Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 309 match current filters Page 5 of 7

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	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

309 of 1,814 · page 5 of 7

Code	Recommendation	Inquiry	Response
F87	Ensuring the utility of a health and safety function in a clinical setting The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should …	Mid Staffs Inquiry (2013)	Accepted in Part
F88	Information sharing The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators …	Mid Staffs Inquiry (2013)	Accepted in Part
F89	Information sharing Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and …	Mid Staffs Inquiry (2013)	Accepted in Part
F91	NHS Litigation Authority Improvement of risk management The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not …	Mid Staffs Inquiry (2013)	Accepted in Part
F93	NHS Litigation Authority Improvement of risk management The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, …	Mid Staffs Inquiry (2013)	Accepted in Part
F97	National Patient Safety Agency functions The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this …	Mid Staffs Inquiry (2013)	Accepted in Part
F98	National Patient Safety Agency functions Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm …	Mid Staffs Inquiry (2013)	Accepted in Part
F99	National Patient Safety Agency functions The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative …	Mid Staffs Inquiry (2013)	Accepted in Part
F100	National Patient Safety Agency functions Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt …	Mid Staffs Inquiry (2013)	Accepted in Part
F115	Investigations Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint …	Mid Staffs Inquiry (2013)	Accepted in Part
F117	Support for complainants A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.	Mid Staffs Inquiry (2013)	Accepted in Part
F118	Learning and information from complaints Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's …	Mid Staffs Inquiry (2013)	Accepted in Part
F120	Learning and information from complaints Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on …	Mid Staffs Inquiry (2013)	Accepted in Part
F122	Handling large-scale complaints Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to …	Mid Staffs Inquiry (2013)	Accepted in Part
F124	Duty to require and monitor delivery of fundamental standards The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in …	Mid Staffs Inquiry (2013)	Accepted in Part
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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