Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 928 match current filters Page 12 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 12 of 19

Code	Recommendation	Inquiry	Response
F158	Training and training establishments as a source of safety information The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from …	Mid Staffs Inquiry (2013)	Accepted
F159	Training and training establishments as a source of safety information Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards …	Mid Staffs Inquiry (2013)	Accepted
F160	Training and training establishments as a source of safety information Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences …	Mid Staffs Inquiry (2013)	Accepted
F161	Training and training establishments as a source of safety information Training visits should make an important contribution to the protection of patients: Obtaining information directly from trainees should remain a valuable source …	Mid Staffs Inquiry (2013)	Accepted
F162	Training and training establishments as a source of safety information The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of …	Mid Staffs Inquiry (2013)	Accepted
F163	Safe staff numbers and skills The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of …	Mid Staffs Inquiry (2013)	Accepted
F170	Health Education England Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.	Mid Staffs Inquiry (2013)	Accepted
F171	Deans All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical …	Mid Staffs Inquiry (2013)	Accepted
F172	Proficiency in the English language The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and …	Mid Staffs Inquiry (2013)	Accepted
F173	Principles of openness transparency and candour Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the …	Mid Staffs Inquiry (2013)	Accepted
F174	Candour about harm Where death or serious harm has been or may have been caused to a patient by an act or omission of the …	Mid Staffs Inquiry (2013)	Accepted
F175	Candour about harm Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a …	Mid Staffs Inquiry (2013)	Accepted
F176	Openness with regulators Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not …	Mid Staffs Inquiry (2013)	Accepted
F177	Openness in public statements Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.	Mid Staffs Inquiry (2013)	Accepted
F179	Restrictive contractual clauses "Gagging clauses" or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar …	Mid Staffs Inquiry (2013)	Accepted
F180	Candour about incidents Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the …	Mid Staffs Inquiry (2013)	Accepted
F182	Statutory duty of openness and transparency There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare …	Mid Staffs Inquiry (2013)	Accepted
F184	Enforcement by the Care Quality Commission Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute …	Mid Staffs Inquiry (2013)	Accepted
F185	Focus on culture of caring There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in …	Mid Staffs Inquiry (2013)	Accepted
F186	Practical hands-on training and experience Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all …	Mid Staffs Inquiry (2013)	Accepted
F187	Practical hands-on training and experience There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on …	Mid Staffs Inquiry (2013)	Accepted
F191	Recruitment for values and commitment Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and …	Mid Staffs Inquiry (2013)	Accepted
F196	Nurse leadership The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient …	Mid Staffs Inquiry (2013)	Accepted
F198	Measuring cultural health Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing …	Mid Staffs Inquiry (2013)	Accepted
F199	Key nurses Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for …	Mid Staffs Inquiry (2013)	Accepted
F201	Strengthening the nursing professional voice The Royal College of Nursing should consider whether it should formally divide its "Royal College" functions and its employee representative/trade union functions …	Mid Staffs Inquiry (2013)	Accepted
F202	Strengthening the nursing professional voice Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff …	Mid Staffs Inquiry (2013)	Accepted
F203	Strengthening the nursing professional voice A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of …	Mid Staffs Inquiry (2013)	Accepted
F206	Strengthening the nursing professional voice The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a …	Mid Staffs Inquiry (2013)	Accepted
F210	Code of conduct for healthcare support workers There should be a national code of conduct for healthcare support workers.	Mid Staffs Inquiry (2013)	Accepted
F211	Training standards for healthcare support workers There should be a common set of national standards for the education and training of healthcare support workers.	Mid Staffs Inquiry (2013)	Accepted
F214	Shared training A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and …	Mid Staffs Inquiry (2013)	Accepted
F215	Shared code of ethics A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to …	Mid Staffs Inquiry (2013)	Accepted
F216	Leadership framework The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health …	Mid Staffs Inquiry (2013)	Accepted
F218	Enforcement of standards and accountability Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and …	Mid Staffs Inquiry (2013)	Accepted
F221	Ensuring common standards of competence and compliance Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards …	Mid Staffs Inquiry (2013)	Accepted
F222	General Medical Council Systemic investigation where needed The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be …	Mid Staffs Inquiry (2013)	Accepted
F224	Information sharing Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue …	Mid Staffs Inquiry (2013)	Accepted
F225	Peer reviews The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act …	Mid Staffs Inquiry (2013)	Accepted
F228	Administrative reform It is of concern that the administration of the Nursing and Midwifery Council, which has not been examined by this Inquiry, is …	Mid Staffs Inquiry (2013)	Accepted
F229	Revalidation It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical …	Mid Staffs Inquiry (2013)	Accepted
F230	Profile The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable …	Mid Staffs Inquiry (2013)	Accepted
F231	Coordination with internal procedures It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action …	Mid Staffs Inquiry (2013)	Accepted
F232	Employment liaison officers The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to …	Mid Staffs Inquiry (2013)	Accepted
F233	For joint action Profile While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that …	Mid Staffs Inquiry (2013)	Accepted
F234	Cooperation with the Care Quality Commission Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in …	Mid Staffs Inquiry (2013)	Accepted
F236	Identification of who is responsible for the patient Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so …	Mid Staffs Inquiry (2013)	Accepted
F237	Teamwork There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by …	Mid Staffs Inquiry (2013)	Accepted
F238	Communication with and about patients Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff …	Mid Staffs Inquiry (2013)	Accepted
F239	Continuing responsibility for care The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be …	Mid Staffs Inquiry (2013)	Accepted

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