Public Inquiry Recommendations

F231 Accepted

Mid Staffs Inquiry (2013)

Coordination with internal procedures

It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that its 2018 Fitness to Practise Strategy promotes a "local first" approach, advising that …

F232 Accepted

Mid Staffs Inquiry (2013)

Employment liaison officers

The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it introduced the Employer Link Service (ELS) in 2016 to develop regulatory relationships …

F233 Accepted

Mid Staffs Inquiry (2013)

For joint action Profile

While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that patients and other service users are made aware …

- The Department of Health and Social Care stated in April 2025 that the Nursing and Midwifery Council (NMC) has taken steps to raise its …

F234 Accepted

Mid Staffs Inquiry (2013)

Cooperation with the Care Quality Commission

Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in many cases there should be joint working to …

- The Department of Health and Social Care and NHS England stated in April 2025 that implementation is ongoing, referring to the Joint Strategic Oversight …

F236 Accepted

Mid Staffs Inquiry (2013)

Identification of who is responsible for the patient

Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so that patients and their supporters are clear who …

- The Department of Health and Social Care and NHS England stated in April 2025 that implementation is ongoing, citing requirements in the NHS Constitution …

F237 Accepted

Mid Staffs Inquiry (2013)

Teamwork

There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by an elderly patient; the contribution of cleaners, maintenance …

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Long Term Workforce Plan includes a focus …

F238 Accepted

Mid Staffs Inquiry (2013)

Communication with and about patients

Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff need to be enabled to interact constructively, in …

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Standard Contract requires providers to ensure sufficient …

F239 Accepted

Mid Staffs Inquiry (2013)

Continuing responsibility for care

The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the …

- The Department of Health and Social Care published the Hospital Discharge Service policy in August 2020, detailing discharge requirements for all NHS trusts and …

F240 Accepted

Mid Staffs Inquiry (2013)

Hygiene

All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these.

- NHS England updated the National Infection Prevention and Control Manual for England in 2024, providing evidence-based practice for all care provision (National infection prevention …

F241 Accepted

Mid Staffs Inquiry (2013)

Provision of food and drink

The arrangements and best practice for providing food and drink to elderly patients require constant review, monitoring and implementation.

- NHS England published national standards for healthcare food and drink in hospitals, requiring organisations to demonstrate how they meet these standards (National standards for …

F242 Accepted

Mid Staffs Inquiry (2013)

Medicines administration

In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated …

- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation has been superseded by latest guidance from …

F243 Accepted

Mid Staffs Inquiry (2013)

Recording of routine observations

The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately accessible to all staff electronically in a form …

- DHSC and NHS England stated in April 2025 that most Trusts have electronic patient records (EPR) systems providing digital platforms for patient information and …

F244 Accepted

Mid Staffs Inquiry (2013)

Common information practices shared data and electronic records

There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering …

- DHSC and NHS England stated in April 2025 that the NHS App (launched 2019) and the Federated Data Platform allow for shared data access …

F246 Accepted

Mid Staffs Inquiry (2013)

Comparable quality accounts

Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form to enable comparisons to be made between organisations, …

- NHS healthcare providers are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to publish annual reports on …

F247 Accepted

Mid Staffs Inquiry (2013)

Accountability for quality accounts

Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems regulators.

- The National Health Service (Quality Accounts) Regulations 2010 require Quality Accounts to be published by 30 June each year and submitted to NHS England …

F248 Accepted

Mid Staffs Inquiry (2013)

Accountability for quality accounts

Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to use their professional judgement in examining the reliability …

- DHSC and NHS England stated in April 2025 that external assurance of NHS trust quality accounts has not been mandatory since 2013 (DHSC and …

F252 Accepted

Mid Staffs Inquiry (2013)

Access to data

It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes.

- The Department of Health and Social Care and NHS England stated in April 2025 that NHS England is the statutory custodian for health and …

F253 Accepted

Mid Staffs Inquiry (2013)

Access to quality and risk profile

The information behind the quality and risk profile – as well as the ratings and methodology – should be placed in the public domain, as far as is consistent with …

- The Care Quality Commission (CQC) began a phased rollout of a new Single Assessment Framework in November 2023 and continues to publish inspection reports …

F254 Accepted

Mid Staffs Inquiry (2013)

Access for public and patient comments

While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, it would be helpful for there to be …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Friends and Family Test (FFT) has been rolled …

F255 Accepted

Mid Staffs Inquiry (2013)

Using patient feedback

Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" as possible, even if later adjustments have to …

- NHS England stated in April 2025 that results of the Friends and Family Test are published on a monthly basis (DHSC and NHS England …

F256 Accepted

Mid Staffs Inquiry (2013)

Follow up of patients

A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a wider range of responses and feedback on their …

- The Hospital Discharge Service Policy and Operating Model, published in August 2020, includes patient information leaflets and staff action cards for the discharge process …

F258 Accepted

Mid Staffs Inquiry (2013)

Role of the Health and Social Care Information Centre

The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to comparative performance statistics.

- The Department of Health and Social Care and NHS England stated in April 2025 that NHS England now holds the statutory functions for healthcare …

F259 Accepted

Mid Staffs Inquiry (2013)

Role of the Health and Social Care Information Centre

The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should develop a means of publishing more detailed breakdowns …

- NHS England publishes annual data on written complaints made by or on behalf of patients for both primary and secondary care (DHSC and NHS …

F261 Accepted

Mid Staffs Inquiry (2013)

Information standards

The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.

- The Department of Health and Social Care stated in April 2025 that this recommendation was superseded by actions related to recommendation 252 (DHSC and …

F262 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on the performance of each of their services against …

- The Department of Health and Social Care stated in April 2025 that the Federated Data Platform, Consultant Outcomes Publication, and National Consultant Information Programme …

F263 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in …

- The Department of Health and Social Care stated in April 2025 that 99% of Trusts in England were enrolled in the National Consultant Information …

F264 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review.

- The Department of Health and Social Care stated in April 2025 that statistics on treatment effectiveness are published by NHS Digital and the National …

F265 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to consider how best to develop comparative statistics on …

- The Department of Health and Social Care stated in April 2025 that the NHS Standard Contract requires providers to publish services in the e-Referral …

F266 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and the specialty organisations should seek and have regard …

- The Department of Health and Social Care stated in April 2025 that NHS England conducts public consultations on statistical reports and proposed changes to …

F267 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission.

- The Department of Health and Social Care stated in April 2025 that patient outcome statistics are available via NHS Digital, CQC inspection reports, and …

F268 Accepted

Mid Staffs Inquiry (2013)

Resources

Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.

- The Department of Health and Social Care stated in April 2025 that resources had been allocated to support data collection and publication (DHSC and …

F269 Accepted

Mid Staffs Inquiry (2013)

Improving and assuring accuracy

The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and …

- The Department of Health and Social Care stated in April 2025 that the Data Quality Maturity Index (DQMI) is published monthly to provide transparency …

F270 Accepted

Mid Staffs Inquiry (2013)

Improving and assuring accuracy

There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the patient outcome statistics, including hospital mortality and other …

- NHS England stated in April 2025 that patient outcome statistics are publicly available through its website, Care Quality Commission inspection reports, and public portals …

F271 Accepted

Mid Staffs Inquiry (2013)

Improving and assuring accuracy

To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and the Health and Social Care Information Centre should …

- NHS England stated in April 2025 that the Summary Hospital-Level Mortality Indicator (SHMI) is produced and published monthly as an Accredited Official Statistic (DHSC …

F272 Accepted

Mid Staffs Inquiry (2013)

Improving and assuring accuracy

There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation scheme has been included in the Health and …

- NHS England stated in April 2025 that the Data Alliance Partnership Board (DAPB) assures the quality of information standards to ensure data can be …

F274 Accepted

Mid Staffs Inquiry (2013)

Information to coroners

There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to …

- The National Medical Examiner stated in April 2025 that records of medical examiner scrutiny should be shared with bereaved families where possible, following an …

F276 Accepted

Mid Staffs Inquiry (2013)

Independent medical examiners

Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.

- NHS England stated in April 2025 that all acute NHS Trusts have established medical examiner offices and have been asked to ensure they have …

F277 Accepted

Mid Staffs Inquiry (2013)

Death certification

National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, that similar approaches are universal.

- The Department of Health and Social Care published guidance on completing the new Medical Cause of Death Certificate (MCCD) as part of the 2024 …

F278 Accepted

Mid Staffs Inquiry (2013)

Death certification

It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to …

- Regulation 6 of the Medical Certificate of Cause of Death Regulations 2024 requires medical examiners to carry out a proportionate review of medical records …

F279 Accepted

Mid Staffs Inquiry (2013)

Death certification

So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge …

- The Department of Health and Social Care stated in April 2025 that it is the responsibility of the consultant in charge of a patient's …

F280 Accepted

Mid Staffs Inquiry (2013)

Appropriate and sensitive contact with bereaved families

Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given to …

- The Medical Examiner system became statutory on 9 September 2024, requiring independent scrutiny of all deaths not referred to a coroner (The Medical Examiners …

F281 Accepted

Mid Staffs Inquiry (2013)

Appropriate and sensitive contact with bereaved families

It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how to undertake this sensitive task in a manner …

- The Medical Examiners (England) Regulations 2024 require medical examiners to undertake training to ensure they have the skills to carry out their functions (The …

F282 Accepted

Mid Staffs Inquiry (2013)

Information for and from inquests

Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.

- NHS England stated in April 2025 that Regulation 28 reports (formerly Rule 43) are shared with the CQC when it is a named respondent …

F283 Accepted

Mid Staffs Inquiry (2013)

Information for and from inquests

Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the death of a patient. This should include contact …

- DHSC and NHS England stated in April 2025 that the Judicial College provides induction and annual training for coroners and their officers, and the …

F284 Accepted

Mid Staffs Inquiry (2013)

Appointment of assistant deputy coroners

The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners.

- DHSC and NHS England stated in April 2025 that action was taken regarding the appointment of assistant coroners following the conclusion of the Mid-Staffordshire …

F285 Accepted

Mid Staffs Inquiry (2013)

Appointment of assistant deputy coroners

The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a party in a case.

- DHSC and NHS England stated in April 2025 that the Thirlwall Inquiry has noted action taken in response to this recommendation regarding the appearance …

F286 Accepted

Mid Staffs Inquiry (2013)

Impact assessments before structural change

Impact and risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare system is accepted. Such assessments should cover at …

- DHSC and NHS England stated in April 2025 that an impact assessment was conducted for the Health and Care Act 2022 (DHSC and NHS …

F287 Accepted

Mid Staffs Inquiry (2013)

Impact assessments before structural change

The Department of Health should together with healthcare systems regulators take the lead in developing through obtaining consensus between the public and healthcare professionals, a coherent, and easily accessible structure …

- The Care Quality Commission introduced fundamental standards of care in 2015 as part of its regulatory framework (Health and Social Care Act 2008 (Regulated …

F288 Accepted

Mid Staffs Inquiry (2013)

Clinical input

The Department of Health should ensure that there is senior clinical involvement in all policy decisions which may impact on patient safety and well-being.

- DHSC and NHS England stated in April 2025 that senior clinical advice is embedded through roles including the Chief Medical Officer, Chief Nursing Officer, …

F289 Accepted

Mid Staffs Inquiry (2013)

Experience on the front line

Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who have suffered poor experiences. The Department of Health …

- The Department of Health and Social Care stated in April 2025 that the Connecting Programme was established in June 2013, requiring senior civil servants …