Learning and information from complaints

Source — verbatim from the inquiry

Published evidence summary

Response — verbatim from government

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: Partially implemented - Ongoing. This recommendation was accepted in part by the Government. GP practices produce an annual report on complaints, which they must provide to their commissioning body on request. They must also provide a summary of complaints to NHS England local teams. NHS England expects practices to complete a KO41b data return on complaints. This is published via data collection referenced in response to recommendation 119. ICBs do not have a specific oversight role with GP complaint handling. However, NHS England is currently finalising an oversight and assurance process of ICB complaints handling (delegated from July 2023). In addition, the LFPSE service is a national NHS system for the recording and analysis of patient safety events that occur in healthcare. All healthcare staff in England , including those working in primary care, are encouraged to use the system to record any events where: • a patient was harmed, or could have been harmed • there has been a poor outcome but it is not yet clear whether an incident contributed or not • risks to patient safety in the future have been identified • good care has been delivered that could be learned from to improve patient safety 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
• 1 Jul 2022 · Legislation - Integrated Care Boards (Health and Care Act 2022) Clinical Commissioning Groups replaced by 42 Integrated Care Boards from 1 July 2022 under Health and Care Act 2022. ICBs have broader responsibilities for population health, bringing together NHS organisations, local authorities and partners. Implements some Francis recommendations on commissioning integration. View source → Confirmed Completed
• 1 Apr 2022 · PHSO - NHS Complaint Standards PHSO developed NHS Complaint Standards framework providing consistent approach to complaint handling across NHS. Piloted 2021-2022, introduced across NHS from 2022. Applies to all NHS organisations and independent healthcare providers delivering NHS-funded care. View source → Confirmed Completed
• 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
• 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
• 28 Oct 2013 · UK Government - Clwyd-Hart Review Ann Clwyd MP and Professor Tricia Hart published review of NHS hospital complaints handling on 28 October 2013. Key recommendations: Chief Executives must sign off complaint responses; Trust Boards must scrutinise complaints; trusts must publish annual complaints reports in plain English. View source → Confirmed Completed

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.