Public Inquiry Recommendations

R1 Response Pending

Muckamore Abbey Inquiry (2026)

Implementation monitoring group

The implementation of the following recommendations should be monitored by the DoH and progress should be reported to the DoH Permanent Secretary. To ensure progress is made, an implementation consultation …

R2 Response Pending

Muckamore Abbey Inquiry (2026)

Public acceptance of recommendations within six months

The DoH should indicate publicly within six months of this report which recommendations it accepts and those it does not accept (and why). This should include the recommendations for all …

R3 Response Pending

Muckamore Abbey Inquiry (2026)

Non-acceptance notification within three months

With the exception of Recommendations 88 and 89 (R88 & R89) any other organisation that does not accept a recommendation for which it is named as responsible, should write within …

R4 Response Pending

Muckamore Abbey Inquiry (2026)

Consultation before patient transfers

Prior to the decision to move a service user to a different facility there must be discussion with the staff regularly caring for them, the relevant multidisciplinary team (MDT), the …

R5 Response Pending

Muckamore Abbey Inquiry (2026)

Named person for care plans

Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this person should be involved in and record the …

R6 Response Pending

Muckamore Abbey Inquiry (2026)

Named person approval for transfers

The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring to a new environment within or external to …

R7 Response Pending

Muckamore Abbey Inquiry (2026)

Independent living skills focus

While patients remain in hospital pending resettlement, there should be a focus on enhancing their independent living skills, tailored to their physical and mental capacity.

R8 Response Pending

Muckamore Abbey Inquiry (2026)

Medication audit and NICE compliance

Medication should never be used simply to subdue people in the absence of other forms of treatment and good quality care. DoH should issue a regional audit pro forma to …

R9 Response Pending

Muckamore Abbey Inquiry (2026)

Integrated workforce plans

Each facility or service should have an integrated workforce plan that includes all allied health professionals (AHPs) and all staff involved in patient care. This should be based upon the …

R10 Response Pending

Muckamore Abbey Inquiry (2026)

Access to allied health professionals

It is critical for the wellbeing of people with learning disabilities and autistic people that they are well supported by, and have access to, AHPs including psychologists, speech and language …

R11 Response Pending

Muckamore Abbey Inquiry (2026)

Meaningful daily activities

Like anyone else, people with learning disabilities and autistic people require a variety of meaningful activities on a daily basis to enhance their quality of life. Every person should have …

R12 Response Pending

Muckamore Abbey Inquiry (2026)

Person-centred care plans with family involvement

Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply professional records. While professionals necessarily lead assessments, families …

R13 Response Pending

Muckamore Abbey Inquiry (2026)

Full staff access to care plans

All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.

R14 Response Pending

Muckamore Abbey Inquiry (2026)

Restraint and seclusion observation records

Observation records detailing all use of restraint and seclusion should be completed by the individual observing. In HSCT facilities, if the observer is unregistered, a registered staff member should countersign …

R15 Response Pending

Muckamore Abbey Inquiry (2026)

Independent care plan reviews

Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and should include formal, documented input from the service …

R16 Response Pending

Muckamore Abbey Inquiry (2026)

Missed care incident reporting

If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.

R17 Response Pending

Muckamore Abbey Inquiry (2026)

Co-production training

Creating a co-produced care environment, where people with learning disabilities, families and professionals work collaboratively, requires a fundamental shift in practice. As well as organisational commitments, staff will need education …

R18 Response Pending

Muckamore Abbey Inquiry (2026)

Co-production processes and clinical audit

Specific processes rather than policies should be designed to ensure there is good communication with families and carers to ensure co-production takes place and is effective. Evidence of co-production should …

R19 Response Pending

Muckamore Abbey Inquiry (2026)

Amend Quality Standards for shared decision-making

The 2006 Quality Standards for Health and Social Care should be amended to require HSC organisations to provide all people with learning disabilities, and if they lack capacity, their family …

R20 Response Pending

Muckamore Abbey Inquiry (2026)

Independent advocacy for service users and families

Properly trained independent advocates should be made available to service users and families to support effective communication with staff and for raising concerns and complaints. DoH/SPPG should specify the level …

R21 Response Pending

Muckamore Abbey Inquiry (2026)

Human rights officer in learning disability services

All providers of learning disability services should appoint a human rights officer, as seen in Sheffield Health Partnership University NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust. …

R22 Response Pending

Muckamore Abbey Inquiry (2026)

Easy Read documents

All documents relevant to the service user’s experience and intended for their information must be made available in Easy Read format.

R23 Response Pending

Muckamore Abbey Inquiry (2026)

Regular property and finance compliance checks

All organisations taking responsibility for property and/or finance for people with learning disabilities and autistic people should institute regular checks of adherence to their policies. This includes local checks, corporate …

R24 Response Pending

Muckamore Abbey Inquiry (2026)

Clear records and disclosure policies

Policies must be specific as to records to be kept and for routes to disclosure for relevant family members and people with learning disabilities and autistic people themselves where possible.

R25 Response Pending

Muckamore Abbey Inquiry (2026)

Accessible financial records

The records kept must be easy to manage by staff and easily comprehensible to others, including people with learning disabilities and autistic people, carers and relatives.

R26 Response Pending

Muckamore Abbey Inquiry (2026)

Six-monthly financial accounts to families

Information about the use of cash and other property and six-monthly accounts (or such period as appropriate upon discharge of the person) should be available to the service user concerned …

R27 Response Pending

Muckamore Abbey Inquiry (2026)

RQIA assurance of property processes

RQIA should examine the provider organisation’s internal assurance processes and make recommendations where they are insufficient.

R28 Response Pending

Muckamore Abbey Inquiry (2026)

Restraint Reduction Network principles

The Restraint Reduction Network identifies six principles to avoid the use of restrictive practice. While there is evidence that some Trusts have adopted these principles, further action is needed to …

R29 Response Pending

Muckamore Abbey Inquiry (2026)

Psychology input to reduce restrictive practices

All facilities providing residential services for people with learning disabilities and autistic people should provide sufficient psychology input for each patient, to obviate the need for restrictive practices in all …

R30 Response Pending

Muckamore Abbey Inquiry (2026)

NED champion for restraint reduction

HSCTs should appoint a non-executive director (NED) to act as a champion for restraint reduction, with a mandate to hold executive directors accountable for delivery.

R31 Response Pending

Muckamore Abbey Inquiry (2026)

Restraint education effectiveness metrics

The effectiveness of the education programme for staff in relation to restraint reduction should be measured through defined data metrics. This is to ensure that every instance of restraint is …

R32 Response Pending

Muckamore Abbey Inquiry (2026)

Balanced performance measures including restrictive practices

HSCTs should implement a comprehensive set of balanced performance measures across all services for people with learning disabilities, including those commissioned from third-party providers. These measures should include: Trends in …

R33 Response Pending

Muckamore Abbey Inquiry (2026)

Statistical process control charts

To ensure meaningful interpretation of these trends, all HSCTs should adopt statistical process control (SPC) charts, as developed by Walter Shewhart in 1939. SPC charts use calculated upper and lower …

R34 Response Pending

Muckamore Abbey Inquiry (2026)

Debriefing policies for aggressive behaviour and restraint

All HSCTs should develop two clear operational debriefing policies. The first should apply to both staff and people with learning disabilities and autistic people who are involved in, or affected …

R35 Response Pending

Muckamore Abbey Inquiry (2026)

Inpatient facilities on risk register

Given the elevated risk of inappropriate use of restrictive practices with individuals with learning disabilities and/or autistic people, BHSCT and all HSCTs should automatically place any inpatient facility or facility …

R36 Response Pending

Muckamore Abbey Inquiry (2026)

Seclusion as extraordinary intervention with serious event audit

Use of seclusion should be considered an extraordinary and exceptional intervention. Each intervention should be subject to a serious event audit, conducted by a professional outside the service provider’s learning …

R37 Response Pending

Muckamore Abbey Inquiry (2026)

Human rights-based restrictive practices training

Education and training on the use of restrictive practices should be grounded in human rights principles and the dedicated human rights specialist appointed in accordance with Recommendation 21 (R21) should …

R38 Response Pending

Muckamore Abbey Inquiry (2026)

Clear pathways for raising concerns

People with learning disabilities and autistic people and their families should be provided with clear, written information outlining the available pathways for raising concerns. This information should clearly distinguish between …

R39 Response Pending

Muckamore Abbey Inquiry (2026)

Guidance on recording and presenting concerns

People with learning disabilities and autistic people and their families should be provided with a short description of how best to record and present concerns so as to be effective.

R40 Response Pending

Muckamore Abbey Inquiry (2026)

Record all complaints in electronic system

In HSCTs all complaints, regardless of whether they are resolved immediately at ward level, should be recorded in the Trust’s electronic complaints management system. In private and third sector facilities …

R41 Response Pending

Muckamore Abbey Inquiry (2026)

Inform complainants of complaint management process

Complainants should immediately be informed of how their complaint will be managed (locally or through the corporate complaints process) along with a clear explanation of the corresponding level of investigation …

R42 Response Pending

Muckamore Abbey Inquiry (2026)

Regular updates on complaint progress

Complainants must be regularly updated and informed of the progress of any investigation, including when the process concludes without a specific finding.

R43 Response Pending

Muckamore Abbey Inquiry (2026)

Red-rated complaints shared with all NEDs

All complaints managed at corporate level and rated as red (using the red, amber and green (RAG) rating matrix) should be shared with all non-executive directors (NEDs) on the Board.

R44 Response Pending

Muckamore Abbey Inquiry (2026)

Proactive quality assurance beyond complaints

Complaints alone are a poor indicator of quality of care, particularly in a vulnerable population such as those admitted to MAH. A low volume or absence of complaints does not …

R45 Response Pending

Muckamore Abbey Inquiry (2026)

Incident trend analysis on board dashboards

Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed and trend data reported on every HSCT Board’s …

R46 Response Pending

Muckamore Abbey Inquiry (2026)

Lived experience feedback via external agency

Where people with learning disabilities can participate, the provider should actively seek their lived experience feedback in relation to staff attitudes and behaviours on a quarterly basis through an external …

R47 Response Pending

Muckamore Abbey Inquiry (2026)

Quarterly family feedback via external agency

The provider should actively seek family or carer feedback on the service user’s experience on a quarterly basis via an external agency and report the findings to the public part …

R48 Response Pending

Muckamore Abbey Inquiry (2026)

Holistic safeguarding governance review

HSCTs must review and improve governance of safeguarding to ensure that findings from different safeguarding investigations are considered holistically, synthesised and presented to the public part of a Board-level committee.

R49 Response Pending

Muckamore Abbey Inquiry (2026)

CCTV in high-risk learning disability settings

Hospital settings for people with learning disabilities and autistic people are very high-risk environments for abuse and poor practice, partly because those admitted tend to show high rates of challenging …

R50 Response Pending

Muckamore Abbey Inquiry (2026)

CCTV guidelines for residential and day services

Guidelines should be agreed in relation to providing CCTV systems in residential and day services where requested. Guidelines should be agreed by HSCTs, resettlement service providers, families and people with …