Public Inquiry Recommendations

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. …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle (Hard Truths: the Journey to Putting Patients First, DHSC, …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) noted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle (Hard Truths: the Journey to Putting Patients First, DHSC, …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle (Hard Truths: the Journey to Putting Patients First, DHSC, …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

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 government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F290 Accepted

Mid Staffs Inquiry (2013)

Experience on the front line

The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …