Information for and from inquests
Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013 · Addressed to: Coroners
Source — verbatim from the inquiry
●Inquiry recommendation
Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
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:
- Prevention of Future Deaths (PFD) reports, formerly known as Rule 43 reports, are now governed by Regulation 28 of the Coroners (Investigations) Regulations 2013. Coroners have a duty to make a PFD report where they believe action should be taken to prevent future deaths. Recipients must respond within 56 days (Regulation 28, Coroners (Investigations) Regulations 2013).
- PFD reports can be sent to any person, organisation, local authority, or government department that the coroner believes has the power to take relevant action — this includes CQC where the concerns relate to the quality or safety of care provided by a CQC-registered organisation.
- NHS England published guidance on "Action to Prevent Future Deaths Reports (Regulation 28)" providing a framework for NHS organisations to respond to and learn from PFD reports (NHS England, Action to Prevent Future Deaths Reports).
- PFD reports and responses are published on the judiciary.uk website, maintained by the Chief Coroner's office, providing transparency and enabling learning across the system (Judiciary, Prevention of Future Death Reports).
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 Jun 2025 · National Guardian's Office - Annual Data 2024-25 Over 1,400 Freedom to Speak Up Guardians across healthcare organisations in England. 38,000+ cases raised in 2024-25, cumulative total exceeds 142,000 since inception. However, NHS Staff Survey 2024 shows only 71.5% of staff feel secure raising concerns about unsafe practice (stagnant for years), and only 57% are confident their organisation would address concerns. View source → Reasonable Progress
- 15 Oct 2024 · DHSC - Penny Dash Review of CQC Penny Dash Review (commissioned May 2024) found significant failings at CQC. Health Secretary declared CQC "not fit for purpose". Key findings: one in five services never rated; inspection levels well below pre-pandemic levels; lack of specialist inspector expertise; 5,000 notification-of-concern backlog. CQC consulting on resetting its approach from October 2025. View source → limited_progress
- 9 Sep 2024 · UK Government - Medical Examiner System Medical Examiner system became statutory from 9 September 2024 under Coroners and Justice Act 2009 (as amended by Health and Care Act 2022). Independent medical examiners must scrutinise all deaths not referred to a coroner. Full national rollout achieved, implementing Francis recommendations on death certification. View source → Confirmed Completed
- 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
- 11 Feb 2015 · UK Government - Freedom to Speak Up Review Sir Robert Francis published Freedom to Speak Up Review on 11 February 2015 with 20 principles and actions. Led to: Freedom to Speak Up Guardians mandatory in all NHS trusts from October 2016; National Guardian's Office established January 2016. 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
- 7 Nov 2014 · Legislation - CQC Fundamental Standards New "Fundamental Standards" replaced previous CQC registration requirements from 7 November 2014. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 introduced clearer minimum standards including: person-centred care (Reg 9), dignity (Reg 10), safe care (Reg 12), staffing (Reg 18), good governance (Reg 17), fit and proper persons (Reg 5), duty of candour (Reg 20). View source → Confirmed Completed
- 1 Oct 2014 · CQC - New Inspection Regime CQC overhauled its inspection regime in response to Francis. Professor Sir Mike Richards appointed as first Chief Inspector of Hospitals (July 2013). New methodology based on five key questions (Safe, Effective, Caring, Responsive, Well-led) rolled out nationally October 2014. Four-tier ratings introduced (Outstanding/Good/Requires Improvement/Inadequate). Specialist expert-led inspection teams replaced generalist compliance model. View source → Confirmed Completed
- 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.