Previous Next
Jump to 9 Recommendations

Mid Staffordshire NHS Foundation Trust Public Inquiry

Completed

Mid Staffs Inquiry

Chair Robert Francis QC Legal professional (non-judge)
Established 09 Jun 2010
Final Report 06 Feb 2013
Commissioned by Department of Health and Social Care

Public inquiry into the serious failings in care at Mid Staffordshire NHS Foundation Trust between 2005-2009, where patients were routinely neglected and standards of care were appalling. The Francis Report made 290 recommendations for fundamental culture change to put patients first, including statutory duty of candour, enhanced CQC powers, nursing standards, and NHS leadership reforms.

Evidence & Impact
The Mid Staffordshire NHS Foundation Trust Public Inquiry, chaired by Sir Robert Francis QC, examined failures in care at Stafford Hospital between 2005 and 2009. The inquiry's report, published in February 2013, made 290 recommendations aimed at preventing similar failures across the NHS.

The government responded through two documents: 'Patients First and Foremost' in March 2013 and 'Hard Truths: the Journey to Putting Patients First' in November 2013. According to these responses, the government accepted 201 recommendations (69%), accepted in principle 60 recommendations (21%), partially accepted 20 recommendations (7%), and did not accept 9 recommendations (3%).

The government response identified several key reforms, including establishing a new Chief Inspector of Hospitals, strengthening the Care Quality Commission's inspection regime, introducing a statutory duty of candour, and implementing a fit and proper person test for NHS directors. The response also referenced the creation of Health Education England and Healthwatch England as part of wider NHS reforms.

However, the available evidence indicates limited published documentation of progress beyond these initial responses. Of the 290 recommendations, 281 (97%) are recorded as 'Awaiting Action' with no formal progress updates or implementation reviews identified in the public record. This suggests that while the government accepted the majority of Francis's recommendations and announced several high-profile reforms, comprehensive evidence of wider implementation across all recommendations has not been published.

The absence of systematic progress reporting makes it difficult to assess which of the accepted recommendations have been acted upon beyond the headline reforms announced in 2013. No formal implementation review has been identified that would provide comprehensive evidence of progress across all 290 recommendations.
Reforms Attributed to This Inquiry
- Care Quality Commission inspection regime strengthened with new Chief Inspector of Hospitals position created
- Statutory duty of candour introduced requiring NHS organisations to inform patients when care goes wrong
- Fit and proper person test established for NHS directors
- Fundamental standards of care introduced as regulatory requirements
- NHS Constitution strengthened with explicit patient rights
- Health Education England established to oversee workforce planning and training
- Healthwatch England created as national consumer champion for health and social care
Unfinished Business
- No published evidence identified for progress on 281 of 290 recommendations (97%)
- Recommendations on nurse staffing levels and mandatory minimum ratios
- Proposals for enhanced whistleblowing protections and support systems
- Recommendations on professional regulation reform
- Proposals for patient complaint handling improvements
- Recommendations on healthcare professional training and development
- Proposals for NHS board governance and accountability mechanisms
AI-generated narrative. Generated 26 Mar 2026 using claude-opus-4. Assessment is indicative, not authoritative.
2 years, 8 months Duration
£13m Total Cost
250 Witnesses
139 Hearing Days
1,000,000 Documents
1,781 Report Pages
Inquiry Website
Government Response
Accepted 201
Accepted in Part 80
Not Accepted 9
Total Recommendations 290
Data last updated: 19 Nov 2013 · Source
Data verified: 26 May 2026 (import)
Blanket response: Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
How to read this

Government Response tracks what the government said it would do (accepted, rejected, etc.).

Full methodology

09 Jun 2010
Inquiry Announced
01 Nov 2010
Inquiry Established
06 Feb 2013
Final Report Published
Clear

Recommendations (9)

F19
Not Accepted
Gaps between the understood functions of separate regulators
Recommendation

There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards for all trusts.

Published evidence summary
- The government did not accept the recommendation for a single regulator combining financial and quality oversight. Hard Truths (November 2013) stated that CQC and Monitor would retain separate but complementary roles (Hard Truths Vol 1, Cm 8777, Department of Health, November 2013).
- Monitor and the NHS Trust Development Authority were merged to form NHS Improvement in April 2016, bringing together financial oversight and performance management (NHS Improvement, established April 2016).
- NHS Improvement and NHS England formally merged on 1 July 2022 under the Health and Care Act 2022. Section 33 abolished Monitor and transferred its functions to NHS England; section 36 abolished the NHS Trust Development Authority (Health and Care Act 2022, c.31, ss.33, 36).
- CQC remains a separate regulator responsible for quality and safety standards. The recommendation for a single regulator covering both financial and quality regulation has not been implemented as described (CQC, continuing separate statutory role).
Department of Health and Social Care (Primary)
View Details
F61
Not Accepted
Consolidation of regulatory functions
Recommendation
A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a justification for reduction of the resources allocated to this area … Read more
Published evidence summary
- The government did not merge the system regulatory functions of Monitor and CQC as Francis recommended. Instead, it maintained CQC as an independent quality regulator while restructuring provider regulation separately (Hard Truths Vol 1, Cm 8777, Department of Health, November 2013).
- Monitor merged with the NHS Trust Development Authority to form NHS Improvement on 1 April 2016, bringing together financial regulation, performance management, and patient safety functions within a single organisation (Monitor is now part of NHS Improvement, DHSC, April 2016).
- NHS Improvement merged into NHS England from 1 July 2022 under sections 33 and 36 of the Health and Care Act 2022, formally abolishing Monitor and the NHS Trust Development Authority and transferring their functions to NHS England (Health and Care Act 2022, ss.33, 36).
- CQC remains a separate statutory body from NHS England. The regulatory architecture has been consolidated through successive mergers (Monitor→NHS Improvement→NHS England) but CQC has not been merged with any of these bodies. The specific merger of system regulatory functions between Monitor and CQC that Francis recommended has not been undertaken.
Department of Health and Social Care (Primary)
View Details
F64
Not Accepted
Authorisation of foundation trusts
Recommendation
The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation … Read more
Published evidence summary
- The government did not transfer the foundation trust authorisation process to CQC as Francis recommended. Instead, it maintained separate roles: CQC assessed quality and published ratings, while Monitor (subsequently NHS Improvement, then NHS England) retained responsibility for the provider licensing regime (Hard Truths Vol 1, Cm 8777, Department of Health, November 2013).
- The NHS provider licence, published by Monitor on 14 February 2013, replaced foundation trusts' Terms of Authorisation from 1 April 2013. From 1 April 2023, all NHS trusts were also required to hold a provider licence, bringing both trust types under the same regulatory conditions (NHS provider licence consultation response, NHS England).
- The foundation trust application pipeline was effectively closed. Most applications were paused or deferred by January 2014, and no formal policy announcement ended the programme. The Health and Care Act 2022 significantly narrowed the practical distinction between NHS trusts and foundation trusts by bringing both under the same licensing regime and giving NHS England capital expenditure controls over foundation trusts (Health and Care Act 2022, ss.61-62).
- On 12 November 2025, the Secretary of State announced the Advanced Foundation Trust Programme, under which both NHS trusts and foundation trusts may apply for enhanced autonomy. First wave assessment is scheduled from April 2026. This represents a reinvention of the model rather than the single-regulator approach Francis envisaged (Advanced Foundation Trust Programme guide, NHS England, November 2025).
Department of Health and Social Care (Primary)
View Details
F137
Not Accepted
Intervention and sanctions for substandard or unsafe services
Recommendation
Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other measures necessary to protect patients from the risk of harm. In the provision of the commissioned services, such … Read more
Published evidence summary
- The NHS Standard Contract 2024/25 includes provisions enabling commissioners to take action where providers fail to meet contractual quality standards. These include issuing contract performance notices, requiring remedial action plans, withholding or recovering payments, and ultimately terminating contracts. Commissioners can also require the substitution of named individuals where there are concerns about their performance (NHS Standard Contract 2024/25, NHS England).
- NHS England has powers under the Health and Care Act 2022 to give directions to ICBs and to intervene in ICB commissioning decisions. NHS England's System Oversight Framework provides a graduated approach to intervention, with providers in SOF segments 3 and 4 receiving enhanced oversight and mandated support respectively. In the most serious cases, NHS England can direct that services be provided by alternative providers (NHS System Oversight Framework, NHS England).
- CQC has independent enforcement powers including the power to impose conditions on a provider's registration, issue warning notices, and in the most serious cases to cancel a provider's registration (preventing it from providing services). CQC's enforcement powers operate alongside commissioner contract powers, and both can act independently (CQC enforcement policy; Health and Social Care Act 2008).
- The Health and Care Act 2022 includes provisions for NHS England to direct providers to take specified actions where there are concerns about the quality or safety of services, providing a system-level intervention power that supplements commissioner and regulatory powers (Health and Care Act 2022).
Commissioners (Primary)
View Details
F145
Not Accepted
Structure of Local Healthwatch
Recommendation

There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter 6: Patient and public local involvement and scrutiny.

Published evidence summary
- The Health and Social Care Act 2012 (sections 221-227) established the statutory framework for Local Healthwatch organisations. Every upper-tier local authority in England is required to commission a Local Healthwatch for its area. 152 Local Healthwatch organisations were established from April 2013, covering every local authority area in England (Health and Social Care Act 2012, Part 5, Chapter 1).
- Local Healthwatch organisations have a consistent set of statutory functions set out in the Health and Social Care Act 2012: obtaining the views of people about their needs and experiences of local health and social care services; making reports and recommendations about how services could be improved; providing information and advice to the public; making the views and experiences of people known to Healthwatch England; and making recommendations to those who commission, provide, and regulate health and social care services (Health and Social Care Act 2012, s.221).
- Healthwatch England, initially established as a statutory committee of CQC under the Health and Social Care Act 2012, provides national coordination and support to the Local Healthwatch network. Healthwatch England publishes guidance, quality standards, and best practice resources for Local Healthwatch organisations, promoting consistency across the network (Healthwatch England).
- The Local Healthwatch Regulations 2013 (SI 2013/154) set out further requirements for the governance and operation of Local Healthwatch organisations, including requirements for annual reporting and the involvement of volunteers and lay people in Healthwatch activities (SI 2013/154).
Department of Health and Social Care (Primary)
View Details
F183
Not Accepted
Criminal liability
Recommendation
It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an authorised or registered healthcare organisation: Knowingly to obstruct another in the performance of these statutory duties; To provide … Read more
Published evidence summary
- The Criminal Justice and Courts Act 2015 (sections 20-21), which received Royal Assent on 12 February 2015, created two new criminal offences directly relevant to Francis's recommendation. Section 20 creates the offence of ill-treatment or wilful neglect of an individual by a care worker, carrying a maximum sentence of five years' imprisonment. Section 21 creates the offence of a care provider supplying or publishing a statement that is false or misleading in a material respect, where the statement relates to the provision of health or social care (Criminal Justice and Courts Act 2015, ss.20-21).
- The Health and Social Care Act 2008 (section 91) already made it a criminal offence to knowingly or recklessly provide false or misleading information to CQC, punishable by fine or imprisonment of up to two years. This provision was in force before the Francis Report and remains in force alongside the 2015 Act provisions (Health and Social Care Act 2008, s.91).
- CQC has the power to prosecute providers and individuals for breaches of the Health and Social Care Act 2008, including the offence under section 91. CQC's enforcement policy sets out the circumstances in which it will consider prosecution, including cases of deliberate deception or obstruction (CQC enforcement policy).
- The government's response in "Hard Truths" (Cm 8777, November 2013) stated that legislation would be introduced to create new criminal offences of ill-treatment and wilful neglect. This was implemented through sections 20 and 21 of the Criminal Justice and Courts Act 2015 (Hard Truths, DHSC, November 2013).
Department of Health and Social Care (Primary)
View Details
F209
Not Accepted
Registration of healthcare support workers
Recommendation
A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor (or who are … Read more
Published evidence summary
- The government explicitly rejected this recommendation in "Hard Truths" Volume 2 (Cm 8777, November 2013), one of only nine Francis recommendations not accepted. The government stated that statutory regulation of healthcare support workers "would not add sufficiently to the general assurance provided by the CQC" and considered it too bureaucratic and expensive (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013).
- Instead of statutory registration, the government adopted a package of alternative measures: a voluntary Code of Conduct for Healthcare Support Workers (published March 2013 by Skills for Care and Skills for Health), the Care Certificate (launched April 2015), and reliance on existing CQC provider registration and DBS barring mechanisms.
- The Cavendish Review (July 2013), commissioned by the Secretary of State, had its terms of reference expressly exclude consideration of statutory regulation, and its training-focused recommendations were adopted as the government's alternative approach (Review of Healthcare Assistants and Support Workers in NHS and Social Care, Camilla Cavendish, July 2013).
- Robert Francis publicly criticised the rejection, stating: "Without any registration system or its equivalent, I believe the public will be at risk." He noted that taxi drivers and security guards face stricter registration requirements than healthcare assistants caring for vulnerable patients.
- The Professional Standards Authority accredits approximately 28 voluntary registers for unregulated health practitioners, but there is no PSA-accredited register for healthcare support workers or healthcare assistants specifically (Professional Standards Authority, Accredited Registers programme).
- Healthcare support workers in England remain unregistered as of March 2026. The Nursing Associate role (NMC-regulated from January 2019) creates a separate registered role but does not constitute registration of HCAs themselves.
Department of Health and Social Care (Primary)
View Details
F212
Not Accepted
Training standards for healthcare support workers
Recommendation
The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation with all relevant stakeholders, including the Department of Health, other … Read more
Published evidence summary
- The government's response in "Hard Truths" (Cm 8777, November 2013) rejected this recommendation, as a consequence of rejecting F209 (statutory registration of healthcare support workers). Since the government did not accept that HCAs should be registered, it followed that the NMC would not be given responsibility for maintaining a register, code of conduct, or training standards for this workforce (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013).
- Instead, responsibility for the Code of Conduct and training standards was given to Skills for Care and Skills for Health (non-statutory sector skills bodies) rather than the NMC. The Code of Conduct was published in March 2013 and the Care Certificate launched in April 2015, both maintained by these bodies rather than a statutory regulator.
- The NMC was given regulatory responsibility for the new Nursing Associate role from January 2019 under the Nursing and Midwifery (Amendment) Order 2018 (SI 2018/838), but this is a separate, higher-level role requiring a two-year foundation degree — not regulation of healthcare support workers as Francis envisaged (NMC, Nursing Associates).
- The Professional Standards Authority's accredited voluntary registers programme does not include a register for healthcare support workers, and there is no regulatory body with oversight of HCA conduct, education, or training standards in the way Francis recommended for the NMC (Professional Standards Authority, Accredited Registers).
- The recommendation that the NMC should prepare and maintain HCA standards after consultation with relevant stakeholders has not been implemented; the NMC's remit remains limited to registered nurses, midwives, and nursing associates.
NMC (Primary)
View Details
F213
Not Accepted
Training standards for healthcare support workers
Recommendation
Until such time as the Nursing and Midwifery Council is charged with the recommended regulatory responsibilities, the Department of Health should institute a nationwide system to protect patients and care receivers from harm. This system should be supported by fair … Read more
Published evidence summary
- The government's response in "Hard Truths" (Cm 8777, November 2013) rejected this recommendation, stating that existing safeguards — particularly the Disclosure and Barring Service (DBS) barring mechanisms and CQC provider regulation — were sufficient to protect patients without a dedicated HCA barring system (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013).
- Healthcare support workers in regulated activity are subject to Enhanced DBS checks with Adults' Barred List checks, and employers are legally required to carry these out before engagement. The DBS maintains adults' and children's barred lists under the Safeguarding Vulnerable Groups Act 2006, and individuals can be placed on barred lists without a criminal conviction using the civil standard of proof.
- However, the DBS operates as a negative check (barring known unfit individuals) rather than the positive registration and barring system Francis recommended. Francis noted in his report: "Should a healthcare support worker be dismissed by an employer for being unfit to undertake this form of work, there is no system which prevents the worker being re-engaged by another employer" unless a formal DBS referral has been made.
- There is no nationwide system equivalent to NMC fitness-to-practise proceedings for healthcare support workers. The recommendation envisaged a system with fair due process for dismissed HCAs — the DBS barring process does include a representations stage, but it is not equivalent to a professional regulatory hearing.
- The gap identified by Francis remains: an HCA dismissed for poor care can seek employment elsewhere provided no DBS referral is made. NHS Employers guidance encourages trusts to make DBS referrals where appropriate, but referral rates vary and there is no mandatory reporting mechanism specific to HCAs.
Department of Health and Social Care (Primary)
View Details