Public Inquiry Recommendations
Showing 7 of 1,955 recommendations from Thirlwall Inquiry
What these recommendations are about — Thirlwall Inquiry
Key themes in this inquiry:
Quality and safety oversight ·
No open learning culture ·
Staff policy awareness ·
Flawed mortality reviews ·
Staff training and development
.
Report published 2026 — 17 recommendations across this inquiry.
4
Under consideration
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 …
5
Under consideration
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 …
7
Under consideration
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 …
9
Under consideration
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 …
11
Under consideration
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 …
14
Under consideration
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 …
17
Under consideration
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 …