Public Inquiry Recommendations

Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety …

All Trust Board Members should receive induction training in their statutory duties.

Specific clinical training should always accompany the implementation of important clinical guidelines.

HSC Trusts should ensure that all nurses caring for children have facilitated access to e-learning on paediatric fluid management and hyponatraemia.

There should be training in the completion of the post-mortem examination request form.

There should be training in the communication of appropriate information and documentation to the Coroner's office.

Clinicians caring for children should be trained in effective communication with both parents and children.

Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication …

The practice of involving parents in care and the experience of parents and families should be routinely evaluated and the information used …

Parents should be involved in the preparation and provision of any such training programme.

Training in SAI investigation methods and procedures should be provided to those employed to investigate.

Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.

Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should …

Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.

Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI …

Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.

All Trust Boards should ensure that appropriate governance mechanisms are in place to assure the quality and safety of the healthcare services …

All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a …

General Medical Council ('GMC') 'Good Medical Practice' Code requirements should be incorporated into contracts of employment for doctors.

Likewise, professional codes governing nurses and other healthcare professionals should be incorporated into contracts of employment.

Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters …

Clinical standards of care, such as patients might reasonably expect, should be published and made subject to regular audit.

Trusts should appoint a compliance officer to ensure compliance with protocol and direction.

Implementation of clinical guidelines should be documented and routinely audited.

Trusts should bring significant changes in clinical practice to the attention of the HSCB with expedition.

Trusts should ensure health care data is expertly analysed for patterns of poor performance and issues of patient safety.

Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to …

Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.

Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding …

All Trust Boards should consider the findings and recommendations of this Report and where appropriate amend practice and procedure.

The Department should appoint a Deputy Chief Medical Officer with specific responsibility for children's healthcare.

The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the …

The Department should now institute the office of Independent Medical Examiner to scrutinise those hospital deaths not referred to the Coroner.

The Department should engage with other interested statutory organisations to review the merits of introducing a Child Death Overview Panel.

The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.

The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals …

The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications …

The Department should review healthcare standards in light of the findings and recommendations of this report and make such changes as are …

The Department should review Trust responses to the findings and recommendations of this Report.

The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to …

Given that the public is entitled to expect appropriate transparency from a publically funded service, the Department should bring forward protocol governing …

The Department should provide clear standards to govern the management of healthcare litigation by Trusts and the work of Trust employees and …

The implementation of the following recommendations should be monitored by the DoH and progress should be reported to the DoH Permanent Secretary. …

The DoH should indicate publicly within six months of this report which recommendations it accepts and those it does not accept (and …

With the exception of Recommendations 88 and 89 (R88 & R89) any other organisation that does not accept a recommendation for which …

Prior to the decision to move a service user to a different facility there must be discussion with the staff regularly caring …

Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this …

The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring …

While patients remain in hospital pending resettlement, there should be a focus on enhancing their independent living skills, tailored to their physical …

Medication should never be used simply to subdue people in the absence of other forms of treatment and good quality care. DoH …