Public Inquiry Recommendations
Showing 14 of 1,955 recommendations from Morecambe Bay Investigation
What these recommendations are about — Morecambe Bay Investigation
Key themes in this inquiry:
Staff training and development ·
Patient safety governance ·
Quality and safety oversight ·
Healthcare director fit person tests ·
Complaint record keeping failures
.
Report published 2015 — 44 recommendations across this inquiry.
19
Accepted
Morecambe Bay Investigation
(2015)
Professional bodies review conduct of registrants
In light of the evidence we have heard during the Investigation, we consider that the professional regulatory bodies should review the findings of this Report in detail with a view …
20
Accepted
Morecambe Bay Investigation
(2015)
National review of maternity care in challenging circumstances
There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should …
24
Accepted
Morecambe Bay Investigation
(2015)
Involve patients and relatives in incident investigation
We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious …
25
Accepted
Morecambe Bay Investigation
(2015)
Duty to report external investigation findings
We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the …
26
Accepted
Morecambe Bay Investigation
(2015)
Clear national whistleblowing policy
We commend the introduction of a clear national policy on whistleblowing. As well as protecting the interests of whistleblowers, we recommend that this is implemented in a way that ensures …
27
Accepted
Morecambe Bay Investigation
(2015)
Professional duty to report concerns
Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do …
32
Accepted
Morecambe Bay Investigation
(2015)
Reform Local Supervising Authority for midwives
The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation Trust, not only in individual failures of care …
33
Accepted
Morecambe Bay Investigation
(2015)
CQC and Monitor coordination
We considered carefully the effectiveness of separating organisationally the regulation of quality by the Care Quality Commission from the regulation of finance and performance by Monitor, given the close inter-relationship …
34
Accepted
Morecambe Bay Investigation
(2015)
CQC and PHSO memorandum of understanding
The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between …
37
Accepted
Morecambe Bay Investigation
(2015)
Protocol for organisational change transitions
Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting …
38
Accepted
Morecambe Bay Investigation
(2015)
Improve perinatal mortality recording
Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place …
41
Accepted
Morecambe Bay Investigation
(2015)
Guidance for external service reviews
We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS …
42
Accepted
Morecambe Bay Investigation
(2015)
Register external reviews with CQC
We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that the Care Quality Commission develops a system to …
43
Accepted
Morecambe Bay Investigation
(2015)
Maintain focus on quality
We strongly endorse the emphasis placed on the quality of NHS services that began with the Darzi review, High Quality Care for All, and gathered importance with the response to …