Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 928 match current filters Page 16 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 16 of 19

Code	Recommendation	Inquiry	Response
14	Review clinical leadership arrangements The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure …	Morecambe Bay Investigation (2015)	Accepted
15	Continue governance systems work The University Hospitals of Morecambe Bay NHS Foundation Trust should continue to prioritise the work commenced in response to the review of …	Morecambe Bay Investigation (2015)	Accepted
16	Clarify manager quality responsibilities As part of the governance systems work, we consider that the University Hospitals of Morecambe Bay NHS Foundation Trust should ensure that …	Morecambe Bay Investigation (2015)	Accepted
17	Improve Furness General Hospital delivery suite The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to …	Morecambe Bay Investigation (2015)	Accepted
18	Ensure external oversight of implementation All of the previous recommendations should be implemented with the involvement of Clinical Commissioning Groups, and where necessary, the Care Quality Commission …	Morecambe Bay Investigation (2015)	Accepted
19	Professional bodies review conduct of registrants In light of the evidence we have heard during the Investigation, we consider that the professional regulatory bodies should review the findings …	Morecambe Bay Investigation (2015)	Accepted
20	National review of maternity care in challenging circumstances There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, …	Morecambe Bay Investigation (2015)	Accepted
21	Consider extending review to other rural services The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care …	Morecambe Bay Investigation (2015)	Accepted
22	Recognise educational opportunities in smaller units We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal …	Morecambe Bay Investigation (2015)	Accepted
23	Clear standards for incident reporting in maternity Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation …	Morecambe Bay Investigation (2015)	Accepted
24	Involve patients and relatives in incident investigation We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of …	Morecambe Bay Investigation (2015)	Accepted
25	Duty to report external investigation findings We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into …	Morecambe Bay Investigation (2015)	Accepted
26	Clear national whistleblowing policy We commend the introduction of a clear national policy on whistleblowing. As well as protecting the interests of whistleblowers, we recommend that …	Morecambe Bay Investigation (2015)	Accepted
27	Professional duty to report concerns Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate …	Morecambe Bay Investigation (2015)	Accepted
28	National standards for clinical leads Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but …	Morecambe Bay Investigation (2015)	Accepted
29	Standards for manager quality responsibilities Clear national standards should be drawn up setting out the responsibilities for clinical quality of other managers, including executive directors, middle managers …	Morecambe Bay Investigation (2015)	Accepted
30	National protocol on duties relating to inquests A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This …	Morecambe Bay Investigation (2015)	Accepted
31	Fundamental review of NHS complaints system The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it …	Morecambe Bay Investigation (2015)	Accepted
32	Reform Local Supervising Authority for midwives The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation …	Morecambe Bay Investigation (2015)	Accepted
33	CQC and Monitor coordination We considered carefully the effectiveness of separating organisationally the regulation of quality by the Care Quality Commission from the regulation of finance …	Morecambe Bay Investigation (2015)	Accepted
34	CQC and PHSO memorandum of understanding The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for …	Morecambe Bay Investigation (2015)	Accepted
35	Clarify oversight responsibilities The division of responsibilities between the Care Quality Commission and other parts of the NHS for oversight of service quality and the …	Morecambe Bay Investigation (2015)	Accepted
36	Impact assessment of policy changes The cumulative impact of new policies and processes, particularly the perceived pressure to achieve Foundation Trust status, together with organisational reconfiguration, placed …	Morecambe Bay Investigation (2015)	Accepted
37	Protocol for organisational change transitions Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend …	Morecambe Bay Investigation (2015)	Accepted
38	Improve perinatal mortality recording Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely …	Morecambe Bay Investigation (2015)	Accepted
39	Implement medical examiner system There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning …	Morecambe Bay Investigation (2015)	Accepted
40	Extend medical examiners to stillbirths Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be …	Morecambe Bay Investigation (2015)	Accepted
41	Guidance for external service reviews We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out …	Morecambe Bay Investigation (2015)	Accepted
42	Register external reviews with CQC We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that …	Morecambe Bay Investigation (2015)	Accepted
43	Maintain focus on quality We strongly endorse the emphasis placed on the quality of NHS services that began with the Darzi review, High Quality Care for …	Morecambe Bay Investigation (2015)	Accepted
44	Establish framework for future investigations This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the …	Morecambe Bay Investigation (2015)	Accepted
AG-1	National Register of Armed Policing Recommendations A national policing body should manage a national register of recommendations relating to armed policing, and the response to such recommendations, arising …	Anthony Grainger Inquiry (2019)	Accepted
AG-2	HMICFRS Thematic Inspection of Armed Policing Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) should conduct a thematic inspection or inspections concerning: (i) the selection …	Anthony Grainger Inquiry (2019)	Accepted
AG-3	Code of Practice on New Weapons Approval The Home Secretary should ensure that the new Code of Practice on Police use of Firearms and Less Lethal Weapons contains an …	Anthony Grainger Inquiry (2019)	Accepted
AG-4	North West Armed Policing SOP Amendment The North West Armed Policing Standard Operating Procedure on Weapons and Ammunition should be amended so that it only permits the use …	Anthony Grainger Inquiry (2019)	Accepted
AG-5	GMP Intelligence Policy for Armed Deployments Greater Manchester Police (GMP) should design and promulgate a written policy that specifically relates to the collection, analysis and dissemination of intelligence …	Anthony Grainger Inquiry (2019)	Accepted
AG-6	MASTS Documentation and Training Clarity All documents and training relating to Mobile Armed Support to Surveillance (MASTS) should: clearly differentiate between MASTS as an operational method of …	Anthony Grainger Inquiry (2019)	Accepted
AG-7	Recording of Firearms Operations During post incident proceedings following a police shooting, NPCC should consider the advantages of: Recordings of the communications of firearms commanders and …	Anthony Grainger Inquiry (2019)	Accepted
AG-8	MASTS Vehicle Identification Equipment The National Police Chiefs' Council (NPCC) should consider whether to recommend equipping unmarked vehicles used in Mobile Armed Support to Surveillance (MASTS) …	Anthony Grainger Inquiry (2019)	Accepted
AG-9	Maximum Continuous Duty Period for AFOs The National Police Chiefs' Council (NPCC) and the College of Policing should jointly decide, in the light of independent expert advice, whether …	Anthony Grainger Inquiry (2019)	Accepted
JB-15.1	Clarify separation of SIO and firearms commander roles There should be clearer guidance from the MPS, College of Policing and/or the NPCC on the separation of roles between the Senior …	Jermaine Baker Inquiry (2022)	Accepted
JB-15.2	Require multidimensional risk assessments throughout operations Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those …	Jermaine Baker Inquiry (2022)	Accepted
JB-15.3	Document management system for firearms authorisation forms In order to provide for efficacy and transparency, the NPCC and College of Policing should be tasked with providing a document management …	Jermaine Baker Inquiry (2022)	Accepted
JB-15.4	Amend firearms authorisation forms for risk assessment and tipping points There should be an amendment to FA (and equivalent) forms to: a. encourage a multidimensional risk assessment (to comply with Article 2) …	Jermaine Baker Inquiry (2022)	Accepted
JB-15.5	Compulsory training on firearms authorisation forms Appropriate training and refresher courses on the usage and completion of FA (and equivalent) forms should be made compulsory for firearms commanders …	Jermaine Baker Inquiry (2022)	Accepted
JB-15.6	National review of contain and call out strategy The NPCC should commission a national review of the frequency with which this strategic option is used and its efficacy. The NPCC …	Jermaine Baker Inquiry (2022)	Accepted
JB-15.7	Recording and documentation of firearms planning meetings and briefings MPS Armed Policing Standard Operating Procedure (SOP) to be amended so that: a. Notes and/or audio recordings should be made of all …	Jermaine Baker Inquiry (2022)	Accepted
JB-15.8	National guidance on recording firearms planning meetings The NPCC and/or College of Policing should ensure that these amendments are reflected in the guidance and training given to forces nationally.	Jermaine Baker Inquiry (2022)	Accepted
JB-15.9	Intelligence briefing requirements during operations The College of Policing's Authorised Professional Practice – Armed Policing (APP-AP) should clarify that, during the course of an operation, any relevant …	Jermaine Baker Inquiry (2022)	Accepted
JB-15.10	Training on clear intelligence communication When intelligence is being provided, the use of any language that is capable of misinterpretation is to be avoided. Training to address …	Jermaine Baker Inquiry (2022)	Accepted

‹ Prev Page 16 of 19 Next ›