Public Inquiry Recommendations

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 …

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: …

The Home Office’s ongoing review of the sale of castor beans should consider regulation of the number of castor beans that can …

Phase 2 should consider whether conventional archery bows should be subject to age‑verification prior to sale, delivery restrictions including ID checks, mandatory …

Phase 2 should consider, in parallel with the government’s consultation where possible, a prohibition on the sale of crossbows, a licensing scheme …

The Home Office should provide clear guidance to all UK retailers of archery bows and crossbows on identifying and reporting suspicious behaviour, …

The Commissioner of Police of the Metropolis should consider an investigation, with input from the Crown Prosecution Service if appropriate, as to …

The Home Office should take immediate action to ensure that online knife retailers are complying with the Knives Act 1997, particularly regarding …

Amazon should: 1. Improve its measures to prevent children from making purchases, including making the conditions of use and sale more prominent. …

Phase 2 should consider further measures relating to knives/bladed items sales, including: 1. Restrictions on sharp‑tipped knives. 2. Prohibiting some online sales …

The Department for Education should review and strengthen its guidance to schools on monitoring and filtering systems, including ensuring that the systems …

Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing …

The Department for Science, Innovation and Technology should consider extending the powers under the Online Safety Act 2023 to enable Senior Coroners …

Phase 2 should consider age verification for the use of Virtual Private Network (VPN) software and other options to avoid VPNs being …

Lancashire Constabulary should consider extending Operation Encompass to share automatically relevant information with schools in bordering areas. The Department for Education should …

Lancashire Constabulary, and the College of Policing nationally, should ensure that forms and training emphasise the importance of recording, as precisely as …

Lancashire Constabulary and Merseyside Police should review the effectiveness of their information‑sharing systems and consider whether a more robust process is required. …

Lancashire Constabulary should ensure its training and systems address the risks associated with failing to record case information on police systems so …

Lancashire Constabulary should ensure its procedures and training sufficiently addresses the risks children and young people may pose to others and the …