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F142

Clear lines of responsibility supported by good information flows

Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013 · Addressed to: NHS England

Government responseDepartment of Health and Social Care: Accepted (Nov 2013)

DeliveryDHSC and NHS England say in progress (Feb 2026)Department of Health and Social Care states no delivery position (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the performance manager is not in ignorance of the reality.

Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →

Published evidence summary

AI-generated evidence summary

In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England referred to responses on quality groups, incident reporting, and the NHS Oversight Framework (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted, citing government statements on provider accountability and information flows under the NHS Standard Contract (The Thirlwall Inquiry legal team, May 2024).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

About this summary
This recommendation asks for cultural or behavioural change, which is difficult to verify from published sources alone. The record above reflects policy commitments rather than measured outcomes.

Report-level response context

Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.

Government response

●Department of Health and Social Care · Accepted · 19 Nov 2013

Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013

Accepted.
The reformed NHS system includes a number of different lines of accountability, so it is crucial that there is no ambiguity or confusion about these accountabilities or about the information flows which inform them.
Providers are accountable to their commissioners for the quality of services they deliver. The NHS Standard Contract provides for clarity on information flows between provider and commissioner.
In primary care, the introduction of the General Practice Extraction Service and Calculating Quality Reporting Service ensures that clear and accurate performance management information is provided within services commissioned from GP contractors.
NHS Trusts are also accountable to the NHS Trust Development Authority for their overall performance, including for providing high quality services. The accountability arrangements for NHS Trusts are set out in Delivering High Quality Care for Patients: The Accountability Framework for NHS Trusts. The Accountability Framework is aligned with the standards set by Monitor and the Care Quality Commission, and the Trust Development Authority continues to work with its partners to ensure that it reflects any relevant changes, such as the Care Quality Commission’s new regime for the monitoring, inspection and rating of healthcare providers.
NHS England and the NHS Trust Development Authority have agreed protocols to ensure that there is no uncertainty or duplication in processes for intervening in local health communities where there are concerns about quality or safety.

Response document: Hard Truths: The Journey to Putting Patients First. Volume Two of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry: Response to the Inquiry's Recommendations

Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.

Delivery

●DHSC and NHS England say in progress · 27 Feb 2026

Please see response to recommendations in respect of local and national quality groups (including recommendation 18,31,35 and 41), Incident reporting (recommendation 26 , 36, 40, 44, 99 and 102) and NHS Oversight Framework (recommendation 13, 28 and 138).

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Ongoing”. Table row: section 18.2 No. 142, PDF page 492.

●Department of Health and Social Care states no delivery position · 11 Feb 2015

No further update is required. Please see response to the recommendation in Hard Truths

From: Culture Change in the NHS supporting Annex (annex to Culture change in the NHS: applying the lessons of the Francis Inquiries)

Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.

Site note: The Inquiry addressed this recommendation to NHS England, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.

What other bodies have found

In their own words. These do not change the delivery statement above.

●Thirlwall Inquiry legal team · 15 May 2024

This recommendation was accepted by the Government.

In the January 2014 Hard Truths report, the Government said that providers were accountable to commissioners for the quality of the services they deliver, with clarify on information flows set out in the NHS Standard Contract.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 142, PDF page 459.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.