Recommendation F225: Peer reviews
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic way, in order to be advised whether there are individual concerns. Such reviews could be jointly commissioned with the Care Quality Commission in appropriate cases.
In brief (written by this site)
In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the General Medical Council works alongside other regulators through the Joint Strategic Oversight Group to share intelligence and develop aligned approaches (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and that the council had previously undertaken to explore joint ownership of generic issues (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.
The General Medical Council has made it clear that it is determined to work with others to explore the development of appropriate forms of joint ownership of generic issues, so that unacceptable patient care is identified and dealt with effectively. This may include (but need not be confined to) peer reviews.
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)
NHS England continues to work alongside key regulators, CQC, Health and Care Professions Council, General Medical Council and the Nursing & Midwifery Council through the Joint Strategic Oversight Group (JSOG) function to provide a dedicated space for regulators to share intelligence and develop aligned approaches to support organisations.
The GMC set out how they handle complaints made on their website.
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. 225, PDF page 541.
Department of Health and Social Care says in progress (11 February 2015)
The General Medical Council contributes to the identification and investigation of system or generic concerns by means of its Operational Protocol with the Care Quality Commission and the development of information sharing agreements with other systems regulators. In addition, it shares information with, and participates in, Regional Quality Surveillance Groups and Risk Summits.
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 the General Medical Council, 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.
The Government said in the January 2014 Hard truths report that the General Medical Council had made it clear that it was determined to work with others to explore the development of appropriate forms of joint ownership of generic issues, which could include peer reviews.
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. 225, PDF page 501.
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