Public Inquiry Recommendations

F7 Accepted in Part

Mid Staffs Inquiry (2013)

Clarity of values and principles

All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts …

- The Department of Health and Social Care and NHS England stated in April 2025 that no systematic arrangements were put in place to incorporate …

F9 Accepted in Part

Mid Staffs Inquiry (2013)

Fundamental standards of behaviour

The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers.

- The NHS Constitution, as updated in August 2023, includes a duty for staff to accept professional accountability and maintain standards set by their respective …

F10 Accepted in Part

Mid Staffs Inquiry (2013)

Fundamental standards of behaviour

The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as those produced by the National Institute for Health …

- In April 2025, DHSC and NHS England stated that this recommendation was closed and referred to the 2024 standards of business conduct policy (DHSC …

F14 Accepted in Part

Mid Staffs Inquiry (2013)

The nature of standards

In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance with fundamental standards, and the provision and publication …

- NHS England and the Care Quality Commission published new well-led guidance for NHS trusts and foundation trusts under the Single Assessment Framework in April …

F15 Accepted in Part

Mid Staffs Inquiry (2013)

The nature of standards

All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it …

- An academic review in February 2023 noted that the Care Quality Commission (CQC) inspection regime was overhauled to include a 'Well-led' domain, which assesses …

F17 Accepted in Part

Mid Staffs Inquiry (2013)

Responsibility for setting standards

The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. Failure to comply with such standards should be …

- Integrated Care Boards (ICBs) replaced Clinical Commissioning Groups on 1 July 2022, assuming responsibility for population health and NHS commissioning (Health and Care Act …

F20 Accepted in Part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the indicators by which it intends to monitor compliance …

- The Department of Health and Social Care and NHS England stated in April 2025 that CQC fundamental standards are in place and mapped to …

F21 Accepted in Part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 introduced a statutory duty of candour for NHS bodies (The Health and Social …

F22 Accepted in Part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical means of compliance, and indicators by which compliance …

- The Department of Health and Social Care stated in April 2025 that a Memorandum of Understanding between NICE and the Care Quality Commission, dated …

F33 Accepted in Part

Mid Staffs Inquiry (2013)

Interim measures

Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.

- The government introduced the special measures regime for trusts following the Francis Inquiry (Culture Change in the NHS, Cm 9009, February 2015). - The …

F34 Accepted in Part

Mid Staffs Inquiry (2013)

Interim measures

Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.

- The Department of Health and Social Care stated in April 2025 that the Recovery Support Programme (RSP) provides a collaborative approach for supporting trusts …

F39 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Complaints

The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.

- The Care Quality Commission stated in April 2025 that it no longer uses mandated Provider Information Returns for healthcare providers, except in the Adult …

F41 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Patient safety alerts

The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement …

- NHS England established a redesigned National Patient Safety Alert (NatPSA) system, overseen by the National Patient Safety Alerting Committee (NaPSAC) (NHS England Patient Safety …

F44 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Media

Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for …

- The Department of Health and Social Care stated in April 2025 that the function of examining individual serious incidents has largely transferred to the …

F45 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Inquests

The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.

- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation was superseded by the statutory medical examiner …

F48 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees

The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Care Quality Commission involves governors in inspections and …

F59 Accepted in Part

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of …

- The Department of Health and Social Care stated in April 2025 that the Care Quality Commission is considering its response to the recommendation for …

F60 Accepted in Part

Mid Staffs Inquiry (2013)

Consolidation of regulatory functions

The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established a duty for trusts to ensure directors meet fit and proper person …

F75 Accepted in Part

Mid Staffs Inquiry (2013)

Enhancement of role of governors

The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its …

- The government stated in its 2013 response that it would not seek to prescribe how governors should work day-to-day and that regulators would not …

F79 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established the 'fit and proper person' requirement for directors (Health …

F80 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 mandates that directors must not have been responsible for, or …

F84 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is …

- NHS England published a standardised board member reference template in August 2023 as part of the Fit and Proper Person Test Framework (Fit and …

F87 Accepted in Part

Mid Staffs Inquiry (2013)

Ensuring the utility of a health and safety function in a clinical setting

The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should be given power to prosecute 1974 Act offences …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 granted the Care Quality Commission powers to prosecute providers for breaches related to …

F88 Accepted in Part

Mid Staffs Inquiry (2013)

Information sharing

The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order …

- The Care Quality Commission and the Health and Safety Executive (HSE) maintain a Memorandum of Understanding (MoU) that covers the sharing of statutory notifications, …

F89 Accepted in Part

Mid Staffs Inquiry (2013)

Information sharing

Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.

- The Patient Safety Incident Response Framework (PSIRF), which became mandatory for NHS-funded secondary care providers in Autumn 2023, requires patient safety incident reports to …

F91 Accepted in Part

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority …

- The Department of Health and Social Care stated in April 2025 that NHS Resolution has moved away from assessment against risk management standards (DHSC …

F93 Accepted in Part

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based …

- The Department of Health and Social Care stated in April 2025 that NHS Resolution considers staffing and activity levels in maternity care by incorporating …

F97 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this valuable function to a systems regulator.

- The National Patient Safety Agency (NPSA) was abolished and its functions were transferred to the NHS Commissioning Board (NHS England) on 1 June 2012 …

F98 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part …

- The Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS) for recording and analyzing patient safety events (Learn …

F99 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has …

- The Learn from Patient Safety Events (LFPSE) service uses machine learning to analyze safety events and includes recording forms for primary care settings (Learn …

F100 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that …

- In April 2025, DHSC and NHS England stated that the designation of 'serious incident' had been abolished and replaced by the Learn from Patient …

F115 Accepted in Part

Mid Staffs Inquiry (2013)

Investigations

Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward …

- The Health Services Safety Investigations Body (HSSIB) was established as an independent statutory body in October 2023 to conduct system-focused patient safety investigations (Health …

F117 Accepted in Part

Mid Staffs Inquiry (2013)

Support for complainants

A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.

- The Department of Health and Social Care stated in April 2025 that local authorities are required under the Local Government and Public Involvement in …

F118 Accepted in Part

Mid Staffs Inquiry (2013)

Learning and information from complaints

Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In …

- The Department of Health and Social Care stated in April 2025 that it had not taken forward the recommendation to publish summaries of every …

F120 Accepted in Part

Mid Staffs Inquiry (2013)

Learning and information from complaints

Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This …

- The Department of Health and Social Care stated in April 2025 that GP practices are required to produce annual complaint reports and provide them …

F122 Accepted in Part

Mid Staffs Inquiry (2013)

Handling large-scale complaints

Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to very distressed and anxious members of the public; …

- The Department of Health and Social Care stated in April 2025 that the government had rejected part of this recommendation in the 2013 'Hard …

F124 Accepted in Part

Mid Staffs Inquiry (2013)

Duty to require and monitor delivery of fundamental standards

The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in respect of each item of service it is …

- The NHS Standard Contract 2024/25 includes service condition 37, which allows commissioners and providers to agree on local quality requirements and enhanced standards (DHSC …

F133 Accepted in Part

Mid Staffs Inquiry (2013)

Role of commissioners in complaints

Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, …

- The Parliamentary and Health Service Ombudsman (PHSO) introduced the NHS Complaint Standards in 2022 to provide a consistent approach to complaint handling across the …

F135 Accepted in Part

Mid Staffs Inquiry (2013)

Public accountability of commissioners and public engagement

Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should …

- The Health and Care Act 2022 established Integrated Care Boards (ICBs) to replace Clinical Commissioning Groups (Health and Care Act 2022). - DHSC and …

F141 Accepted in Part

Mid Staffs Inquiry (2013)

Taking responsibility for quality

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 …

- The Health Services Safety Investigations Body (HSSIB) was launched in October 2023 as an independent statutory body with powers of entry, inspection, and seizure …

F146 Accepted in Part

Mid Staffs Inquiry (2013)

Finance and oversight of Local Healthwatch

Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the …

- The government stated in November 2013 that it did not accept that local authorities should be required to pass over centrally provided funds, leaving …

F150 Accepted in Part

Mid Staffs Inquiry (2013)

Inspection powers

Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger …

- DHSC stated in April 2025 that this recommendation has not yet been actioned (DHSC/NHS England implementation update to the Thirlwall Inquiry, April 2025). - …

F151 Accepted in Part

Mid Staffs Inquiry (2013)

Complaints to MPs

MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns …

- DHSC stated in April 2025 that this recommendation has not yet been actioned and provided no further update (DHSC/NHS England implementation update to the …

F153 Accepted in Part

Mid Staffs Inquiry (2013)

Medical training

The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between …

- The DHSC and NHS England stated in April 2025 that implementation was ongoing and that action taken following the Inquiry had been reviewed (DHSC …

F164 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision …

- DHSC and NHS England stated in April 2025 that Approved Practice Setting requirements were introduced by the GMC in June 2014 (DHSC/NHS England implementation …

F165 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public.

- DHSC and NHS England stated in April 2025 that the GMC introduced Approved Practice Setting requirements in June 2014 (DHSC/NHS England implementation update to …

F166 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view …

- DHSC and NHS England stated in April 2025 that the GMC introduced Approved Practice Setting requirements in June 2014 (DHSC/NHS England implementation update to …

F167 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments …

- DHSC and NHS England stated in April 2025 that the GMC embedded Approved Practice Setting arrangements within the Responsible Officer Regulations in June 2014, …

F168 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for …

- DHSC and NHS England stated in April 2025 that the Approved Practice Setting scheme was incorporated into the regulatory framework via the Responsible Officer …

F169 Accepted in Part

Mid Staffs Inquiry (2013)

Role of the Department of Health and the National Quality Board

The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation …

- DHSC and NHS England stated in April 2025 that a Patient Safety Syllabus and associated training courses have been published for providers and regulators …