Public Inquiry Recommendations

F79 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 introduced the Fit and Proper Person Requirement, in force from …

F80 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications …

- The model core constitution for NHS foundation trusts, published by Monitor in May 2013 and updated in September 2014, includes disqualification criteria for directors. …

F81 Accepted

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires that directors possess "the qualifications, competence, skills and experience …

F82 Accepted

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom the regulator is satisfied is not or is …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 provides that CQC can require the removal of directors who …

F83 Accepted

Mid Staffs Inquiry (2013)

Accountability of providers' directors

If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would exercise its power to require the removal or …

- CQC published guidance on Regulation 5 (Fit and Proper Persons: Directors) setting out the requirements that providers must meet and the approach CQC takes …

F84 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is …

- The NHS England FPPT Framework (effective September 2023) mandates that organisations complete a Board Member Reference (BMR) when any board member leaves their position, …

F85 Accepted

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event of an executive or non-executive director being found …

- CQC published guidance on Regulation 5 (Fit and Proper Persons: Directors) setting out the circumstances in which directors may be found not to meet …

F86 Accepted

Mid Staffs Inquiry (2013)

Requirement of training of directors

A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.

- The NHS Leadership Academy provides multiple board-level development programmes including the Nye Bevan Programme (12-month programme for aspiring board members), the Aspiring Chief Executive …

F87 Accepted in Part

Mid Staffs Inquiry (2013)

Ensuring the utility of a health and safety function in a clinical setting

The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should be given power to prosecute 1974 Act offences …

- CQC was given powers to prosecute for offences of ill-treatment or wilful neglect of individuals by care providers or care workers under sections 20 …

F88 Accepted in Part

Mid Staffs Inquiry (2013)

Information sharing

The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order …

- HSE and CQC published a memorandum of understanding setting out arrangements for information sharing between the two organisations. Under the MoU, HSE shares information …

F89 Accepted in Part

Mid Staffs Inquiry (2013)

Information sharing

Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.

- HSE and CQC published a memorandum of understanding (most recently revised 2014) providing for reciprocal information sharing. Under the MoU, CQC shares serious incident …

F90 Accepted

Mid Staffs Inquiry (2013)

Assistance in deciding on prosecutions

In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences for any victims, that the public interest requires …

- HSE published guidance on the selection and management of expert witnesses in enforcement proceedings, including healthcare-related cases. HSE uses expert medical and clinical advisors …

F91 Accepted in Part

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority …

- NHS Resolution (formerly the NHS Litigation Authority, renamed in April 2017) operates three risk management schemes: the Clinical Negligence Scheme for Trusts (CNST), the …

F92 Accepted

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.

- NHS Resolution (formerly the NHS Litigation Authority) operated a Clinical Risk Management Standards (CRMS) assessment scheme with three levels, where trusts assessed at level …

F93 Accepted in Part

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based …

- NICE published safe staffing guidance SG1 (Safe staffing for nursing in adult inpatient wards in acute hospitals) in July 2014, directly in response to …

F94 Accepted

Mid Staffs Inquiry (2013)

Evidence-based assessment

As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider …

- NHS Resolution (formerly the NHS Litigation Authority, renamed April 2017) maintains a claims management database covering all CNST claims. The NHS Resolution annual report …

F95 Accepted

Mid Staffs Inquiry (2013)

Information sharing

As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed over risk reports, consideration should also be given …

- NHS Resolution shares claims data and risk information with CQC. The NHS Resolution annual report (2023-24) states that the organisation works with CQC and …

F96 Accepted

Mid Staffs Inquiry (2013)

Information sharing

The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of its standards assessments and of the reliance which …

- NHS Resolution (formerly the NHS Litigation Authority) discontinued the three-level Clinical Risk Management Standards (CRMS) assessment programme. The CRMS assessments were the "standards assessments" …

F97 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this valuable function to a systems regulator.

- The National Patient Safety Agency (NPSA) was abolished on 1 June 2012. Its patient safety functions, including the National Reporting and Learning System, were …

F98 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20 (duty of candour), requires registered providers to act in an open …

F99 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has …

- The Learn from Patient Safety Events (LFPSE) service, which replaced the National Reporting and Learning System (NRLS, decommissioned June 2024), was specifically designed to …

F100 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that …

- The Learn from Patient Safety Events (LFPSE) service accepts reports from individual staff members as well as organisational reporters. Individual clinicians or other healthcare …

F101 Accepted

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it should be possible to organise for mutual peer …

- The National Patient Safety Agency (NPSA) was abolished on 1 June 2012, with its patient safety functions transferred to NHS England. The recommendation related …

F102 Accepted

Mid Staffs Inquiry (2013)

Transparency use and sharing of information

Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others facilitated in that task.

- The National Reporting and Learning System (NRLS), originally operated by the NPSA and subsequently by NHS England, published regular data summaries and analysis. The …

F103 Accepted

Mid Staffs Inquiry (2013)

Transparency use and sharing of information

The National Patient Safety Agency or its successor should regularly share information with Monitor.

- The National Patient Safety Agency (NPSA) was abolished on 1 June 2012, with its patient safety functions transferred to NHS England. Monitor merged into …

F104 Accepted

Mid Staffs Inquiry (2013)

Transparency use and sharing of information

The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency or its successor to assist it in identifying …

- CQC confirmed that it uses patient safety incident data from the National Reporting and Learning System (and its successor LFPSE) as part of its …

F105 Accepted

Mid Staffs Inquiry (2013)

Transparency use and sharing of information

Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.

- The Summary Hospital-level Mortality Indicator (SHMI) is published quarterly by NHS England (formerly by the Health and Social Care Information Centre, now NHS Digital, …

F106 Accepted

Mid Staffs Inquiry (2013)

Health Protection Agency Coordination and publication of providers' information on healthcare associated infections

The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation to healthcare associated infections, working with the Health …

- The Health Protection Agency was abolished on 1 April 2013 and its functions were transferred to Public Health England (PHE), which in turn was …

F107 Accepted

Mid Staffs Inquiry (2013)

Sharing concerns

If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider's management of healthcare associated infections is …

- The Health Protection Agency was abolished on 1 April 2013. Its health protection functions were transferred to Public Health England, which was subsequently replaced …

F108 Accepted

Mid Staffs Inquiry (2013)

Support for other agencies

Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers' infection …

- Public Health England (PHE) was established on 1 April 2013, assuming the health protection functions of the Health Protection Agency. PHE was subsequently replaced …

F109 Accepted

Mid Staffs Inquiry (2013)

Effective complaints handling

Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, …

- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (SI 2009/309) established a single complaints procedure for health and social …

F110 Accepted

Mid Staffs Inquiry (2013)

Lowering barriers

Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may be prudent for parties in actual or potential …

- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 do not contain any provision requiring or permitting complaints to be …

F111 Accepted

Mid Staffs Inquiry (2013)

Lowering barriers

Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually …

- The NHS Constitution (revised 2023) includes a pledge that "the NHS will ensure you are treated with courtesy and you receive appropriate support throughout …

F112 Accepted

Mid Staffs Inquiry (2013)

Lowering barriers

Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as …

- The PHSO's NHS Complaint Standards (July 2022) state that organisations should treat all expressions of dissatisfaction that require a response as complaints, regardless of …

F113 Accepted

Mid Staffs Inquiry (2013)

Complaints handling

The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.

- The Patients Association conducted a peer review of complaints handling at Mid Staffordshire NHS Foundation Trust, published in 2011. The review made recommendations about …

F114 Accepted

Mid Staffs Inquiry (2013)

Complaints handling

Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.

- The Patient Safety Incident Response Framework (PSIRF), mandatory for NHS trusts from autumn 2023, requires trusts to consider all sources of information — including …

F115 Accepted in Part

Mid Staffs Inquiry (2013)

Investigations

Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward …

- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 require responsible bodies to investigate complaints but do not prescribe specific …

F116 Accepted

Mid Staffs Inquiry (2013)

Support for complainants

Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those …

- The Health and Social Care Act 2012 (section 185) placed a duty on local authorities to commission independent advocacy services for people making or …

F117 Accepted in Part

Mid Staffs Inquiry (2013)

Support for complainants

A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.

- The Health and Social Care Act 2012 (section 185) placed a duty on local authorities to commission independent advocacy services for people making NHS …

F118 Accepted in Part

Mid Staffs Inquiry (2013)

Learning and information from complaints

Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In …

- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 require NHS bodies to prepare an annual report on complaints handling, …

F119 Accepted

Mid Staffs Inquiry (2013)

Learning and information from complaints

Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.

- Local Healthwatch organisations were established under the Health and Social Care Act 2012 (sections 221-227), replacing Local Involvement Networks (LINks) from April 2013. Local …

F120 Accepted in Part

Mid Staffs Inquiry (2013)

Learning and information from complaints

Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This …

- Integrated Care Boards (ICBs), which replaced Clinical Commissioning Groups from July 2022 under the Health and Care Act 2022, have responsibility for commissioning most …

F121 Accepted

Mid Staffs Inquiry (2013)

Learning and information from complaints

The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints …

- CQC's Insight intelligence model draws on complaints data from multiple sources to identify providers requiring regulatory attention. CQC receives information about complaints through its …

F122 Accepted in Part

Mid Staffs Inquiry (2013)

Handling large-scale complaints

Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to very distressed and anxious members of the public; …

- The National Quality Board (NQB), a multi-stakeholder body bringing together NHS England, CQC, NICE, HSSIB, NHSE regional teams and other system partners, has published …

F123 Accepted

Mid Staffs Inquiry (2013)

Responsibility for monitoring delivery of standards and quality

GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the …

- The Health and Care Act 2022 established Integrated Care Boards (ICBs) as the statutory commissioners of NHS services from July 2022, replacing Clinical Commissioning …

F124 Accepted in Part

Mid Staffs Inquiry (2013)

Duty to require and monitor delivery of fundamental standards

The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in respect of each item of service it is …

- The NHS Standard Contract 2024/25, mandated for all NHS-funded secondary care services, includes quality requirements, performance standards, and provisions for remedial action where standards …

F125 Accepted

Mid Staffs Inquiry (2013)

Responsibility for requiring and monitoring delivery of enhanced standards

In addition to their duties with regard to the fundamental standards, commissioners should be enabled to promote improvement by requiring compliance with enhanced standards or development towards higher standards. They …

- The Commissioning for Quality and Innovation (CQUIN) framework enables commissioners to incentivise quality improvement above the level of fundamental standards. CQUIN links a proportion …

F126 Accepted

Mid Staffs Inquiry (2013)

Preserving corporate memory

The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This …

- The Health and Care Act 2022 established Integrated Care Boards (ICBs) from July 2022, replacing 106 CCGs with 42 ICBs (subsequently reduced to 36 …

F127 Accepted

Mid Staffs Inquiry (2013)

Resources for scrutiny

The NHS Commissioning Board and local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny of its providers' services, based on sound commissioning …

- The Health and Care Act 2022 established Integrated Care Boards (ICBs) as statutory bodies with their own budgets, staff, and governance arrangements. ICBs are …

F128 Accepted

Mid Staffs Inquiry (2013)

Expert support

Commissioners must have access to the wide range of experience and resources necessary to undertake a highly complex and technical task, including specialist clinical advice and procurement expertise. When groups …

- Integrated Care Boards (ICBs) are required under the Health and Care Act 2022 to have access to clinical expertise for commissioning decisions. ICBs must …