Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 1,417 match current filters Page 19 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 19 of 29

Code	Recommendation	Inquiry	Response
F230	Profile The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable …	Mid Staffs Inquiry (2013)	Accepted
F231	Coordination with internal procedures It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action …	Mid Staffs Inquiry (2013)	Accepted
F232	Employment liaison officers The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to …	Mid Staffs Inquiry (2013)	Accepted
F233	For joint action Profile While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that …	Mid Staffs Inquiry (2013)	Accepted
F234	Cooperation with the Care Quality Commission Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in …	Mid Staffs Inquiry (2013)	Accepted
F235	Joint proceedings The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under …	Mid Staffs Inquiry (2013)	Accepted in Part
F236	Identification of who is responsible for the patient Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so …	Mid Staffs Inquiry (2013)	Accepted
F237	Teamwork There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by …	Mid Staffs Inquiry (2013)	Accepted
F238	Communication with and about patients Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff …	Mid Staffs Inquiry (2013)	Accepted
F239	Continuing responsibility for care The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be …	Mid Staffs Inquiry (2013)	Accepted
F240	Hygiene All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged …	Mid Staffs Inquiry (2013)	Accepted
F241	Provision of food and drink The arrangements and best practice for providing food and drink to elderly patients require constant review, monitoring and implementation.	Mid Staffs Inquiry (2013)	Accepted
F242	Medicines administration In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse …	Mid Staffs Inquiry (2013)	Accepted
F243	Recording of routine observations The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately …	Mid Staffs Inquiry (2013)	Accepted
F244	Common information practices shared data and electronic records There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. …	Mid Staffs Inquiry (2013)	Accepted
F245	Board accountability Each provider organisation should have a board level member with responsibility for information.	Mid Staffs Inquiry (2013)	Accepted in Part
F246	Comparable quality accounts Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form …	Mid Staffs Inquiry (2013)	Accepted
F247	Accountability for quality accounts Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems …	Mid Staffs Inquiry (2013)	Accepted
F248	Accountability for quality accounts Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to …	Mid Staffs Inquiry (2013)	Accepted
F249	Accountability for quality accounts Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying …	Mid Staffs Inquiry (2013)	Accepted in Part
F250	Accountability for quality accounts It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account …	Mid Staffs Inquiry (2013)	Accepted in Part
F251	Regulatory oversight of quality accounts The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled …	Mid Staffs Inquiry (2013)	Accepted in Part
F252	Access to data It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes.	Mid Staffs Inquiry (2013)	Accepted
F253	Access to quality and risk profile The information behind the quality and risk profile – as well as the ratings and methodology – should be placed in the …	Mid Staffs Inquiry (2013)	Accepted
F254	Access for public and patient comments While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, …	Mid Staffs Inquiry (2013)	Accepted
F255	Using patient feedback Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" …	Mid Staffs Inquiry (2013)	Accepted
F256	Follow up of patients A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a …	Mid Staffs Inquiry (2013)	Accepted
F257	Role of the Health and Social Care Information Centre The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the …	Mid Staffs Inquiry (2013)	Accepted in Part
F258	Role of the Health and Social Care Information Centre The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to …	Mid Staffs Inquiry (2013)	Accepted
F259	Role of the Health and Social Care Information Centre The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should …	Mid Staffs Inquiry (2013)	Accepted
F260	Information standards The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in …	Mid Staffs Inquiry (2013)	Accepted in Part
F261	Information standards The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.	Mid Staffs Inquiry (2013)	Accepted
F262	Enhancing the use analysis and dissemination of healthcare information All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on …	Mid Staffs Inquiry (2013)	Accepted
F263	Enhancing the use analysis and dissemination of healthcare information It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for …	Mid Staffs Inquiry (2013)	Accepted
F264	Enhancing the use analysis and dissemination of healthcare information In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and …	Mid Staffs Inquiry (2013)	Accepted
F265	Enhancing the use analysis and dissemination of healthcare information The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to …	Mid Staffs Inquiry (2013)	Accepted
F266	Enhancing the use analysis and dissemination of healthcare information In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and …	Mid Staffs Inquiry (2013)	Accepted
F267	Enhancing the use analysis and dissemination of healthcare information All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care …	Mid Staffs Inquiry (2013)	Accepted
F268	Resources Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant …	Mid Staffs Inquiry (2013)	Accepted
F269	Improving and assuring accuracy The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This …	Mid Staffs Inquiry (2013)	Accepted
F270	Improving and assuring accuracy There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the …	Mid Staffs Inquiry (2013)	Accepted
F271	Improving and assuring accuracy To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and …	Mid Staffs Inquiry (2013)	Accepted
F272	Improving and assuring accuracy There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation …	Mid Staffs Inquiry (2013)	Accepted
F273	Information to coroners The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable …	Mid Staffs Inquiry (2013)	Accepted in Part
F274	Information to coroners There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of …	Mid Staffs Inquiry (2013)	Accepted
F275	Independent medical examiners It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.	Mid Staffs Inquiry (2013)	Accepted in Part
F276	Independent medical examiners Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the …	Mid Staffs Inquiry (2013)	Accepted
F277	Death certification National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, …	Mid Staffs Inquiry (2013)	Accepted
F278	Death certification It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or …	Mid Staffs Inquiry (2013)	Accepted
F279	Death certification So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or …	Mid Staffs Inquiry (2013)	Accepted

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