Public Inquiry Recommendations

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 …

- The National Patient Safety Agency (NPSA) was abolished on 1 June 2012, with its patient safety functions transferred to NHS England. The recommendation related …

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.

- The National Reporting and Learning System (NRLS), originally operated by the NPSA and subsequently by NHS England, published regular data summaries and analysis. The …

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.

- The National Patient Safety Agency (NPSA) was abolished on 1 June 2012, with its patient safety functions transferred to NHS England. Monitor merged into …

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 …

- CQC confirmed that it uses patient safety incident data from the National Reporting and Learning System (and its successor LFPSE) as part of its …

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.

- The Summary Hospital-level Mortality Indicator (SHMI) is published quarterly by NHS England (formerly by the Health and Social Care Information Centre, now NHS Digital, …

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 …

- The Health Protection Agency was abolished on 1 April 2013 and its functions were transferred to Public Health England (PHE), which in turn was …

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 …

- The Health Protection Agency was abolished on 1 April 2013. Its health protection functions were transferred to Public Health England, which was subsequently replaced …

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 …

- Public Health England (PHE) was established on 1 April 2013, assuming the health protection functions of the Health Protection Agency. PHE was subsequently replaced …

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 (SI 2009/309) established a single complaints procedure for health and social …

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 contain any provision requiring or permitting complaints to be …

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 …

- The NHS Constitution (revised 2023) includes a pledge that "the NHS will ensure you are treated with courtesy and you receive appropriate support throughout …

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 PHSO's NHS Complaint Standards (July 2022) state that organisations should treat all expressions of dissatisfaction that require a response as complaints, regardless of …

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 Patients Association conducted a peer review of complaints handling at Mid Staffordshire NHS Foundation Trust, published in 2011. The review made recommendations about …

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 Patient Safety Incident Response Framework (PSIRF), mandatory for NHS trusts from autumn 2023, requires trusts to consider all sources of information — including …

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 Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 require responsible bodies to investigate complaints but do not prescribe specific …

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 Health and Social Care Act 2012 (section 185) placed a duty on local authorities to commission independent advocacy services for people making or …

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 Health and Social Care Act 2012 (section 185) placed a duty on local authorities to commission independent advocacy services for people making NHS …

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 Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 require NHS bodies to prepare an annual report on complaints handling, …

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.

- Local Healthwatch organisations were established under the Health and Social Care Act 2012 (sections 221-227), replacing Local Involvement Networks (LINks) from April 2013. Local …

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 …

- Integrated Care Boards (ICBs), which replaced Clinical Commissioning Groups from July 2022 under the Health and Care Act 2022, have responsibility for commissioning most …

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 …

- CQC's Insight intelligence model draws on complaints data from multiple sources to identify providers requiring regulatory attention. CQC receives information about complaints through its …

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 National Quality Board (NQB), a multi-stakeholder body bringing together NHS England, CQC, NICE, HSSIB, NHSE regional teams and other system partners, has published …

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 …

- The Health and Care Act 2022 established Integrated Care Boards (ICBs) as the statutory commissioners of NHS services from July 2022, replacing Clinical Commissioning …

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, mandated for all NHS-funded secondary care services, includes quality requirements, performance standards, and provisions for remedial action where standards …

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 Commissioning for Quality and Innovation (CQUIN) framework enables commissioners to incentivise quality improvement above the level of fundamental standards. CQUIN links a proportion …

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 established Integrated Care Boards (ICBs) from July 2022, replacing 106 CCGs with 42 ICBs (subsequently reduced to 36 …

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 statutory bodies with their own budgets, staff, and governance arrangements. ICBs are …

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 …

- Integrated Care Boards (ICBs) are required under the Health and Care Act 2022 to have access to clinical expertise for commissioning decisions. ICBs must …

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 …

- The NHS Standard Contract 2024/25 includes a suite of quality indicators and performance measures that commissioners use to monitor provider compliance with safety and …

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 establishes ICBs as the statutory commissioners responsible for planning and commissioning NHS services to meet the needs of …

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 Provider Selection Regime (PSR), introduced in January 2024 under SI 2023/1348, provides commissioners with a structured framework for identifying and selecting alternative providers. …

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 2024/25 includes comprehensive provisions for commissioner monitoring of provider performance. The contract requires providers to submit regular quality and performance …

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 NHS Standard Contract 2024/25 includes provisions requiring providers to have effective complaint handling arrangements and to report complaints data to commissioners. Commissioners can …

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.

- The Health and Social Care Act 2012 (section 185) placed a duty on local authorities (not NHS commissioners) to commission independent advocacy services for …

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 requires ICBs to involve patients and the public in decisions about the commissioning of services. ICBs must make …

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 …

- Integrated Care Boards (ICBs) are established as statutory NHS bodies under the Health and Care Act 2022, with their own legal identity, branding, websites, …

F137 Not Accepted

Mid Staffs Inquiry (2013)

Intervention and sanctions for substandard or unsafe services

Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other measures necessary to protect patients from the risk …

- The NHS Standard Contract 2024/25 includes provisions enabling commissioners to take action where providers fail to meet contractual quality standards. These include issuing contract …

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's System Oversight Framework (SOF) includes requirements for ICBs and NHS England regional teams to have contingency plans for the continuity of services …

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 …

- NHS England's System Oversight Framework (SOF) establishes patient safety and quality as the primary considerations in oversight of NHS providers and ICBs. SOF assessment …

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 …

- NHS England and CQC operate a memorandum of understanding governing the sharing of information about provider quality and safety. The agreement provides for the …

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 System Oversight Framework (SOF) provides a structured mechanism for resolving differences between NHS England (as performance manager) and CQC (as regulator) regarding provider …

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 a statutory framework for information flows within the NHS. ICBs have duties to obtain information about the …

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 NHS Outcomes Framework (NHS OF) provides a national set of outcome indicators across five domains: preventing people from dying prematurely, enhancing quality of …

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 …

- NHS England (originally the NHS Commissioning Board) developed and maintains the NHS Outcomes Framework, a suite of outcome indicators used to assess the overall …

F145 Not Accepted

Mid Staffs Inquiry (2013)

Structure of Local Healthwatch

There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter 6: Patient and public local involvement and scrutiny.

- The Health and Social Care Act 2012 (sections 221-227) established the statutory framework for Local Healthwatch organisations. Every upper-tier local authority in England is …

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 Health and Social Care Act 2012 placed a duty on local authorities to commission Local Healthwatch for their area, with funding provided through …

F147 Accepted

Mid Staffs Inquiry (2013)

Coordination of local public scrutiny bodies

Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.

- The Department of Health and Social Care published updated guidance on Health and Wellbeing Boards in November 2022, following the Health and Care Act …

F148 Accepted

Mid Staffs Inquiry (2013)

Training

The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.

- Healthwatch England provides a programme of support and development resources for Local Healthwatch organisations, including guidance documents, webinars, and network events. Healthwatch England's Quality …

F149 Accepted

Mid Staffs Inquiry (2013)

Expert assistance

Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.

- The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 (SI 2013/218) set out the powers and duties of local …

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 …

- The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 (SI 2013/218) provide local authority health scrutiny committees with powers …