Public Inquiry Recommendations

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 …

- NHS England maintains the Friends and Family Test (FFT) as a continuous feedback tool for patients to rate their experience of NHS services (Friends …

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 Parliamentary and Health Service Ombudsman defines a complaint as any expression of dissatisfaction, whether spoken or written, that requires a response (NHS Complaint …

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 Department of Health and Social Care and NHS England stated in April 2025 that the PHSO NHS Complaint Standards address the requirements for …

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 Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 mandate that NHS bodies investigate and respond to complaints regarding health …

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 Health Services Safety Investigations Body (HSSIB) was established as an independent statutory body in October 2023 to conduct system-focused patient safety investigations (Health …

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 Department of Health and Social Care and NHS England stated in April 2025 that the Independent NHS Complaints Advocacy Service supports individuals wishing …

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 Department of Health and Social Care stated in April 2025 that local authorities are required under the Local Government and Public Involvement in …

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 Department of Health and Social Care stated in April 2025 that it had not taken forward the recommendation to publish summaries of every …

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.

- The Department of Health and Social Care stated in April 2025 that Local Healthwatch can access annual complaint reports by requesting them from NHS …

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 …

- The Department of Health and Social Care stated in April 2025 that GP practices are required to produce annual complaint reports and provide them …

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 …

- The Care Quality Commission (CQC) stated in April 2025 that it uses Regulation 16(3) of the Health and Social Care Act 2008 (Regulated Activities) …

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 Department of Health and Social Care stated in April 2025 that the government had rejected part of this recommendation in the 2013 'Hard …

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 …

- NHS England issued national guidance on System Quality Groups (SQGs) in January 2022 to facilitate intelligence-sharing and learning between all organisations in an integrated …

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 includes service condition 37, which allows commissioners and providers to agree on local quality requirements and enhanced standards (DHSC …

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 NHS Standard Contract 2024/25 enables commissioners to promote improvement by requiring compliance with enhanced standards through local quality requirements (DHSC and NHS England …

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 abolished Clinical Commissioning Groups and established 42 Integrated Care Boards (ICBs) with broader responsibilities for population health (Health …

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 the statutory bodies responsible for NHS commissioning and service oversight (Health and …

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 …

- The Health and Care Act 2022 permits Integrated Care Boards to enter joint working arrangements with other ICBs to manage complex commissioning tasks (Health …

F129 Accepted

Mid Staffs Inquiry (2013)

Ensuring assessment and enforcement of fundamental standards through contracts

In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard patients and to ensure that at least fundamental …

- DHSC and NHS England stated in April 2025 that the Commissioning for Quality and Innovation (CQUIN) scheme is used to select indicators for measuring …

F130 Accepted

Mid Staffs Inquiry (2013)

Relative position of commissioner and provider

Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be provided, and for that purpose will have to …

- The Health and Care Act 2022 mandates that Integrated Care Boards are responsible for planning health services and managing the NHS budget for their …

F131 Accepted

Mid Staffs Inquiry (2013)

Development of alternative sources of provision

Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken on behalf of consortia of commissioning groups to …

- The Health and Care Act 2022 established 42 Integrated Care Systems (ICSs) to bring together health and care organisations to develop shared plans (Health …

F132 Accepted

Mid Staffs Inquiry (2013)

Monitoring tools

Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: Such monitoring may include requiring quality information generated by …

- The NHS Standard Contract includes provisions allowing commissioners to require audits of provider performance and to enter premises for inspection (DHSC/NHS England implementation update …

F133 Accepted in Part

Mid Staffs Inquiry (2013)

Role of commissioners in complaints

Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, …

- The Parliamentary and Health Service Ombudsman (PHSO) introduced the NHS Complaint Standards in 2022 to provide a consistent approach to complaint handling across the …

F134 Accepted

Mid Staffs Inquiry (2013)

Role of commissioners in provision of support for complainants

Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.

- Local Authorities are responsible for commissioning independent health complaint advocacy services (DHSC/NHS England implementation update to the Thirlwall Inquiry, April 2025). - DHSC and …

F135 Accepted in Part

Mid Staffs Inquiry (2013)

Public accountability of commissioners and public engagement

Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should …

- The Health and Care Act 2022 established Integrated Care Boards (ICBs) to replace Clinical Commissioning Groups (Health and Care Act 2022). - DHSC and …

F136 Accepted

Mid Staffs Inquiry (2013)

Public accountability of commissioners and public engagement

Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of technical support. Effective local commissioning can only work …

- The Health and Care Act 2022 established 42 Integrated Care Boards with statutory responsibilities for population health, bringing together NHS organisations and local authorities …

F137 Not Accepted

Mid Staffs Inquiry (2013)

Intervention and sanctions for substandard or unsafe services

Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other measures necessary to protect patients from the risk …

- The government did not accept this recommendation in 2013 (Hard Truths: the journey to putting patients first volume 2, DHSC, November 2013). - DHSC …

F138 Accepted

Mid Staffs Inquiry (2013)

Local scrutiny

Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at risk from substandard or unsafe services.

- NHS England published the NHS Oversight Framework to identify where providers require support and to provide an objective basis for intervention (NHS Oversight Framework, …

F139 Accepted

Mid Staffs Inquiry (2013)

The need to put patients first at all times

The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient safety and quality standards are being met. Such …

- The Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework in Autumn 2023, making system-based learning mandatory for all NHS-funded secondary care …

F140 Accepted

Mid Staffs Inquiry (2013)

Performance managers working constructively with regulators

Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant information with the relevant regulator, including information about …

- National guidance on System Quality Groups was issued in January 2022 to facilitate intelligence-sharing and learning between all organisations within an integrated care system …

F141 Accepted in Part

Mid Staffs Inquiry (2013)

Taking responsibility for quality

Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its …

- The Health Services Safety Investigations Body (HSSIB) was launched in October 2023 as an independent statutory body with powers of entry, inspection, and seizure …

F142 Accepted

Mid Staffs Inquiry (2013)

Clear lines of responsibility supported by good information flows

For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the performance manager is not in ignorance of the …

- The Health and Care Act 2022 established Integrated Care Boards to replace Clinical Commissioning Groups, creating new architecture for health and care systems (Health …

F143 Accepted

Mid Staffs Inquiry (2013)

Clear metrics on quality

Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms to be established so that outliers or progression …

- The Learn from Patient Safety Events (LFPSE) service, which became fully operational in June 2024, uses machine learning to improve trend identification and analysis …

F144 Accepted

Mid Staffs Inquiry (2013)

Need for ownership of quality metrics at a strategic level

The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing the performance of providers, and retain oversight of …

- The Health and Care Act 2022 replaced Clinical Commissioning Groups with 42 Integrated Care Boards (ICBs) tasked with oversight of population health and provider …

F145 Not Accepted

Mid Staffs Inquiry (2013)

Structure of Local Healthwatch

There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter 6: Patient and public local involvement and scrutiny.

- The government stated in November 2013 that it did not accept the recommendation for a consistent basic structure for Local Healthwatch, citing the importance …

F146 Accepted in Part

Mid Staffs Inquiry (2013)

Finance and oversight of Local Healthwatch

Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the …

- The government stated in November 2013 that it did not accept that local authorities should be required to pass over centrally provided funds, leaving …

F147 Accepted

Mid Staffs Inquiry (2013)

Coordination of local public scrutiny bodies

Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.

- DHSC stated in April 2025 that guidance on local authority health scrutiny was updated in January 2024 (DHSC/NHS England implementation update to the Thirlwall …

F148 Accepted

Mid Staffs Inquiry (2013)

Training

The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.

- DHSC stated in April 2025 that Healthwatch England continues to offer a range of training and resources for local Healthwatch staff and volunteers (DHSC/NHS …

F149 Accepted

Mid Staffs Inquiry (2013)

Expert assistance

Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.

- DHSC stated in April 2025 that updated guidance for local authority scrutiny was issued in January 2024 to provide benchmarks and support (DHSC/NHS England …

F150 Accepted in Part

Mid Staffs Inquiry (2013)

Inspection powers

Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger …

- DHSC stated in April 2025 that this recommendation has not yet been actioned (DHSC/NHS England implementation update to the Thirlwall Inquiry, April 2025). - …

F151 Accepted in Part

Mid Staffs Inquiry (2013)

Complaints to MPs

MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns …

- DHSC stated in April 2025 that this recommendation has not yet been actioned and provided no further update (DHSC/NHS England implementation update to the …

F152 Accepted

Mid Staffs Inquiry (2013)

Medical training

Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the acceptability of training provided by a healthcare provider, …

- DHSC stated in April 2025 that the Education Quality Framework was refreshed in 2024 to provide multi-professional quality standards for clinical learning environments (DHSC/NHS …

F153 Accepted in Part

Mid Staffs Inquiry (2013)

Medical training

The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between …

- The DHSC and NHS England stated in April 2025 that implementation was ongoing and that action taken following the Inquiry had been reviewed (DHSC …

F154 Accepted

Mid Staffs Inquiry (2013)

Medical training

The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight of medical training to coordinate their oversight of …

- The DHSC and NHS England stated in April 2025 that this recommendation was superseded as Monitor and Health Education England had been merged into …

F155 Accepted

Mid Staffs Inquiry (2013)

Medical training

The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance with the following principles: The Postgraduate Dean should …

- The GMC stated in April 2025 that it had revised its standards for medical education and training in 2018 and enhanced the role of …

F156 Accepted

Mid Staffs Inquiry (2013)

Medical training

The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.

- The DHSC and NHS England stated in April 2025 that the NHS Long Term Workforce Plan supports the commitment to improving the quality of …

F157 Accepted

Mid Staffs Inquiry (2013)

Matters to be reported to the General Medical Council

The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical Council either routinely or as they arise. Reports …

- The GMC stated in April 2025 that Local Education and Training Boards (LETBs) and Deaneries routinely report progress against concerns, including patient safety, via …

F158 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers …

- The GMC stated in April 2025 that its "Promoting excellence" standards require local education providers to take action when concerns are raised that impact …

F159 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical …

- The GMC stated in April 2025 that its National Training Survey (NTS) has included patient safety questions since 2014 and that it shares monthly …

F160 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences in relation to raising concerns.

- The DHSC and NHS England stated in April 2025 that awareness of Freedom to Speak Up (FTSU) processes is monitored via the annual National …