Public Inquiry Recommendations

Proposals should be brought forward as soon as possible to improve the checking of people from overseas who want to work with …

As a priority, legislation should be brought forward to enable the CRB to access the following additional databases for the purpose of …

Given the risks associated with HM Coastguard's use of network flexing for small boat search and rescue – whereby its workforce is …

HM Coastguard should seek, at pace, to invest in the technology required to support its ability to reconcile duplicate small boat incidents. …

There should be regular assessments by HM Coastguard of the adequacy of the available assets and human resources to respond to both …

HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one …

Those involved in maritime search and rescue should adopt formally the Mass Persons in the Water Triage procedure to govern the operational …

Those involved in maritime search and rescue should continue to undertake joint exercises on the application of the Mass Persons in the …

The Department for Transport must consider recommending to the International Maritime Organization that it consider incorporating an in-water mass casualty triage tool …

HM Coastguard should amend its existing policies to incorporate the need to provide more comprehensive advice about survivability to people in distress …

HM Coastguard should examine whether it is using the most appropriate modelling for survivability in cold water. HM Coastguard should amend its …

HM Coastguard must continue to liaise with search and rescue partners in the UK and abroad to identify opportunities for the development …

The role and functions of HM Coastguard should be set out in up-to-date legislation.

An independent external body should be given responsibility for the regular assessment of the effectiveness and efficiency of HM Coastguard. Consideration should …

The government should reconsider Mr Downer's recommendation in his independent review of Border Force that Border Force Maritime should not be providing …

For so long as the current arrangements in relation to search and rescue in the English Channel remain in place, the roles …

HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved …

HM Coastguard should develop a mass rescue operation plan that includes command and control, co-ordination, external stakeholders, medical and law enforcement roles, …

HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard …

The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details …

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 …

1. Lancashire Constabulary should strengthen its autism spectrum disorder‑related training for new officers and through continuous development. 2. National policing bodies, with …