Recommendation F141: Taking responsibility for quality
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its retained individual responsibility to take whatever action within its power is necessary in the interests of patient safety.
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NHS England referred to their update on the Patient Safety Incident Response Framework, considering the recommendation superseded (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found that the government had accepted the recommendation in principle, citing mechanisms under the NHS Standard Contract and regulatory powers enabling intervention when patient safety is at risk (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.
About this summary
This recommendation asks for cultural or behavioural change, which is difficult to verify from published sources alone. The record reflects policy commitments rather than measured outcomes.
Government response
Accepted in principle.
Commissioners and regulators should have clear and distinct roles in ensuring the safety of people who use services and should act swiftly where patients are at risk. Local and regional Quality Surveillance Groups actively share information and intelligence, including qualitative intelligence, including issues and cases of media and public interest, between commissioners, regulators and other organisations on the quality of care being delivered. This provides a mechanism to share and discuss safety concerns between commissioners and regulators. In addition to the coordinated process outlined in recommendation 19 as part of the single failure regime, the NHS Standard Contract enables commissioners to intervene where substandard or unsafe services are being provided. This includes the ability to suspend services, or elements of them, and terminate contracts. See recommendation 137 for further details.
In addition, the Care Quality Commission will retain its ability to stop a service from providing care if it is putting people at immediate risk of harm as outlined by the Health and Social Care Act 2008. The Act states that where the Care Quality Commission has ‘reasonable cause’ to believe that unless it acts people may be exposed to the risk of harm, it may impose or vary a condition of a provider’s registration or suspend it from the point written notice is given as part of an urgent response.
In addition, subject to the passage of regulations, during 2014 the Care Quality Commission will also have new powers to prosecute a provider for failing to provide fundamental levels of care, without having to issue a formal warning first. See recommendation 28 for further details.
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 state no delivery position (27 February 2026)
Please see response to recommendation 26 above for information on the Patient Safety Framework and Patient safety Incident Response Framework
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 “Superseded”. Table row: section 18.2 No. 141, PDF page 491-492.
Department of Health and Social Care states no delivery position (11 February 2015)
No further update is required. Please see response to the recommendation in Hard Truths
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 in principle by the Government.
In the January 2014 Hard Truths report, the Government said that commissioners and regulators should have clear and distinct roles. The Government referred to commissioners’ ability to share information and discuss safety concerns with regulators, as well as intervene under the NHS Standard Contract where substandard or unsafe services are being provided.
The Care Quality Commission was to retain its ability to stop a service from providing care, impose conditions on a provider’s registration or suspend it.
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. 141, PDF page 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