Public Inquiry Recommendations

Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the …

Support and protection should be given to those who properly fulfil their duty of candour.

Trusts should monitor compliance and take disciplinary action against breach.

Regulation and Quality Improvement Authority ('RQIA') should review overall compliance and consideration should be given to granting it the power to prosecute …

The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both …

Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in …

There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.

Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.

The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.

A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept …

The names of both the consultant responsible and the accountable nurse should be prominently displayed at the bed in order that all …

Any change in clinical accountability should be recorded in the notes.

The names of all on-call consultants should be prominently displayed in children's wards.

To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The …

Children's ward rounds should be led by a consultant and occur every morning and evening.

The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.

Clinicians should respect parental knowledge and expertise in relation to a child's care needs and incorporate the same into their care plans.

The care plan should be available at the bed and the reasons for any change in treatment should be recorded.

All blood test results should state clearly when the sample was taken, when the test was performed and when the results were …

All instances of drug prescription and administration should be entered into the main clinical notes and paediatric pharmacists should monitor, query and, …

Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect …

Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in …

Consideration should be given to recording and/or emailing information and advices provided for the purpose of obtaining informed consent.

Record keeping should be subject to rigorous, routine and regular audit.

Confidential on-line opportunities for reporting clinical concerns should be developed, implemented and reviewed.

Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').

Failure to report an SAI should be a disciplinary offence.

Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.

Failure to co-operate with investigation should be a disciplinary offence.

Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.

Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of …

Investigations should be subject to multi-disciplinary peer review.

Investigation teams should reconvene after an agreed period to assess both investigation and response.

Learning and trends identified in SAI investigations should inform programmes of clinical audit.

Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.

In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the …

A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.

Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of …

Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.

Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.

In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy …

The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.

Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should …

The Health and Social Care ('HSCB') should be notified promptly of all forthcoming healthcare related inquests by the Chief Executive of the …

Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.

Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.

In the event of a Trust asserting entitlement to legal privilege in respect of an expert report or other document relevant to …

Professional bereavement counselling for families should be made available and should fully co-ordinate bereavement information, follow-up service and facilitated access to family …

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.