Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 575 match current filters Page 10 of 12

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

575 of 1,814 · page 10 of 12

Code	Recommendation	Inquiry	Response
IHRD-57	Clinical Training for Guidelines Specific clinical training should always accompany the implementation of important clinical guidelines.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-58	Paediatric Fluid Management Training HSC Trusts should ensure that all nurses caring for children have facilitated access to e-learning on paediatric fluid management and hyponatraemia.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-59	Post-Mortem Request Form Training There should be training in the completion of the post-mortem examination request form.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-60	Coroner Communication Training There should be training in the communication of appropriate information and documentation to the Coroner's office.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-61	Paediatric Communication Training Clinicians caring for children should be trained in effective communication with both parents and children.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-62	Adverse Incident Communication Training Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-63	Evaluation of Parental Involvement The practice of involving parents in care and the experience of parents and families should be routinely evaluated and the information used …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-64	Parental Involvement in Training Parents should be involved in the preparation and provision of any such training programme.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-65	SAI Investigator Training Training in SAI investigation methods and procedures should be provided to those employed to investigate.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-66	Time for SAI Learning Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-67	Informing Teaching Authorities Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-68	Using Investigations for Training Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-69	Executive Director Responsibilities Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-70	Board Meeting Minutes Preservation Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-71	Children's Healthcare Governance All Trust Boards should ensure that appropriate governance mechanisms are in place to assure the quality and safety of the healthcare services …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-72	Candour in Trust Communications All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-73	GMC Code in Employment Contracts General Medical Council ('GMC') 'Good Medical Practice' Code requirements should be incorporated into contracts of employment for doctors.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-74	Professional Codes in Employment Contracts Likewise, professional codes governing nurses and other healthcare professionals should be incorporated into contracts of employment.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-75	Independent Disciplinary Action Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-76	Publication of Clinical Standards Clinical standards of care, such as patients might reasonably expect, should be published and made subject to regular audit.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-77	Trust Compliance Officer Trusts should appoint a compliance officer to ensure compliance with protocol and direction.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-78	Clinical Guidelines Audit Implementation of clinical guidelines should be documented and routinely audited.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-79	Reporting Clinical Practice Changes Trusts should bring significant changes in clinical practice to the attention of the HSCB with expedition.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-80	Healthcare Data Analysis Trusts should ensure health care data is expertly analysed for patterns of poor performance and issues of patient safety.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-81	Board Awareness of SAI Reports Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-82	Policy on Learning from SAI Deaths Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-83	SAI Deaths in Annual Reports Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-84	Trust Board Review of IHRD Report All Trust Boards should consider the findings and recommendations of this Report and where appropriate amend practice and procedure.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-85	Deputy CMO for Children's Healthcare The Department should appoint a Deputy Chief Medical Officer with specific responsibility for children's healthcare.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-86	Expand RQIA Remit and Resources The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-87	Independent Medical Examiner The Department should now institute the office of Independent Medical Examiner to scrutinise those hospital deaths not referred to the Coroner.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-88	Child Death Overview Panel The Department should engage with other interested statutory organisations to review the merits of introducing a Child Death Overview Panel.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-89	Patient Concern Organisation The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-90	Clinical Guidance Dissemination Protocol The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-91	Synchronise Patient Safety Systems The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-92	Review Healthcare Standards The Department should review healthcare standards in light of the findings and recommendations of this report and make such changes as are …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-93	Review Trust Responses The Department should review Trust responses to the findings and recommendations of this Report.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-95	Legal Privilege Protocol Given that the public is entitled to expect appropriate transparency from a publically funded service, the Department should bring forward protocol governing …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-96	Healthcare Litigation Standards The Department should provide clear standards to govern the management of healthcare litigation by Trusts and the work of Trust employees and …	Hyponatraemia Inquiry (2018)	Accepted
R1	National IT system for police intelligence A national IT system for England and Wales to support police intelligence should be introduced as a matter of urgency. The Home …	Bichard Inquiry (2004)	Accepted
R2	PLX system introduction The PLX system, which flags that intelligence is held about someone by particular police forces, should be introduced in England and Wales …	Bichard Inquiry (2004)	Accepted
R3	Police IT procurement review The procurement of IT systems by the police should be reviewed to ensure that, wherever possible, national solutions are delivered to national …	Bichard Inquiry (2004)	Accepted
R4	PNC investment Investment should be made available by Government to secure the PNC's medium and long-term future, given its importance to intelligence-led policing and …	Bichard Inquiry (2004)	Accepted
R5	PNC Code of Practice implementation The new Code of Practice, made under the Police Reform Act 2002, dealing with the quality and timeliness of PNC data input, …	Bichard Inquiry (2004)	Accepted
R6	PNC data quality inspection The quality and timeliness of PNC data input should be routinely inspected as part of the Policing Performance Assessment Framework (PPAF) and …	Bichard Inquiry (2004)	Accepted
R7	Court results PNC transfer The transfer of responsibility for inputting court results onto the PNC should be reaffirmed by the Court Service and the Home Office …	Bichard Inquiry (2004)	Accepted
R8	Information management Code of Practice A Code of Practice should be produced covering record creation, review, retention, deletion and information sharing. This should be made under the …	Bichard Inquiry (2004)	Accepted
R9	Key principles of information management The Code of Practice must clearly set out the key principles of good information management (capture, review, retention, deletion and sharing), having …	Bichard Inquiry (2004)	Accepted
R10	Information management standards The Code of Practice must set out the standards to be met in terms of systems (including IT), accountability, training, resources and …	Bichard Inquiry (2004)	Accepted
R11	Sexual offences intelligence retention The Code of Practice should have particular regard to the factors to be considered when reviewing the retention or deletion of intelligence …	Bichard Inquiry (2004)	Accepted

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