Public Inquiry Recommendations

Each provider organisation should have a board level member with responsibility for information.

Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying …

It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account …

The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled …

The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the …

The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in …

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable …

It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.

All police officers and police staff should be obliged to register in confidence with the Chief Officer of their police force, at …

The Panel recommends the creation of a statutory duty of candour, to be owed by all law enforcement agencies to those whom …

All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased …

All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the …

All NHS trusts should routinely audit the access data of all facilities used to store deceased people.

The practice of using shared electronic swipe cards for specific staff groups should cease immediately.

All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. …

All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be …

The NHS should ensure that the security standards required for body stores are the same as those required for facilities licensed by …

All NHS trusts should consider the installation of 'swipe to exit' for mortuary facilities. This would allow trusts to monitor and audit …

All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine …

NHS trusts should ensure that Designated Individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.

NHS trusts should ensure that senior managers, including the Chief Executive, have a clear understanding of the role of the Designated Individual, …

NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as …

A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.

NHS trusts should assure themselves that the Mortuary Manager has adequate resources and support to perform their role effectively, including meeting any …

All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include …

Trust boards should assure themselves that the recommendations in this Report have been implemented.

Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage …

Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent …

NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.

The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased …

NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.

There should be a process to routinely review who is permitted to access the mortuary unsupervised.

Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary …

Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must …

Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration …

Routine and regular audits of security must be conducted, encompassing both access to and exit from the mortuary and movement within it, …

Immediate steps must be taken to commission a specialist strategic review of the systems in place to protect the deceased, which should …

There must be no reliance on keys and keypad codes alone to secure access to the mortuary.

Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.

CCTV must be installed inside the mortuary facing all doors and access points, the reception area and the doors of all fridges …

Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.

All policies and procedures in relation to the security of the mortuary must be accurately and comprehensively reflected in a single security …

There must be a process to ensure that, where there is a requirement for funding to strengthen mortuary security, it is expedited …

There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be …

There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, …

There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as …

The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must …

The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal …

All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service …

The implementation of these recommendations must be reported to the relevant statutory committee.