Public Inquiry Recommendations

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.

- DHSC stated in April 2025 that guidance on local authority health scrutiny was updated in January 2024 (DHSC/NHS England implementation update to the Thirlwall …

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.

- DHSC stated in April 2025 that Healthwatch England continues to offer a range of training and resources for local Healthwatch staff and volunteers (DHSC/NHS …

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.

- DHSC stated in April 2025 that updated guidance for local authority scrutiny was issued in January 2024 to provide benchmarks and support (DHSC/NHS England …

F152 Accepted

Mid Staffs Inquiry (2013)

Medical training

Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the acceptability of training provided by a healthcare provider, …

- DHSC stated in April 2025 that the Education Quality Framework was refreshed in 2024 to provide multi-professional quality standards for clinical learning environments (DHSC/NHS …

F154 Accepted

Mid Staffs Inquiry (2013)

Medical training

The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight of medical training to coordinate their oversight of …

- The DHSC and NHS England stated in April 2025 that this recommendation was superseded as Monitor and Health Education England had been merged into …

F155 Accepted

Mid Staffs Inquiry (2013)

Medical training

The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance with the following principles: The Postgraduate Dean should …

- The GMC stated in April 2025 that it had revised its standards for medical education and training in 2018 and enhanced the role of …

F156 Accepted

Mid Staffs Inquiry (2013)

Medical training

The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.

- The DHSC and NHS England stated in April 2025 that the NHS Long Term Workforce Plan supports the commitment to improving the quality of …

F157 Accepted

Mid Staffs Inquiry (2013)

Matters to be reported to the General Medical Council

The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical Council either routinely or as they arise. Reports …

- The GMC stated in April 2025 that Local Education and Training Boards (LETBs) and Deaneries routinely report progress against concerns, including patient safety, via …

F158 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers …

- The GMC stated in April 2025 that its "Promoting excellence" standards require local education providers to take action when concerns are raised that impact …

F159 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical …

- The GMC stated in April 2025 that its National Training Survey (NTS) has included patient safety questions since 2014 and that it shares monthly …

F160 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences in relation to raising concerns.

- The DHSC and NHS England stated in April 2025 that awareness of Freedom to Speak Up (FTSU) processes is monitored via the annual National …

F161 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Training visits should make an important contribution to the protection of patients: Obtaining information directly from trainees should remain a valuable source of information – but it should not be …

- The GMC stated in April 2025 that it conducts quality activities including visits and talking to students and trainees to check how organisations address …

F162 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of medical training and education maintains as its first …

- DHSC and NHS England stated in April 2025 that the GMC uses an enhanced monitoring process for training institutions where persistent and serious patient …

F163 Accepted

Mid Staffs Inquiry (2013)

Safe staff numbers and skills

The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of …

- DHSC and NHS England stated in April 2025 that the GMC published standards for medical education and training in July 2015, specifically requirement R1.7 …

F170 Accepted

Mid Staffs Inquiry (2013)

Health Education England

Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.

- Health Education England merged with NHS England on 1 April 2023 (Health and Care Act 2022, July 2022). - DHSC and NHS England stated …

F171 Accepted

Mid Staffs Inquiry (2013)

Deans

All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education.

- The Department of Health and Social Care and NHS England stated in April 2025 that Local Education Training Boards (LETBs) have been replaced by …

F172 Accepted

Mid Staffs Inquiry (2013)

Proficiency in the English language

The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required …

- The Department of Health and Social Care and NHS England stated in April 2025 that professional regulators, including the Nursing and Midwifery Council and …

F173 Accepted

Mid Staffs Inquiry (2013)

Principles of openness transparency and candour

Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never …

- The Department of Health and Social Care and NHS England stated in April 2025 that a statutory Duty of Candour was introduced in 2014 …

F174 Accepted

Mid Staffs Inquiry (2013)

Candour about harm

Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any …

- The Department of Health and Social Care and NHS England stated in April 2025 that the statutory Duty of Candour and the Patient Safety …

F175 Accepted

Mid Staffs Inquiry (2013)

Candour about harm

Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled …

- The Department of Health and Social Care and NHS England stated in April 2025 that the joint duty of candour guidance by the Nursing …

F176 Accepted

Mid Staffs Inquiry (2013)

Openness with regulators

Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.

- The Department of Health and Social Care and NHS England stated in April 2025 that the statutory Duty of Candour applies to statements made …

F177 Accepted

Mid Staffs Inquiry (2013)

Openness in public statements

Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Standard contract includes requirements to ensure submissions …

F179 Accepted

Mid Staffs Inquiry (2013)

Restrictive contractual clauses

"Gagging clauses" or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona …

- The Department of Health and Social Care and NHS England stated in April 2025 that NHS Employers has published guidance on the use of …

F180 Accepted

Mid Staffs Inquiry (2013)

Candour about incidents

Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.

- The Department of Health and Social Care and NHS England stated in April 2025 that the 'Being Open' guidance has been superseded by the …

F182 Accepted

Mid Staffs Inquiry (2013)

Statutory duty of openness and transparency

There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf …

- The Department of Health and Social Care stated in April 2025 that this recommendation is addressed through the statutory Duty of Candour and the …

F184 Accepted

Mid Staffs Inquiry (2013)

Enforcement by the Care Quality Commission

Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and …

- The Department of Health and Social Care stated in April 2025 that the CQC has implemented this recommendation and it remains an ongoing piece …

F185 Accepted

Mid Staffs Inquiry (2013)

Focus on culture of caring

There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures …

- The Nursing and Midwifery Council (NMC) updated its pre-registration nursing and midwifery education standards in 2018 and 2019 to emphasize compassionate, person-centred care (NMC …

F186 Accepted

Mid Staffs Inquiry (2013)

Practical hands-on training and experience

Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.

- The Nursing and Midwifery Council stated in April 2025 that all education programmes require 50% of time to be spent in practice learning and …

F187 Accepted

Mid Staffs Inquiry (2013)

Practical hands-on training and experience

There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision …

- The Nursing and Midwifery Council stated in April 2025 that 50% of education hours (2,300 hours) must be spent in practice learning, with a …

F191 Accepted

Mid Staffs Inquiry (2013)

Recruitment for values and commitment

Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should …

- The Department of Health and Social Care stated in April 2025 that the NHS operates a values-based recruitment approach to align employee behaviours with …

F196 Accepted

Mid Staffs Inquiry (2013)

Nurse leadership

The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient care and, in particular, to the priority to …

- The government stated in April 2025 that the Knowledge and Skills Framework is no longer updated by NHS Employers and has been superseded by …

F198 Accepted

Mid Staffs Inquiry (2013)

Measuring cultural health

Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience …

- The government stated in April 2025 that the NHS Staff Survey and NHS People Pulse provide a standardised framework for measuring employee experience and …

F199 Accepted

Mid Staffs Inquiry (2013)

Key nurses

Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for each allocated patient. The named key nurse on …

- The Department of Health and Social Care and NHS England stated in April 2025 that the role of the Named Nurse is used within …

F201 Accepted

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

The Royal College of Nursing should consider whether it should formally divide its "Royal College" functions and its employee representative/trade union functions between two bodies rather than behind internal "Chinese …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Royal College of Nursing (RCN) continues to act …

F202 Accepted

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff to undertake this role, and employers and unions …

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Terms and Conditions Handbook (Part 4, Section …

F203 Accepted

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of coordinating the leadership of the nursing profession.

- The Department of Health and Social Care and NHS England stated in April 2025 that the Chief Nursing Officer (CNO) for England provides professional …

F206 Accepted

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a recognised leading representative of the nursing profession as …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Chief Nursing Officer (CNO) reports directly to the …

F210 Accepted

Mid Staffs Inquiry (2013)

Code of conduct for healthcare support workers

There should be a national code of conduct for healthcare support workers.

- The Care Certificate, launched in April 2015, includes 15 standards that serve as a national code of conduct and training standard for healthcare assistants …

F211 Accepted

Mid Staffs Inquiry (2013)

Training standards for healthcare support workers

There should be a common set of national standards for the education and training of healthcare support workers.

- The Care Certificate was introduced on 1 April 2015 as the national standard for the education and training of healthcare support workers (Care Certificate, …

F214 Accepted

Mid Staffs Inquiry (2013)

Shared training

A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and leadership to potential senior staff; promote healthcare leadership …

- The NHS Leadership Academy provides national leadership and management training programmes for staff at all levels (DHSC and NHS England implementation update provided to …

F215 Accepted

Mid Staffs Inquiry (2013)

Shared code of ethics

A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the …

- The NHS Leadership Competency Framework for Board members was published in February 2024, designed around six competency domains to support the Fit and Proper …

F216 Accepted

Mid Staffs Inquiry (2013)

Leadership framework

The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health service. This could be done by, for example, …

- The Department of Health and Social Care stated in April 2025 that Competency 1 of the Leadership Competency Framework focuses on high quality and …

F218 Accepted

Mid Staffs Inquiry (2013)

Enforcement of standards and accountability

Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be …

- The Department of Health and Social Care stated in April 2025 that it is exploring options to introduce professional standards for NHS managers and …

F221 Accepted

Mid Staffs Inquiry (2013)

Ensuring common standards of competence and compliance

Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards of health service bodies which are not foundation …

- The Department of Health and Social Care stated in April 2025 that the Care Quality Commission assesses corporate governance for all health and adult …

F222 Accepted

Mid Staffs Inquiry (2013)

General Medical Council Systemic investigation where needed

The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be made to it, enabling a more proactive approach …

- The Department of Health and Social Care stated in April 2025 that the General Medical Council publishes information on how complaints and referrals are …

F224 Accepted

Mid Staffs Inquiry (2013)

Information sharing

Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue guidance for use by employers of doctors to …

- The Department of Health and Social Care stated in April 2025 that this recommendation is considered closed following actions taken after the conclusion of …

F225 Accepted

Mid Staffs Inquiry (2013)

Peer reviews

The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic …

- The Department of Health and Social Care stated in April 2025 that the General Medical Council (GMC) and NHS England share intelligence through the …

F228 Accepted

Mid Staffs Inquiry (2013)

Administrative reform

It is of concern that the administration of the Nursing and Midwifery Council, which has not been examined by this Inquiry, is still found by other reviews to be wanting. …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it introduced a team of Case Examiners in March 2015 to decide whether …

F229 Accepted

Mid Staffs Inquiry (2013)

Revalidation

It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status …

- The Nursing and Midwifery Council (NMC) introduced the nursing revalidation process on 1 April 2016, requiring all nurses and midwives to revalidate every three …

F230 Accepted

Mid Staffs Inquiry (2013)

Profile

The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable source of information about the conduct of nurses. …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it relaunched its website in 2014 to be more public-focused and introduced a …