Recommendation 41: Guidance for external service reviews
From Report of the Morecambe Bay Investigation, published 3 March 2015.
Recommendation
We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS Foundation Trust. We recommend that systematic guidance be drawn up setting out an appropriate framework for external reviews and professional responsibilities in undertaking them. Action: the Academy of Medical Royal Colleges, the Royal College of Nursing, the Royal College of Midwives.
In brief (written by this site)
In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, following the Academy of Medical Royal Colleges publishing an updated framework for invited reviews in March 2022 (Academy of Medical Royal Colleges, Mar 2022; DHSC and NHS England, Feb 2026). They stated that the guidance provides operating principles for professional bodies conducting reviews across healthcare organisations and should improve the escalation of issues and disclosure to regulators (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
Sources
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
109. We accept this recommendation, and there are actions in train, which go some way to meeting it. For example, the Serious Incident Framework published by NHS England and updated in March 2015, sets out details of when and how investigations – including independent investigations - should be undertaken. 110. As noted earlier, the Government are accepting the Public Administration Select Committee's recommendation to establish an independent patient safety investigation function for the NHS, and will be taking this forward in the coming months (the Independent Patient Safety Investigation Service). One of the tasks will be to work with stakeholders to consider how the new function will operate alongside and complement existing bodies that relate to NHS organisations and this will include organisations that may be carrying out other reviews (including professional and external reviews).
How this response relates to the recommendation
Site note: This is the Department of Health's response, "Learning not blaming" (Cm 9113, July 2015), to the Morecambe Bay Investigation and two other reports. The department has been the Department of Health and Social Care since January 2018, and the rows are filed under that name. Every word is the department's, including where it reports what another body has done or will do.
Site note: The recommendation is addressed to the Academy of Medical Royal Colleges; the passage is the Department of Health's account, not that body's.
Delivery
DHSC and NHS England say completed (27 February 2026)
The Thirlwall Inquiry has noted action taken in response to this recommendation.
In response to this recommendation, the Academy of Royal Colleges published their updated invited review framework in March 2022. It provides a framework of operating principles for royal colleges and other professional bodies (reviewing organisations) when undertaking invited reviews on behalf of healthcare organisations across the UK. The framework should lead to an improvement in the disclosure of reports to CQC and escalation of issues.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Closed”. Table row: section 23.2 No. 41, PDF page 655-656.
Academy of Medical Royal Colleges says completed (1 March 2022)
This document replaces the earlier version published in 2016. It provides a framework
of operating principles for royal colleges and other professional bodies (reviewing
organisations) when undertaking invited reviews on behalf of healthcare organisations
across the UK.
From: Managing invited reviews within healthcare: a framework of operating principles
Site note: The Academy of Medical Royal Colleges' framework for invited reviews, whose Background quotes this recommendation. The document gives only its month (March 2022, "Revised February 2022"), so the row is dated the first of that month. It replaces a first version published in 2016, which the site has not read.
Department of Health and Social Care says in progress (2 March 2020)
NHS England and NHS Improvement have agreed to establish an advisory function for independent reviews which they sponsor, commission or oversee. This will advise on the establishment and best practice management of these types of reviews.
From: NHS Trusts: Reviews (written question UIN 20428)
Site note: Written answer of 2 March 2020 by Nadine Dorries for the Department of Health and Social Care. The question cites the Morecambe Bay Investigation report and asks what has been done on this recommendation. The recommendation is addressed to the Academy of Medical Royal Colleges, the Royal College of Nursing and the Royal College of Midwives; this is the Department's answer, not theirs.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
Department of Health response (July 2015):
Accepted in principle.
“… there are actions in train, which go some way to meeting it. For example, the Serious Incident Framework published by NHS England and updated in March 2015, sets out details of when and how investigations – including independent investigations - should be undertaken.
As noted earlier, the Government are accepting the Public Administration Select Committee’s recommendation to establish an independent patient safety investigation function for the NHS … we will be taking this forward … One of the tasks will be …to consider how the new function will operate alongside and complement existing bodies that relate to NHS … organisations that may be carrying out other reviews (including professional and external reviews).” (p. 95)
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 20.2 No. 41, PDF page 620-621.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Academy of Medical Royal Colleges
Delivery statement - Thirlwall Inquiry legal team
Finding