Public Inquiry Recommendations

The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should publish guidance for the implementation of visiting restrictions in hospitals …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with trusts and health boards to ensure that pandemic …

The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place …

The UK government should establish a standing pharmaceutical expert advisory panel, in consultation with the Department of Health and Social Care and …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should maintain networks with local communities to produce targeted vaccination strategies …

Each of the four UK public health or health security agencies should work together to: maintain accurate, UK-wide insight into the state …

The UK government and devolved administrations should work together, with their respective health delivery services, to facilitate and coordinate regulatory bodies' access …

The UK government must reform the Vaccine Damage Payment Scheme as soon as possible. The reform should include as a minimum: increasing …

We recommend that the preservation of police records be reviewed to ensure that all such documents are treated as public records, held …

We recommend that, once a copy of all material has been placed on a Digital Archive, private owners - including the FA …

We recommend the appointment of an Editor-in-Chief to oversee the presentation on the Digital Archive of documents relating to the disaster, and …

We recommend the development of a protocol which identifies the criteria according to which material not disclosed by the Panel may be …

Given the risks associated with HM Coastguard's use of network flexing for small boat search and rescue – whereby its workforce is …

HM Coastguard should seek, at pace, to invest in the technology required to support its ability to reconcile duplicate small boat incidents. …

There should be regular assessments by HM Coastguard of the adequacy of the available assets and human resources to respond to both …

HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one …

Those involved in maritime search and rescue should adopt formally the Mass Persons in the Water Triage procedure to govern the operational …

Those involved in maritime search and rescue should continue to undertake joint exercises on the application of the Mass Persons in the …

The Department for Transport must consider recommending to the International Maritime Organization that it consider incorporating an in-water mass casualty triage tool …

HM Coastguard should amend its existing policies to incorporate the need to provide more comprehensive advice about survivability to people in distress …

HM Coastguard should examine whether it is using the most appropriate modelling for survivability in cold water. HM Coastguard should amend its …

HM Coastguard must continue to liaise with search and rescue partners in the UK and abroad to identify opportunities for the development …

The role and functions of HM Coastguard should be set out in up-to-date legislation.

An independent external body should be given responsibility for the regular assessment of the effectiveness and efficiency of HM Coastguard. Consideration should …

The government should reconsider Mr Downer's recommendation in his independent review of Border Force that Border Force Maritime should not be providing …

For so long as the current arrangements in relation to search and rescue in the English Channel remain in place, the roles …

HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved …

HM Coastguard should develop a mass rescue operation plan that includes command and control, co-ordination, external stakeholders, medical and law enforcement roles, …

HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard …

The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details …

Phase 2 should consider what single agency or structure should be appointed or established to record, monitor and co-ordinate interventions for children …

Phase 2 should consider the development of a shared multi‑agency risk‑assessment tool that is clear, accessible and suitable for use across public …

Phase 2 should consider whether there should be a further ability to restrict or monitor access to the internet on the part …

The Department for Transport should require local authorities to ensure that all licensed taxi drivers have a clear duty promptly to report …

The Department for Transport should ensure that local authorities establish effective arrangements between licensed taxi companies and schools. These should enable school …

All police forces should ensure that their policies, guidance and training address taking on a calculated degree of risk in recognition of …

All police forces that have not implemented a model providing immediate and direct support to Force Incident Managers, ideally through a second …

NHS England should review funding, and consider providing additional resources, to enable all emergency response ambulance staff to participate in appropriate training …

North West Ambulance Service should review its procedures for declaring a Major Incident or Major Incident (Standby) to ensure clarity in how …

Merseyside Police and North West Ambulance Service should review the terminology used in their systems and procedures to ensure shared understanding and …

The Department for Education should update the out‑of‑school settings guidance by reviewing the health and safety section to ensure terminology is clear …

Phase 2 should consider systems to detect and report concerning online behaviour and suspicious combinations of purchases. This should include consideration of: …