Inquiries · Recommendations

Public Inquiry Recommendations

1,814 tracked recommendations 35 inquiries 542 match current filters Page 10 of 11

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

542 of 1,814 · page 10 of 11

Code	Recommendation	Inquiry	Response
R4	Local HAI Task Forces Scottish Government should develop local healthcare Associated infection (HAI) Task Forces within each Health Board area.	Vale of Leven Inquiry (2014)	Accepted
R5	Hospital future uncertainty resolution Scottish Government should ensure that where any uncertainty over the future of any hospital or service exists, resolution of the uncertainty is …	Vale of Leven Inquiry (2014)	Accepted
R6	Service change continuity plans Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place …	Vale of Leven Inquiry (2014)	Accepted
R7	Reorganisation due diligence In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the …	Vale of Leven Inquiry (2014)	Accepted
R8	Reorganisation management structure In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable …	Vale of Leven Inquiry (2014)	Accepted
R9	IPC clinical governance meetings Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to …	Vale of Leven Inquiry (2014)	Accepted
R10	CDI patient information Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis.	Vale of Leven Inquiry (2014)	Accepted
R11	CDI severity awareness Health Boards should ensure that patients, and relatives where appropriate, are made aware that CDI is a condition that can be life-threatening, …	Vale of Leven Inquiry (2014)	Accepted
R12	CDI infection control advice Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary …	Vale of Leven Inquiry (2014)	Accepted
R13	Clear nursing responsibility line Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.	Vale of Leven Inquiry (2014)	Accepted
R14	Patient records compliance audit Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous …	Vale of Leven Inquiry (2014)	Accepted
R15	CDI patient observations records Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, …	Vale of Leven Inquiry (2014)	Accepted
R16	CDI outbreak reporting Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) …	Vale of Leven Inquiry (2014)	Accepted
R17	Ward admission responsibility Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility …	Vale of Leven Inquiry (2014)	Accepted
R18	Care planning system Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation …	Vale of Leven Inquiry (2014)	Accepted
R19	ICN instructions recorded Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient …	Vale of Leven Inquiry (2014)	Accepted
R20	Stool records for CDI patients Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's …	Vale of Leven Inquiry (2014)	Accepted
R21	Nursing staff for relatives Health Boards should ensure that a member of nursing staff is available to deal with questions from relatives during visiting periods.	Vale of Leven Inquiry (2014)	Accepted
R22	Relative discussions recorded Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant …	Vale of Leven Inquiry (2014)	Accepted
R23	TVN training and qualification Health Boards should ensure that a nurse appointed as Tissue Viability Nurse (TVN) is appropriately trained and possesses, or is working towards, …	Vale of Leven Inquiry (2014)	Accepted
R24	TVN instructions recorded Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the …	Vale of Leven Inquiry (2014)	Accepted
R25	Pressure damage risk assessment Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool …	Vale of Leven Inquiry (2014)	Accepted
R26	Wound documentation Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of …	Vale of Leven Inquiry (2014)	Accepted
R27	Positional change records Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.	Vale of Leven Inquiry (2014)	Accepted
R28	Nutritional screening Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening …	Vale of Leven Inquiry (2014)	Accepted
R29	Patient weighing equipment Health Boards should ensure that there is appropriate equipment in each ward to weigh all patients. Patients should be weighed on admission …	Vale of Leven Inquiry (2014)	Accepted
R30	Fluid balance monitoring Health Boards should ensure that where patients require fluid monitoring as part of their critical care, nursing staff complete fluid balance charts …	Vale of Leven Inquiry (2014)	Accepted
R31	Staffing and skills mix review Health Boards should ensure that the staffing and skills mix is appropriate for each ward, and that it is reviewed in response …	Vale of Leven Inquiry (2014)	Accepted
R32	Staffing concerns escalation Health Boards should ensure that there is straightforward and timely escalation process for nurses to report concerns about staffing numbers/skill mix.	Vale of Leven Inquiry (2014)	Accepted
R33	Nursing complaint investigation Health Boards should ensure that where a complaint is made about nursing practice on a ward this complaint is investigated by an …	Vale of Leven Inquiry (2014)	Accepted
R34	Antimicrobial guidance implementation Health Boards should ensure that changes in policy and/or guidance on antimicrobial practice issued by or on behalf of Scottish Government are …	Vale of Leven Inquiry (2014)	Accepted
R35	Antibiotic prescribing monitoring Scottish Government should monitor the implementation of policies and/or guidance on antibiotic prescribing issued in connection with healthcare associated infection.	Vale of Leven Inquiry (2014)	Accepted
R36	Medical staffing levels Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high-quality care.	Vale of Leven Inquiry (2014)	Accepted
R37	CDI senior assessment and treatment Health Boards should ensure that any patient with suspected CDI receives full clinical assessment by senior medical staff, that specific antibiotic therapy …	Vale of Leven Inquiry (2014)	Accepted
R38	Medical record keeping Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to …	Vale of Leven Inquiry (2014)	Accepted
R39	DNAR decision awareness Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.	Vale of Leven Inquiry (2014)	Accepted
R40	Prudent antibiotic prescribing Health Boards should ensure that the key principles of prudent antibiotic prescribing are adhered to and that implementation of policy is rigorously …	Vale of Leven Inquiry (2014)	Accepted
R41	Laboratory specimen processing Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific …	Vale of Leven Inquiry (2014)	Accepted
R42	Mandatory IPC training Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention control training that includes CDI on …	Vale of Leven Inquiry (2014)	Accepted
R43	IPC staff regular training Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control of which …	Vale of Leven Inquiry (2014)	Accepted
R44	IPC staff appraisals Health Boards should ensure that performance appraisals of infection prevention and control staff take place at least annually.	Vale of Leven Inquiry (2014)	Accepted
R45	Manager IPC job description Health Boards should ensure that where a manager has responsibility for oversight of infection prevention control, this is specified in the job …	Vale of Leven Inquiry (2014)	Accepted
R46	ICM direct responsibility Health Boards should ensure that the Infection Control Manager has direct responsibility for the infection prevention control service and its staff.	Vale of Leven Inquiry (2014)	Accepted
R47	ICM reports to CEO Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive or, at least, to an executive board …	Vale of Leven Inquiry (2014)	Accepted
R48	ICM Board HAI reporting Health Boards should ensure that the ICM is responsible for reporting to the Board on the state of HAI in the organisation.	Vale of Leven Inquiry (2014)	Accepted
R49	National ICM role guidance Scottish Government should re-issue national guidance on the role of the ICM, stipulating that the ICM must be responsible for the management …	Vale of Leven Inquiry (2014)	Accepted
R50	24/7 IPC cover Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans …	Vale of Leven Inquiry (2014)	Accepted
R51	ICT functions as team Health Boards should ensure that any Infection Control Team functions as a team, with clear lines of communication and regular meetings.	Vale of Leven Inquiry (2014)	Accepted
R52	IPC policy adherence audits Health Boards should ensure that adherence to infection prevention and control polices, for example C. difficile and Loose Stools Policies, is audited …	Vale of Leven Inquiry (2014)	Accepted
R53	Surveillance systems fit for purpose Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential …	Vale of Leven Inquiry (2014)	Accepted

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