Public Inquiry Recommendations

F178 Accepted in Part

Mid Staffs Inquiry (2013)

Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and candour

The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, …

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Constitution was updated in February 2024 to …

F181 Accepted in Part

Mid Staffs Inquiry (2013)

Enforcement of the duty Statutory duties of candour in relation to harm to patients

A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has …

- Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established a statutory duty of candour for all CQC-regulated providers …

F188 Accepted in Part

Mid Staffs Inquiry (2013)

Aptitude test for compassion and caring

The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in …

- The Nursing and Midwifery Council stated in April 2025 that its pre-registration standards negate the need for a specific aptitude test (DHSC and NHS …

F189 Accepted in Part

Mid Staffs Inquiry (2013)

Consistent training

The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.

- The Nursing and Midwifery Council stated in April 2025 that it reviewed the use of aptitude tests and common examinations but identified affordability, scalability, …

F190 Accepted in Part

Mid Staffs Inquiry (2013)

National standards

There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it performs Education Quality Assurance to ensure nursing education programmes meet standards for …

F192 Accepted in Part

Mid Staffs Inquiry (2013)

Strong nursing voice

The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and accountable to, the Nursing and Midwifery Council.

- The government stated in April 2025 that the specific role of a "Responsible Officer" for nursing was not introduced, but the NMC established a …

F193 Accepted in Part

Mid Staffs Inquiry (2013)

Standards for appraisal and support

Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which responsible officers would be obliged to comply. They …

- The government stated in April 2025 that the Nursing and Midwifery Council has introduced a revalidation process for all nurses and midwives to maintain …

F194 Accepted in Part

Mid Staffs Inquiry (2013)

Standards for appraisal and support

As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of nursing practice …

- The government stated in April 2025 that the NMC revalidation process requires nurses to demonstrate continuing professional development (CPD), reflective discussions, and declarations of …

F195 Accepted in Part

Mid Staffs Inquiry (2013)

Nurse leadership

Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. …

- The government stated in April 2025 that this recommendation was superseded by Royal College of Nursing (RCN) Workforce Standards and the rollout of Professional …

F197 Accepted in Part

Mid Staffs Inquiry (2013)

Nurse leadership

Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all …

- The government stated in April 2025 that eight national development programmes are available through the NHS Leadership Academy, training approximately 20,000 participants annually (DHSC …

F200 Accepted in Part

Mid Staffs Inquiry (2013)

Key nurses

Consideration should be given to the creation of a status of Registered Older Person's Nurse.

- The Department of Health and Social Care and NHS England stated in April 2025 that Health Education England funded an Older Persons Fellowship for …

F204 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as …

- The National Health Service Trusts (Membership and Procedure) Regulations require Trust and Foundation Trust Boards to include a nurse or midwife executive director (The …

F205 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety …

- The Department of Health and Social Care and NHS England stated in April 2025 that all Boards are required to have a nurse/midwife executive …

F207 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening identification of healthcare support workers and nurses

There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.

- DHSC and NHS England stated in April 2025 that the development of local uniform policy remains the responsibility of local organisations (DHSC and NHS …

F208 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening identification of healthcare support workers and nurses

Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse.

- DHSC and NHS England stated in April 2025 that provider organisations are responsible for local uniform policies and that uniforms and name badges should …

F217 Accepted in Part

Mid Staffs Inquiry (2013)

Common selection criteria

A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn could inform a list of competences a leader …

- The Department of Health and Social Care stated in April 2025 that a Leadership Competency Framework has been developed for board members (DHSC and …

F219 Accepted in Part

Mid Staffs Inquiry (2013)

A regulator as an alternative

An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up an independent professional regulator. The need for this …

- The Department of Health and Social Care stated in April 2025 that an independent professional regulator for managers has not yet been actioned (DHSC …

F220 Accepted in Part

Mid Staffs Inquiry (2013)

Accreditation

A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, at least initally, the objective should be to …

- The Department of Health and Social Care stated in April 2025 that the NHS Leadership Academy provides eight national development programmes for entry-level to …

F223 Accepted in Part

Mid Staffs Inquiry (2013)

Enhanced resources

If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater resources, or better cooperation with the Care Quality …

- The Department of Health and Social Care stated in April 2025 that the General Medical Council entered an information-sharing agreement with the Academy of …

F226 Accepted in Part

Mid Staffs Inquiry (2013)

Nursing and Midwifery Council Investigation of systemic concerns

To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it has established Memorandums of Understanding (MoUs) and joint working protocols with the …

F227 Accepted in Part

Mid Staffs Inquiry (2013)

Nursing and Midwifery Council Investigation of systemic concerns

The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it introduced a new internal Pre-case enquiries and referrals policy in January 2024, …

F235 Accepted in Part

Mid Staffs Inquiry (2013)

Joint proceedings

The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for …

- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation has not yet been actioned (DHSC and …

F245 Accepted in Part

Mid Staffs Inquiry (2013)

Board accountability

Each provider organisation should have a board level member with responsibility for information.

- The Records Management Code of Practice published by NHS England states that records management should be a specific corporate responsibility with a designated member …

F249 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability for quality accounts

Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying that they believe the contents of the account …

- The government stated in April 2025 that this recommendation was superseded, as the review of quality accounts determined that local Healthwatch challenge was a …

F250 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability for quality accounts

It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account are true if it contains a misstatement of …

- DHSC and NHS England stated in April 2025 that action had been taken in response to this recommendation following the 2013 inquiry (DHSC and …

F251 Accepted in Part

Mid Staffs Inquiry (2013)

Regulatory oversight of quality accounts

The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled to require corrections to be issued where appropriate. …

- Section 9 of the Health Act 2009 requires providers to republish Quality Accounts with corrections within 21 days if notified of an error by …

F257 Accepted in Part

Mid Staffs Inquiry (2013)

Role of the Health and Social Care Information Centre

The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the agreement of the devolved governments, the United Kingdom. …

- The Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS) and was fully implemented by June 2024 (NHS …

F260 Accepted in Part

Mid Staffs Inquiry (2013)

Information standards

The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It …

- The Department of Health and Social Care and NHS England stated in April 2025 that information regarding patient safety events is managed through the …

F273 Accepted in Part

Mid Staffs Inquiry (2013)

Information to coroners

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a …

- Schedule 5 of the Coroners and Justice Act 2009 confers power on coroners to order the disclosure of evidence, including written statements and documents …

F275 Accepted in Part

Mid Staffs Inquiry (2013)

Independent medical examiners

It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.

- NHS England stated in April 2025 that operational arrangements at NHS bodies must support the independent role of medical examiners and that combining these …