Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 1,417 match current filters Page 18 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 18 of 29

Code	Recommendation	Inquiry	Response
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
F181	Enforcement of the duty Statutory duties of candour in relation to harm to patients A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F183	Criminal liability It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an …	Mid Staffs Inquiry (2013)	Not 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
F188	Aptitude test for compassion and caring The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered …	Mid Staffs Inquiry (2013)	Accepted in Part
F189	Consistent training The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.	Mid Staffs Inquiry (2013)	Accepted in Part
F190	National standards There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F192	Strong nursing voice The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and …	Mid Staffs Inquiry (2013)	Accepted in Part
F193	Standards for appraisal and support Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which …	Mid Staffs Inquiry (2013)	Accepted in Part
F194	Standards for appraisal and support As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual …	Mid Staffs Inquiry (2013)	Accepted in Part
F195	Nurse leadership Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F197	Nurse leadership Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F200	Key nurses Consideration should be given to the creation of a status of Registered Older Person's Nurse.	Mid Staffs Inquiry (2013)	Accepted in Part
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
F204	Strengthening the nursing professional voice All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and …	Mid Staffs Inquiry (2013)	Accepted in Part
F205	Strengthening the nursing professional voice Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F207	Strengthening identification of healthcare support workers and nurses There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.	Mid Staffs Inquiry (2013)	Accepted in Part
F208	Strengthening identification of healthcare support workers and nurses Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily …	Mid Staffs Inquiry (2013)	Accepted in Part
F209	Registration of healthcare support workers A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to …	Mid Staffs Inquiry (2013)	Not 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
F212	Training standards for healthcare support workers The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by …	Mid Staffs Inquiry (2013)	Not Accepted
F213	Training standards for healthcare support workers Until such time as the Nursing and Midwifery Council is charged with the recommended regulatory responsibilities, the Department of Health should institute …	Mid Staffs Inquiry (2013)	Not 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
F217	Common selection criteria A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F219	A regulator as an alternative An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up …	Mid Staffs Inquiry (2013)	Accepted in Part
F220	Accreditation A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F223	Enhanced resources If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater …	Mid Staffs Inquiry (2013)	Accepted in Part
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
F226	Nursing and Midwifery Council Investigation of systemic concerns To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council …	Mid Staffs Inquiry (2013)	Accepted in Part
F227	Nursing and Midwifery Council Investigation of systemic concerns The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where …	Mid Staffs Inquiry (2013)	Accepted in Part
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

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