Public Inquiry Recommendations

The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should publish guidance for the implementation of visiting restrictions in hospitals …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with trusts and health boards to ensure that pandemic …

The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place …

The UK government should establish a standing pharmaceutical expert advisory panel, in consultation with the Department of Health and Social Care and …

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should maintain networks with local communities to produce targeted vaccination strategies …

Each of the four UK public health or health security agencies should work together to: maintain accurate, UK-wide insight into the state …

The UK government and devolved administrations should work together, with their respective health delivery services, to facilitate and coordinate regulatory bodies' access …

The UK government must reform the Vaccine Damage Payment Scheme as soon as possible. The reform should include as a minimum: increasing …

We recommend that the preservation of police records be reviewed to ensure that all such documents are treated as public records, held …

We recommend that, once a copy of all material has been placed on a Digital Archive, private owners - including the FA …

We recommend the appointment of an Editor-in-Chief to oversee the presentation on the Digital Archive of documents relating to the disaster, and …

We recommend the development of a protocol which identifies the criteria according to which material not disclosed by the Panel may be …

The implementation of the following recommendations should be monitored by the DoH and progress should be reported to the DoH Permanent Secretary. …

The DoH should indicate publicly within six months of this report which recommendations it accepts and those it does not accept (and …

With the exception of Recommendations 88 and 89 (R88 & R89) any other organisation that does not accept a recommendation for which …

Prior to the decision to move a service user to a different facility there must be discussion with the staff regularly caring …

Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this …

The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring …

While patients remain in hospital pending resettlement, there should be a focus on enhancing their independent living skills, tailored to their physical …

Medication should never be used simply to subdue people in the absence of other forms of treatment and good quality care. DoH …

Each facility or service should have an integrated workforce plan that includes all allied health professionals (AHPs) and all staff involved in …

It is critical for the wellbeing of people with learning disabilities and autistic people that they are well supported by, and have …

Like anyone else, people with learning disabilities and autistic people require a variety of meaningful activities on a daily basis to enhance …

Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply …

All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.

Observation records detailing all use of restraint and seclusion should be completed by the individual observing. In HSCT facilities, if the observer …

Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and …

If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using …

Creating a co-produced care environment, where people with learning disabilities, families and professionals work collaboratively, requires a fundamental shift in practice. As …

Specific processes rather than policies should be designed to ensure there is good communication with families and carers to ensure co-production takes …

The 2006 Quality Standards for Health and Social Care should be amended to require HSC organisations to provide all people with learning …

Properly trained independent advocates should be made available to service users and families to support effective communication with staff and for raising …

All providers of learning disability services should appoint a human rights officer, as seen in Sheffield Health Partnership University NHS Foundation Trust …

All documents relevant to the service user’s experience and intended for their information must be made available in Easy Read format.

All organisations taking responsibility for property and/or finance for people with learning disabilities and autistic people should institute regular checks of adherence …

Policies must be specific as to records to be kept and for routes to disclosure for relevant family members and people with …

The records kept must be easy to manage by staff and easily comprehensible to others, including people with learning disabilities and autistic …

Information about the use of cash and other property and six-monthly accounts (or such period as appropriate upon discharge of the person) …

RQIA should examine the provider organisation’s internal assurance processes and make recommendations where they are insufficient.

The Restraint Reduction Network identifies six principles to avoid the use of restrictive practice. While there is evidence that some Trusts have …

All facilities providing residential services for people with learning disabilities and autistic people should provide sufficient psychology input for each patient, to …

HSCTs should appoint a non-executive director (NED) to act as a champion for restraint reduction, with a mandate to hold executive directors …

The effectiveness of the education programme for staff in relation to restraint reduction should be measured through defined data metrics. This is …