Public Inquiry Recommendations

F11 Accepted

Mid Staffs Inquiry (2013)

Fundamental standards of behaviour

Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established fundamental standards that all healthcare providers must meet to maintain registration with …

F12 Accepted

Mid Staffs Inquiry (2013)

Fundamental standards of behaviour

Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff …

- NHS England decommissioned the National Reporting and Learning System (NRLS) on 30 June 2024, replacing it with the Learn from Patient Safety Events (LFPSE) …

F13 Accepted

Mid Staffs Inquiry (2013)

The nature of standards

Standards should be divided into: Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm should …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established fundamental standards of care that are monitored and enforced by the Care …

F14 Accepted in Part

Mid Staffs Inquiry (2013)

The nature of standards

In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance with fundamental standards, and the provision and publication …

- NHS England and the Care Quality Commission published new well-led guidance for NHS trusts and foundation trusts under the Single Assessment Framework in April …

F15 Accepted in Part

Mid Staffs Inquiry (2013)

The nature of standards

All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it …

- An academic review in February 2023 noted that the Care Quality Commission (CQC) inspection regime was overhauled to include a 'Well-led' domain, which assesses …

F16 Accepted

Mid Staffs Inquiry (2013)

Responsibility for setting standards

The Government, through regulation, but after so far as possible achieving consensus between the public and professional representatives, should provide for the fundamental standards which should define outcomes for patients …

- The DHSC and NHS England stated in April 2025 that fundamental standards were implemented via regulations 8 to 20A of the Health and Social …

F17 Accepted in Part

Mid Staffs Inquiry (2013)

Responsibility for setting standards

The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. Failure to comply with such standards should be …

- Integrated Care Boards (ICBs) replaced Clinical Commissioning Groups on 1 July 2022, assuming responsibility for population health and NHS commissioning (Health and Care Act …

F18 Accepted

Mid Staffs Inquiry (2013)

Responsibility for setting standards

It is essential that professional bodies in which doctors and nurses have confidence are fully involved in the formulation of standards and in the means of measuring compliance.

- The Department of Health and Social Care and NHS England stated in April 2025 that professional regulators are members of the Joint Strategic Oversight …

F19 Not Accepted

Mid Staffs Inquiry (2013)

Gaps between the understood functions of separate regulators

There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards for all trusts.

- The government did not accept this recommendation in 2013 (Mid Staffordshire NHS FT public inquiry: government response, Department of Health and Social Care, 19 …

F20 Accepted in Part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the indicators by which it intends to monitor compliance …

- The Department of Health and Social Care and NHS England stated in April 2025 that CQC fundamental standards are in place and mapped to …

F21 Accepted in Part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 introduced a statutory duty of candour for NHS bodies (The Health and Social …

F22 Accepted in Part

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical means of compliance, and indicators by which compliance …

- The Department of Health and Social Care stated in April 2025 that a Memorandum of Understanding between NICE and the Care Quality Commission, dated …

F23 Accepted

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the …

- The Department of Health and Social Care stated in April 2025 that NICE issued guidance on safe staffing in 2014-2015 and continues to publish …

F24 Accepted

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted by the public and healthcare professionals.

- The Department of Health and Social Care and NHS England stated in April 2025 that the CQC assessment approach links back to fundamental standards …

F25 Accepted

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

It should be considered the duty of all specialty professional bodies, ideally together with the National Institute for Health and Clinical Excellence, to develop measures of outcome in relation to …

- DHSC and NHS England stated in April 2025 that 99% of NHS Trusts and Foundation Trusts are enrolled in the National Consultant Information Programme …

F26 Accepted

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and …

- The Care Quality Commission stated in February 2026 that its Single Assessment Framework emphasizes direct observation and feedback from patients and staff (CQC evidence …

F27 Accepted

Mid Staffs Inquiry (2013)

Responsibility for regulating and monitoring compliance

The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental standards; and allowing no place for favourable assumptions, …

- The Department of Health and Social Care stated in April 2025 that the CQC enforcement policy and decision tree govern the use of enforcement …

F28 Accepted

Mid Staffs Inquiry (2013)

Sanctions and interventions for non-compliance

Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable to an organisation in the case of a …

- The Criminal Justice and Courts Act 2015 created criminal offences for wilful neglect or ill-treatment by care workers and provider organisations (Criminal Justice and …

F29 Accepted

Mid Staffs Inquiry (2013)

Sanctions and interventions for non-compliance

It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory requirements, or, in any other case of breach, …

- The Criminal Justice and Courts Act 2015 created a new criminal offence of ill-treatment or wilful neglect by care workers and care provider organisations …

F30 Accepted

Mid Staffs Inquiry (2013)

Interim measures

The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach of fundamental standards, even if it has yet …

- The Department of Health and Social Care stated in April 2025 that the CQC enforcement policy allows for immediate protective steps where there is …

F31 Accepted

Mid Staffs Inquiry (2013)

Interim measures

Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place policies which ensure that they constantly review whether …

- NHS England stated that the Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System as of 30 June 2024 …

F32 Accepted

Mid Staffs Inquiry (2013)

Interim measures

Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to …

- The Department of Health and Social Care stated in April 2025 that the CQC possesses civil powers to impose conditions, suspend registration, or cancel …

F33 Accepted in Part

Mid Staffs Inquiry (2013)

Interim measures

Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.

- The government introduced the special measures regime for trusts following the Francis Inquiry (Culture Change in the NHS, Cm 9009, February 2015). - The …

F34 Accepted in Part

Mid Staffs Inquiry (2013)

Interim measures

Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.

- The Department of Health and Social Care stated in April 2025 that the Recovery Support Programme (RSP) provides a collaborative approach for supporting trusts …

F35 Accepted

Mid Staffs Inquiry (2013)

Need to share information between regulators

Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed …

- The Department of Health and Social Care stated in April 2025 that a Memorandum of Understanding exists between the CQC and NHS England to …

F36 Accepted

Mid Staffs Inquiry (2013)

Use of information for effective regulation

A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should …

- The Department of Health and Social Care and NHS England stated in April 2025 that multiple coordinated data collections exist, including the Model Hospital …

F37 Accepted

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Quality accounts

Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent …

- Section 92 of the Care Act 2014 established a criminal offence for care providers who supply, publish, or make available false or misleading information …

F38 Accepted

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Complaints

The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and …

- The Care Quality Commission stated in April 2025 that it has moved away from mandated Provider Information Returns in most sectors but uses powers …

F39 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Complaints

The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.

- The Care Quality Commission stated in April 2025 that it no longer uses mandated Provider Information Returns for healthcare providers, except in the Adult …

F40 Accepted

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Complaints

It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers.

- The Parliamentary and Health Service Ombudsman introduced NHS Complaint Standards in 2022 which require organisations to promote a learning culture and share narrative learning …

F41 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Patient safety alerts

The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement …

- NHS England established a redesigned National Patient Safety Alert (NatPSA) system, overseen by the National Patient Safety Alerting Committee (NaPSAC) (NHS England Patient Safety …

F42 Accepted

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Serious untoward incidents

Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.

- The "Serious Untoward Incident" classification was removed and replaced by the Patient Safety Incident Response Framework (PSIRF), which is a contractual requirement under the …

F43 Accepted

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Media

Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.

- The Care Quality Commission stated in April 2025 that its national media and regional engagement teams conduct regular media monitoring to identify services where …

F44 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Media

Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for …

- The Department of Health and Social Care stated in April 2025 that the function of examining individual serious incidents has largely transferred to the …

F45 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Inquests

The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.

- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation was superseded by the statutory medical examiner …

F46 Accepted

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Quality and risk profiles

The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important that this is explained carefully and clearly as …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Quality and Risk Profile had been superseded by …

F47 Accepted

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees

The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Care Quality Commission works with Foundation Trust governors …

F48 Accepted in Part

Mid Staffs Inquiry (2013)

Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees

The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Care Quality Commission involves governors in inspections and …

F49 Accepted

Mid Staffs Inquiry (2013)

Enhancement of monitoring and the importance of inspection

Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Single Assessment Framework allows the Care Quality Commission …

F50 Accepted

Mid Staffs Inquiry (2013)

Enhancement of monitoring and the importance of inspection

The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.

- The Department of Health and Social Care and NHS England stated in April 2025 that the Care Quality Commission's methodology includes both on-site and …

F51 Accepted

Mid Staffs Inquiry (2013)

Enhancement of monitoring and the importance of inspection

The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Care Quality Commission retains specialist inspectors for hospitals, …

F52 Accepted

Mid Staffs Inquiry (2013)

Enhancement of monitoring and the importance of inspection

The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.

- The Department of Health and Social Care and NHS England stated in April 2025 that the Care Quality Commission conducts joint inspections with Ofsted, …

F53 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.

- The Department of Health and Social Care and NHS England stated in April 2025 that the Care Quality Commission's regulatory approach has evolved from …

F54 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the …

- The Department of Health and Social Care stated in April 2025 that the Care Quality Commission records all decision-making meetings and actions (DHSC and …

F55 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined …

- The Department of Health and Social Care stated in April 2025 that a new Single Assessment Framework was rolled out by the Care Quality …

F56 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have …

- The Department of Health and Social Care stated in April 2025 that the Care Quality Commission is considering its strategic direction in response to …

F57 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the …

- The Department of Health and Social Care stated in April 2025 that an evaluation of the Care Quality Commission's approach was conducted by Manchester …

F58 Accepted

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council …

- The Department of Health and Social Care stated in April 2025 that the Care Quality Commission retains the Experts by Experience programme to integrate …

F59 Accepted in Part

Mid Staffs Inquiry (2013)

Care Quality Commission independence strategy and culture

Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of …

- The Department of Health and Social Care stated in April 2025 that the Care Quality Commission is considering its response to the recommendation for …

F60 Accepted in Part

Mid Staffs Inquiry (2013)

Consolidation of regulatory functions

The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established a duty for trusts to ensure directors meet fit and proper person …