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F227

Nursing and Midwifery Council Investigation of systemic concerns

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

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

DeliveryDHSC and NHS England say partially delivered (Feb 2026)Department of Health and Social Care says in progress (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide to seek the cooperation of the Care Quality Commission, but as an independent regulator it must be empowered to act on its own if it considers it necessary in the public interest. This will require resources in terms of appropriately expert staff, data systems and finance. Given the power of the registrar to refer cases without a formal third party complaint, it would not appear that a change of regulation is necessary, but this should be reviewed.

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 commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was partially implemented, noting that while the Nursing and Midwifery Council did not support directly investigating systems issues, it introduced a Regulatory Intelligence Unit in 2020 and an internal pre-case enquiries policy in January 2024 (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team observed in May 2024 that the council did not support being tasked directly with investigating systems issues, pointing to the distinct roles of professional and systems regulators (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.

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 in part · 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 in principle.
The Nursing and Midwifery Council are taking a different approach to achieving this recommendation. The Nursing and Midwifery Council is committed to working closely with the Care Quality Commission and with other regulators to ensure that the most serious matters are appropriately addressed in a systematic manner.

Extract from: 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 partially delivered · 27 Feb 2026

Whilst the NMC did not support this recommendation, it introduced a range of new measures and processes aimed at enhancing its ability to identify, manage and respond to wider systems issues in collaboration with partners. This includes the introduction of a Regulatory Intelligence Unit in 2020 and strengthened working relationships and formal agreements with key stakeholders such as the Care Quality Commission, Healthcare Improvement Scotland, Healthcare Inspectorate Wales, and agreed further memoranda of understanding such as the framework for sharing intelligence with health and care regulators in Scotland and Northern Ireland

Pursuant to Article 22(6) of the Nursing and Midwifery Order 2001 and Rule 2A of The Nursing and Midwifery Council (Fitness to Practise) Rules 2004 (as amended by the Nursing Midwifery Council (Fitness to Practise) (Education, Registrations and Registrations Appeals) (Amendment) Rules order of Council 2015 , if the NMC come into possession of information or intelligence outside of its usual referral process that could indicate a concern, it can make further enquiries to understand whether it’s something that requires action, including whether it should be referred to the screening team to open a case. This could include information that might indicate a potential fitness to practise or education concern. It could also include information that might indicate a potential concern about the wider system. In January 2024 the NMC introduced a new internal Pre-case enquiries and referrals policy which confirms its ability to make enquiries and referrals outside of a formal complaint. It sets out the process to take, including when to share intelligence externally for action, helping ensure concerns are effectively responded to and acted upon across the system.

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 “Partially implemented – Ongoing”. Table row: section 18.2 No. 227, PDF page 542-543.

●Department of Health and Social Care says in progress · 11 Feb 2015

See response to 226. The Nursing and Midwifery Council uses its powers to open cases if there is public interest in doing so. Where it has a statutory role in systems – through education and midwifery supervision – the Nursing and Midwifery Council takes joint action with the Care Quality Commission when that is the most effective way of protecting the public.

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 the Nursing and Midwifery Council, 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 in principle by the Government.

In its July 2013 response, the Nursing and Midwifery Council did not support the recommendation that it should be tasked directly with investigating systems issues, pointing to the distinct roles and responsibilities of professional and systems regulators. The Nursing and Midwifery Council considered that working closer together with the Care Quality Commission and other systems regulators on patient safety issues would provide a better solution.

In the February 2015 Culture Change report, the Government said that the Nursing and Midwifery Council used its powers to open cases if there was a public interest in doing so.

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. 227, PDF page 502.

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.