Public Inquiry Recommendations

R51 Response Pending

Muckamore Abbey Inquiry (2026)

CCTV in non-public areas only in best interests

The installation of CCTV in non-public areas should be considered only where this will be in the best interests of the individual service user and following full consultation taking the …

R52 Response Pending

Muckamore Abbey Inquiry (2026)

CCTV policies agreed with staff residents and families

Policies governing the use of CCTV should be agreed only after consultation with staff, residents and their families using the service.

R53 Response Pending

Muckamore Abbey Inquiry (2026)

CCTV viewing circumstances

Policies should include careful consideration of the circumstances in which the CCTV should be viewed; for example, that it should be viewed when concerns are raised by residents, families or …

R54 Response Pending

Muckamore Abbey Inquiry (2026)

Independent CCTV viewers

Viewers of the CCTV should be independent of the setting, i.e. not involved in day-to-day care of the residents.

R55 Response Pending

Muckamore Abbey Inquiry (2026)

External CCTV oversight

Oversight of the CCTV analysis should sit outside the setting in which the CCTV is recording, and should include audits of referrals and outcomes.

R56 Response Pending

Muckamore Abbey Inquiry (2026)

CCTV referral guidance for police

Policies should include clear guidance and definitions of behaviour and circumstances in which information should be passed to PSNI about possible offences.

R57 Response Pending

Muckamore Abbey Inquiry (2026)

Regulator access to CCTV

Policies should be clear about the circumstances in which a regulator, such as RQIA, could access the CCTV.

R58 Response Pending

Muckamore Abbey Inquiry (2026)

CCTV for staff training consideration

Those drafting the policy should consider whether CCTV could ever be used for staff training and, if so, how this would be done.

R59 Response Pending

Muckamore Abbey Inquiry (2026)

CCTV explained in accessible format

All service users and their families should have the CCTV explained to them in easily understood language and with easy access materials, so that they are aware that it is …

R60 Response Pending

Muckamore Abbey Inquiry (2026)

Staff CCTV training

All staff should receive training on the reasons for the use of CCTV and the processes for its analysis.

R61 Response Pending

Muckamore Abbey Inquiry (2026)

Statutory adult safeguarding function

Vulnerable children and adults are inherently more susceptible to abuse or neglect than other people. Adult safeguarding should be formally recognised as a statutory function, equivalent to child protection.

R62 Response Pending

Muckamore Abbey Inquiry (2026)

Monthly safeguarding dashboard

Metrics on both child and adult safeguarding processes should be reported monthly via a safeguarding dashboard, with the same visibility and status as monitoring elective surgery or emergency department waiting …

R63 Response Pending

Muckamore Abbey Inquiry (2026)

Peer-on-peer abuse in safeguarding metrics

Incidents of peer-on-peer abuse should be included in adult safeguarding metrics and included on a published safeguarding dashboard.

R64 Response Pending

Muckamore Abbey Inquiry (2026)

Safeguarding dashboard with screening decisions

The dashboard should include the number of allegations reported, together with the screening decision (referral to the Adult Safeguarding Gateway, referral to the joint protocol or no further action). Particular …

R65 Response Pending

Muckamore Abbey Inquiry (2026)

Common safeguarding investigation standards

There should be common standards for the conduct of safeguarding investigations. These should be drafted and approved by the Northern Ireland Adult Safeguarding Partnership (NIASP) and adopted by the DoH …

R66 Response Pending

Muckamore Abbey Inquiry (2026)

Quarterly safeguarding file audit

A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with incident data and reported to the Executive Team, …

R67 Response Pending

Muckamore Abbey Inquiry (2026)

Independent review of systemic abuse conditions

Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An independent review of enabling conditions should be conducted …

R68 Response Pending

Muckamore Abbey Inquiry (2026)

Cumulative risk assessment across protection plans

Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable adults within a single unit, cumulative risks arising …

R69 Response Pending

Muckamore Abbey Inquiry (2026)

Needs-based staffing with acuity measures

Staffing should be based on service user needs rather than a fixed budget, using daily acuity measures designed specifically for units caring for people with learning disabilities. These should include …

R70 Response Pending

Muckamore Abbey Inquiry (2026)

Mandatory monthly clinical supervision

Clinical supervision (where individuals’ practice with individual patients is discussed) should be mandatory for all ward staff, including healthcare assistants, and should occur monthly. Clinical supervisors should be trained in …

R71 Response Pending

Muckamore Abbey Inquiry (2026)

Specialist training for healthcare assistants

All healthcare assistants working with people with learning disabilities and autistic people should be provided with training, which should include specialist learning disability training as well as basic positive behaviour …

R72 Response Pending

Muckamore Abbey Inquiry (2026)

Review supervision models for commissioned services

SPPG must commission a review of the potential models for supervision of staff in private and third sector services commissioned by HSCTs, including all associated costs.

R73 Response Pending

Muckamore Abbey Inquiry (2026)

Band 4 associate practitioners

Consideration should be given to enhancing the post of healthcare assistant by creating Band 4 associate practitioners in both hospital and community settings in order to increase the skills of …

R74 Response Pending

Muckamore Abbey Inquiry (2026)

Staffing review in safeguarding investigations

Consideration of staffing (including skill mix as well as total numbers) should be a mandatory part of safeguarding investigations in all settings.

R75 Response Pending

Muckamore Abbey Inquiry (2026)

Executive Director of Clinical and Social Care Governance

There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance for complex systems requires specialist skills. While this …

R76 Response Pending

Muckamore Abbey Inquiry (2026)

NED with clinical governance expertise

NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as …

R77 Response Pending

Muckamore Abbey Inquiry (2026)

Triennial Board governance reviews

The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.

R78 Response Pending

Muckamore Abbey Inquiry (2026)

Audit committee implementation tracking

HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months and one year after the internal audit report …

R79 Response Pending

Muckamore Abbey Inquiry (2026)

Board member learning framework

The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in …

R80 Response Pending

Muckamore Abbey Inquiry (2026)

NED for confidential staff reporting

Consideration should be given to the creation of a role for a NED in each HSCT with the specific remit to receive confidential reports from members of staff. The individual …

R81 Response Pending

Muckamore Abbey Inquiry (2026)

Expert clinical governance advisory function

The DoH should establish an expert clinical/social governance advisory function to support providers.

R82 Response Pending

Muckamore Abbey Inquiry (2026)

Risk-based inspection prediction

RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of services tend to be associated with abuse: service …

R83 Response Pending

Muckamore Abbey Inquiry (2026)

RQIA use of CCTV in inspections

The RQIA needs to reconsider whether to make use of CCTV when it is in operation in a service it is inspecting where concerns have been raised.

R84 Response Pending

Muckamore Abbey Inquiry (2026)

Learning disability service culture measure

RQIA needs to consider adopting a measure of service culture specific to learning disability services for use in its inspections. Such measures have already been developed for learning disability residential …

R85 Response Pending

Muckamore Abbey Inquiry (2026)

RQIA communication with patients

RQIA needs to spend proportionately more time talking to patients/residents, and its staff need to be trained in specific communication techniques such as Makaton and Talking Mats.

R86 Response Pending

Muckamore Abbey Inquiry (2026)

PCC information on quality of care standards

The PCC should support service users/families and provide information on what constitutes good quality care for people with learning disabilities and autistic people, and how to spot when care is …

R87 Response Pending

Muckamore Abbey Inquiry (2026)

PCC awareness of statutory functions

The PCC should take further steps to ensure that health service users, including carers and families of people with learning disabilities and autistic people, are aware of its statutory functions …

R88 Response Pending

Muckamore Abbey Inquiry (2026)

PSNI investigation file review processes

PSNI needs to improve its processes for the review of live investigation files, and have an effective escalation process when progress is delayed. PSNI should consider how it assures the …

R89 Response Pending

Muckamore Abbey Inquiry (2026)

Review of prosecution system timeliness

The Department of Justice should review the timeliness of the handling of each aspect of the prosecution system that has led to the delay in bringing those accused of causing …

R90 Response Pending

Muckamore Abbey Inquiry (2026)

Regional standing committee of service users and families

A regional standing committee of people with learning disabilities and autistic people and their relatives should be established, to be consulted by the DoH and other bodies on services for …

R91 Response Pending

Muckamore Abbey Inquiry (2026)

Higher-funded resettlement team for complex needs

There needs to be a recognition that those service users in Northern Ireland yet to be resettled (if there are any by the time of publication of this report) will …

R92 Response Pending

Muckamore Abbey Inquiry (2026)

Time frame and financial information for families

Families should be provided by the relevant Trust with a time frame for resettlement and relevant financial information. Families should also be afforded an appropriate amount of time to consider …

R93 Response Pending

Muckamore Abbey Inquiry (2026)

Regional service map with vacancies

There needs to be a clear regional view of all services available in the community, especially given the variety of services and providers of services now available. The service map …

R94 Response Pending

Muckamore Abbey Inquiry (2026)

Continuing community support provision

There will be a continuing need, which must be met, for new and ongoing community-based support for young people and adults with learning disabilities and autistic people whose families become …

R95 Response Pending

Muckamore Abbey Inquiry (2026)

Blue light protocol for at-risk registers

HSCTs must develop registers of those at risk of requiring unplanned inpatient treatment, similar to the NHS England ‘blue light protocol’, in order to target community resources efficiently and prevent …

R96 Response Pending

Muckamore Abbey Inquiry (2026)

Access to mainstream mental health services

SPPG must ensure that people with learning disabilities and autistic people have access to mainstream (i.e. the same services that are available to those without a learning disability) mental health …

R97 Response Pending

Muckamore Abbey Inquiry (2026)

Funded access to primary care

The SPPG must ensure that commissioning includes provision for people with learning disabilities and autistic people cared for in any facility to have fully funded access to primary care services. …

R98 Response Pending

Muckamore Abbey Inquiry (2026)

AHP and social care workforce recruitment

The DoH must devise ways to recruit and retain more allied health professionals and social care staff in the community for autistic people and people with learning disabilities.

R99 Response Pending

Muckamore Abbey Inquiry (2026)

Key individual for resettlement communication

Communication between the HSCTs and/or resettlement service providers and families and people with learning disabilities should be more open and transparent. Each service user/family should have appointed to them a …

R100 Response Pending

Muckamore Abbey Inquiry (2026)

Person-centred day activities and supported employment

Trusts, private and 3rd sector care providers must ensure that person-centred day activities (including supported employment where appropriate) should be available and offered to all people with learning disabilities and …