Inquiries · Recommendations

Public Inquiry Recommendations

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

Code	Recommendation	Inquiry	Response
P1-10	Regular CCTV review with swipe card data Maidstone and Tunbridge Wells NHS Trust must ensure that footage from the CCTV is reviewed on a regular basis by appropriately trained …	Fuller Inquiry (2023)	Accepted
P1-11	Share HTA reports with reliant organisations Maidstone and Tunbridge Wells NHS Trust must proactively share Human Tissue Authority reports with organisations that rely on Human Tissue Authority licensing …	Fuller Inquiry (2023)	Accepted
P1-12	Local authorities examine contractual arrangements Kent County Council and East Sussex County Council should examine their contractual arrangements with Maidstone and Tunbridge Wells NHS Trust to ensure …	Fuller Inquiry (2023)	Accepted
P1-13	Board review governance - assurance not reassurance We have illustrated throughout this Report how Maidstone and Tunbridge Wells NHS Trust relied on reassurance rather than assurance in monitoring its …	Fuller Inquiry (2023)	Accepted
P1-14	Board oversight of licensed mortuary activity Maidstone and Tunbridge Wells NHS Trust Board must have greater oversight of licensed activity in the mortuary. It must ensure that the …	Fuller Inquiry (2023)	Accepted
P1-15	Treat HTA compliance as Trust statutory responsibility Maidstone and Tunbridge Wells NHS Trust should treat compliance with Human Tissue Authority standards as a statutory responsibility for the Trust, notwithstanding …	Fuller Inquiry (2023)	Accepted
P1-16	Chief Nurse responsible for mortuary assurance The Chief Nurse should be made explicitly responsible for assuring the Maidstone and Tunbridge Wells NHS Trust Board that mortuary management is …	Fuller Inquiry (2023)	Accepted
P1-17	Deceased treated with same dignity as patients Maidstone and Tunbridge Wells NHS Trust must treat the deceased with the same due regard to dignity and safeguarding as it does …	Fuller Inquiry (2023)	Accepted
P2-22	Independent sector SOPs for deceased patients Independent sector healthcare providers should ensure that there are Standard Operating Procedures and policies in place to protect the security and dignity …	Fuller Inquiry (2025)	Accepted
P2-23	Independent sector accompanied access to deceased Independent sector healthcare providers should ensure that only people who have a legitimate reason to access a room that contains a deceased …	Fuller Inquiry (2025)	Accepted
P2-26	HTA require anatomy adverse incidents reported as HTARIs The Human Tissue Authority should change its guidance to require that relevant adverse incidents in the anatomy sector are formally reported as …	Fuller Inquiry (2025)	Accepted
P2-27	Hospice security and access controls Hospices that care for deceased people on their premises should: introduce auditable access control of the area where deceased people are kept; …	Fuller Inquiry (2025)	Accepted
P2-28	CQC guidance on hospice inspection scope To avoid confusion over its remit, the Care Quality Commission should issue clear guidance to inspectors (and others) that hospice inspections should …	Fuller Inquiry (2025)	Accepted
P2-30	Ambulance data on conveying deceased Data on how often deceased patients are conveyed in ambulances, and the reasons for this, should be routinely collected and reported to …	Fuller Inquiry (2025)	Accepted
P2-31	Ambulance policy on crew position with deceased Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should …	Fuller Inquiry (2025)	Accepted
P2-32	Ambulance policies on deceased security and dignity NHS ambulance services should also have policies regarding the security and dignity of the deceased, including when the deceased should be covered …	Fuller Inquiry (2025)	Accepted
P2-33	Ambulance photography policies Every NHS ambulance service must put policies in place regarding taking photographs of deceased patients, including any circumstances in which this may …	Fuller Inquiry (2025)	Accepted
P2-34	Recommendations apply to independent ambulances The Inquiry has focused its investigations into ambulance services on NHS ambulance services. However, the Inquiry considers that these recommendations could also …	Fuller Inquiry (2025)	Accepted
P2-75	Government responsible for implementation monitoring The government should take responsibility for the implementation of all the recommendations we make in this Report, regardless of the primary organisation …	Fuller Inquiry (2025)	Accepted
2	Patient-focused correspondence We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, …	Paterson Inquiry (2020)	Accepted
3	Explaining independent sector differences We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients …	Paterson Inquiry (2020)	Accepted
5	CQC assurance on MDT meetings We recommend that CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national …	Paterson Inquiry (2020)	Accepted
6a	Communicating complaint escalation We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the …	Paterson Inquiry (2020)	Accepted
7	UHB patient recall We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and …	Paterson Inquiry (2020)	Accepted
8	Spire patient recall We recommend that Spire should check that all patients of Ian Paterson have been recalled, and to communicate with any who have …	Paterson Inquiry (2020)	Accepted
9	National patient recall framework We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated, …	Paterson Inquiry (2020)	Accepted
11	Regulatory system patient safety priority We recommend that the government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety …	Paterson Inquiry (2020)	Accepted
14	Board apologies We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing …	Paterson Inquiry (2020)	Accepted

‹ Prev Page 19 of 19