Recommendation, verbatim from the inquiry
●Inquiry recommendation
The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a party in a case.
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 recorded the recommendation as implemented and closed, stating that action taken in response had been noted (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the Chief Coroner had issued guidance on bias in September 2014 (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 · 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 Chief Coroner will look carefully at the issue of bias, and the appearance of bias, and consider whether guidance or training by the Judicial College could be used to address these concerns.
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 completed · 27 Feb 2026
The Thirlwall Inquiry has noted action taken in response to this recommendation following the conclusion of the Mid-Staffordshire Inquiry 2013.
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 – Closed”. Table row: section 18.2 No. 285, PDF page 576-577.
Site note: DHSC and NHS England's entry for this recommendation says that the Thirlwall Inquiry noted action taken on it. The entry gives no other account of what was done.
●Department of Health and Social Care says in progress · 11 Feb 2015
The current round of coroner continuation training and Chief Coroner guidance will cover the issue of bias.
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 Chief Coroner, 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. Bias guidance was issued by the Chief Coroner in September 2014.
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 colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 16.2 No. 285, PDF page 529.