Public Inquiry Recommendations

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 …

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 …

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 …

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 …

F209 Not Accepted

Mid Staffs Inquiry (2013)

Registration of healthcare support workers

A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of …

- The government did not accept the recommendation to create a registration system for healthcare support workers (Hard Truths: the journey to putting patients first …

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, …

F212 Not Accepted

Mid Staffs Inquiry (2013)

Training standards for healthcare support workers

The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation …

- The government did not accept the recommendation that the Nursing and Midwifery Council should prepare and maintain the code of conduct and registration for …

F213 Not Accepted

Mid Staffs Inquiry (2013)

Training standards for healthcare support workers

Until such time as the Nursing and Midwifery Council is charged with the recommended regulatory responsibilities, the Department of Health should institute a nationwide system to protect patients and care …

- The government did not accept the recommendation to institute a nationwide system for dismissing healthcare support workers for serious breaches of conduct (Hard Truths: …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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, …

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 …

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 …

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 …

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 …

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 …

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 …

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 …