Recommendation F290: Experience on the front line
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making information publicly available about performance at the most detailed level possible.
In brief (written by this site)
In commentary published in February 2026, the Department of Health and Social Care and NHS England reported that, as of September 2024, measures in place to increase transparency around care deficiencies included the organizational duty of candour, the Patient Safety Incident Response Framework, and national clinical audits (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and highlighted its initial transparency measures (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 respect of deficiencies wherever they come in the health and care system, the Department of Health needs to be explicitly and clearly on the side of patients and the public. We have put in place a number of measures to increase transparency in the NHS including the duty of candour on organisations, and the appointment of Chief Inspectors of Hospitals, Primary Care and Adult Social Care. These measures will help to identify poor practice, increase public accountability and, while for some the exposure of failings in care will be difficult, over the long-term we expect these measures will increase public trust in health and care organisations.
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)
A number of measures are in place to increase transparency in the NHS around deficiencies in care including the duty of candour on organisations, a national learning from deaths policy (with public reporting on deaths thought to be due to problems in care), publication of reported patient safety incidents, the Patient Safety Incident Response Framework (PSIRF) and CQC inspection reports. These increase public and patient accountability.
Further, the National Clinical Audit and Patient Outcomes Programme (NCAPOP) audits are commissioned and managed on behalf of NHS England by the Healthcare Quality Improvement Partnership (HQIP). The programme comprises more than 30 national audits related to some of the most commonly-occurring conditions. These collect and analyse data supplied by local clinicians to provide a national picture of care standards for that specific condition. On a local level, NCAPOP audits provide local trusts with individual benchmarked reports on their compliance and performance, feeding back comparative findings to help participants identify necessary improvements for patients. As well as the 30-plus national clinical audits, NCAPOP also encompasses the four Clinical Outcome Review Programmes (CORP). These help assess the quality of healthcare and stimulate improvement by enabling clinicians, managers and policy makers to learn from adverse events and other relevant data
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. 290, PDF page 579.
Department of Health and Social Care says in progress (11 February 2015)
The Department and the national organisations for the NHS have continued to put in place a number of measures to ensure that there is widespread transparency for patients and the public. The ‘my NHS’ website is providing more detailed, comparative information for patients and the public than ever before. The duty of candour will form part of the Fundamental Standards, and comes into force for NHS bodies in November 2014 and apply to all providers of health and care services registered by the Care Quality Commission from April 2015.
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.
The tracker describes this as a long-term recommendation: systemic or cultural, with no single completion point.
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 referred to the various measures it had put in place to increase transparency in the NHS, including the duty of candour.
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. 290, PDF page 531.
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