Public Inquiry Recommendations

F51 Accepted

Mid Staffs Inquiry (2013)

Enhancement of monitoring and the importance of inspection

The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by …

- The government stated in Hard Truths (November 2013) that CQC would develop specialist inspection teams led by trained inspectors, including clinicians, other experts, and …

F52 Accepted

Mid Staffs Inquiry (2013)

Enhancement of monitoring and the importance of inspection

The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.

- CQC conducts Joint Targeted Area Inspections (JTAIs) alongside Ofsted, HMICFRS, and HM Inspectorate of Probation. These unannounced joint inspections evaluate the multi-agency response to …

F53 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.

- The government stated in Hard Truths (November 2013) that it would retain CQC and reform it rather than replace it, consistent with this recommendation …

F54 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the …

- The government stated in Hard Truths (November 2013) that CQC's independence would be strengthened and that relationships between CQC and other bodies would be …

F55 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined …

- CQC undertook a comprehensive review of its processes following the Francis Report. The new inspection regime launched from October 2014 replaced the previous compliance-based …

F56 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have …

- CQC published a series of "A fresh start" strategy documents in October 2013 setting out its new approach to regulation and inspection by sector, …

F57 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the …

- CQC developed "Intelligent Monitoring" reports from March 2014, which brought together over 150 indicators for acute NHS trusts to help identify where risks to …

F58 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council …

- CQC's Experts by Experience programme integrates people with personal experience of using health and social care services into inspection teams. Experts by Experience conduct …

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 …

- CQC's board composition is governed by Schedule 1 to the Health and Social Care Act 2008, which provides for a Chair and non-executive members …

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 Fit and Proper Person Requirement (Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014) came into force in …

F61 Not Accepted

Mid Staffs Inquiry (2013)

Consolidation of regulatory functions

A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a …

- The government did not merge the system regulatory functions of Monitor and CQC as Francis recommended. Instead, it maintained CQC as an independent quality …

F62 Accepted

Mid Staffs Inquiry (2013)

Improved patient focus

For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is …

- Monitor merged with the NHS Trust Development Authority to form NHS Improvement on 1 April 2016. NHS Improvement subsequently merged into NHS England from …

F63 Accepted

Mid Staffs Inquiry (2013)

Improved transparency

Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.

- Monitor's Risk Assessment Framework (revised August 2015) described how it assessed foundation trust compliance with licence conditions. Monitor assigned quarterly risk ratings for finance …

F64 Not Accepted

Mid Staffs Inquiry (2013)

Authorisation of foundation trusts

The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public …

- The government did not transfer the foundation trust authorisation process to CQC as Francis recommended. Instead, it maintained separate roles: CQC assessed quality and …

F65 Accepted

Mid Staffs Inquiry (2013)

Quality of care as a pre-condition for foundation trust applications

The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support …

- The NHS Trust Development Authority, established in 2012, oversaw NHS trusts that had not achieved foundation trust status. The TDA merged into NHS Improvement …

F66 Accepted

Mid Staffs Inquiry (2013)

Improving contribution of stakeholder opinions

The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is …

- The government stated in Hard Truths (November 2013) that it would strengthen the foundation trust application process, including stakeholder consultation (Hard Truths Vol 1, …

F67 Accepted

Mid Staffs Inquiry (2013)

Focus on compliance with fundamental standards

The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as …

- The NHS Trust Development Authority oversaw NHS trusts and was responsible for supporting and assessing potential foundation trust applicants. The TDA merged into NHS …

F68 Accepted

Mid Staffs Inquiry (2013)

Focus on compliance with fundamental standards

No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of …

- Strategic Health Authorities were abolished on 1 April 2013 under the Health and Social Care Act 2012. Their performance management functions transferred to the …

F69 Accepted

Mid Staffs Inquiry (2013)

Focus on compliance with fundamental standards

The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality standards at the same time as complying with …

- The NHS provider licence, which replaced foundation trusts' Terms of Authorisation from 1 April 2013, includes Condition FT4 (Governance) requiring providers to demonstrate clear …

F70 Accepted

Mid Staffs Inquiry (2013)

Duty of utmost good faith

A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant information material to the application and to ensure …

- Regulation 17(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires providers to submit written reports to CQC within 28 …

F71 Accepted

Mid Staffs Inquiry (2013)

Role of Secretary of State

The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a service to patients which is, at the time …

- The foundation trust application pipeline was effectively closed by 2014, with most applications paused or deferred. No further trusts were authorised as foundation trusts …

F72 Accepted

Mid Staffs Inquiry (2013)

Assessment process for authorisation

The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas as well as all wards to determine whether …

- The foundation trust application pipeline was effectively closed by 2014. No published evidence has been identified that a specific requirement for full physical inspection …

F73 Accepted

Mid Staffs Inquiry (2013)

Need for constructive working with other parts of the system

The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with the Department of Health and whether the appropriate …

- The government stated in Hard Truths (November 2013) that it would strengthen the accountability and performance management of arm's-length bodies including Monitor and CQC …

F74 Accepted

Mid Staffs Inquiry (2013)

Enhancement of role of governors

Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation to account to the public, and in particular …

- Monitor published "Your Statutory Duties: A Reference Guide for NHS Foundation Trust Governors" in August 2013, updated November 2013. This guide sets out governors' …

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 …

- Section 151 of the Health and Social Care Act 2012 strengthened the role of councils of governors. New paragraph 10C inserted into Schedule 7 …

F76 Accepted

Mid Staffs Inquiry (2013)

Enhancement of role of governors

Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large – it is important that regular and constructive …

- Section 151 of the Health and Social Care Act 2012 strengthened governor accountability by requiring councils of governors to hold non-executive directors to account …

F77 Accepted

Mid Staffs Inquiry (2013)

Enhancement of role of governors

Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and …

- NHS Providers (formerly the Foundation Trust Network) operates the GovernWell programme, established in 2013, providing national training and support for NHS foundation trust governors. …

F78 Accepted

Mid Staffs Inquiry (2013)

Enhancement of role of governors

The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in relation to compliance with healthcare standards as will …

- Section 39A of the National Health Service Act 2006 (inserted by the Health and Social Care Act 2012) provides for a panel to consider …

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 introduced the Fit and Proper Person Requirement, in force from …

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 …

- The model core constitution for NHS foundation trusts, published by Monitor in May 2013 and updated in September 2014, includes disqualification criteria for directors. …

F81 Accepted

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires that directors possess "the qualifications, competence, skills and experience …

F82 Accepted

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom the regulator is satisfied is not or is …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 provides that CQC can require the removal of directors who …

F83 Accepted

Mid Staffs Inquiry (2013)

Accountability of providers' directors

If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would exercise its power to require the removal or …

- CQC published guidance on Regulation 5 (Fit and Proper Persons: Directors) setting out the requirements that providers must meet and the approach CQC takes …

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 …

- The NHS England FPPT Framework (effective September 2023) mandates that organisations complete a Board Member Reference (BMR) when any board member leaves their position, …

F85 Accepted

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event of an executive or non-executive director being found …

- CQC published guidance on Regulation 5 (Fit and Proper Persons: Directors) setting out the circumstances in which directors may be found not to meet …

F86 Accepted

Mid Staffs Inquiry (2013)

Requirement of training of directors

A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.

- The NHS Leadership Academy provides multiple board-level development programmes including the Nye Bevan Programme (12-month programme for aspiring board members), the Aspiring Chief Executive …

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 …

- CQC was given powers to prosecute for offences of ill-treatment or wilful neglect of individuals by care providers or care workers under sections 20 …

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 …

- HSE and CQC published a memorandum of understanding setting out arrangements for information sharing between the two organisations. Under the MoU, HSE shares information …

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.

- HSE and CQC published a memorandum of understanding (most recently revised 2014) providing for reciprocal information sharing. Under the MoU, CQC shares serious incident …

F90 Accepted

Mid Staffs Inquiry (2013)

Assistance in deciding on prosecutions

In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences for any victims, that the public interest requires …

- HSE published guidance on the selection and management of expert witnesses in enforcement proceedings, including healthcare-related cases. HSE uses expert medical and clinical advisors …

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 …

- NHS Resolution (formerly the NHS Litigation Authority, renamed in April 2017) operates three risk management schemes: the Clinical Negligence Scheme for Trusts (CNST), the …

F92 Accepted

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.

- NHS Resolution (formerly the NHS Litigation Authority) operated a Clinical Risk Management Standards (CRMS) assessment scheme with three levels, where trusts assessed at level …

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 …

- NICE published safe staffing guidance SG1 (Safe staffing for nursing in adult inpatient wards in acute hospitals) in July 2014, directly in response to …

F94 Accepted

Mid Staffs Inquiry (2013)

Evidence-based assessment

As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider …

- NHS Resolution (formerly the NHS Litigation Authority, renamed April 2017) maintains a claims management database covering all CNST claims. The NHS Resolution annual report …

F95 Accepted

Mid Staffs Inquiry (2013)

Information sharing

As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed over risk reports, consideration should also be given …

- NHS Resolution shares claims data and risk information with CQC. The NHS Resolution annual report (2023-24) states that the organisation works with CQC and …

F96 Accepted

Mid Staffs Inquiry (2013)

Information sharing

The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of its standards assessments and of the reliance which …

- NHS Resolution (formerly the NHS Litigation Authority) discontinued the three-level Clinical Risk Management Standards (CRMS) assessment programme. The CRMS assessments were the "standards assessments" …

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 on 1 June 2012. Its patient safety functions, including the National Reporting and Learning System, were …

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 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20 (duty of candour), requires registered providers to act in an open …

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, which replaced the National Reporting and Learning System (NRLS, decommissioned June 2024), was specifically designed to …

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 …

- The Learn from Patient Safety Events (LFPSE) service accepts reports from individual staff members as well as organisational reporters. Individual clinicians or other healthcare …