Public Inquiry Recommendations

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- The Department of Health and Social Care stated in April 2025 that this recommendation has been superseded by the current inspection regime (DHSC and …

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 Department of Health and Social Care stated in April 2025 that it holds quarterly accountability meetings with the Care Quality Commission, including half-yearly …

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 …

- NHS England stated in April 2025 that it published an updated reference guide for governors in 2022 to explain changes in the NHS landscape …

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 …

- The National Service Act 2006, as amended, establishes a statutory duty for councils of governors to represent the interests of trust members and the …

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 England published an updated Code of Governance for NHS provider trusts in April 2023, which requires governors to receive appropriate induction and regular …

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 …

- The Care Quality Commission published guidance for foundation trust governors in 2019 to assist them in carrying out their duties regarding healthcare standards (Guidance …

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 established requirements for directors to possess the qualifications, competence, skills, …

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 …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 5) allows the Care Quality Commission to take enforcement action against a …

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 …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 came into force in November 2014, establishing the fitness requirements …

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 …

- NHS England published the Fit and Proper Person Test Framework in August 2023, which outlines procedures for assessing directors and handling cases of non-compliance …

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.

- NHS England published an updated Code of Governance for NHS provider trusts in April 2023, stating that all directors should receive appropriate induction and …

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 …

- The Department of Health and Social Care stated in April 2025 that a Memorandum of Understanding (MoU) exists between the Care Quality Commission (CQC) …

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.

- The Department of Health and Social Care stated in April 2025 that NHS Resolution no longer uses the previous levels of risk management standards …

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 …

- The Department of Health and Social Care stated in April 2025 that a best practice guide was published in 2021 to assist trusts in …

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 …

- The Department of Health and Social Care stated in April 2025 that NHS Resolution shares relevant information with the Care Quality Commission as part …

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 …

- The Department of Health and Social Care stated in April 2025 that the NHS Litigation Authority previously included an explanation of the limitations of …

F101 Accepted

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it should be possible to organise for mutual peer …

- In April 2025, DHSC and NHS England stated that NHS England hosts Patient-led Assessments of the Care Environment (PLACE) where local people assess hospital …

F102 Accepted

Mid Staffs Inquiry (2013)

Transparency use and sharing of information

Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others facilitated in that task.

- In April 2025, DHSC and NHS England stated that incident data is open to analysis via the LFPSE service, which includes an online service …

F103 Accepted

Mid Staffs Inquiry (2013)

Transparency use and sharing of information

The National Patient Safety Agency or its successor should regularly share information with Monitor.

- In April 2025, DHSC and NHS England stated that this recommendation was superseded because NHS England is the successor to both the National Patient …

F104 Accepted

Mid Staffs Inquiry (2013)

Transparency use and sharing of information

The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency or its successor to assist it in identifying …

- In April 2025, DHSC and NHS England stated that patient safety incident reports are provided to the Care Quality Commission (DHSC and NHS England …

F105 Accepted

Mid Staffs Inquiry (2013)

Transparency use and sharing of information

Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.

- In April 2025, DHSC and NHS England stated that mortality information is triangulated via the Learning from Deaths policy and a dashboard for NHS …

F106 Accepted

Mid Staffs Inquiry (2013)

Health Protection Agency Coordination and publication of providers' information on healthcare associated infections

The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation to healthcare associated infections, working with the Health …

- In April 2025, DHSC and NHS England stated that the UK Health Security Agency (UKHSA) collects and publishes data on hospital and community-acquired infections …

F107 Accepted

Mid Staffs Inquiry (2013)

Sharing concerns

If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider's management of healthcare associated infections is …

- In April 2025, DHSC and NHS England stated that UKHSA regional teams lead responses to health-related incidents and provide specialist input to local authorities …

F108 Accepted

Mid Staffs Inquiry (2013)

Support for other agencies

Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers' infection …

- The Department of Health and Social Care and NHS England stated in April 2025 that the review of support and training for local oversight …

F109 Accepted

Mid Staffs Inquiry (2013)

Effective complaints handling

Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, …

- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 require NHS bodies and primary care providers to publicise their complaints …

F110 Accepted

Mid Staffs Inquiry (2013)

Lowering barriers

Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may be prudent for parties in actual or potential …

- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 do not prohibit parallel litigation and complaint investigations (The Local Authority …

F111 Accepted

Mid Staffs Inquiry (2013)

Lowering barriers

Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually …

- NHS England maintains the Friends and Family Test (FFT) as a continuous feedback tool for patients to rate their experience of NHS services (Friends …

F112 Accepted

Mid Staffs Inquiry (2013)

Lowering barriers

Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as …

- The Parliamentary and Health Service Ombudsman defines a complaint as any expression of dissatisfaction, whether spoken or written, that requires a response (NHS Complaint …

F113 Accepted

Mid Staffs Inquiry (2013)

Complaints handling

The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.

- The Department of Health and Social Care and NHS England stated in April 2025 that the PHSO NHS Complaint Standards address the requirements for …

F114 Accepted

Mid Staffs Inquiry (2013)

Complaints handling

Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.

- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 mandate that NHS bodies investigate and respond to complaints regarding health …

F116 Accepted

Mid Staffs Inquiry (2013)

Support for complainants

Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Independent NHS Complaints Advocacy Service supports individuals wishing …

F119 Accepted

Mid Staffs Inquiry (2013)

Learning and information from complaints

Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.

- The Department of Health and Social Care stated in April 2025 that Local Healthwatch can access annual complaint reports by requesting them from NHS …

F121 Accepted

Mid Staffs Inquiry (2013)

Learning and information from complaints

The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints …

- The Care Quality Commission (CQC) stated in April 2025 that it uses Regulation 16(3) of the Health and Social Care Act 2008 (Regulated Activities) …

F123 Accepted

Mid Staffs Inquiry (2013)

Responsibility for monitoring delivery of standards and quality

GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the …

- NHS England issued national guidance on System Quality Groups (SQGs) in January 2022 to facilitate intelligence-sharing and learning between all organisations in an integrated …

F125 Accepted

Mid Staffs Inquiry (2013)

Responsibility for requiring and monitoring delivery of enhanced standards

In addition to their duties with regard to the fundamental standards, commissioners should be enabled to promote improvement by requiring compliance with enhanced standards or development towards higher standards. They …

- The NHS Standard Contract 2024/25 enables commissioners to promote improvement by requiring compliance with enhanced standards through local quality requirements (DHSC and NHS England …

F126 Accepted

Mid Staffs Inquiry (2013)

Preserving corporate memory

The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This …

- The Health and Care Act 2022 abolished Clinical Commissioning Groups and established 42 Integrated Care Boards (ICBs) with broader responsibilities for population health (Health …

F127 Accepted

Mid Staffs Inquiry (2013)

Resources for scrutiny

The NHS Commissioning Board and local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny of its providers' services, based on sound commissioning …

- The Health and Care Act 2022 established Integrated Care Boards (ICBs) as the statutory bodies responsible for NHS commissioning and service oversight (Health and …

F128 Accepted

Mid Staffs Inquiry (2013)

Expert support

Commissioners must have access to the wide range of experience and resources necessary to undertake a highly complex and technical task, including specialist clinical advice and procurement expertise. When groups …

- The Health and Care Act 2022 permits Integrated Care Boards to enter joint working arrangements with other ICBs to manage complex commissioning tasks (Health …

F129 Accepted

Mid Staffs Inquiry (2013)

Ensuring assessment and enforcement of fundamental standards through contracts

In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard patients and to ensure that at least fundamental …

- DHSC and NHS England stated in April 2025 that the Commissioning for Quality and Innovation (CQUIN) scheme is used to select indicators for measuring …

F130 Accepted

Mid Staffs Inquiry (2013)

Relative position of commissioner and provider

Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be provided, and for that purpose will have to …

- The Health and Care Act 2022 mandates that Integrated Care Boards are responsible for planning health services and managing the NHS budget for their …

F131 Accepted

Mid Staffs Inquiry (2013)

Development of alternative sources of provision

Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken on behalf of consortia of commissioning groups to …

- The Health and Care Act 2022 established 42 Integrated Care Systems (ICSs) to bring together health and care organisations to develop shared plans (Health …

F132 Accepted

Mid Staffs Inquiry (2013)

Monitoring tools

Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: Such monitoring may include requiring quality information generated by …

- The NHS Standard Contract includes provisions allowing commissioners to require audits of provider performance and to enter premises for inspection (DHSC/NHS England implementation update …

F134 Accepted

Mid Staffs Inquiry (2013)

Role of commissioners in provision of support for complainants

Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.

- Local Authorities are responsible for commissioning independent health complaint advocacy services (DHSC/NHS England implementation update to the Thirlwall Inquiry, April 2025). - DHSC and …

F136 Accepted

Mid Staffs Inquiry (2013)

Public accountability of commissioners and public engagement

Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of technical support. Effective local commissioning can only work …

- The Health and Care Act 2022 established 42 Integrated Care Boards with statutory responsibilities for population health, bringing together NHS organisations and local authorities …

F138 Accepted

Mid Staffs Inquiry (2013)

Local scrutiny

Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at risk from substandard or unsafe services.

- NHS England published the NHS Oversight Framework to identify where providers require support and to provide an objective basis for intervention (NHS Oversight Framework, …

F139 Accepted

Mid Staffs Inquiry (2013)

The need to put patients first at all times

The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient safety and quality standards are being met. Such …

- The Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework in Autumn 2023, making system-based learning mandatory for all NHS-funded secondary care …

F140 Accepted

Mid Staffs Inquiry (2013)

Performance managers working constructively with regulators

Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant information with the relevant regulator, including information about …

- National guidance on System Quality Groups was issued in January 2022 to facilitate intelligence-sharing and learning between all organisations within an integrated care system …

F142 Accepted

Mid Staffs Inquiry (2013)

Clear lines of responsibility supported by good information flows

For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the performance manager is not in ignorance of the …

- The Health and Care Act 2022 established Integrated Care Boards to replace Clinical Commissioning Groups, creating new architecture for health and care systems (Health …

F143 Accepted

Mid Staffs Inquiry (2013)

Clear metrics on quality

Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms to be established so that outliers or progression …

- The Learn from Patient Safety Events (LFPSE) service, which became fully operational in June 2024, uses machine learning to improve trend identification and analysis …

F144 Accepted

Mid Staffs Inquiry (2013)

Need for ownership of quality metrics at a strategic level

The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing the performance of providers, and retain oversight of …

- The Health and Care Act 2022 replaced Clinical Commissioning Groups with 42 Integrated Care Boards (ICBs) tasked with oversight of population health and provider …