Medicines administration
Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013 · Addressed to: Healthcare providers
Source — verbatim from the inquiry
●Inquiry recommendation
In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated delegate. A frequent check needs to be done to ensure that all patients have received what they have been prescribed and what they need. This is particularly the case when patients are moved from one ward to another, or they are returned to the ward after treatment.
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 Secretary of State for Health and Social Care issued Electronic Prescribing and Medicines Administration (ePMA) Directions in May 2024, placing a legal obligation on NHS England to collect and analyse secondary care ePMA data from all trusts using electronic prescribing systems. From 13 January 2025, NHS England collects weekly medicines data from each secondary care provider using ePMA (NHS England, ePMA Directions 2024).
- ePMA adoption rose from 19% of trusts in 2018 to an estimated 80%+ by March 2021. However, as of 2023, only 25% of trusts were fully electronic, with 71% using mixed paper and electronic systems, meaning not all medication administration is digitally tracked across all trusts.
- The NMC Code (2018) requires nurses to administer medicines in line with all relevant legal and ethical frameworks and adhere to national standards. The nurse in charge of a ward retains responsibility for overseeing patient care including medication administration, though specific standards on medication round oversight by the nurse in charge are embedded in local trust policies rather than a single national standard.
- Francis's specific concern about medication oversight when patients are moved between wards is addressed by electronic prescribing systems that maintain a continuous medication record, and by the PRSB transfer-of-care standards requiring medicines reconciliation at each transition point.
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
- 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 Apr 2016 · NMC - Nursing Revalidation NMC Revalidation launched 1 April 2016 in direct response to Francis Report. All nurses and midwives must revalidate every three years. Replaced the Post-Registration Education and Practice system. Updated NMC Code published March 2015 strengthened requirements around candour and raising concerns. View source → Confirmed Completed
- 31 Mar 2015 · NMC - Updated Professional Code (2015) NMC published updated Code of Professional Standards for nurses and midwives (March 2015). Standard 14 specifically requires nurses and midwives to be open and candid with all service users about all aspects of care, including when mistakes or harm have occurred. 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
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.