Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 1,417 match current filters Page 16 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 16 of 29

Code	Recommendation	Inquiry	Response
F80	Accountability of providers' directors A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be …	Mid Staffs Inquiry (2013)	Accepted in Part
F81	Accountability of providers' directors Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude …	Mid Staffs Inquiry (2013)	Accepted
F82	Accountability of providers' directors Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom …	Mid Staffs Inquiry (2013)	Accepted
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
F84	Accountability of providers' directors Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F87	Ensuring the utility of a health and safety function in a clinical setting The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should …	Mid Staffs Inquiry (2013)	Accepted in Part
F88	Information sharing The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators …	Mid Staffs Inquiry (2013)	Accepted in Part
F89	Information sharing Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F91	NHS Litigation Authority Improvement of risk management The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F93	NHS Litigation Authority Improvement of risk management The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F97	National Patient Safety Agency functions The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this …	Mid Staffs Inquiry (2013)	Accepted in Part
F98	National Patient Safety Agency functions Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm …	Mid Staffs Inquiry (2013)	Accepted in Part
F99	National Patient Safety Agency functions The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative …	Mid Staffs Inquiry (2013)	Accepted in Part
F100	National Patient Safety Agency functions Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt …	Mid Staffs Inquiry (2013)	Accepted in Part
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

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