Public Inquiry Recommendations

All service users and their families should have the CCTV explained to them in easily understood language and with easy access materials, …

All staff should receive training on the reasons for the use of CCTV and the processes for its analysis.

Vulnerable children and adults are inherently more susceptible to abuse or neglect than other people. Adult safeguarding should be formally recognised as …

Metrics on both child and adult safeguarding processes should be reported monthly via a safeguarding dashboard, with the same visibility and status …

Incidents of peer-on-peer abuse should be included in adult safeguarding metrics and included on a published safeguarding dashboard.

The dashboard should include the number of allegations reported, together with the screening decision (referral to the Adult Safeguarding Gateway, referral to …

There should be common standards for the conduct of safeguarding investigations. These should be drafted and approved by the Northern Ireland Adult …

A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with …

Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An …

Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable …

Staffing should be based on service user needs rather than a fixed budget, using daily acuity measures designed specifically for units caring …

Clinical supervision (where individuals’ practice with individual patients is discussed) should be mandatory for all ward staff, including healthcare assistants, and should …

All healthcare assistants working with people with learning disabilities and autistic people should be provided with training, which should include specialist learning …

SPPG must commission a review of the potential models for supervision of staff in private and third sector services commissioned by HSCTs, …

Consideration should be given to enhancing the post of healthcare assistant by creating Band 4 associate practitioners in both hospital and community …

Consideration of staffing (including skill mix as well as total numbers) should be a mandatory part of safeguarding investigations in all settings.

There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance …

NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical …

The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.

HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months …

The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should …

Consideration should be given to the creation of a role for a NED in each HSCT with the specific remit to receive …

The DoH should establish an expert clinical/social governance advisory function to support providers.

RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of …

The RQIA needs to reconsider whether to make use of CCTV when it is in operation in a service it is inspecting …

RQIA needs to consider adopting a measure of service culture specific to learning disability services for use in its inspections. Such measures …

RQIA needs to spend proportionately more time talking to patients/residents, and its staff need to be trained in specific communication techniques such …

The PCC should support service users/families and provide information on what constitutes good quality care for people with learning disabilities and autistic …

The PCC should take further steps to ensure that health service users, including carers and families of people with learning disabilities and …

PSNI needs to improve its processes for the review of live investigation files, and have an effective escalation process when progress is …

The Department of Justice should review the timeliness of the handling of each aspect of the prosecution system that has led to …

A regional standing committee of people with learning disabilities and autistic people and their relatives should be established, to be consulted by …

There needs to be a recognition that those service users in Northern Ireland yet to be resettled (if there are any by …

Families should be provided by the relevant Trust with a time frame for resettlement and relevant financial information. Families should also be …

There needs to be a clear regional view of all services available in the community, especially given the variety of services and …

There will be a continuing need, which must be met, for new and ongoing community-based support for young people and adults with …

HSCTs must develop registers of those at risk of requiring unplanned inpatient treatment, similar to the NHS England ‘blue light protocol’, in …

SPPG must ensure that people with learning disabilities and autistic people have access to mainstream (i.e. the same services that are available …

The SPPG must ensure that commissioning includes provision for people with learning disabilities and autistic people cared for in any facility to …

The DoH must devise ways to recruit and retain more allied health professionals and social care staff in the community for autistic …

Communication between the HSCTs and/or resettlement service providers and families and people with learning disabilities should be more open and transparent. Each …

Trusts, private and 3rd sector care providers must ensure that person-centred day activities (including supported employment where appropriate) should be available and …

Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole …

DoH should establish a comprehensive, centralised workforce intelligence function, similar to those in the rest of the UK, within 12 months of …

A live dashboard of performance, quality and safety indicators within learning disabilities must be developed and made publicly available within 12 months …

A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for …

Consideration should be given to a different approach to the prosecution of organisations for failing to prevent deliberate harm being caused by …

In relation to direct redress, including consideration of financial compensation, we recommend that the DoH set up a small working party to …

A national IT system for England and Wales to support police intelligence should be introduced as a matter of urgency. The Home …

The PLX system, which flags that intelligence is held about someone by particular police forces, should be introduced in England and Wales …