Inquiries · Recommendations

Recommendations: Mid Staffs Inquiry

1,814 tracked recommendations 35 inquiries 290 match current filters Page 3 of 6

Recommendations issued by UK statutory and non-statutory inquiries, with their tracked government response and supporting evidence.

Recommendations

290 of 1,814 · page 3 of 6

Code	Recommendation	Inquiry	Response
F101	National Patient Safety Agency functions While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it …	Mid Staffs Inquiry (2013)	Accepted
F102	Transparency use and sharing of information Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others …	Mid Staffs Inquiry (2013)	Accepted
F103	Transparency use and sharing of information The National Patient Safety Agency or its successor should regularly share information with Monitor.	Mid Staffs Inquiry (2013)	Accepted
F104	Transparency use and sharing of information The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency …	Mid Staffs Inquiry (2013)	Accepted
F105	Transparency use and sharing of information Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality …	Mid Staffs Inquiry (2013)	Accepted
F106	Health Protection Agency Coordination and publication of providers' information on healthcare associated infections The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation …	Mid Staffs Inquiry (2013)	Accepted
F107	Sharing concerns If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that …	Mid Staffs Inquiry (2013)	Accepted
F108	Support for other agencies Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in …	Mid Staffs Inquiry (2013)	Accepted
F109	Effective complaints handling Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, …	Mid Staffs Inquiry (2013)	Accepted
F110	Lowering barriers Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may …	Mid Staffs Inquiry (2013)	Accepted
F111	Lowering barriers Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be …	Mid Staffs Inquiry (2013)	Accepted
F112	Lowering barriers Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of …	Mid Staffs Inquiry (2013)	Accepted
F113	Complaints handling The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be …	Mid Staffs Inquiry (2013)	Accepted
F114	Complaints handling Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.	Mid Staffs Inquiry (2013)	Accepted
F115	Investigations Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint …	Mid Staffs Inquiry (2013)	Accepted in Part
F116	Support for complainants Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be …	Mid Staffs Inquiry (2013)	Accepted
F117	Support for complainants A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.	Mid Staffs Inquiry (2013)	Accepted in Part
F118	Learning and information from complaints Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's …	Mid Staffs Inquiry (2013)	Accepted in Part
F119	Learning and information from complaints Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in …	Mid Staffs Inquiry (2013)	Accepted
F120	Learning and information from complaints Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on …	Mid Staffs Inquiry (2013)	Accepted in Part
F121	Learning and information from complaints The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should …	Mid Staffs Inquiry (2013)	Accepted
F122	Handling large-scale complaints Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to …	Mid Staffs Inquiry (2013)	Accepted in Part
F123	Responsibility for monitoring delivery of standards and quality GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should …	Mid Staffs Inquiry (2013)	Accepted
F124	Duty to require and monitor delivery of fundamental standards The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in …	Mid Staffs Inquiry (2013)	Accepted in Part
F125	Responsibility for requiring and monitoring delivery of enhanced standards In addition to their duties with regard to the fundamental standards, commissioners should be enabled to promote improvement by requiring compliance with …	Mid Staffs Inquiry (2013)	Accepted
F126	Preserving corporate memory The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the …	Mid Staffs Inquiry (2013)	Accepted
F127	Resources for scrutiny The NHS Commissioning Board and local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny …	Mid Staffs Inquiry (2013)	Accepted
F128	Expert support Commissioners must have access to the wide range of experience and resources necessary to undertake a highly complex and technical task, including …	Mid Staffs Inquiry (2013)	Accepted
F129	Ensuring assessment and enforcement of fundamental standards through contracts In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard …	Mid Staffs Inquiry (2013)	Accepted
F130	Relative position of commissioner and provider Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be …	Mid Staffs Inquiry (2013)	Accepted
F131	Development of alternative sources of provision Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken …	Mid Staffs Inquiry (2013)	Accepted
F132	Monitoring tools Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: Such …	Mid Staffs Inquiry (2013)	Accepted
F133	Role of commissioners in complaints Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to …	Mid Staffs Inquiry (2013)	Accepted in Part
F134	Role of commissioners in provision of support for complainants Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.	Mid Staffs Inquiry (2013)	Accepted
F135	Public accountability of commissioners and public engagement Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public …	Mid Staffs Inquiry (2013)	Accepted in Part
F136	Public accountability of commissioners and public engagement Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of …	Mid Staffs Inquiry (2013)	Accepted
F137	Intervention and sanctions for substandard or unsafe services Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other …	Mid Staffs Inquiry (2013)	Not Accepted
F138	Local scrutiny Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at …	Mid Staffs Inquiry (2013)	Accepted
F139	The need to put patients first at all times The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient …	Mid Staffs Inquiry (2013)	Accepted
F140	Performance managers working constructively with regulators Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant …	Mid Staffs Inquiry (2013)	Accepted
F141	Taking responsibility for quality Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and …	Mid Staffs Inquiry (2013)	Accepted in Part
F142	Clear lines of responsibility supported by good information flows For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the …	Mid Staffs Inquiry (2013)	Accepted
F143	Clear metrics on quality Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms …	Mid Staffs Inquiry (2013)	Accepted
F144	Need for ownership of quality metrics at a strategic level The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing …	Mid Staffs Inquiry (2013)	Accepted
F145	Structure of Local Healthwatch There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter …	Mid Staffs Inquiry (2013)	Not Accepted
F146	Finance and oversight of Local Healthwatch Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to …	Mid Staffs Inquiry (2013)	Accepted in Part
F147	Coordination of local public scrutiny bodies Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.	Mid Staffs Inquiry (2013)	Accepted
F148	Training The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well …	Mid Staffs Inquiry (2013)	Accepted
F149	Expert assistance Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and …	Mid Staffs Inquiry (2013)	Accepted
F150	Inspection powers Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or …	Mid Staffs Inquiry (2013)	Accepted in Part

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