Reports & recommendations
96 recommendations, each with the government response on the record. Filter by government response or delivery status.
Reports (2)
| Title | Volume | Publication Date | Recommendations | Links |
|---|---|---|---|---|
| Report of the Inquiry into Hyponatraemia-related Deaths | Final | 31 Jan 2018 | 96 | |
| Inquiry into Hyponatraemia-related Deaths | Final Report | 31 Jan 2018 | 0 |
Recommendations (96)
Statutory Duty of Candour
A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public. (ii) Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or duly authorised representative) should be informed of the incident and given a full and honest explanation of the circumstances. (iii) Full and honest answers must be given to any question reasonably asked about treatment by a patient (or duly authorised representative). (iv) Any statement made to a regulator or other individual acting pursuant to statutory duty must be truthful and not misleading by omission. (v) Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission. (vi) Healthcare organisations who believe or suspect that treatment or care provided by it, has caused death or serious injury to a patient, must inform that patient (or duly authorised representative) as soon as is practicable and provide a full and honest explanation of the circumstances. (vii) Registered clinicians and other registered healthcare professionals, who believe or suspect that treatment or care provided to a patient by or on behalf of any healthcare organisation by which they are employed has caused death or serious injury to the patient, must report their belief or suspicion to their employer as soon as is reasonably practicable.
The Inquiry recommended introducing a statutory duty of candour for healthcare organisations and their staff. In September 2025, Mike Nesbitt, the Minister of Health, stated that officials had been tasked with developing a bill creating an organisational duty of candour during the mandate, while an individual duty was not mentioned (Mike Nesbitt, Sep 2025). In September 2024, the Minister stated that options for Northern Ireland would take account of wider discussions across the United Kingdom following the Infected Blood Inquiry (Mike Nesbitt, Sep 2024). In June 2024, the Minister stated that he was unsure whether imposing a statutory duty on individuals was the best mechanism to encourage honest reporting (Mike Nesbitt, Jun 2024).
Criminal Liability for Candour Breach
Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.
The Inquiry recommended attaching criminal liability to breaching or obstructing the duty of candour. In September 2025, Mike Nesbitt, Minister of Health, reaffirmed support for an organisational duty of candour, though criminal liability and obstruction were not mentioned (Mike Nesbitt, Sep 2025). In November 2024, the Minister questioned in the Northern Ireland Assembly whether an individual duty with criminal sanctions would enforce a "chill factor" or open things up (Mike Nesbitt, Nov 2024). In October 2022, the Department of Health (Northern Ireland) stated that initial work had been completed and transferred responsibility to a departmental policy area (Department of Health (Northern Ireland), Oct 2022).
Guidance on Statutory Duty of Candour
Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.
The Inquiry recommended that guidance be issued to Trusts on meeting the statutory duty. In an implementation programme update published in October 2022, the Department of Health (Northern Ireland) stated that "initial work has been completed" across 37 actions (Department of Health (Northern Ireland), Oct 2022). The department explained that it was now appropriate to transfer responsibility for these recommendations from the inquiry implementation programme to the appropriate departmental policy area (Department of Health (Northern Ireland), Oct 2022).
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 healthcare.
The Inquiry asked trusts to ensure healthcare professionals understand the duty of candour. In October 2022, the Department of Health (Northern Ireland) stated that "initial work has been completed" across a group of 37 actions that includes this recommendation (Department of Health (Northern Ireland), Oct 2022). The department reported that responsibility was transferring from the implementation programme to the appropriate departmental policy area, though its statement did not mention trust awareness or healthcare staff (Department of Health (Northern Ireland), Oct 2022).
Employment Contracts and Duty of Candour
Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.
In October 2022, the Department of Health (Northern Ireland) stated that implementation of this recommendation was in progress under the oversight of its programme team (Department of Health (Northern Ireland), Oct 2022). The department reported in October 2022 that although initial work had concluded across workstreams and sub-groups, "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
Support for Candour Compliance
Support and protection should be given to those who properly fulfil their duty of candour.
In an implementation update published in October 2022, the Department of Health (Northern Ireland) recorded the recommendation as in progress (Department of Health (Northern Ireland), Oct 2022). The department stated that initial work had been completed, but noted that it was now "appropriate to transfer responsibility for these recommendations from the IHRD implementation programme to the appropriate DoH policy area" (Department of Health (Northern Ireland), Oct 2022).
Monitoring Candour Compliance
Trusts should monitor compliance and take disciplinary action against breach.
In an October 2022 implementation update, the Department of Health (Northern Ireland) recorded the status of this recommendation as in progress (Department of Health (Northern Ireland), Oct 2022). It stated that the measure was among 20 actions overseen by the implementation programme team where initial work had been completed by workstreams and sub-groups (Department of Health (Northern Ireland), Oct 2022). The department noted that "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
RQIA Compliance Review Powers
Regulation and Quality Improvement Authority ('RQIA') should review overall compliance and consideration should be given to granting it the power to prosecute in cases of serial non-compliance or serious and wilful deception.
The Inquiry recommended reviewing the Regulation and Quality Improvement Authority's compliance and prosecution powers. In October 2022, the Department of Health (Northern Ireland) stated that initial work on the recommendation had been completed and transferred responsibility from its implementation programme to an internal policy area (Department of Health (Northern Ireland), Oct 2022). The department's statement does not mention reviewing overall compliance or considering powers to prosecute serial non-compliance or serious and wilful deception (Department of Health (Northern Ireland), Oct 2022).
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.
In June 2023, the Department of Health (Northern Ireland) recorded this recommendation on leadership development as completed, placing it under a table heading designating Phase 1 recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In that June 2023 document, the department applied the heading collectively across 66 actions together rather than providing an individual progress assessment for this measure (Department of Health (Northern Ireland), Jun 2023).
Age-Appropriate Hospital Settings
Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in age-appropriate hospital settings.
The Inquiry asked Health and Social Care (HSC) Trusts to publish age-appropriate hospital care procedures. In June 2023, the Department of Health (Northern Ireland) listed the recommendation under phase one actions that were "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In that June 2023 update, the department did not mention policies or procedures for caring for children and young people in age-appropriate hospital settings (Department of Health (Northern Ireland), Jun 2023). The department did not specify in June 2023 whether any individual trusts had published the required policies (Department of Health (Northern Ireland), Jun 2023).
Patient Transfer Protocol
There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.
The Department of Health (Northern Ireland) reported in June 2023 that this recommendation was completed, grouping it under a table heading of phase 1 recommendations marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). This status was applied collectively to 66 actions listed together in the department's update (Department of Health (Northern Ireland), Jun 2023). The department's document did not provide an individual narrative or specific details on the protocol for hospital transfers (Department of Health (Northern Ireland), Jun 2023).
Senior Paediatric Responsibility
Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.
In June 2023, the Department of Health (Northern Ireland) recorded that the recommendation for senior paediatric medical staff to hold overall patient responsibility in shared children's wards was completed (Department of Health (Northern Ireland), Jun 2023). Relaying the position for HSC Trusts in its June 2023 update on inquiry recommendations, the department placed the measure under a table heading designated as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Foundation Doctors in Children's Wards
Foundation doctors should not be employed in children's wards.
In June 2023, the Department of Health (Northern Ireland) recorded the recommendation that foundation doctors should not be employed in children's wards as completed (Department of Health (Northern Ireland), Jun 2023). The department listed the measure under a table heading designating Phase 1 recommendations as "ACTIONED" in its updated implementation report (Department of Health (Northern Ireland), Jun 2023). This status update covered 66 actions together rather than addressing this specific recommendation individually (Department of Health (Northern Ireland), Jun 2023).
Clinician Competence Assessment
The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.
The Department of Health (Northern Ireland) stated in June 2023 that the recommendation to assess the experience and competence of clinicians caring for children in acute hospital settings before employment was complete (Department of Health (Northern Ireland), Jun 2023). In the same June 2023 update, the department listed the recommendation addressed to HSC Trusts under the table heading "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Consultant Notification on Admission
A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept informed of the patient's condition, to ensure senior clinical involvement and leadership.
In June 2023, the Department of Health (Northern Ireland) relayed the position for HSC Trusts by listing this recommendation under a table of Phase 1 recommendations marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). The department applied this table heading collectively across 66 actions within the implementation programme, rather than providing an individual progress update for this specific recommendation (Department of Health (Northern Ireland), Jun 2023).
Bedside Display of Responsible Staff
The names of both the consultant responsible and the accountable nurse should be prominently displayed at the bed in order that all can know who is in charge and responsible.
The Department of Health (Northern Ireland) stated in June 2023 that this recommendation was completed, categorising it under its published list of actioned phase one recommendations (Department of Health (Northern Ireland), Jun 2023). The department recorded the measure under a collective table heading designating phase one recommendations as "ACTIONED", with no separate detail provided on displaying the names of responsible staff at patient beds (Department of Health (Northern Ireland), Jun 2023).
Recording Changes in Accountability
Any change in clinical accountability should be recorded in the notes.
The Department of Health (Northern Ireland) stated in June 2023 that the inquiry recommendation requiring HSC Trusts to record any change in clinical accountability in patient notes was "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In its published June 2023 review of phase one and phase two recommendations, the department marked the delivery status for the trust addressees as completed (Department of Health (Northern Ireland), Jun 2023).
On-Call Consultant Display
The names of all on-call consultants should be prominently displayed in children's wards.
The Department of Health (Northern Ireland) reported in June 2023 that this recommendation was completed, categorising it under a table of Phase 1 recommendations marked as actioned (Department of Health (Northern Ireland), Jun 2023). In that June 2023 update, the department applied the actioned heading collectively to 66 recommendations, providing no individual detail on whether the names of all on-call consultants are prominently displayed in children's wards (Department of Health (Northern Ireland), Jun 2023).
Senior Lead Nurse in Children's Wards
To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating to each patient, be visible to both patients and staff and be available to discuss concerns with parents. Such leadership is necessary to reinforce nursing standards and to audit and enforce compliance. The post should be provided in addition to current staffing levels.
The Department of Health (Northern Ireland) reported in June 2023 that this recommendation was completed, listing it under a table heading describing phase one recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In that June 2023 update, the department applied this status collectively across all recommendations in the table, without providing a separate narrative on senior lead nurse staffing in children's wards (Department of Health (Northern Ireland), Jun 2023).
Consultant-Led Ward Rounds
Children's ward rounds should be led by a consultant and occur every morning and evening.
The Inquiry recommended that consultants lead morning and evening ward rounds for children. In an update published in June 2023, the Department of Health (Northern Ireland) recorded the recommendation under a table heading designating Phase 1 recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). Earlier, in a March 2021 written ministerial statement to the Northern Ireland Assembly, Mr Swann, Minister of Health, stated that the department accepted the recommendations of the O'Hara Report in their entirety (Mr Swann response, Mar 2021).
Nurse Attendance at Clinical Interactions
The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.
The Department of Health (Northern Ireland) reported in June 2023 that this recommendation addressed to HSC Trusts had been completed (Department of Health (Northern Ireland), Jun 2023). In its published progress report covering phase one and phase two implementation, the department categorised the measure regarding nurse attendance at clinical interactions between doctors and child patients under the heading "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Parental Knowledge in Care Plans
Clinicians should respect parental knowledge and expertise in relation to a child's care needs and incorporate the same into their care plans.
The Department of Health (Northern Ireland) stated in June 2023 that this recommendation was complete, listing it under a table heading of Phase 1 recommendations marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In the same June 2023 document, the department applied that heading collectively to 66 actions together, without providing an individual account of how clinicians in HSC Trusts incorporate parental knowledge into care plans (Department of Health (Northern Ireland), Jun 2023).
Care Plan Availability at Bedside
The care plan should be available at the bed and the reasons for any change in treatment should be recorded.
The Department of Health (Northern Ireland) recorded this recommendation addressed to HSC Trusts as completed in an official progress report published in June 2023 (Department of Health (Northern Ireland), Jun 2023). In that June 2023 report, the department placed the requirement to keep care plans at the bedside and document treatment changes under a table of Phase 1 recommendations marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Blood Test Result Documentation
All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.
The Inquiry recommended documenting blood test timings and recording serum sodium on fluid charts. In June 2023, the Department of Health (Northern Ireland) listed the recommendation under a table heading of Phase 1 recommendations that were "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). The department did not mention the specific requirements to record when samples were taken, tested, and communicated, nor did it refer to recording serum sodium on fluid balance charts (Department of Health (Northern Ireland), Jun 2023).
Drug Prescription Documentation
All instances of drug prescription and administration should be entered into the main clinical notes and paediatric pharmacists should monitor, query and, if necessary, correct prescriptions. In the event of correction the pharmacist should inform the prescribing clinician.
The Department of Health (Northern Ireland), acting on behalf of the addressee HSC Trusts, reported in June 2023 that this recommendation on drug prescription documentation was completed (Department of Health (Northern Ireland), Jun 2023). In its official update covering Phase 1 and Phase 2 implementation, the department categorised the recommendation on clinical notes and paediatric pharmacist monitoring under the table heading "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Recording Clinical Discussions
Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.
In June 2023, the Department of Health (Northern Ireland) recorded that this recommendation addressed to HSC Trusts had been completed (Department of Health (Northern Ireland), Jun 2023). In its June 2023 official report on Phase 1 and Phase 2 recommendations, the department included the measure on recording clinical discussions under a table heading designating Phase 1 recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Electronic Patient Information Systems
Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.
The Inquiry asked for electronic patient information systems providing immediately accessible care records. In June 2023, the Department of Health (Northern Ireland) listed this recommendation under a table heading designating Phase 1 recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). The department did not describe the development of electronic patient information systems in its update (Department of Health (Northern Ireland), Jun 2023). It also did not address making records of observation and intervention immediately accessible to those involved in care (Department of Health (Northern Ireland), Jun 2023).
Informed Consent Documentation
Consideration should be given to recording and/or emailing information and advices provided for the purpose of obtaining informed consent.
The Department of Health (Northern Ireland) recorded this recommendation, addressed to HSC Trusts regarding the recording or emailing of information and advice for informed consent, as completed in June 2023 (Department of Health (Northern Ireland), Jun 2023). In its official report updating Phase 1 and Phase 2 recommendations, the department accounted for the measure under a collective table heading designated as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Record Keeping Audit
Record keeping should be subject to rigorous, routine and regular audit.
The Department of Health (Northern Ireland), reporting for HSC Trusts, stated in June 2023 that this recommendation was complete (Department of Health (Northern Ireland), Jun 2023). In its June 2023 progress document on Phase 1 and Phase 2 recommendations, the department placed the recommendation that record keeping be subject to routine audit under a collective table heading marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Confidential Reporting of Clinical Concerns
Confidential on-line opportunities for reporting clinical concerns should be developed, implemented and reviewed.
The Inquiry asked trusts to establish and review confidential online reporting for clinical concerns. In June 2023, the Department of Health (Northern Ireland) listed the measure under a table heading designating Phase 1 recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). The department did not describe the development, implementation, or review of confidential online reporting opportunities (Department of Health (Northern Ireland), Jun 2023). The sources do not state whether any further action on this measure remains outstanding (Department of Health (Northern Ireland), Jun 2023).
SAI Reporting Understanding
Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').
In June 2026, the Minister of Health, Mike Nesbitt, stated that this recommendation is "under active consideration" as part of an ongoing programme to redesign the Serious Adverse Incident procedure (Mike Nesbitt, Jun 2026). The Minister noted that further detail on how it will be addressed will be available once final strategic proposals have been considered and agreed (Mike Nesbitt, Jun 2026). The Department of Health (Northern Ireland) had previously reported in October 2022 that initial work was completed before transferring responsibility for the recommendation to the relevant policy area (Department of Health (Northern Ireland), Oct 2022).
SAI Reporting as Disciplinary Offence
Failure to report an SAI should be a disciplinary offence.
In June 2026, the Minister of Health, Mike Nesbitt, stated that this recommendation was under "active consideration as part of the Department’s ongoing programme to redesign the extant SAI Procedure" (Mike Nesbitt, Jun 2026). The Minister noted that further detail on the extent to which it will be addressed will be available once final strategic proposals have been agreed (Mike Nesbitt, Jun 2026). Previously, the Department of Health reported in October 2022 that initial work had been completed but further work was required to ensure implementation at service level (Department of Health (Northern Ireland), Oct 2022).
CEO Responsibility for Investigations
Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.
In June 2026, the Minister of Health, Mike Nesbitt, stated that this recommendation was "under active consideration" as part of the Department of Health's programme to redesign the SAI procedure, with further detail to follow once he agreed final strategic proposals (Mike Nesbitt, Jun 2026). The department had previously reported in October 2022 that initial work had been completed and responsibility was transferred to an internal policy area (Department of Health (Northern Ireland), Oct 2022).
Independent SAI Investigation
The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.
The Inquiry recommended that independent investigators outside Northern Ireland investigate serious clinical incidents. In June 2026, Minister of Health Mike Nesbitt stated that recommendations relating to serious adverse incidents (SAIs) were under active consideration in the Department of Health (Northern Ireland) to redesign the existing procedure, though independent investigators and powers to seize evidence were not mentioned (Mike Nesbitt, Jun 2026). The Minister added that further detail on how this recommendation will be addressed will be available once he has considered and agreed final strategic proposals (Mike Nesbitt, Jun 2026). Earlier, in October 2022, the department stated that initial work had finished and responsibility had transferred to its policy area (Department of Health (Northern Ireland), Oct 2022).
Non-Cooperation as Disciplinary Offence
Failure to co-operate with investigation should be a disciplinary offence.
In June 2026, Mike Nesbitt, Minister of Health, stated that this recommendation is "under active consideration" as part of the Department of Health (Northern Ireland)'s programme to redesign the extant SAI procedure, with further detail to follow once he agrees final strategic proposals (Mike Nesbitt, Jun 2026). Earlier, in October 2022, the department reported that initial work had been completed, but further work was required to ensure implementation at service level (Department of Health (Northern Ireland), Oct 2022).
Separation of Investigation and Litigation
Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.
In June 2023, the Department of Health (Northern Ireland) categorised this recommendation as actioned within its Phase 1 implementation update table (Department of Health (Northern Ireland), Jun 2023). Prior to this, in October 2022, the department reported that initial work across this group of actions had been completed by relevant workstreams and sub-groups, but noted that "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
Family Involvement in SAI Investigations
Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the opportunity to become involved in setting the terms of reference for an investigation. (iii) Families should, if they so wish, engage with the investigation and receive feedback on progress. (iv) A fully funded Patient Advocacy Service should be established, independent of individual Trusts, to assist families in the process. It should be allowed funded access to independent expert advice in complex cases. (v) Families in cases of SAI related child death should be entitled to see relevant documentation, including all records, written communication between healthcare professionals and expert reports. (vi) All written Trust communication to parents or family after a SAI related child death should be signed or co-signed by the chief executive. (vii) Families should be afforded the opportunity to respond to the findings of an investigation report and all such responses should be answered in writing. (viii) Family GPs should, with family consent, receive copies of feedback provided. (ix) Families should be formally advised of the lessons learned and the changes effected. (x) Trusts should seek, and where appropriate act upon, feedback from families about adverse clinical incident handling and investigation.
The Inquiry asked trusts to maximise family involvement in Serious Adverse Incident (SAI) investigations. In June 2026, Minister of Health Mike Nesbitt stated that recommendations relating to SAIs are under active consideration as part of an ongoing departmental programme to redesign the existing procedure (Mike Nesbitt, Jun 2026). The Minister explained that further detail on the extent to which each recommendation will be addressed through the programme will be available once final strategic proposals are agreed (Mike Nesbitt, Jun 2026).
Multi-Disciplinary Peer Review
Investigations should be subject to multi-disciplinary peer review.
In June 2026, the Minister of Health, Mike Nesbitt, stated that this recommendation is under active consideration as part of the programme to redesign the Serious Adverse Incident procedure, with further details on how it will be addressed to be provided once final strategic proposals are agreed (Mike Nesbitt, Jun 2026). Previously, the Department of Health reported in October 2022 that initial work had been completed and responsibility was transferred to an internal policy area (Department of Health (Northern Ireland), Oct 2022).
Investigation Team Reconvening
Investigation teams should reconvene after an agreed period to assess both investigation and response.
In June 2026, the Minister of Health, Mike Nesbitt, stated that this recommendation is under active consideration as part of an ongoing departmental programme to redesign the Serious Adverse Incident procedure (Mike Nesbitt, Jun 2026). The Minister noted that further detail on how it will be addressed will be available once final strategic proposals have been considered and agreed (Mike Nesbitt, Jun 2026). Previously, the Department of Health (Northern Ireland) reported in October 2022 that initial work had finished and responsibility had been transferred to an internal policy area (Department of Health (Northern Ireland), Oct 2022).
SAI Learning Informing Clinical Audit
Learning and trends identified in SAI investigations should inform programmes of clinical audit.
In June 2026, Minister of Health Mike Nesbitt stated in a written assembly answer that the Department of Health assessed this recommendation on Serious Adverse Incident learning as actioned under Phase 1 of the implementation programme (Mike Nesbitt, Jun 2026). The Minister noted that this position was outlined in an update published by the department in June 2023, which listed the recommendation as actioned (Department of Health (Northern Ireland), Jun 2023; Mike Nesbitt, Jun 2026).
Publication of External Investigation Reports
Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.
The Department of Health (Northern Ireland), reporting on behalf of health and social care trusts, recorded this recommendation as completed in an official update published in June 2023 (Department of Health (Northern Ireland), Jun 2023). It placed the recommendation to publish external investigation reports within a schedule of phase one actions that the department categorised under the table heading "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Sharing New Investigation Information
In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.
In June 2026, Mike Nesbitt, Minister of Health, stated that this recommendation is "under active consideration" as part of an ongoing programme to redesign the Serious Adverse Incident procedure, noting that further detail will follow once he has considered and agreed final strategic proposals (Mike Nesbitt, Jun 2026). Previously, the Department of Health reported in October 2022 that initial work had been completed and responsibility was transferred to an internal policy area (Department of Health (Northern Ireland), Oct 2022).
GP Notification of Death Circumstances
A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.
The Department of Health (Northern Ireland) reported in October 2022 that delivery of this recommendation remained in progress (Department of Health (Northern Ireland), Oct 2022). It stated that initial preparatory work had been completed by the relevant workstreams and sub-groups, but explained that "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022). This ongoing work was to be overseen directly by the implementation programme team (Department of Health (Northern Ireland), Oct 2022).
Post-Mortem Limitation Authorisation
Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of the family.
In June 2023, the Department of Health (Northern Ireland) listed the recommendation on post-mortem limitation authorisation under a table heading classifying Phase 1 recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In that June 2023 progress report, the department placed the measure within a collective table covering sixty-six separate actions together rather than providing an individual assessment of this recommendation (Department of Health (Northern Ireland), Jun 2023).
Post-Mortem Documentation Checklist
Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.
The Department of Health (Northern Ireland), relaying the position for HSC Trusts, recorded in June 2023 that the recommendation to establish post-mortem documentation checklist protocols was complete (Department of Health (Northern Ireland), Jun 2023). In its progress update covering Phase 1 and Phase 2 recommendations, the department categorised the measure within a schedule of Phase 1 recommendations marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Clinician Attendance at Post-Mortem Discussions
Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.
The Department of Health (Northern Ireland) recorded this recommendation on clinician attendance at post-mortem discussions as completed in June 2023 (Department of Health (Northern Ireland), Jun 2023). In its Phase 1 and Phase 2 progress document, the department listed the measure within a table of 66 recommendations grouped under the collective heading "ACTIONED", rather than providing an individual assessment of its implementation (Department of Health (Northern Ireland), Jun 2023).
Post-Mortem Reporting Standards
In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy and completeness of the information briefed them. (ii) Work in liaison with the clinicians involved. (iii) Provide preliminary and final reports with expedition. (iv) Sign the post-mortem report. (v) Forward a copy of the post-mortem report to the family GP.
In June 2023, the Department of Health (Northern Ireland) categorised this recommendation on post-mortem reporting standards alongside other Phase 1 recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). Previously, in March 2021, Mr Swann, the Minister of Health, stated in a written ministerial statement to the Northern Ireland Assembly that the department accepted the inquiry's recommendations in their entirety (Mr Swann response, Mar 2021).
Mortality Meeting Recording and Audit
The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
The Department of Health (Northern Ireland) reported in October 2022 that implementation of the recommendation on mortality meeting recording and audits remained in progress (Department of Health (Northern Ireland), Oct 2022). The department stated in October 2022 that although workstreams and subgroups had completed initial work, "further work is now required to ensure appropriate implementation at service level" under the oversight of its programme team (Department of Health (Northern Ireland), Oct 2022).
Multi-Trust Mortality Meeting Engagement
Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant organisations should, in so far as is practicable, engage with the meeting.
In an October 2022 update, the Department of Health (Northern Ireland) reported that this recommendation was in progress (Department of Health (Northern Ireland), Oct 2022). The department stated in October 2022 that although initial work had been completed by workstreams and sub-groups, further work was "now required to ensure appropriate implementation at service level" to be overseen by the programme team (Department of Health (Northern Ireland), Oct 2022).
HSCB Notification of Inquests
The Health and Social Care ('HSCB') should be notified promptly of all forthcoming healthcare related inquests by the Chief Executive of the Trust(s) involved.
The Department of Health (Northern Ireland) stated in October 2022 that work on notifying the Health and Social Care Board of inquests remained in progress (Department of Health (Northern Ireland), Oct 2022). The department reported that this measure was one of twenty actions overseen by its programme team (Department of Health (Northern Ireland), Oct 2022). It explained that while initial work had been completed by workstreams and subgroups, "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
Independence of Coroner Witness Statements
Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.
In June 2023, the Department of Health (Northern Ireland) listed this recommendation regarding the independence of coroner witness statements as actioned in its published implementation update (Department of Health (Northern Ireland), Jun 2023). The department had previously reported in October 2022 that the measure remained in progress, noting that although initial work had been completed, "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
Inquest Duties Protocol
Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.
The Department of Health (Northern Ireland) recorded this recommendation under its actioned Phase 1 recommendations in an implementation update in June 2023 (Department of Health (Northern Ireland), Jun 2023). It previously stated in October 2022 that initial work had been completed by workstreams and sub-groups, but noted that "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
Legal Privilege Disclosure to Coroner
In the event of a Trust asserting entitlement to legal privilege in respect of an expert report or other document relevant to the proceedings of an inquest, it should inform the Coroner as to the existence and nature of the document for which privilege is claimed.
In an October 2022 statement, the Department of Health (Northern Ireland) reported that this recommendation was in progress under the oversight of its implementation programme team (Department of Health (Northern Ireland), Oct 2022). The department stated in that same October 2022 update that while initial work had been completed by workstreams and sub-groups, further work was required "to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
Bereavement Counselling Services
Professional bereavement counselling for families should be made available and should fully co-ordinate bereavement information, follow-up service and facilitated access to family support groups.
In an official progress report published in June 2023, the Department of Health (Northern Ireland), reporting on behalf of HSC Trusts, recorded this recommendation on bereavement counselling services as completed (Department of Health (Northern Ireland), Jun 2023). In that June 2023 update on inquiry implementation, the department catalogued the measure alongside other phase one recommendations under the collective table heading "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
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.
The Inquiry recommended training trust board members to scrutinise executive directors on patient safety. In June 2023, the Department of Health (Northern Ireland) recorded the measure in a table of Phase 1 recommendations marked "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). The department did not describe any specific training provided to Health and Social Care (HSC) Trust Chairs or Non-Executive Board Members, and scrutiny of Executive Directors regarding patient safety objectives was not mentioned (Department of Health (Northern Ireland), Jun 2023).
Board Member Induction Training
All Trust Board Members should receive induction training in their statutory duties.
The Department of Health (Northern Ireland) reported in its June 2023 update that the recommendation for all Trust board members to receive induction training in their statutory duties was "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). The department recorded the recommendation as completed by placing it within a collective table of Phase 1 actions across the wider implementation programme (Department of Health (Northern Ireland), Jun 2023).
Clinical Training for Guidelines
Specific clinical training should always accompany the implementation of important clinical guidelines.
The Department of Health (Northern Ireland) recorded the delivery status of this recommendation on clinical training as completed in an official update published in June 2023 (Department of Health (Northern Ireland), Jun 2023). In that June 2023 progress report regarding Phase 1 and Phase 2 recommendations, the department categorised the measure within a table heading designating Phase 1 recommendations as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
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.
The Department of Health (Northern Ireland) reported in June 2023 that this recommendation to ensure nurses have facilitated access to e-learning on paediatric fluid management was "ACTIONED" under its Phase 1 work programme (Department of Health (Northern Ireland), Jun 2023). In that June 2023 update on Phase 1 and Phase 2 inquiry recommendations, the department recorded the delivery status for the health and social care trusts as completed (Department of Health (Northern Ireland), Jun 2023).
Post-Mortem Request Form Training
There should be training in the completion of the post-mortem examination request form.
In June 2023, the Department of Health (Northern Ireland) reported that the recommendation had been completed (Department of Health (Northern Ireland), Jun 2023). The department included the measure in a table of Phase 1 recommendations listed under the heading "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). It did not provide specific narrative commentary on the delivery of training in completing the post-mortem examination request form for HSC Trusts (Department of Health (Northern Ireland), Jun 2023).
Coroner Communication Training
There should be training in the communication of appropriate information and documentation to the Coroner's office.
The Department of Health (Northern Ireland) stated in June 2023 that the recommendation to provide training in the communication of appropriate information and documentation to the coroner's office was completed (Department of Health (Northern Ireland), Jun 2023). In the same June 2023 report, the department designated the measure as actioned within its phase one schedule for HSC Trusts (Department of Health (Northern Ireland), Jun 2023).
Paediatric Communication Training
Clinicians caring for children should be trained in effective communication with both parents and children.
The Department of Health (Northern Ireland) recorded this recommendation as "ACTIONED" under its Phase 1 implementation schedule in June 2023 (Department of Health (Northern Ireland), Jun 2023). In that June 2023 progress document addressing Phase 1 and Phase 2 recommendations, the department listed the requirement for paediatric communication training within a table covering 66 actions marked collectively with completed status (Department of Health (Northern Ireland), Jun 2023).
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.
In a June 2026 written answer, Mike Nesbitt, Minister of Health, stated that this recommendation was one of five referencing serious adverse incidents "assessed by the Department as actioned" under Phase 1 of the implementation programme, reiterating a position published in June 2023 (Mike Nesbitt, Jun 2026). In its June 2023 update, the department had listed Phase 1 recommendations under a table heading marking them as actioned (Department of Health (Northern Ireland), Jun 2023).
Evaluation of Parental Involvement
The practice of involving parents in care and the experience of parents and families should be routinely evaluated and the information used to inform training and improvement.
The Department of Health (Northern Ireland) reported in June 2023 that this recommendation addressed to HSC Trusts was completed (Department of Health (Northern Ireland), Jun 2023). In its Phase 1 and Phase 2 update, the department placed the recommendation within a table of actions marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). That table heading applied collectively to 66 actions together, rather than providing a separate statement on the routine evaluation of parental involvement in care (Department of Health (Northern Ireland), Jun 2023).
Parental Involvement in Training
Parents should be involved in the preparation and provision of any such training programme.
In June 2023, the Department of Health (Northern Ireland) recorded this recommendation addressed to HSC Trusts as completed in its review of phase one and phase two inquiry recommendations (Department of Health (Northern Ireland), Jun 2023). In that same June 2023 update, the department listed the requirement for parental involvement in the preparation and provision of training programmes under a schedule of actions designated as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
SAI Investigator Training
Training in SAI investigation methods and procedures should be provided to those employed to investigate.
In June 2026, the Minister of Health, Mike Nesbitt, stated in a written parliamentary answer that the Department of Health had assessed this recommendation regarding Serious Adverse Incident investigator training as actioned under Phase 1 of the implementation programme (Mike Nesbitt, Jun 2026). The Minister noted that this position was originally outlined in a departmental update published in June 2023, which recorded the recommendation within a table of actioned Phase 1 recommendations (Department of Health (Northern Ireland), Jun 2023; Mike Nesbitt, Jun 2026).
Time for SAI Learning
Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
In June 2026, the Minister of Health, Mike Nesbitt, stated that this recommendation remains "under active consideration as part of the Department’s ongoing programme to redesign the extant SAI Procedure", with further detail to follow once he has agreed final strategic proposals (Mike Nesbitt, Jun 2026). Previously, in October 2022, the Department of Health reported that initial work had been completed and responsibility had transferred to the relevant policy area (Department of Health (Northern Ireland), Oct 2022).
Informing Teaching Authorities
Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.
The Department of Health (Northern Ireland) reported in June 2023 that this recommendation addressed to HSC Trusts had been actioned, recording its delivery status as completed (Department of Health (Northern Ireland), Jun 2023). In that June 2023 update, the department listed the measure to notify relevant teaching authorities of education inadequacies identified during reviews under its Phase 1 recommendations (Department of Health (Northern Ireland), Jun 2023).
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.
In June 2023, the Department of Health (Northern Ireland) recorded this recommendation as completed, categorising it under a schedule of Phase 1 recommendations marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). Previously, in a March 2021 written ministerial statement to the Northern Ireland Assembly, Mr Swann, Minister of Health, confirmed that the department accepted the recommendation (Mr Swann response, Mar 2021).
Executive Director Responsibilities
Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI related patient deaths.
In June 2026, the Minister of Health, Mike Nesbitt, stated that the Department of Health assessed recommendation 69(iii), on appointing and training Executive Directors with responsibility for learning from serious adverse incident patient deaths, as actioned under Phase 1 of the implementation programme (Mike Nesbitt, Jun 2026). The Minister noted that this position had been outlined in a departmental update published in June 2023 for recommendations referencing serious adverse incidents (Mike Nesbitt, Jun 2026).
Board Meeting Minutes Preservation
Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.
The Department of Health (Northern Ireland) stated in an official report update in June 2023 that the recommendation to take effective measures ensuring the preservation of board and committee meeting minutes was completed (Department of Health (Northern Ireland), Jun 2023). In its report on Phase 1 and Phase 2 progress, the department recorded this delivery status by placing the measure under a table heading marking recommendations as actioned (Department of Health (Northern Ireland), Jun 2023).
Children's Healthcare Governance
All Trust Boards should ensure that appropriate governance mechanisms are in place to assure the quality and safety of the healthcare services provided for children and young people.
In an official implementation report published in June 2023, the Department of Health (Northern Ireland) recorded this children's healthcare governance recommendation addressed to HSC Trusts as completed (Department of Health (Northern Ireland), Jun 2023). The department confirmed in June 2023 that the requirement for Trust Boards to assure the quality and safety of healthcare services for children and young people had been "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Candour in Trust Communications
All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a nominated non-executive Director.
In an October 2022 implementation update, the Department of Health (Northern Ireland) reported that this recommendation on trust communications was in progress (Department of Health (Northern Ireland), Oct 2022). The department stated in October 2022 that it was among 37 actions where "initial work has been completed" (Department of Health (Northern Ireland), Oct 2022). It noted in October 2022 that responsibility for the measure was being transferred from the inquiry implementation programme to the appropriate departmental policy area (Department of Health (Northern Ireland), Oct 2022).
GMC Code in Employment Contracts
General Medical Council ('GMC') 'Good Medical Practice' Code requirements should be incorporated into contracts of employment for doctors.
In October 2022, the Department of Health (Northern Ireland) reported that work on this recommendation was in progress under the oversight of its implementation programme team (Department of Health (Northern Ireland), Oct 2022). In that October 2022 update, the department noted that workstreams and sub-groups had concluded initial work, but "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
Professional Codes in Employment Contracts
Likewise, professional codes governing nurses and other healthcare professionals should be incorporated into contracts of employment.
In an October 2022 implementation programme statement, the Department of Health (Northern Ireland) reported that work on incorporating professional codes into employment contracts was in progress (Department of Health (Northern Ireland), Oct 2022). The department noted in October 2022 that although initial work had been completed by workstreams and sub-groups, "further work is now required to ensure appropriate implementation at service level" under the programme team's oversight (Department of Health (Northern Ireland), Oct 2022).
Independent Disciplinary Action
Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.
In October 2022, the Department of Health (Northern Ireland) reported that action on this recommendation was in progress (Department of Health (Northern Ireland), Oct 2022). The department stated in October 2022 that while initial work had been completed by workstreams and sub-groups, "further work is now required to ensure appropriate implementation at service level" under the oversight of its programme team (Department of Health (Northern Ireland), Oct 2022).
Publication of Clinical Standards
Clinical standards of care, such as patients might reasonably expect, should be published and made subject to regular audit.
In June 2023, the Department of Health (Northern Ireland) recorded this recommendation regarding the publication and regular audit of clinical standards of care as completed (Department of Health (Northern Ireland), Jun 2023). The department presented this position in June 2023 under a shared table heading designating Phase 1 recommendations as "ACTIONED", which applies collectively to sixty-six separate actions rather than providing an individual progress account for Health and Social Care Trusts (Department of Health (Northern Ireland), Jun 2023).
Trust Compliance Officer
Trusts should appoint a compliance officer to ensure compliance with protocol and direction.
The Department of Health (Northern Ireland) stated in an official report in June 2023 that the recommendation for health and social care trusts to appoint a compliance officer was complete (Department of Health (Northern Ireland), Jun 2023). In that June 2023 document covering phase one and phase two recommendations, the department listed the requirement to ensure compliance with protocol and direction in a table of actions marked "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Clinical Guidelines Audit
Implementation of clinical guidelines should be documented and routinely audited.
The Department of Health (Northern Ireland) stated in June 2023 that this recommendation, which requires HSC Trusts to document and routinely audit the implementation of clinical guidelines, was included in a table of Phase 1 recommendations marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In its published update covering Phase 1 and Phase 2 recommendations, the department recorded the delivery status for this measure as completed (Department of Health (Northern Ireland), Jun 2023).
Reporting Clinical Practice Changes
Trusts should bring significant changes in clinical practice to the attention of the HSCB with expedition.
The Department of Health (Northern Ireland) reported in June 2023 that this recommendation was completed, listing it within an official update on inquiry recommendations (Department of Health (Northern Ireland), Jun 2023). In that publication, the department placed the requirement for Health and Social Care Trusts to report clinical practice changes within a table of phase one recommendations designated as actioned (Department of Health (Northern Ireland), Jun 2023).
Healthcare Data Analysis
Trusts should ensure health care data is expertly analysed for patterns of poor performance and issues of patient safety.
The Department of Health (Northern Ireland) stated in October 2022 that delivery of this recommendation was in progress (Department of Health (Northern Ireland), Oct 2022). In the same October 2022 update, the department noted that initial work had been completed by workstreams and sub-groups, but "further work is now required to ensure appropriate implementation at service level" under the oversight of the programme team (Department of Health (Northern Ireland), Oct 2022).
Board Awareness of SAI Reports
Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.
In June 2026, Minister of Health Mike Nesbitt stated in a written parliamentary answer that five recommendations referencing Serious Adverse Incidents, including this measure, were assessed by the Department of Health as actioned under Phase 1 of the implementation programme (Mike Nesbitt, Jun 2026). In June 2023, the department had published an update that similarly recorded the recommendation as actioned (Department of Health (Northern Ireland), Jun 2023).
Policy on Learning from SAI Deaths
Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.
In June 2026, Mike Nesbitt, Minister of Health, stated that this recommendation was "under active consideration as part of the Department’s ongoing programme to redesign the extant SAI Procedure" (Mike Nesbitt, Jun 2026). The Minister noted that further detail on how it will be addressed will be available once he has considered and agreed final strategic proposals (Mike Nesbitt, Jun 2026). Previously, the Department of Health (Northern Ireland) stated in October 2022 that initial work had been completed and responsibility transferred to an internal policy area (Department of Health (Northern Ireland), Oct 2022).
SAI Deaths in Annual Reports
Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.
In June 2026, the Minister of Health, Mike Nesbitt, stated that this recommendation is "under active consideration" as part of an ongoing programme to redesign the Serious Adverse Incident procedure, with further detail to follow once he agrees final strategic proposals (Mike Nesbitt, Jun 2026). Previously, in October 2022, the Department of Health reported that initial work had been completed and transferred responsibility for the recommendation from the inquiry implementation programme to an internal policy area (Department of Health (Northern Ireland), Oct 2022).
Trust Board Review of IHRD Report
All Trust Boards should consider the findings and recommendations of this Report and where appropriate amend practice and procedure.
The Department of Health (Northern Ireland), reporting delivery progress on behalf of Health and Social Care Trusts, last addressed this recommendation in June 2023 (Department of Health (Northern Ireland), Jun 2023). In that June 2023 report, the department recorded the recommendation for trust boards to consider the inquiry findings and amend practice as completed under the phase one table heading marked "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Deputy CMO for Children's Healthcare
The Department should appoint a Deputy Chief Medical Officer with specific responsibility for children's healthcare.
The Inquiry recommended appointing a Deputy Chief Medical Officer for children's healthcare. In June 2023, the Department of Health (Northern Ireland) listed this recommendation under a table heading of Phase 1 recommendations that were "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In that June 2023 document, the department did not describe an appointment, and appointing a Deputy Chief Medical Officer is not mentioned in the sources (Department of Health (Northern Ireland), Jun 2023). It did not state in June 2023 whether any work on the recommendation remained outstanding (Department of Health (Northern Ireland), Jun 2023).
Expand RQIA Remit and Resources
The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the SAI process (ii) be strengthened in its capacity to investigate and review individual cases or groups of cases, and (iii) scrutinise adherence to duty of candour.
In its October 2022 implementation programme statement, the Department of Health (Northern Ireland) reported that work on this recommendation was in progress (Department of Health (Northern Ireland), Oct 2022). The department noted that initial work had been completed across a group of actions that included this recommendation (Department of Health (Northern Ireland), Oct 2022). It stated that it was "now appropriate to transfer responsibility" for these recommendations from the inquiry implementation programme to the relevant departmental policy area (Department of Health (Northern Ireland), Oct 2022).
Independent Medical Examiner
The Department should now institute the office of Independent Medical Examiner to scrutinise those hospital deaths not referred to the Coroner.
The Inquiry recommended establishing an independent medical examiner to review unreferred hospital deaths. In an update from October 2022, the Department of Health (Northern Ireland) stated that "A non-statutory prototype Independent Medical Examiner service is now operating across all five Health and Social Care Trusts" (Department of Health (Northern Ireland), Oct 2022). While the department described action to run this prototype across the regional trusts, its statement did not mention the scrutiny of hospital deaths not referred to the coroner (Department of Health (Northern Ireland), Oct 2022).
Child Death Overview Panel
The Department should engage with other interested statutory organisations to review the merits of introducing a Child Death Overview Panel.
The Inquiry recommended reviewing the merits of introducing a Child Death Overview Panel. In June 2023, the Department of Health (Northern Ireland) published an update on phase one and phase two recommendations from the inquiry, placing this recommendation under a table heading marked "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). However, the department's update does not describe any engagement with other interested statutory organisations, and a review of the merits of introducing such a panel is not mentioned (Department of Health (Northern Ireland), Jun 2023).
Patient Concern Organisation
The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.
The Department of Health (Northern Ireland) last addressed this recommendation in June 2023, listing the proposal to consider establishing a patient concern organisation under a table of Phase 1 recommendations marked as "ACTIONED" (Department of Health (Northern Ireland), Jun 2023). In that June 2023 document, the department recorded the delivery status of the measure on the record as completed (Department of Health (Northern Ireland), Jun 2023).
Clinical Guidance Dissemination Protocol
The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals fixed with responsibility for implementation and audit to ensure accountability. (ii) The identification of specific training requirements necessary for effective implementation.
The Department of Health (Northern Ireland) stated in an official update published on 19 June 2023 that this recommendation on the clinical guidance dissemination protocol was completed (Department of Health (Northern Ireland), Jun 2023). Within that June 2023 document covering the inquiry recommendations for phase one and phase two, the department recorded the recommendation under the table heading "ACTIONED" (Department of Health (Northern Ireland), Jun 2023).
Synchronise Patient Safety Systems
The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional information.
In June 2026, Mike Nesbitt, Minister of Health, stated that the recommendation was "under active consideration" as part of a programme to redesign the SAI procedure, with further details on how it will be addressed pending his agreement of final strategic proposals (Mike Nesbitt, Jun 2026). Previously, in October 2022, the Department of Health reported that initial work had been completed and responsibility was being transferred from the inquiry implementation programme to the relevant departmental policy area (Department of Health (Northern Ireland), Oct 2022).
Review Healthcare Standards
The Department should review healthcare standards in light of the findings and recommendations of this report and make such changes as are necessary.
The Department of Health (Northern Ireland) recorded in an official update in June 2023 that this recommendation regarding the review of healthcare standards was "ACTIONED" under its Phase 1 work (Department of Health (Northern Ireland), Jun 2023). Previously, Mr Swann, Minister of Health, confirmed in a March 2021 written ministerial statement to the Northern Ireland Assembly that the department accepted the recommendation (Mr Swann response, Mar 2021).
Review Trust Responses
The Department should review Trust responses to the findings and recommendations of this Report.
The Department of Health (Northern Ireland) stated in June 2023 that the recommendation to review Trust responses to the inquiry's findings and recommendations had been actioned (Department of Health (Northern Ireland), Jun 2023). In that June 2023 update on its progress, the department listed the requirement under the collective table heading "ACTIONED", which covered sixty-six phase one recommendations together (Department of Health (Northern Ireland), Jun 2023).
Clinical Negligence Litigation Reform
The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical negligence litigation as it presently operates might be abolished or reformed and/or whether appropriate alternatives can be recommended.
The Inquiry recommended establishing a government committee to examine reforming or abolishing clinical negligence litigation. In October 2022, the Department of Health (Northern Ireland) reported that initial work had been completed by workstreams and subgroups on twenty actions overseen by the Inquiry into Hyponatraemia-related Deaths (IHRD) Programme Team (Department of Health (Northern Ireland), Oct 2022). While the department did not specifically mention clinical negligence litigation or a review committee, it noted that "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).
Legal Privilege Protocol
Given that the public is entitled to expect appropriate transparency from a publically funded service, the Department should bring forward protocol governing how and when legal privilege entitlement might properly be asserted by Trusts.
The Department of Health (Northern Ireland) reported in October 2022 that implementation of the recommendation was in progress (Department of Health (Northern Ireland), Oct 2022). In the same October 2022 update, the department stated that initial work had been completed by workstreams and sub-groups, but "further work is now required to ensure appropriate implementation at service level" under the oversight of its programme team (Department of Health (Northern Ireland), Oct 2022).
Healthcare Litigation Standards
The Department should provide clear standards to govern the management of healthcare litigation by Trusts and the work of Trust employees and legal advisors in this connection should be audited.
The Department of Health (Northern Ireland) stated in October 2022 that work to provide litigation standards remained in progress, explaining that the recommendation formed one of 20 actions overseen by its programme team where initial work had been completed by workstreams and sub-groups (Department of Health (Northern Ireland), Oct 2022). The department added in October 2022 that "further work is now required to ensure appropriate implementation at service level" (Department of Health (Northern Ireland), Oct 2022).