to the Thirlwall Inquiry (April 2025). This is the government's own account of progress, submitted to the inquiry. Reviewed extent of implementation: Superseded. The Thirlwall Inquiry has noted action taken in response to this recommendation following the conclusion of the Inquiry. The NHS Litigation Authority, now NHS Resolution (NHSR), adopts guidance from organisations, where relevant, on staffing and activity levels in higher risk areas. For example, as part of its requirements for Trusts to meet the relevant workforce safety actions as part of its Maternity Incentive Scheme, NHSR will consider input from the Anaesthesia Clinical Services Accreditation and the British Association of Perinatal Medicine. This scheme does not extend beyond maternity and perinatal care. NHSR also takes into account more general staffing guidance produced by NHS England in its risk assessment. Safe Staffing Evidence-based decision-making on safe and effective staffing is a requirement for all NHS organisations. The National Quality Board sets out expectations for nursing and midwifery staffing to help NHS provider boards make local decisions that will deliver high-quality care for patients within the available staffing resource. The NHS Standard Contract requires that providers ensure that there are sufficient appropriately registered, qualified and experienced medical, nursing and other clinical and non-clinical Staff to deliver services, and have regard to applicable staffing guidance (GC5). Service Specifications may set out further requirements around staffing levels. Please see our response to recommendation 187 for related detail on the NHS Long-Term workforce plan. Source →
- 6 Feb 2023 · Academic Review - Ten Years After Francis Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS. View source → Reasonable Progress
- 11 Feb 2015 · UK Government - Culture Change in the NHS Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year. View source → Good Progress
- 15 Jul 2014 · NICE - Safe Staffing Guidance SG1 NICE published "Safe staffing for nursing in adult inpatient wards in acute hospitals" (SG1) on 15 July 2014. Evidence showed increased risk when registered nurse cares for >8 patients. Red flag: fewer than 2 RNs on any ward during any shift. However, NICE's broader safe staffing programme was controversially halted in June 2015 by NHS England. No mandatory nurse-to-patient ratios introduced in England (unlike Wales). View source → Reasonable Progress
- 19 Nov 2013 · UK Government - Hard Truths Vol 1 & 2 Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted. View source → Good Progress
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
How this page is built
Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.