Inquiries · Recommendations

Public Inquiry Recommendations

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

Code	Recommendation	Inquiry	Response
R54	Surveillance system training Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to …	Vale of Leven Inquiry (2014)	Accepted
R55	CDI reporting to CEO and Board Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the Chief …	Vale of Leven Inquiry (2014)	Accepted
R56	Regular IPC group meetings Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through …	Vale of Leven Inquiry (2014)	Accepted
R57	IPC committee minutes reporting Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to …	Vale of Leven Inquiry (2014)	Accepted
R58	Lay representation on IPC committee Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy …	Vale of Leven Inquiry (2014)	Accepted
R59	Priority attendance at IPC meetings Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority.	Vale of Leven Inquiry (2014)	Accepted
R60	Cleanliness Champions implementation Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as Cleanliness Champions …	Vale of Leven Inquiry (2014)	Accepted
R61	Unannounced inspections with lay representation Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay …	Vale of Leven Inquiry (2014)	Accepted
R62	Senior manager clinical visits Health Boards should ensure that senior managers accompanied by IPC staff visit clinical areas at least weekly to verify that proper attention …	Vale of Leven Inquiry (2014)	Accepted
R63	Effective CDI patient isolation Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure …	Vale of Leven Inquiry (2014)	Accepted
R64	Cohorting only exceptional Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in …	Vale of Leven Inquiry (2014)	Accepted
R65	Isolation for infectious diarrhoea Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.	Vale of Leven Inquiry (2014)	Accepted
R66	Healthcare environment maintenance Health Boards should ensure that the healthcare environment does not compromise effective IPC, and that poor maintenance practices are not tolerated.	Vale of Leven Inquiry (2014)	Accepted
R67	Link Nurse training Health Boards should ensure that, where a local Link Nurse system is in place as part of the IPS system, the Link …	Vale of Leven Inquiry (2014)	Accepted
R68	Consultant involvement in death certificates Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patients care is involved in …	Vale of Leven Inquiry (2014)	Accepted
R69	Explanation to relatives on CDI death Health boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing …	Vale of Leven Inquiry (2014)	Accepted
R70	COPFS death reporting guidance review Crown Office and the Procurator Fiscal service (COPFS) should review its guidance on the reporting of deaths regularly and at least every …	Vale of Leven Inquiry (2014)	Accepted
R71	National CDI death monitoring Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.	Vale of Leven Inquiry (2014)	Accepted
R72	Internal investigation independence Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.	Vale of Leven Inquiry (2014)	Accepted
R73	OCT report detail sufficiency Health Boards should ensure that OCT3 reports provide sufficient details of the key factors in the spread of infection to allow a …	Vale of Leven Inquiry (2014)	Accepted
R74	Review of UK IPC reports Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports …	Vale of Leven Inquiry (2014)	Accepted
R75	Health Board review of IPC reports Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or …	Vale of Leven Inquiry (2014)	Accepted
FP1	Fingerprint evidence as opinion Fingerprint evidence should be recognised as opinion evidence, not fact, and those involved in the criminal justice system need to assess it …	Fingerprint Inquiry (2011)	Accepted
FP3	Discontinue certainty claims Examiners should discontinue reporting conclusions on identification or exclusion with a claim to 100% certainty or on any other basis suggesting that …	Fingerprint Inquiry (2011)	Accepted
FP5	Basis of conclusions Experts should list all variables considered and state whether the conclusion has been reached through training and personal experience or on any …	Fingerprint Inquiry (2011)	Accepted
FP9	Features demonstrable to lay persons Features on which examiners rely should be demonstrable to a lay person with normal eye sight as observable in the mark.	Fingerprint Inquiry (2011)	Accepted
FP16-18	Academic study requirement Expert opinion should be informed by proper academic study of the subject.	Fingerprint Inquiry (2011)	Accepted
FP53	Note-taking general practice Note-taking as to the detail found on analysis and the process of comparison, though not mandatory, should become the general practice for …	Fingerprint Inquiry (2011)	Accepted
FP60	Disclosure of opinion basis - recording Experts should record and properly disclose all of the basis of their opinion to enable a court to understand it and the …	Fingerprint Inquiry (2011)	Accepted
FP66	Unable to exclude findings Before a finding of 'unable to exclude' is led in evidence, careful consideration will require to be given to (a) the types …	Fingerprint Inquiry (2011)	Accepted
FP-COMPLEX	Complex marks examination Processes should be developed to ensure that complex marks such as those in question are treated differently, by examination by three suitably …	Fingerprint Inquiry (2011)	Accepted
SHI-1	Communication strategy for patients and families Health boards must ensure that in the event of any adverse situation that could affect the wellbeing of patients and their families, …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-2	Risk assessment on funding model changes Accordingly, in situations where the funding model or procurement route changes mid project, a risk assessment should be conducted to assess whether …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-3	Clarity in brief for healthcare facility construction It is critical that a health board formulates and then presents its requirements for the key building systems in a proposed healthcare …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-4	Standard form for derogations from guidance The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-5	Streamlining NHS construction quality procedures A range of procedures now exists to help ensure health board projects meet appropriate standards. One is the NHS Scotland Design Assessment …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-6	Information on common construction errors It is important that common project errors are not repeated. One helpful step is to ensure health boards undertaking projects have information …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-7	Independent validation of hospital construction It is clearly desirable that a health board has the assurance prior to the handover of a new or refurbished healthcare facility …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-8	IPC role specifications and staffing levels I accordingly recommend that priority be given to protecting scarce IPC resources. With that objective in view, what is expected of consideration …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-9	Documentation of technical adviser advice I accordingly recommend that a similar procedure should be considered when technical advisers (particularly engineers) are providing specific technical advice in relation …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-10	Uniform policy for obtaining technical advice This issue was highlighted in the Grant Thornton report where similar recommendations are made to what is set out above. NHSL has …	Scottish Hospitals Inquiry (2025)	Accepted
SHI-11	Training for IPC professionals engineers and clinicians I would recommend that IPC professionals should receive some basic training on the recommendations made by the NHS's own guidance for engineering …	Scottish Hospitals Inquiry (2025)	Accepted

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