Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 1,417 match current filters Page 17 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 17 of 29

Code	Recommendation	Inquiry	Response
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
F133	Role of commissioners in complaints Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F135	Public accountability of commissioners and public engagement Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F137	Intervention and sanctions for substandard or unsafe services Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other …	Mid Staffs Inquiry (2013)	Not 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
F141	Taking responsibility for quality Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F145	Structure of Local Healthwatch There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter …	Mid Staffs Inquiry (2013)	Not Accepted
F146	Finance and oversight of Local Healthwatch Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F150	Inspection powers Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or …	Mid Staffs Inquiry (2013)	Accepted in Part
F151	Complaints to MPs MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F153	Medical training The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of …	Mid Staffs Inquiry (2013)	Accepted in Part
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
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
F164	Approved Practice Settings The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate …	Mid Staffs Inquiry (2013)	Accepted in Part
F165	Approved Practice Settings The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be …	Mid Staffs Inquiry (2013)	Accepted in Part
F166	Approved Practice Settings The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with …	Mid Staffs Inquiry (2013)	Accepted in Part
F167	Approved Practice Settings The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of …	Mid Staffs Inquiry (2013)	Accepted in Part
F168	Approved Practice Settings The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved …	Mid Staffs Inquiry (2013)	Accepted in Part
F169	Role of the Department of Health and the National Quality Board The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F178	Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and candour The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and …	Mid Staffs Inquiry (2013)	Accepted in Part
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

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