Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 928 match current filters Page 11 of 19

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

Browse by inquiry

35 inquiries with tracked recs

Inquiry	Recs	Accepted
Mid Staffs Inquiry	290	281
Manchester Arena Inquiry	169	169
IICSA	107	96
Muckamore Abbey Inquiry	106	—
Grenfell Tower Inquiry	104	104
Infected Blood Inquiry	103	102
Hyponatraemia Inquiry	96	96
Fuller Inquiry	92	71
Leveson Inquiry	92	77
Vale of Leven Inquiry	75	75
Baha Mousa Inquiry	73	72
Southport Inquiry	67	—
RHI Inquiry	45	44
COVID-19 Inquiry	44	24
Morecambe Bay Investigation	44	44
Brook House Inquiry	33	28
Bichard Inquiry	31	31
Angiolini Inquiry	30	29
Post Office Horizon Inquiry	27	25
Jermaine Baker Inquiry	26	22
Edinburgh Tram Inquiry	24	21
Daniel Morgan Panel	23	21
Cranston Inquiry	18	—
Paterson Inquiry	17	15
HIA Inquiry	12	12
Scottish Hospitals Inquiry	11	11
Anthony Grainger Inquiry	9	9
Al-Sweady Inquiry	9	9
Hillsborough Panel	9	5
Fingerprint Inquiry	9	9
ICL Inquiry	7	6
Litvinenko Inquiry	5	5
Azelle Rodney Inquiry	3	3
Billy Wright Inquiry	3	3
Penrose Inquiry	1	1

Recommendations

928 of 1,814 · page 11 of 19

Code	Recommendation	Inquiry	Response
F83	Accountability of providers' directors If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would …	Mid Staffs Inquiry (2013)	Accepted
F85	Accountability of providers' directors Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event …	Mid Staffs Inquiry (2013)	Accepted
F86	Requirement of training of directors A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of …	Mid Staffs Inquiry (2013)	Accepted
F90	Assistance in deciding on prosecutions In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences …	Mid Staffs Inquiry (2013)	Accepted
F92	NHS Litigation Authority Improvement of risk management The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.	Mid Staffs Inquiry (2013)	Accepted
F94	Evidence-based assessment As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to …	Mid Staffs Inquiry (2013)	Accepted
F95	Information sharing As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed …	Mid Staffs Inquiry (2013)	Accepted
F96	Information sharing The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of …	Mid Staffs Inquiry (2013)	Accepted
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
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
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
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
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
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
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
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
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
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
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
F152	Medical training Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the …	Mid Staffs Inquiry (2013)	Accepted
F154	Medical training The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight …	Mid Staffs Inquiry (2013)	Accepted
F155	Medical training The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance …	Mid Staffs Inquiry (2013)	Accepted
F156	Medical training The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.	Mid Staffs Inquiry (2013)	Accepted
F157	Matters to be reported to the General Medical Council The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical …	Mid Staffs Inquiry (2013)	Accepted

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