Public Inquiry Recommendations
Showing 12 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.
21
Accepted in part
Morecambe Bay Investigation
(2015)
Consider extending review to other rural services
The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care and paediatrics. We recommend that NHS England consider …
22
Accepted in part
Morecambe Bay Investigation
(2015)
Recognise educational opportunities in smaller units
We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and …
23
Accepted in part
Morecambe Bay Investigation
(2015)
Clear standards for incident reporting in maternity
Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and …
28
Accepted in part
Morecambe Bay Investigation
(2015)
National standards for clinical leads
Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads …
29
Accepted in part
Morecambe Bay Investigation
(2015)
Standards for manager quality responsibilities
Clear national standards should be drawn up setting out the responsibilities for clinical quality of other managers, including executive directors, middle managers and non-executives. All Trusts should provide evidence to …
30
Accepted in part
Morecambe Bay Investigation
(2015)
National protocol on duties relating to inquests
A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the …
31
Accepted in part
Morecambe Bay Investigation
(2015)
Fundamental review of NHS complaints system
The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the …
35
Accepted in part
Morecambe Bay Investigation
(2015)
Clarify oversight responsibilities
The division of responsibilities between the Care Quality Commission and other parts of the NHS for oversight of service quality and the implementation of measures to correct patient safety failures …
36
Accepted in part
Morecambe Bay Investigation
(2015)
Impact assessment of policy changes
The cumulative impact of new policies and processes, particularly the perceived pressure to achieve Foundation Trust status, together with organisational reconfiguration, placed significant pressure on the management capacity of the …
39
Accepted in part
Morecambe Bay Investigation
(2015)
Implement medical examiner system
There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly …
40
Accepted in part
Morecambe Bay Investigation
(2015)
Extend medical examiners to stillbirths
Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, …
44
Accepted in part
Morecambe Bay Investigation
(2015)
Establish framework for future investigations
This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, …