Tag

Training

Recommendations requiring staff training

133 recommendations 89% accepted

Tag overview

Government Response
Accepted (106)
Accepted in Part (12)
Not Accepted (3)
Under Review (2)
Awaiting Response (10)
Recommendations in This Theme

recommendation across 18 inquiries

Across 18 inquiries

Tagged Recommendations

133 total
SHI-11 Accepted Scottish Hospitals Inquiry

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 systems, insofar as they are made in the …

- On 13 March 2025, Cabinet Secretary Neil Gray MSP accepted this recommendation (Scottish Government Parliamentary Statement, 13 March 2025). - On 17 September 2025, …
Scottish Government
R17 Response Pending Muckamore Abbey Inquiry

Co-production training

Creating a co-produced care environment, where people with learning disabilities, families and professionals work collaboratively, requires a fundamental shift in practice. As well as organisational commitments, staff will need education …

Department of Health NI
R31 Response Pending Muckamore Abbey Inquiry

Restraint education effectiveness metrics

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

Northern Ireland Executi…
R37 Response Pending Muckamore Abbey Inquiry

Human rights-based restrictive practices training

Education and training on the use of restrictive practices should be grounded in human rights principles and the dedicated human rights specialist appointed in accordance with Recommendation 21 (R21) should …

Northern Ireland Executi…
R71 Response Pending Muckamore Abbey Inquiry

Specialist training for healthcare assistants

All healthcare assistants working with people with learning disabilities and autistic people should be provided with training, which should include specialist learning disability training as well as basic positive behaviour …

Department of Health NI
R76 Response Pending Muckamore Abbey Inquiry

NED with clinical governance expertise

NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as …

Northern Ireland Executi…
R79 Response Pending Muckamore Abbey Inquiry

Board member learning framework

The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in …

Department of Health NI
CR15 Response Pending Cranston Inquiry

Joint training exercises plan

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

HM Coastguard
CR4 Response Pending Cranston Inquiry

Training on normalcy bias

HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one being the need to avoid normalcy bias, in …

HM Coastguard
CR6 Response Pending Cranston Inquiry

Joint exercises on triage procedure

Those involved in maritime search and rescue should continue to undertake joint exercises on the application of the Mass Persons in the Water Triage procedure.

HM Coastguard
P2-19 Accepted in Part Fuller Inquiry

Deceased included in safeguarding training and policy

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

- The government stated in December 2025 that this recommendation on safeguarding training for staff with access to deceased persons was accepted in principle. Full …
NHS England
P2-25 Under Consideration Fuller Inquiry

Postgraduate training governance clarity

Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include …

- The government stated in December 2025 that this recommendation on governance of postgraduate anatomy training was under consideration. Full government response due Summer 2026 …
Department of Health and…
P2-31 Accepted Fuller Inquiry

Ambulance policy on crew position with deceased

Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should include reference to the risk of abuse of …

- The government stated in December 2025 that this recommendation on ambulance seating policies to protect the dignity of deceased persons was accepted in full. …
NHS England
P2-70 Under Consideration Fuller Inquiry

Chief Coroner review practice consistency

The Chief Coroner should review the difference in practice between coronial areas as soon as possible to ensure that: All coroners are informed of the findings of this Inquiry. All …

- The government stated in December 2025 that this recommendation on coroner reporting on the treatment of the deceased was under consideration. Full government response …
Ministry of Justice
P1-11 Accepted Grenfell Tower Inquiry

Train incident commanders on control room communications

All officers who may be expected to act as incident commanders (i.e. all those above the rank of Crew Manager) receive training directed to the specific requirements of communication with …

- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-12 Accepted Grenfell Tower Inquiry

Train control room operators on incident commander communications

All control room operators of Assistant Operations Manager rank and above receive training directed to the specific requirements of communication with the incident commander.

- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-15 Accepted Grenfell Tower Inquiry

Regular refresher training for control room operators

The LFB provide regular and more effective refresher training to control room operators at all levels, including supervisors.

- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - The government's Phase …
London Fire Brigade
P1-19 Accepted Grenfell Tower Inquiry

Train control room staff on evacuation advice changes

Control room staff receive training directed specifically to handling such a change of advice and conveying it effectively to callers.

- NFCC accepted all Phase 1 recommendations directed to it (NFCC Response, 2020). - The government's Phase 1 progress report stated this recommendation is complete, …
National Fire Chiefs Cou…
P1-2 Accepted Grenfell Tower Inquiry

Train fire personnel on external wall fire risks

All fire and rescue services ensure that their personnel at all levels understand the risk of fire taking hold in the external walls of high-rise buildings and know how to …

- NFCC accepted all Phase 1 recommendations directed to it, committing to develop national guidance across all 43 fire and rescue services in England (NFCC …
National Fire Chiefs Cou…
P1-22 Accepted Grenfell Tower Inquiry

LFB improve deployment control policies

The LFB develop policies and training to ensure better control of deployments and the use of resources.

- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-23 Accepted Grenfell Tower Inquiry

Improve crew debrief information systems

The LFB develop policies and training to ensure that better information is obtained from crews returning from deployments and that the information is recorded in a form that enables it …

- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-27 Accepted Grenfell Tower Inquiry

Command support system operational on all units

Urgent steps be taken to ensure that the command support system is fully operative on all command units and that crews are trained in its use.

- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-29 Accepted Grenfell Tower Inquiry

Fire services develop evacuation policies and training

Fire and rescue services develop policies for partial and total evacuation of high-rise residential buildings and training to support them.

- NFCC accepted all Phase 1 recommendations directed to it (NFCC Response, 2020). - National Evacuation Guidelines were published on 5 February 2024 (National Evacuation …
National Fire Chiefs Cou…
P1-3 Accepted Grenfell Tower Inquiry

LFB to review PN633 Appendix 1

The LFB review, and revise as appropriate, Appendix 1 to PN633 to ensure that it fully reflects the principles in GRA 3.2.

- LFB accepted all Phase 1 recommendations directed to it in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - …
London Fire Brigade
P1-4 Accepted Grenfell Tower Inquiry

Train LFB officers on high-rise inspections

The LFB ensure that all officers of the rank of Crew Manager and above are trained in carrying out the requirements of PN633 relating to the inspection of high-rise buildings.

- LFB accepted all Phase 1 recommendations directed to it in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - …
London Fire Brigade
P2-18 Accepted Grenfell Tower Inquiry

Develop fire engineering courses for construction professionals

That the government, working in collaboration with industry and professional bodies, encourage the development of courses in the principles of fire engineering for construction professionals and members of the fire …

- The government accepted this recommendation in February 2025, committing to work with industry and professional bodies to encourage fire engineering courses for construction professionals …
UK Government
P2-19 Accepted Grenfell Tower Inquiry

Review architect education and training for fire safety

We recognise that both the Architects Registration Board (ARB) and the Royal Institute of British Architects (RIBA) have taken steps since the Grenfell Tower fire to improve the education and …

- ARB and RIBA accepted this recommendation in February 2025, noting both had taken steps since the Grenfell Tower fire to improve education and training …
ARB/RIBA
P2-29 Accepted in Part Grenfell Tower Inquiry

Establish independent College of Fire and Rescue

That the government establish [an independent College of Fire and Rescue] immediately with sufficient resources to provide the following services nationally: a) practical training at all levels supplementary to that …

- The government accepted this recommendation in principle in February 2025, recognising the importance of fire and rescue service training and noting HMICFRS also recommended …
UK Government
P2-30 Accepted in Part Grenfell Tower Inquiry

College to have permanent staff and training facilities

That [the college] should have a permanent staff of sufficient size to manage its operations and develop its functions in response to the demands of fire and rescue services nationally …

- The government accepted this recommendation in principle in February 2025, linking it to the College of Fire and Rescue consultation (Government Response to Grenfell …
UK Government
P2-32 Accepted Grenfell Tower Inquiry

Inspect London Fire Brigade incident commander training

That as soon as reasonably possible the Inspectorate inspect the London Fire Brigade to examine and report on the arrangements it has in place for assessing the training of incident …

- HMICFRS accepted this recommendation in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, MHCLG, February 2025). - HMICFRS Round 3 inspection …
HM Inspectorate of Const…
P2-37 Accepted Grenfell Tower Inquiry

Train firefighters on communications loss response

Since radio communications are inherently unreliable in certain environments, we recommend that firefighters be trained to respond appropriately to the loss of communications and to understand how to restore them. …

- NFCC accepted this recommendation on behalf of all fire and rescue services in February 2025, having reviewed national operational guidance content (Government Response to …
National Fire Chiefs Cou…
P2-38 Accepted Grenfell Tower Inquiry

Provide water supply system training to all firefighters

That basic training on the structure and operation of the water supply system, including the different types of hydrants in use and their functions, be given to all firefighters. Training …

- NFCC accepted this recommendation on behalf of all fire and rescue services in February 2025, having reviewed national operational guidance on water supply training …
National Fire Chiefs Cou…
P2-41 Accepted Grenfell Tower Inquiry

Consider guidance on firefighter initiative deviations

That National Fire Chiefs Council consider whether, and if so in what circumstances, firefighters should be discouraged from departing from their instructions on their own initiative and provide appropriate training …

- NFCC accepted this recommendation in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, MHCLG, February 2025). - The government's annual report …
National Fire Chiefs Cou…
P2-46 Accepted Grenfell Tower Inquiry

Revise London Gold arrangements guidance

Events demonstrated, however, that there is a need for a clearer understanding of the nature of the London Gold arrangements, in particular in situations in which a single borough is …

- The government expressed support for this recommendation directed at London local authorities in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, …
London Authorities
P2-48 Accepted in Part Grenfell Tower Inquiry

Verify training quality of Category 1 responders

That a mechanism be introduced for independently verifying the frequency and quality of training provided by local authorities and other Category 1 responders. (113.71)

- The government accepted this recommendation in principle in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, MHCLG, February 2025). - The …
UK Government
P2-49 Accepted Grenfell Tower Inquiry

Train all local authority employees on resilience

That local authorities train all their employees, including chief executives, to regard resilience as an integral part of their responsibilities. (113.73)

- The government expressed support for this recommendation directed at local authorities in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, MHCLG, …
Local Authorities
ANG-2 Accepted Angiolini Inquiry

Improve guidance and training on indecent exposure

By December 2024, the College of Policing, in collaboration with the National Police Chiefs' Council, should improve guidance and training on indecent exposure, in order to improve the quality of …

- The government accepted this recommendation on 25 March 2024, with the NPCC and College of Policing committing to address recommendations on police culture and …
College of Policing
ANG-27 No Response Angiolini Inquiry

Perpetrator focus and interventions

Immediately, the Home Office, in conjunction with the Ministry of Justice, the Department for Transport, and national and local policing organisations, should prioritise prevention activity targeting the perpetrators of sexually …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for immediate prioritisation of prevention …
Home Office
12 Accepted in Part Brook House Inquiry

Annual training on Rule 40 and Rule 42 segregation powers

The Home Office and contractors operating immigration removal centres must provide regular training, at least annually, on the operation of Rule 40 and Rule 42 of the Detention Centre Rules …

- In March 2024, the Home Office committed to including staff training requirements and compliance auditing as part of the substantive DSO revision on Rule …
Home Office
19 Not Accepted Brook House Inquiry

Healthcare staff guidance and training on use of force incidents

The Home Office must ensure that guidance is issued to healthcare staff in immigration removal centres clarifying their role in use of force incidents. It must liaise as necessary with …

- In March 2024, the government rejected this recommendation, stating that NHS England commissions healthcare services and that it is their responsibility, alongside the Care …
Home Office
24 Accepted in Part Brook House Inquiry

Mandatory staff training on mental health and trauma-informed approaches

The Home Office, in conjunction with contractors, must ensure that all relevant immigration removal centre staff receive mandatory introductory and annual training on: mental health; race and diversity; a trauma-informed …

- In March 2024, the Home Office stated that the Initial Training Course for all new contracted service provider staff was undergoing a full review, …
Home Office
28 Accepted in Part Brook House Inquiry

Address barriers to detainee complaints including fear of repercussions

The Home Office and its contractors operating immigration removal centres must take steps to identify and address the barriers to making complaints that are faced by detained people, including a …

- In March 2024, the Home Office committed to a comprehensive review of complaints processes, including barriers faced by detainees, in consultation with residents, IMBs, …
Home Office
8 Accepted in Part Brook House Inquiry

Mandatory comprehensive Rule 34 and Rule 35 training

The Home Office (in collaboration with NHS England as required) must ensure that comprehensive training on Rule 34 and Rule 35 of the Detention Centre Rules 2001 is rolled out …

- In March 2024, the Home Office committed to reviewing Adults at Risk policy and Detention Centre Rules 34 and 35, and stated that NHS …
Home Office
31 Accepted IICSA

DBS and training compliance for Church officers

Individuals engaged in regulated activity who have failed to undergo a Disclosure and Barring Service check or complete compulsory training should not be permitted to hold voluntary offices within the …

- In June 2019, the Church of England agreed that those in regulated roles who have failed to undergo a DBS check or complete compulsory …
Church of England
26 Accepted IICSA

Youth Custody Service safeguarding training

The Chair and Panel recommend that the Youth Custody Service takes steps to ensure that its training provides staff with an appropriate understanding of safeguarding in the context of the …

- In July 2019, the Ministry of Justice stated that the Youth Custody Service would review mandatory training for frontline staff including safeguarding components (Government …
Youth Custody Service
22 Accepted IICSA

National chaperone policy for healthcare (England)

The Chair and Panel recommend that the Department of Health and Social Care develops a national policy for the training and use of chaperones in the treatment of children in …

- In July 2019, the UK government stated that NHS England had developed chaperone guidance notes setting out principles of chaperoning and practical guidance for …
Department of Health and…
23 Accepted IICSA

National chaperone policy for healthcare (Wales)

The Chair and Panel recommend that the Welsh Government develops a national policy for the training and use of chaperones in the treatment of children in healthcare services. The Chair …

- On 6 January 2020, the Welsh Government published guidance for health boards and trusts on good working practice for the use of chaperones in …
Welsh Government
77 Not Accepted IICSA

CSA experience for Chief Officer progression

The Chair and Panel recommend that any police officer (or staff equivalent) who wants to progress to the Chief Officer cadre must first be required to: have operational policing experience …

- In July 2019, the UK government stated that the Home Office and College of Policing had drawn up a programme of non-legislative changes to …
Home Office
95 Accepted IICSA

CICA specialist caseworker training

The Chair and Panel recommend that the Criminal Injuries Compensation Authority ensures that claims relating to child sexual abuse are only considered by caseworkers who have specific and detailed training …

- In December 2018, the UK government stated that all Criminal Injuries Compensation Authority operational staff are given training on handling sexual offences and child …
Criminal Injuries Compen…
53 Accepted IICSA

Lambeth councillor safeguarding training

All Lambeth Council elected members should receive training on: (i) safeguarding and (ii) corporate parenting. Newly elected members should receive training on these matters as soon as possible following their …

- On 27 July 2021, Lambeth Council stated that all councillors are required to complete safeguarding training as well as training on corporate parenting responsibilities, …
London Borough of Lambeth
55 Accepted IICSA

Religious organisation child protection policies

All religious organisations should have a child protection policy and supporting procedures, which should include advice and guidance on responding to disclosures of abuse and the needs of victims and …

- Between January and March 2022, the Methodist Church, Triratna Buddhist Order and Community, and the United Reformed Church stated that they had updated their …
Religious Organisations
48 Accepted IICSA

Mandatory Catholic safeguarding training

The Catholic Bishops' Conference of England and Wales should ensure that safeguarding training is mandatory for all staff and volunteers in roles where they work with children or victims and …

- On 30 April 2021, the Catholic Council for the Inquiry stated that it had mandated that clergy and parish safeguarding representatives must undergo basic …
Catholic Bishops Confere…
JB-15.1 Accepted Jermaine Baker Inquiry

Clarify separation of SIO and firearms commander roles

There should be clearer guidance from the MPS, College of Policing and/or the NPCC on the separation of roles between the Senior Investigating Officer (SIO) and the Tactical and Strategic …

- The Metropolitan Police Service stated on 28 October 2022 that MO19 had commenced an internal review in July 2021 and that DAC Barbara Gray …
College of Policing
JB-15.10 Accepted Jermaine Baker Inquiry

Training on clear intelligence communication

When intelligence is being provided, the use of any language that is capable of misinterpretation is to be avoided. Training to address this point should be provided to all officers …

- The Metropolitan Police Service stated on 28 October 2022 that it was actively reviewing steps to address consistency of language between firearms officers and …
College of Policing
JB-15.11 Accepted Jermaine Baker Inquiry

Training requirement for covert monitoring post officers

Only those officers who have received the requisite training and accreditation should be posted to a Covert Monitoring Post (CMP).

- The Metropolitan Police Service stated on 28 October 2022 that significant CMP training improvements had been made, with 172 H2-trained staff and 350 CMP …
College of Policing
JB-15.13 Accepted Jermaine Baker Inquiry

Training on note-taking for covert monitoring officers

The training referred to in paragraph 15.11 must emphasise the importance of covert monitoring officers (CMOs) making accurate notes of: (a) what they have heard; and (b) what they have …

- The Metropolitan Police Service stated on 28 October 2022 that H2 training and the CMP operatives awareness course comprehensively covered accurate note-taking and dissemination …
College of Policing
JB-15.18 Accepted Jermaine Baker Inquiry

Mandatory CLIO system training for command officers

Training should be made mandatory for command officers in the use of the Computer Logging of Intelligence Operations (CLIO) system and the Serious Organised Crime Tasking and Briefing (SOCTAB) system …

- The Metropolitan Police Service stated on 28 October 2022 that MO3 had led work on CLIO training at command level and that SOCTAB CLIO …
College of Policing
JB-15.19 Accepted Jermaine Baker Inquiry

Guidance on uniformity of firearms commands

Advice should be given by the College of Policing about the benefits of uniformity in instructions and commands. Ultimate discretion as to what is said must be left to the …

- The Metropolitan Police Service stated on 28 October 2022 that it was in consultation with the College of Policing on uniformity of commands and …
College of Policing
JB-15.2 Accepted Jermaine Baker Inquiry

Require multidimensional risk assessments throughout operations

Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those risk assessments should assess the future threat and …

- The Metropolitan Police Service stated on 28 October 2022 that firearms trainers were required to watch Inquiry hearing recordings and that particular focus had …
College of Policing
JB-15.22 Accepted Jermaine Baker Inquiry

Training for officers presenting firearms court applications

There should be training of those who are authorised by reason of rank to present such applications at court, and no-one should act as a substitute for a properly authorised …

- The College of Policing updated APP-AP in August 2023, addressing training for officers authorised to present firearms presence applications at court (College of Policing …
College of Policing
JB-15.5 Accepted Jermaine Baker Inquiry

Compulsory training on firearms authorisation forms

Appropriate training and refresher courses on the usage and completion of FA (and equivalent) forms should be made compulsory for firearms commanders and Tactical Advisors.

- The Metropolitan Police Service stated on 28 October 2022 that it had taken steps to set aside time during training days to focus trainees …
College of Policing
JB-15.8 Accepted Jermaine Baker Inquiry

National guidance on recording firearms planning meetings

The NPCC and/or College of Policing should ensure that these amendments are reflected in the guidance and training given to forces nationally.

- The Metropolitan Police Service stated on 28 October 2022 that it understood the College of Policing would review APP-AP in respect of the amendments …
National Police Chiefs C…
RHI-3 Accepted RHI Inquiry

Policy Skills Training

As far as practicable, Northern Ireland Civil Service teams working on policies, particularly new and untested initiatives, should be trained and supported so that they have the skills to do …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …
Northern Ireland Executi…
RHI-30 Accepted RHI Inquiry

Budget Holder Financial Training

Civil servants who are responsible for holding and monitoring a budget should have to demonstrate core requirements in financial literacy and an understanding of how public spending operates, including what …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …
Department of Finance
RHI-5 Accepted RHI Inquiry

Ministerial Training and Support

One role of Ministers in a democratic system is to decide on policies and they can only do so effectively if they are prepared, in appropriate cases, to question and …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …
Northern Ireland Executi…
RHI-7 Accepted RHI Inquiry

Special Adviser Induction

There should be a clearly defined induction process for new Special Advisers, shared by the appointing Minister and the relevant Permanent Secretary, in the course of which the structure and …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …
Northern Ireland Executi…
RHI-9 Accepted RHI Inquiry

Commercial Awareness

Commercial and business awareness amongst policy officials, particularly those working in roles relating to the economy of Northern Ireland, must be improved. It is important that the leadership of the …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …
Northern Ireland Executi…
AG-2 Accepted Anthony Grainger Inquiry

HMICFRS Thematic Inspection of Armed Policing

Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) should conduct a thematic inspection or inspections concerning: (i) the selection and training of officers authorised to use weapons …

HM Inspectorate of Const…
AG-6 Accepted Anthony Grainger Inquiry

MASTS Documentation and Training Clarity

All documents and training relating to Mobile Armed Support to Surveillance (MASTS) should: clearly differentiate between MASTS as an operational method of supporting surveillance (and delivering a standard range of …

National Police Chiefs C…
IHRD-31 Accepted Hyponatraemia Inquiry

SAI Reporting Understanding

Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').

HSC Trusts
IHRD-4 Accepted Hyponatraemia Inquiry

Trust Awareness of Duty of Candour

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

HSC Trusts
IHRD-55 Accepted Hyponatraemia Inquiry

Board Member Training on Patient Safety

Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.

HSC Trusts
IHRD-56 Accepted Hyponatraemia Inquiry

Board Member Induction Training

All Trust Board Members should receive induction training in their statutory duties.

HSC Trusts
IHRD-57 Accepted Hyponatraemia Inquiry

Clinical Training for Guidelines

Specific clinical training should always accompany the implementation of important clinical guidelines.

HSC Trusts
IHRD-58 Accepted Hyponatraemia Inquiry

Paediatric Fluid Management Training

HSC Trusts should ensure that all nurses caring for children have facilitated access to e-learning on paediatric fluid management and hyponatraemia.

HSC Trusts
IHRD-59 Accepted Hyponatraemia Inquiry

Post-Mortem Request Form Training

There should be training in the completion of the post-mortem examination request form.

HSC Trusts
IHRD-60 Accepted Hyponatraemia Inquiry

Coroner Communication Training

There should be training in the communication of appropriate information and documentation to the Coroner's office.

HSC Trusts
IHRD-61 Accepted Hyponatraemia Inquiry

Paediatric Communication Training

Clinicians caring for children should be trained in effective communication with both parents and children.

HSC Trusts
IHRD-62 Accepted Hyponatraemia Inquiry

Adverse Incident Communication Training

Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.

HSC Trusts
IHRD-64 Accepted Hyponatraemia Inquiry

Parental Involvement in Training

Parents should be involved in the preparation and provision of any such training programme.

HSC Trusts
IHRD-65 Accepted Hyponatraemia Inquiry

SAI Investigator Training

Training in SAI investigation methods and procedures should be provided to those employed to investigate.

HSC Trusts
IHRD-68 Accepted Hyponatraemia Inquiry

Using Investigations for Training

Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.

HSC Trusts
IHRD-9 Accepted Hyponatraemia Inquiry

Leadership Development

The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.

Department of Health NI
14 Accepted Morecambe Bay Investigation

Review clinical leadership arrangements

The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with …

- In July 2015, the government stated that the Trust had "reviewed clinical leadership in terms of individuals and structures in obstetrics, paediatrics and midwifery" …
University Hospitals of …
2 Accepted Morecambe Bay Investigation

Review clinical staff competencies

The University Hospitals of Morecambe Bay NHS Foundation Trust should review the skills, knowledge, competencies and professional duties of care of all obstetric, paediatric, midwifery and neonatal nursing staff, and …

- In July 2015, the government stated that a review of skills, knowledge, competencies and professional duties of care had been "started" and was to …
University Hospitals of …
22 Accepted Morecambe Bay Investigation

Recognise educational opportunities in smaller units

We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and …

- In July 2015, the government stated: "We accept this recommendation in principle" and confirmed that Health Education England had established a working group to …
NHS England
28 Accepted Morecambe Bay Investigation

National standards for clinical leads

Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 28 and 29) and described work between the Department of …
NHS England
3 Accepted Morecambe Bay Investigation

Deliver staff training and development plans

The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up plans to deliver the training and development of staff identified as a result of the review of maternity, …

- In July 2015, the government stated that the Trust was putting "substantial plans in place" including staff training and development programmes (Learning Not Blaming, …
University Hospitals of …
AS-3 Accepted Al-Sweady Inquiry

Training Material Dating and Archiving

All training material should be dated, appropriately retained and archived in such a way that it can easily be established when the training material was composed, when it came into …

Ministry of Defence
R23 Accepted Vale of Leven Inquiry

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, a recognised specialist post-registration qualification.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …
NHS Health Boards (Scotl…
R42 Accepted Vale of Leven Inquiry

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 appointment.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …
NHS Health Boards (Scotl…
R43 Accepted Vale of Leven Inquiry

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 a record should be kept.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …
NHS Health Boards (Scotl…
R54 Accepted Vale of Leven Inquiry

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 use and respond to the data available.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …
NHS Health Boards (Scotl…
R60 Accepted Vale of Leven Inquiry

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 Programme, are implemented without undue delay.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …
NHS Health Boards (Scotl…
R67 Accepted Vale of Leven Inquiry

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 Nurses have specific training for that role.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …
NHS Health Boards (Scotl…
F108 Accepted Mid Staffs Inquiry

Support for other agencies

Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers' infection …

- Public Health England (PHE) was established on 1 April 2013, assuming the health protection functions of the Health Protection Agency. PHE was subsequently replaced …
F148 Accepted Mid Staffs Inquiry

Training

The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.

- Healthwatch England provides a programme of support and development resources for Local Healthwatch organisations, including guidance documents, webinars, and network events. Healthwatch England's Quality …
F185 Accepted Mid Staffs Inquiry

Focus on culture of caring

There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation and committed to strengthening values-based recruitment and training across the NHS …
NMC
F186 Accepted Mid Staffs Inquiry

Practical hands-on training and experience

Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation and committed to reviewing nursing training to incorporate sufficient practical elements …
NMC
F187 Accepted Mid Staffs Inquiry

Practical hands-on training and experience

There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle and committed to ensuring nursing students gain sufficient direct …
NMC
F189 Accepted in Part Mid Staffs Inquiry

Consistent training

The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.

- The government's response in "Hard Truths" (Cm 8777, November 2013) noted this recommendation and stated that it would work with the NMC and other …
NMC
F190 Accepted in Part Mid Staffs Inquiry

National standards

There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation and committed to establishing national training standards for nurses (Hard Truths: …
NMC
F197 Accepted in Part Mid Staffs Inquiry

Nurse leadership

Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation and committed to making leadership training available at all levels of …
NHS
F211 Accepted Mid Staffs Inquiry

Training standards for healthcare support workers

There should be a common set of national standards for the education and training of healthcare support workers.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …
Department of Health and…
F214 Accepted Mid Staffs Inquiry

Shared training

A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and leadership to potential senior staff; promote healthcare leadership …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …
F220 Accepted in Part Mid Staffs Inquiry

Accreditation

A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, at least initally, the objective should be to …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle (Hard Truths: the Journey to Putting Patients First, DHSC, …
F281 Accepted Mid Staffs Inquiry

Appropriate and sensitive contact with bereaved families

It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how to undertake this sensitive task in a manner …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …
Department of Health and…
F51 Accepted Mid Staffs Inquiry

Enhancement of monitoring and the importance of inspection

The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by …

- The government stated in Hard Truths (November 2013) that CQC would develop specialist inspection teams led by trained inspectors, including clinicians, other experts, and …
CQC
F77 Accepted Mid Staffs Inquiry

Enhancement of role of governors

Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and …

- NHS Providers (formerly the Foundation Trust Network) operates the GovernWell programme, established in 2013, providing national training and support for NHS foundation trust governors. …
NHS England
F81 Accepted Mid Staffs Inquiry

Accountability of providers' directors

Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires that directors possess "the qualifications, competence, skills and experience …
CQC
F86 Accepted Mid Staffs Inquiry

Requirement of training of directors

A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.

- The NHS Leadership Academy provides multiple board-level development programmes including the Nye Bevan Programme (12-month programme for aspiring board members), the Aspiring Chief Executive …
NHS Trusts
FP16-18 Accepted Fingerprint Inquiry

Academic study requirement

Expert opinion should be informed by proper academic study of the subject.

SPA Forensic Services
BAHA-14 Accepted Baha Mousa Inquiry

Communicating Sight Deprivation Reasons

JDP 1-10 should include guidance that where practicable CPErS should be told the reason why sight deprivation is being applied. Suitable simple phrases in relation to sight deprivation should be …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that guidance on communicating with captured persons about …
Ministry of Defence
BAHA-23 Not Accepted Baha Mousa Inquiry

Ban Harsh Approach in Tactical Questioning

The harsh approach should no longer have a place in tactical questioning. The MoD should forbid tactical questioners from using what is currently known as the harsh approach and this …

- The Defence Secretary stated on 8 September 2011 that the government did not accept this recommendation. The Defence Secretary decided to retain the ability …
Ministry of Defence
BAHA-46 Accepted Baha Mousa Inquiry

Lessons Learned Process

The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that lessons learned processes had been improved for …
Ministry of Defence
BAHA-47 Accepted Baha Mousa Inquiry

CPErS Training Content

CPErS training should include both theoretical and practical training in what Forces personnel can and should do when handling CPErS. It is important that training is not limited to prohibitions …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that captured persons training had been expanded to …
Ministry of Defence
BAHA-48 Accepted Baha Mousa Inquiry

End-to-End CPErS Training

CPErS training should be woven into the full range of military exercises and training. Such training should be 'end to end', not just focused on planning and the actual combat …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that captured persons handling had been incorporated throughout …
Ministry of Defence
BAHA-49 Accepted Baha Mousa Inquiry

Consistent Training Materials

Training materials across the Services need to be reviewed to ensure that the messages about all aspects of CPErS handling are clear and consistent. The arrangement whereby the PM(A) will …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training materials had been reviewed and made …
Ministry of Defence
BAHA-50 Accepted Baha Mousa Inquiry

MATT 7 Presentation Update

The MATT 7 PowerPoint presentation on the five techniques should be amended to ensure that the definitions of the techniques are consistent with amendments to JDP 1-10; that it is …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the MATT 7 PowerPoint presentation on the …
Ministry of Defence
BAHA-51 Accepted Baha Mousa Inquiry

Prisoner Handling DVD Update

The 2005 prisoner handling DVD should be amended to avoid misleading messages about sight deprivation in the context of interrogation, and the inappropriate presentation of the interrogation facility. 'Bagged and …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the prisoner handling DVD had been reviewed …
Ministry of Defence
BAHA-52 Accepted Baha Mousa Inquiry

Restraint Positions Guidance

Greater clarity and guidance should be given in training in relation to the concept of 'restraint positions'. More must be done to give practical guidance to help service personnel distinguish …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that clearer guidance on distinguishing unlawful stress positions …
Ministry of Defence
BAHA-53 Accepted Baha Mousa Inquiry

Positional Asphyxia Training

MATT 7 and mission specific training for CPErS handling should incorporate suitably pitched training on the risks of positional asphyxia/death by struggle against restraint.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training on positional asphyxia risks had been …
Ministry of Defence
BAHA-55 Accepted Baha Mousa Inquiry

Operational Law Training Currency

Those responsible for designing the mandatory operational law and values and standards training must keep the training relevant and up-to-date both in its content and in the style and means …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that processes for keeping operational law training current …
Ministry of Defence
BAHA-56 Accepted Baha Mousa Inquiry

Operational Law Training Quality

Unit commanders should ensure that the annual operational law training is delivered to the highest standards, so as to avoid it becoming stale or routine. Different media should be used …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that guidance on maintaining high standards in operational …
Ministry of Defence
BAHA-57 Accepted Baha Mousa Inquiry

Remove Shock of Capture Language

Training soldiers to maintain or prolong the shock of capture is apt to be misunderstood and should not feature in general training. Phrases such as 'calm, neutral and professional' and …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that references to training soldiers to maintain or …
Ministry of Defence
BAHA-58 Accepted Baha Mousa Inquiry

Moral Courage Training

MATT 6 training should include discussion and role play scenarios relevant to moral courage. Training materials should include reference to occasions when UK troops have breached the Law of Armed …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that MATT 6 training had been enhanced to …
Ministry of Defence
BAHA-60 Accepted Baha Mousa Inquiry

Annual Legal Review of TQ Training

The annual legal review of training materials planned by Defence Intelligence and Security Centre (DISC) is a necessary step. It must include a rigorous scrutiny of the detail of the …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that annual legal reviews of tactical questioning training …
Ministry of Defence
BAHA-63 Accepted Baha Mousa Inquiry

Complete TQ Training in Approaches

The tactical questioning and interrogation courses must train students adequately in all approaches that they may be required to use operationally. The current compromise whereby tactical questioning students are given …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that tactical questioning courses now provide complete training …
Ministry of Defence
BAHA-64 Accepted Baha Mousa Inquiry

Geneva Convention Compliance in Training

The MoD should give further careful consideration to the examples used in training for bridging between questioning sessions to ensure that they comply with the Geneva Conventions.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training examples for bridging between questioning sessions …
Ministry of Defence
BAHA-66 Accepted Baha Mousa Inquiry

Remove Shock of Capture from DISC

DISC should give consideration to avoiding the terminology 'maintain the shock of capture' and 'prolong the shock of capture' even in their own courses. As a minimum, students on the …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that DISC courses now warn students against misuse …
Ministry of Defence
BAHA-67 Accepted Baha Mousa Inquiry

Resistance Training Warning

All theoretical and practical resistance training must include a warning which explains in terms that the training is to show conduct that can be expected of a non-Geneva Conventions compliant …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that all resistance training now includes clear warnings …
Ministry of Defence
BAHA-70 Accepted Baha Mousa Inquiry

MCTC Control and Restraint Monitoring

The Military Correction Training Centre (MCTC) should continue to monitor that breakaway, personal protection and control and restraint techniques taught on the All Arms Unit Custody Staff Course (AAUCSC) are …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the Military Correction Training Centre continues to …
Ministry of Defence
BAHA-72 Accepted Baha Mousa Inquiry

Detention Sergeant Training

Unit Detention Sergeants (see recommendation 41) should be properly trained in CPErS handling practices.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training requirements for Detention Sergeants (as established …
Ministry of Defence