Public Inquiry Recommendations

F61 Not Accepted

Mid Staffs Inquiry (2013)

Consolidation of regulatory functions

A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a …

- The government did not accept the recommendation to merge system regulatory functions between Monitor and the Care Quality Commission (Hard Truths: the journey to …

F62 Accepted

Mid Staffs Inquiry (2013)

Improved patient focus

For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is …

- The Department of Health and Social Care stated in April 2025 that NHS commissioning organisations have a legal duty to involve the public in …

F63 Accepted

Mid Staffs Inquiry (2013)

Improved transparency

Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.

- The Department of Health and Social Care and NHS England stated in April 2025 that the policy position has changed and no further Foundation …

F64 Not Accepted

Mid Staffs Inquiry (2013)

Authorisation of foundation trusts

The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public …

- The government did not accept this recommendation in 2013, stating that the Care Quality Commission should focus on safety and quality while Monitor focused …

F65 Accepted

Mid Staffs Inquiry (2013)

Quality of care as a pre-condition for foundation trust applications

The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support …

- The Department of Health and Social Care and NHS England stated in April 2025 that the policy position has changed and no further Foundation …

F66 Accepted

Mid Staffs Inquiry (2013)

Improving contribution of stakeholder opinions

The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is …

- The Department of Health and Social Care and NHS England stated in April 2025 that the policy position has changed and no further Foundation …

F67 Accepted

Mid Staffs Inquiry (2013)

Focus on compliance with fundamental standards

The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as …

- The Department of Health and Social Care and NHS England stated in April 2025 that the policy position has changed and no further Foundation …

F68 Accepted

Mid Staffs Inquiry (2013)

Focus on compliance with fundamental standards

No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of …

- The Department of Health and Social Care and NHS England stated in April 2025 that the policy position has changed and no further Foundation …

F69 Accepted

Mid Staffs Inquiry (2013)

Focus on compliance with fundamental standards

The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality standards at the same time as complying with …

- The Department of Health and Social Care and NHS England stated in April 2025 that the policy position has changed and no further Foundation …

F70 Accepted

Mid Staffs Inquiry (2013)

Duty of utmost good faith

A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant information material to the application and to ensure …

- The Department of Health and Social Care and NHS England stated in April 2025 that the policy position has changed and no further Foundation …

F71 Accepted

Mid Staffs Inquiry (2013)

Role of Secretary of State

The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a service to patients which is, at the time …

- The Department of Health and Social Care and NHS England stated in April 2025 that the policy position has changed and no further Foundation …

F72 Accepted

Mid Staffs Inquiry (2013)

Assessment process for authorisation

The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas as well as all wards to determine whether …

- The Department of Health and Social Care stated in April 2025 that this recommendation has been superseded by the current inspection regime (DHSC and …

F73 Accepted

Mid Staffs Inquiry (2013)

Need for constructive working with other parts of the system

The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with the Department of Health and whether the appropriate …

- The Department of Health and Social Care stated in April 2025 that it holds quarterly accountability meetings with the Care Quality Commission, including half-yearly …

F74 Accepted

Mid Staffs Inquiry (2013)

Enhancement of role of governors

Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation to account to the public, and in particular …

- NHS England stated in April 2025 that it published an updated reference guide for governors in 2022 to explain changes in the NHS landscape …

F75 Accepted in Part

Mid Staffs Inquiry (2013)

Enhancement of role of governors

The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its …

- The government stated in its 2013 response that it would not seek to prescribe how governors should work day-to-day and that regulators would not …

F76 Accepted

Mid Staffs Inquiry (2013)

Enhancement of role of governors

Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large – it is important that regular and constructive …

- The National Service Act 2006, as amended, establishes a statutory duty for councils of governors to represent the interests of trust members and the …

F77 Accepted

Mid Staffs Inquiry (2013)

Enhancement of role of governors

Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and …

- NHS England published an updated Code of Governance for NHS provider trusts in April 2023, which requires governors to receive appropriate induction and regular …

F78 Accepted

Mid Staffs Inquiry (2013)

Enhancement of role of governors

The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in relation to compliance with healthcare standards as will …

- The Care Quality Commission published guidance for foundation trust governors in 2019 to assist them in carrying out their duties regarding healthcare standards (Guidance …

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 established the 'fit and proper person' requirement for directors (Health …

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 …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 mandates that directors must not have been responsible for, or …

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 established requirements for directors to possess the qualifications, competence, skills, …

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 …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 5) allows the Care Quality Commission to take enforcement action against a …

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 …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 came into force in November 2014, establishing the fitness requirements …

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 …

- NHS England published a standardised board member reference template in August 2023 as part of the Fit and Proper Person Test Framework (Fit and …

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 …

- NHS England published the Fit and Proper Person Test Framework in August 2023, which outlines procedures for assessing directors and handling cases of non-compliance …

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.

- NHS England published an updated Code of Governance for NHS provider trusts in April 2023, stating that all directors should receive appropriate induction and …

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 …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 granted the Care Quality Commission powers to prosecute providers for breaches related to …

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 …

- The Care Quality Commission and the Health and Safety Executive (HSE) maintain a Memorandum of Understanding (MoU) that covers the sharing of statutory notifications, …

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.

- The Patient Safety Incident Response Framework (PSIRF), which became mandatory for NHS-funded secondary care providers in Autumn 2023, requires patient safety incident reports to …

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 …

- The Department of Health and Social Care stated in April 2025 that a Memorandum of Understanding (MoU) exists between the Care Quality Commission (CQC) …

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 …

- The Department of Health and Social Care stated in April 2025 that NHS Resolution has moved away from assessment against risk management standards (DHSC …

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.

- The Department of Health and Social Care stated in April 2025 that NHS Resolution no longer uses the previous levels of risk management standards …

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 …

- The Department of Health and Social Care stated in April 2025 that NHS Resolution considers staffing and activity levels in maternity care by incorporating …

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 …

- The Department of Health and Social Care stated in April 2025 that a best practice guide was published in 2021 to assist trusts in …

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 …

- The Department of Health and Social Care stated in April 2025 that NHS Resolution shares relevant information with the Care Quality Commission as part …

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 …

- The Department of Health and Social Care stated in April 2025 that the NHS Litigation Authority previously included an explanation of the limitations of …

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 and its functions were transferred to the NHS Commissioning Board (NHS England) on 1 June 2012 …

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 Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS) for recording and analyzing patient safety events (Learn …

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 uses machine learning to analyze safety events and includes recording forms for primary care settings (Learn …

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 …

- In April 2025, DHSC and NHS England stated that the designation of 'serious incident' had been abolished and replaced by the Learn from Patient …

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 …

- In April 2025, DHSC and NHS England stated that NHS England hosts Patient-led Assessments of the Care Environment (PLACE) where local people assess hospital …

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.

- In April 2025, DHSC and NHS England stated that incident data is open to analysis via the LFPSE service, which includes an online service …

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.

- In April 2025, DHSC and NHS England stated that this recommendation was superseded because NHS England is the successor to both the National Patient …

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 …

- In April 2025, DHSC and NHS England stated that patient safety incident reports are provided to the Care Quality Commission (DHSC and NHS England …

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.

- In April 2025, DHSC and NHS England stated that mortality information is triangulated via the Learning from Deaths policy and a dashboard for NHS …

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 …

- In April 2025, DHSC and NHS England stated that the UK Health Security Agency (UKHSA) collects and publishes data on hospital and community-acquired infections …

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 …

- In April 2025, DHSC and NHS England stated that UKHSA regional teams lead responses to health-related incidents and provide specialist input to local authorities …

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 …

- The Department of Health and Social Care and NHS England stated in April 2025 that the review of support and training for local oversight …

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 require NHS bodies and primary care providers to publicise their complaints …

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 prohibit parallel litigation and complaint investigations (The Local Authority …