Public Inquiry Recommendations

F229 Accepted

Mid Staffs Inquiry (2013)

Revalidation

It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F230 Accepted

Mid Staffs Inquiry (2013)

Profile

The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable source of information about the conduct of nurses. …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F231 Accepted

Mid Staffs Inquiry (2013)

Coordination with internal procedures

It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F232 Accepted

Mid Staffs Inquiry (2013)

Employment liaison officers

The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F233 Accepted

Mid Staffs Inquiry (2013)

For joint action Profile

While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that patients and other service users are made aware …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F234 Accepted

Mid Staffs Inquiry (2013)

Cooperation with the Care Quality Commission

Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in many cases there should be joint working to …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F235 Accepted in Part

Mid Staffs Inquiry (2013)

Joint proceedings

The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle (Hard Truths: the Journey to Putting Patients First, DHSC, …

F236 Accepted

Mid Staffs Inquiry (2013)

Identification of who is responsible for the patient

Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so that patients and their supporters are clear who …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F237 Accepted

Mid Staffs Inquiry (2013)

Teamwork

There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by an elderly patient; the contribution of cleaners, maintenance …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F238 Accepted

Mid Staffs Inquiry (2013)

Communication with and about patients

Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff need to be enabled to interact constructively, in …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F239 Accepted

Mid Staffs Inquiry (2013)

Continuing responsibility for care

The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F240 Accepted

Mid Staffs Inquiry (2013)

Hygiene

All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F241 Accepted

Mid Staffs Inquiry (2013)

Provision of food and drink

The arrangements and best practice for providing food and drink to elderly patients require constant review, monitoring and implementation.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F242 Accepted

Mid Staffs Inquiry (2013)

Medicines administration

In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F243 Accepted

Mid Staffs Inquiry (2013)

Recording of routine observations

The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately accessible to all staff electronically in a form …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F244 Accepted

Mid Staffs Inquiry (2013)

Common information practices shared data and electronic records

There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F245 Accepted in Part

Mid Staffs Inquiry (2013)

Board accountability

Each provider organisation should have a board level member with responsibility for information.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F246 Accepted

Mid Staffs Inquiry (2013)

Comparable quality accounts

Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form to enable comparisons to be made between organisations, …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F247 Accepted

Mid Staffs Inquiry (2013)

Accountability for quality accounts

Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems regulators.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F248 Accepted

Mid Staffs Inquiry (2013)

Accountability for quality accounts

Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to use their professional judgement in examining the reliability …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle (Hard Truths: the Journey to Putting Patients First, DHSC, …

F249 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability for quality accounts

Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying that they believe the contents of the account …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in part (Hard Truths: the Journey to Putting Patients First, DHSC, …

F250 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability for quality accounts

It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account are true if it contains a misstatement of …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F251 Accepted in Part

Mid Staffs Inquiry (2013)

Regulatory oversight of quality accounts

The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled to require corrections to be issued where appropriate. …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle (Hard Truths: the Journey to Putting Patients First, DHSC, …

F252 Accepted

Mid Staffs Inquiry (2013)

Access to data

It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F253 Accepted

Mid Staffs Inquiry (2013)

Access to quality and risk profile

The information behind the quality and risk profile – as well as the ratings and methodology – should be placed in the public domain, as far as is consistent with …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F254 Accepted

Mid Staffs Inquiry (2013)

Access for public and patient comments

While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, it would be helpful for there to be …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F255 Accepted

Mid Staffs Inquiry (2013)

Using patient feedback

Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" as possible, even if later adjustments have to …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F256 Accepted

Mid Staffs Inquiry (2013)

Follow up of patients

A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a wider range of responses and feedback on their …

- The government's response in "Hard Truths" (Cm 8777, November 2013) noted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F257 Accepted in Part

Mid Staffs Inquiry (2013)

Role of the Health and Social Care Information Centre

The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the agreement of the devolved governments, the United Kingdom. …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation in principle (Hard Truths: the Journey to Putting Patients First, DHSC, …

F258 Accepted

Mid Staffs Inquiry (2013)

Role of the Health and Social Care Information Centre

The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to comparative performance statistics.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F259 Accepted

Mid Staffs Inquiry (2013)

Role of the Health and Social Care Information Centre

The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should develop a means of publishing more detailed breakdowns …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F260 Accepted in Part

Mid Staffs Inquiry (2013)

Information standards

The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F261 Accepted

Mid Staffs Inquiry (2013)

Information standards

The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F262 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on the performance of each of their services against …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F263 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F264 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F265 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to consider how best to develop comparative statistics on …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F266 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and the specialty organisations should seek and have regard …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F267 Accepted

Mid Staffs Inquiry (2013)

Enhancing the use analysis and dissemination of healthcare information

All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F268 Accepted

Mid Staffs Inquiry (2013)

Resources

Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F269 Accepted

Mid Staffs Inquiry (2013)

Improving and assuring accuracy

The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F270 Accepted

Mid Staffs Inquiry (2013)

Improving and assuring accuracy

There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the patient outcome statistics, including hospital mortality and other …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F271 Accepted

Mid Staffs Inquiry (2013)

Improving and assuring accuracy

To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and the Health and Social Care Information Centre should …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F272 Accepted

Mid Staffs Inquiry (2013)

Improving and assuring accuracy

There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation scheme has been included in the Health and …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F273 Accepted in Part

Mid Staffs Inquiry (2013)

Information to coroners

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F274 Accepted

Mid Staffs Inquiry (2013)

Information to coroners

There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F275 Accepted in Part

Mid Staffs Inquiry (2013)

Independent medical examiners

It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F276 Accepted

Mid Staffs Inquiry (2013)

Independent medical examiners

Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F277 Accepted

Mid Staffs Inquiry (2013)

Death certification

National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, that similar approaches are universal.

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …

F278 Accepted

Mid Staffs Inquiry (2013)

Death certification

It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to …

- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …