Recommendation F139: The need to put patients first at all times
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient safety and quality standards are being met. Such an organisation must require convincing evidence to be available before accepting that such standards are being complied with.
In brief (written by this site)
The Department of Health and Social Care and NHS England stated in September 2024 that fundamental standards were in place with Care Quality Commission enforcement powers mapped to Quality Statements within the Single Assessment Framework, though the regulator does not enforce enhanced standards (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had historically relied on provider licensing, registration, and inspection regimes to provide assurance (The Thirlwall Inquiry legal team, May 2024).
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
Accepted.
Registration by the Care Quality Commission and Monitor’s licencing of providers gives an assurance to commissioners that a provider meets fundamental standards of care. The NHS Standard Contract provides a framework for commissioners to receive on-going assurance on compliance with standards, through its routine performance management processes.
How this response relates to the recommendation
Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.
Blanket government agreement does not establish acceptance or delivery by each addressee. Some response passages cover groups of recommendations.
Scope of the government 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.
Delivery
DHSC and NHS England say in progress (27 February 2026)
Fundamental standards are in place and CQC has enforcement powers in relation to them. They are mapped to Quality Statements within the Single Assessment Framework. CQC look at the accuracy of information, governance systems and how the provider considers standards / best practice recommendations above the fundamental standards of care, but do not enforce ('police') against any enhanced standards.
Please see response to recommendation 28 and 138 for information on the NHS Oversight Framework and 137 in respect of the provisions of the Standard Contract.
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 – Ongoing”. Table row: section 18.2 No. 139, PDF page 491.
Department of Health and Social Care says in progress (11 February 2015)
The Care Quality Commission’s new-style inspections involve larger teams and more in depth inspections. These inspections against the new fundamental standards of care, provide greater clarity on a hospital’s performance and show where improvements are required, if necessary.
Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.
Site note: The Inquiry addressed this recommendation to NHS England, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was accepted by the Government.
In the January 2014 Hard Truths report, the Government said that registration by the Care Quality Commission and Monitor’s licensing of providers would give assurance to commissioners that a provider meets fundamental standards of care. Further, the NHS Standard Contract would provide a framework for commissioners to receive ongoing assurance on compliance with standards. In the February 2015 Culture Change report, the Government said that further assurance would be given by the Care Quality Commission’s new inspection regime.
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 does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 139, PDF page 457-458.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding