Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 1,417 match current filters Page 15 of 29

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

1,417 of 1,814 · page 15 of 29

Code	Recommendation	Inquiry	Response
F30	Interim measures The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach …	Mid Staffs Inquiry (2013)	Accepted
F31	Interim measures Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place …	Mid Staffs Inquiry (2013)	Accepted
F32	Interim measures Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take …	Mid Staffs Inquiry (2013)	Accepted
F33	Interim measures Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the …	Mid Staffs Inquiry (2013)	Accepted in Part
F34	Interim measures Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim …	Mid Staffs Inquiry (2013)	Accepted in Part
F35	Need to share information between regulators Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all …	Mid Staffs Inquiry (2013)	Accepted
F36	Use of information for effective regulation A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in …	Mid Staffs Inquiry (2013)	Accepted
F37	Use of information about compliance by regulator from: Quality accounts Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each …	Mid Staffs Inquiry (2013)	Accepted
F38	Use of information about compliance by regulator from: Complaints The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant …	Mid Staffs Inquiry (2013)	Accepted
F39	Use of information about compliance by regulator from: Complaints The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.	Mid Staffs Inquiry (2013)	Accepted in Part
F40	Use of information about compliance by regulator from: Complaints It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the …	Mid Staffs Inquiry (2013)	Accepted
F41	Use of information about compliance by regulator from: Patient safety alerts The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee …	Mid Staffs Inquiry (2013)	Accepted in Part
F42	Use of information about compliance by regulator from: Serious untoward incidents Strategic Health Authorities/their successors should	Mid Staffs Inquiry (2013)	Accepted
F43	Use of information about compliance by regulator from: Media Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.	Mid Staffs Inquiry (2013)	Accepted
F44	Use of information about compliance by regulator from: Media Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was …	Mid Staffs Inquiry (2013)	Accepted in Part
F45	Use of information about compliance by regulator from: Inquests The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.	Mid Staffs Inquiry (2013)	Accepted in Part
F46	Use of information about compliance by regulator from: Quality and risk profiles The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important …	Mid Staffs Inquiry (2013)	Accepted
F47	Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. …	Mid Staffs Inquiry (2013)	Accepted
F48	Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them …	Mid Staffs Inquiry (2013)	Accepted in Part
F49	Enhancement of monitoring and the importance of inspection Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring …	Mid Staffs Inquiry (2013)	Accepted
F50	Enhancement of monitoring and the importance of inspection The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.	Mid Staffs Inquiry (2013)	Accepted
F51	Enhancement of monitoring and the importance of inspection The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of …	Mid Staffs Inquiry (2013)	Accepted
F52	Enhancement of monitoring and the importance of inspection The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage …	Mid Staffs Inquiry (2013)	Accepted
F53	Care Quality Commission independence strategy and culture Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a …	Mid Staffs Inquiry (2013)	Accepted
F54	Care Quality Commission independence strategy and culture Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to …	Mid Staffs Inquiry (2013)	Accepted
F55	Care Quality Commission independence strategy and culture The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and …	Mid Staffs Inquiry (2013)	Accepted
F56	Care Quality Commission independence strategy and culture The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, …	Mid Staffs Inquiry (2013)	Accepted
F57	Care Quality Commission independence strategy and culture The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and …	Mid Staffs Inquiry (2013)	Accepted
F58	Care Quality Commission independence strategy and culture Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there …	Mid Staffs Inquiry (2013)	Accepted
F59	Care Quality Commission independence strategy and culture Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the …	Mid Staffs Inquiry (2013)	Accepted in Part
F60	Consolidation of regulatory functions The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be …	Mid Staffs Inquiry (2013)	Accepted in Part
F61	Consolidation of regulatory functions A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such …	Mid Staffs Inquiry (2013)	Not Accepted
F62	Improved patient focus For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into …	Mid Staffs Inquiry (2013)	Accepted
F63	Improved transparency Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.	Mid Staffs Inquiry (2013)	Accepted
F64	Authorisation of foundation trusts The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this …	Mid Staffs Inquiry (2013)	Not Accepted
F65	Quality of care as a pre-condition for foundation trust applications The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of …	Mid Staffs Inquiry (2013)	Accepted
F66	Improving contribution of stakeholder opinions The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to …	Mid Staffs Inquiry (2013)	Accepted
F67	Focus on compliance with fundamental standards The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for …	Mid Staffs Inquiry (2013)	Accepted
F68	Focus on compliance with fundamental standards No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager …	Mid Staffs Inquiry (2013)	Accepted
F69	Focus on compliance with fundamental standards The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality …	Mid Staffs Inquiry (2013)	Accepted
F70	Duty of utmost good faith A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant …	Mid Staffs Inquiry (2013)	Accepted
F71	Role of Secretary of State The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a …	Mid Staffs Inquiry (2013)	Accepted
F72	Assessment process for authorisation The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas …	Mid Staffs Inquiry (2013)	Accepted
F73	Need for constructive working with other parts of the system The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with …	Mid Staffs Inquiry (2013)	Accepted
F74	Enhancement of role of governors Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation …	Mid Staffs Inquiry (2013)	Accepted
F75	Enhancement of role of governors The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the …	Mid Staffs Inquiry (2013)	Accepted in Part
F76	Enhancement of role of governors Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large …	Mid Staffs Inquiry (2013)	Accepted
F77	Enhancement of role of governors Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to …	Mid Staffs Inquiry (2013)	Accepted
F78	Enhancement of role of governors The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in …	Mid Staffs Inquiry (2013)	Accepted
F79	Accountability of providers' directors There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for …	Mid Staffs Inquiry (2013)	Accepted in Part

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