Public Inquiry Recommendations

F7 Accepted in part

Mid Staffs Inquiry (2013)

Clarity of values and principles

All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts …

F9 Accepted in part

Mid Staffs Inquiry (2013)

Fundamental standards of behaviour

The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers.

F10 Accepted in part

Mid Staffs Inquiry (2013)

Fundamental standards of behaviour

The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as those produced by the National Institute for Health …

F14 Accepted in part

Mid Staffs Inquiry (2013)

The nature of standards

In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance with fundamental standards, and the provision and publication …

F15 Accepted in part

Mid Staffs Inquiry (2013)

The nature of standards

All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it …

F17 Accepted in part

Mid Staffs Inquiry (2013)

Responsibility for setting standards

The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. Failure to comply with such standards should be …

F20 Accepted in part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the indicators by which it intends to monitor compliance …

F21 Accepted in part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. …

F22 Accepted in part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical means of compliance, and indicators by which compliance …

F33 Accepted in part

Mid Staffs Inquiry (2013)

Interim measures

Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.

F34 Accepted in part

Mid Staffs Inquiry (2013)

Interim measures

Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.

F39 Accepted in part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Complaints

The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.

F41 Accepted in part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Patient safety alerts

The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement …

F44 Accepted in part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Media

Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for …

F45 Accepted in part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Inquests

The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.

F48 Accepted in part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees

The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to …

F59 Accepted in part

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of …

F60 Accepted in part

Mid Staffs Inquiry (2013)

Consolidation of regulatory functions

The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to …

F75 Accepted in part

Mid Staffs Inquiry (2013)

Enhancement of role of governors

The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its …

F79 Accepted in part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper …

F80 Accepted in part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications …

F84 Accepted in part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is …

F87 Accepted in part

Mid Staffs Inquiry (2013)

Ensuring the utility of a health and safety function in a clinical setting

The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should be given power to prosecute 1974 Act offences …

F88 Accepted in part

Mid Staffs Inquiry (2013)

Information sharing

The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order …

F89 Accepted in part

Mid Staffs Inquiry (2013)

Information sharing

Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.

F91 Accepted in part

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority …

F93 Accepted in part

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based …

F97 Accepted in part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this valuable function to a systems regulator.

F98 Accepted in part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part …

F99 Accepted in part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has …

F100 Accepted in part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that …

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 …

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.

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 …

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 …

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; …

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 …

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, …

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 …

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 …

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 …

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 …

F151 Accepted in part

Mid Staffs Inquiry (2013)

Complaints to MPs

MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns …

F153 Accepted in part

Mid Staffs Inquiry (2013)

Medical training

The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between …

F164 Accepted in part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision …

F165 Accepted in part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public.

F166 Accepted in part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view …

F167 Accepted in part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments …

F168 Accepted in part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for …

F169 Accepted in part

Mid Staffs Inquiry (2013)

Role of the Department of Health and the National Quality Board

The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation …