Public Inquiry Recommendations

Showing 17 of 1,856 recommendations from Thirlwall Inquiry

What these recommendations are about — Thirlwall Inquiry

Report published 2026 — 17 recommendations across this inquiry.
Browse by inquiry — filtered to Thirlwall Inquiry
Inquiry Recs Accepted
All inquiries (1,856)
Mid Staffs Inquiry 290 281
Manchester Arena Inquiry 169 169
IICSA 107 96
Muckamore Abbey Inquiry 106 —
Grenfell Tower Inquiry 104 104
Infected Blood Inquiry 103 102
Hyponatraemia Inquiry 96 96
Fuller Inquiry 92 71
Leveson Inquiry 92 64
Vale of Leven Inquiry 75 75
Baha Mousa Inquiry 73 72
Southport Inquiry 67 67
COVID-19 Inquiry 55 24
RHI Inquiry 45 44
Morecambe Bay Investigation 44 44
Brook House Inquiry 33 31
Bichard Inquiry 31 31
Angiolini Inquiry 29 16
Post Office Horizon Inquiry 27 25
Jermaine Baker Inquiry 26 22
Edinburgh Tram Inquiry 24 21
Daniel Morgan Panel 23 19
Cranston Inquiry 18 15
Thirlwall Inquiry 17 —
Paterson Inquiry 17 15
HIA Inquiry 12 12
Allitt Inquiry 12 9
Scottish Hospitals Inquiry 11 11
Anthony Grainger Inquiry 9 9
Al-Sweady Inquiry 9 9
Hillsborough Panel 9 5
Fingerprint Inquiry 9 9
Urology Services Inquiry 8 —
ICL Inquiry 7 6
Azelle Rodney Inquiry 3 3
Billy Wright Inquiry 3 3
Penrose Inquiry 1 1
Clear
1 Response Pending
Thirlwall Inquiry (2026)
CCTV and monitoring
All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
2 Response Pending
Thirlwall Inquiry (2026)
Insulin
i. Digital devices should be used to restrict access of insulin to authorised people and record access to insulin storage units. I acknowledge that steps are being taken to achieve …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
3 Response Pending
Thirlwall Inquiry (2026)
Bereavement care
The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
4 Response Pending
Thirlwall Inquiry (2026)
Safeguarding and contracts of employment
i. All Trusts must provide safeguarding training to all staff (appropriate to their role and expertise) and Board members, including Non-Executive Directors. This training should include how to deal with …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
5 Response Pending
Thirlwall Inquiry (2026)
Operating systems (interoperability)
NHS England must provide, by 31 March 2027, a clear and timed route to ensuring that computer systems are harmonised across the NHS by December 2028. Work on the development …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
6 Response Pending
Thirlwall Inquiry (2026)
Monitoring deaths in hospitals
i. By 31 March 2027, all hospital Trusts must have in place effective mechanisms for Board- level monitoring of all deaths of children and babies. ii. By 31 March 2027, …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
7 Response Pending
Thirlwall Inquiry (2026)
Data reporting
i. All hospitals with a neonatal unit should name a ‘lead reporter’ with responsibility for inputting data regularly (at least weekly) and reviewing real-time data viewers on neonatal and maternity …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
8 Response Pending
Thirlwall Inquiry (2026)
Sudden Unexpected Death in Infancy and Childhood (SUDIC)
i. NHS England must: a. Immediately inform all Trusts with a neonatal unit that the SUDIC process applies to the sudden and unexpected deaths of babies who have never left …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
9 Response Pending
Thirlwall Inquiry (2026)
Suspicion of Deliberate Harm Protocol and guidance
Protocol i. By 31 March 2027, NHS England must produce and distribute a one-page protocol setting out the steps to be taken by managers when concerns or suspicions are raised …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
10 Response Pending
Thirlwall Inquiry (2026)
Panel of experts
Serious consideration should be given by DHSC to the setting up of a panel of independent experts from all specialties to be called upon in situations where there are emerging …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
11 Response Pending
Thirlwall Inquiry (2026)
Medical examiners
i. The National Medical Examiner should, by 31 March 2027, prepare and distribute a one-page document setting out all the steps to be taken by a medical examiner when dealing …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
12 Response Pending
Thirlwall Inquiry (2026)
Paediatric and perinatal pathologists
DHSC and NHS England must ensure that, by June 2033, there are 37 doctors in training posts as paediatric and perinatal pathologists, in line with the workforce requirement set out …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
13 Response Pending
Thirlwall Inquiry (2026)
Accountability and regulation of managers
i. DHSC and NHS England must develop and put in place a barring system for all managers (clinical and non-clinical) by September 2027. It should be reviewed in 2030 with …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
14 Response Pending
Thirlwall Inquiry (2026)
Care Quality Commission (CQC)
i. CQC should conduct without-notice inspections of hospital departments. Inspection teams should include at least two current practising experts in the relevant field (in this case paediatrics/neonatology). ii. Inspectors should …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
15 Response Pending
Thirlwall Inquiry (2026)
Assessment of the performance of CQC
There must be a rigorous and consistent review and assessment of the performance of CQC by the Health and Social Care Committee, initially once a year and, once the committee …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
16 Response Pending
Thirlwall Inquiry (2026)
Parliamentary and Health Service Ombudsman
The functions of the National Guardian’s Office should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman’s powers must be increased to include: a. investigating …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
17 Response Pending
Thirlwall Inquiry (2026)
Implementation of recommendations
A new responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office. Funding for appropriate additional staffing should …
No formal government response has been recorded for this recommendation. No independent verification has been carried out.