Public Inquiry Recommendations

Each provider organisation should have a board level member with responsibility for information.

Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying …

It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account …

The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled …

The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the …

The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in …

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable …

It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.

Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of …

Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour …

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

Foundation doctors should not be employed in children's wards.

The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with …

The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to …

Scottish Ministers should review public inquiries to find cost-effective methods of avoiding establishment delays, potentially creating a dedicated unit within the Scottish …

Scottish Ministers must not appoint any department, agency, or government organization as inquiry sponsor where it or its employees had involvement in …

Guidance should address: circumstances for civil servant transfers within government; which positions may use agency staff; and whether temporary contracts suit positions …

When reporting public inquiry costs, Scottish Ministers should disclose net costs to the public purse, excluding previously-incurred accommodation and staffing expenses, alongside …

Optimism bias guidance, based on decades-old data, requires updating to include light rail projects and reflect current empirical evidence, with reviews every …

Scottish Ministers should establish a joint working group with Convention of Scottish Local Authorities representatives to leverage Transport Scotland's project management experience …

Scottish Ministers and local authorities funding light rail should protect public funds through: conditional grant payments with review hold points; critical review …

All police officers and police staff should be obliged to register in confidence with the Chief Officer of their police force, at …

The Panel recommends the creation of a statutory duty of candour, to be owed by all law enforcement agencies to those whom …

A new scheme should be introduced requiring all LPG suppliers to be registered and accredited.

The Inquiry recommends that the Northern Ireland Assembly should strengthen the scrutiny role of Assembly Committees, reviewing whether the existing balance between …

All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased …

All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the …

All NHS trusts should routinely audit the access data of all facilities used to store deceased people.

The practice of using shared electronic swipe cards for specific staff groups should cease immediately.

All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. …

All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be …

The NHS should ensure that the security standards required for body stores are the same as those required for facilities licensed by …

All NHS trusts should consider the installation of 'swipe to exit' for mortuary facilities. This would allow trusts to monitor and audit …

All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine …

NHS trusts should ensure that Designated Individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.

NHS trusts should ensure that senior managers, including the Chief Executive, have a clear understanding of the role of the Designated Individual, …

NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as …

A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.

NHS trusts should assure themselves that the Mortuary Manager has adequate resources and support to perform their role effectively, including meeting any …

All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include …

Trust boards should assure themselves that the recommendations in this Report have been implemented.

Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage …

Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent …

NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.

The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased …

NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.

There should be a process to routinely review who is permitted to access the mortuary unsupervised.

Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary …

Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must …

Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration …