Public Inquiry Recommendations

F279 Accepted

Mid Staffs Inquiry (2013)

Death certification

So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge …

- 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). …

F280 Accepted

Mid Staffs Inquiry (2013)

Appropriate and sensitive contact with bereaved families

Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given 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). …

F281 Accepted

Mid Staffs Inquiry (2013)

Appropriate and sensitive contact with bereaved families

It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how to undertake this sensitive task in a manner …

- 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). …

F282 Accepted

Mid Staffs Inquiry (2013)

Information for and from inquests

Coroners should send copies of relevant Rule 43 reports to 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). …

F283 Accepted

Mid Staffs Inquiry (2013)

Information for and from inquests

Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the death of a patient. This should include contact …

- 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). …

F284 Accepted

Mid Staffs Inquiry (2013)

Appointment of assistant deputy coroners

The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners.

- 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). …

F285 Accepted

Mid Staffs Inquiry (2013)

Appointment of assistant deputy coroners

The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a party in a 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). …

F286 Accepted

Mid Staffs Inquiry (2013)

Impact assessments before structural change

Impact and risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare system is accepted. Such assessments should cover at …

- 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, …

F287 Accepted

Mid Staffs Inquiry (2013)

Impact assessments before structural change

The Department of Health should together with healthcare systems regulators take the lead in developing through obtaining consensus between the public and healthcare professionals, a coherent, and easily accessible structure …

- 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). …

F288 Accepted

Mid Staffs Inquiry (2013)

Clinical input

The Department of Health should ensure that there is senior clinical involvement in all policy decisions which may impact on patient safety and well-being.

- 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). …

F289 Accepted

Mid Staffs Inquiry (2013)

Experience on the front line

Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who have suffered poor experiences. The Department of Health …

- 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). …

F290 Accepted

Mid Staffs Inquiry (2013)

Experience on the front line

The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making …

- 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). …

1 Accepted

Hillsborough Panel (2012)

Chief Coroner guidance on coroners' records

We recommend that the Lord Chancellor and Secretary of State for Justice invite the Chief Coroner to prepare guidance for all coroners on the appropriate retention and archiving of documents …

Government reports this recommendation as delivered. Implemented.

2 No Response

Hillsborough Panel (2012)

Police records under Public Records Act 1958

We recommend that the preservation of police records be reviewed to ensure that all such documents are treated as public records, held on behalf of the public, subject to the …

Government response: No Response. Last substantive update was December 2012. No recent public evidence of further progress.

3 Accepted

Hillsborough Panel (2012)

Central government documents to National Archives

We recommend that relevant central government documents - particularly those of the Cabinet Office and No 10 - be transferred to the National Archives, thus enabling full public access to …

Government reports this recommendation as delivered. Implemented.

4 Accepted

Hillsborough Panel (2012)

Distributed Permanent Archive at Sheffield/Liverpool/Kew

We recommend that a Distributed Permanent Archive be established across the Central Library in Sheffield, the Liverpool Record Office and the National Archives, Kew, so that all original materials are …

Government reports this recommendation as delivered. Implemented.

5 No Response

Hillsborough Panel (2012)

Private owners encouraged to deposit records

We recommend that, once a copy of all material has been placed on a Digital Archive, private owners - including the FA and SWFC - be encouraged to deposit original …

Government response: No Response. Last substantive update was December 2012. No recent public evidence of further progress.

6 No Response

Hillsborough Panel (2012)

Editor-in-Chief for digital archive

We recommend the appointment of an Editor-in-Chief to oversee the presentation on the Digital Archive of documents relating to the disaster, and to the role of each of the organisations …

The government has not accepted this recommendation.

7 No Response

Hillsborough Panel (2012)

Protocol for adding/removing archive material

We recommend the development of a protocol which identifies the criteria according to which material not disclosed by the Panel may be added in the future, and material currently disclosed …

The government has not accepted this recommendation.

8 Accepted

Hillsborough Panel (2012)

Digital archive accessible with professional support

We recommend that the Digital Archive be permanently accessible at the Liverpool Record Office, the Central Library, Sheffield and other appropriate local venues, so that members of the public have …

Government reports this recommendation as delivered. Implemented.

9 Accepted

Hillsborough Panel (2012)

Digital archive permanently archived at National Archives

We recommend that the Digital Archive be permanently archived at the National Archives at Kew (or its successor). Regardless of any developments in relation to the Digital Archive, this permanent …

Government reports this recommendation as delivered. Implemented.

LIT-1 Accepted

Litvinenko Inquiry (2016)

Closed Recommendation

One recommendation contained within the closed section of the report (classified).

Government reports this recommendation as delivered. Sanctions and arrest warrants remain in place.

LIT-2 Accepted

Litvinenko Inquiry (2016)

Asset Freezes on Suspects

Asset freezes should be implemented against the suspects Andrey Lugovoy and Dmitri Kovtun.

Government reports this recommendation as delivered. Sanctions and arrest warrants remain in place.

LIT-3 Accepted

Litvinenko Inquiry (2016)

Maintain Arrest Warrants

Interpol notices and European Arrest Warrants should remain in place for the suspects.

Government reports this recommendation as delivered. Sanctions and arrest warrants remain in place.

LIT-4 Accepted

Litvinenko Inquiry (2016)

Diplomatic Representations to Russia

Senior diplomatic representations should be made to Russia regarding its failure to cooperate with justice.

Government reports this recommendation as delivered. Sanctions and arrest warrants remain in place.

LIT-5 Accepted

Litvinenko Inquiry (2016)

Review Further Legal Actions

The Director of Public Prosecutions should consider whether further action can be taken on extradition and asset freezing.

Government reports this recommendation as delivered. Sanctions and arrest warrants remain in place.

AS-1 Accepted

Al-Sweady Inquiry (2014)

Document Retention and Storage Policy

Consideration should be given to the establishment of a policy by the Ministry of Defence to ensure that all documents or other material, including electronic material, are retrieved from theatre …

Government response: Accepted. No public evidence of delivery has been found.

AS-2 Accepted

Al-Sweady Inquiry (2014)

Recording of Interrogation and Tactical Questioning

Digital video and audio recordings should be made of both interrogation and tactical questioning sessions. Such recordings should be retrieved from theatre, catalogued and stored in the same way and …

Government response: Accepted. No public evidence of delivery has been found.

AS-3 Accepted

Al-Sweady Inquiry (2014)

Training Material Dating and Archiving

All training material should be dated, appropriately retained and archived in such a way that it can easily be established when the training material was composed, when it came into …

Government response: Accepted. No public evidence of delivery has been found.

AS-4 Accepted

Al-Sweady Inquiry (2014)

Shooting Incident Policy

A Shooting Incident Policy should be drafted which is achievable in practice in Theatre, which is compliant with Article 2 of the ECHR and which enables the ascertainment of the …

Government response: Accepted. No public evidence of delivery has been found.

AS-5 Accepted

Al-Sweady Inquiry (2014)

Detainee Capture and Condition Records

Appropriate procedures should be introduced to ensure that there is an accurate and detailed contemporaneous record of the circumstances relating to the original capture/detention of a prisoner and his general …

Government response: Accepted. No public evidence of delivery has been found.

AS-6 Accepted

Al-Sweady Inquiry (2014)

Informing Detainees of Rights

All detainees should be clearly informed of their rights and obligations as soon as is practicable upon arrival at any detention facility. As a minimum this should include informing the …

Government response: Accepted. No public evidence of delivery has been found.

AS-7 Accepted

Al-Sweady Inquiry (2014)

Strip-Search Safeguards

Appropriate measures should be taken to ensure that minimum safeguards are in place where a detainee is to be strip-searched. These include informing a detainee as to the necessity for …

Government response: Accepted. No public evidence of delivery has been found.

AS-8 Accepted

Al-Sweady Inquiry (2014)

Interpreter Availability

There should be an appropriate review of all current, relevant policy and procedures to ensure that a sufficient number of suitably trained interpreters are readily available and on hand during …

Government response: Accepted. No public evidence of delivery has been found.

AS-9 Accepted

Al-Sweady Inquiry (2014)

Medical Fitness for Detention Forms

Appropriate forms should be made available to allow a medical examiner to declare a detainee unfit for detention and questioning. The decision as to whether a detainee has been declared …

Government response: Accepted. No public evidence of delivery has been found.

AR-1 Accepted

Azelle Rodney Inquiry (2013)

Full Review of Operation Tayport

I recommend that, as soon as is reasonably practicable, the MPS undertake a full, thorough review of all aspects of Operation Tayport. The review should be conducted by a senior …

Government reports this recommendation as delivered. Implementation status based on Commander Basu's MPS review and updates provided in August 2014..

AR-2 Accepted

Azelle Rodney Inquiry (2013)

Protocol for Post-Incident Debriefing

At an early date there should be liaison between the IPCC, the MPS and ACPO (and, more significantly, lawyers acting for each) with a view to establishing a protocol for …

Government reports this recommendation as delivered. Implementation status based on Commander Basu's MPS review and updates provided in August 2014..

AR-3 Accepted

Azelle Rodney Inquiry (2013)

Commissioner to Appoint Debrief Officer

In the event of a shooting by an MPS officer that results in death or serious injury, the Commissioner should thereupon appoint a senior officer to conduct a full, operational …

Government reports this recommendation as delivered. Implementation status based on Commander Basu's MPS review and updates provided in August 2014..

R1 Accepted

Billy Wright Inquiry (2010)

Prison records retention

Given what we discovered about the destruction of prisoners' files, many of which would have been important historical records, we recommend that the SOSNI should satisfy himself whether any other …

Government response: Accepted. No public evidence of delivery has been found.

R2 Accepted

Billy Wright Inquiry (2010)

HMP Maghaberry lessons learned

Many of the problems of HMP Maze in 1997 arose from the fact that by then it was the sole prison in Northern Ireland holding the most dangerous terrorist prisoners. …

Government response: Accepted. No public evidence of delivery has been found.

R3 Accepted

Billy Wright Inquiry (2010)

Prison service reform process

We have identified a series of failures in the management of the NIPS in 1997. What we learned about the current management of the NIPS in the course of the …

Government response: Accepted. No public evidence of delivery has been found.

BAHA-1 Accepted

Baha Mousa Inquiry (2011)

Prohibition on Hooding

The MoD should retain its current absolute prohibition on the use of hoods on Captured Personnel (CPErS).

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and that the prohibition on hooding had been maintained and …

BAHA-2 Accepted

Baha Mousa Inquiry (2011)

Standard Orders Prohibiting Five Techniques

Joint Doctrine Publication (JDP) 1-10 should include the requirement for standard orders to be issued for each operation prohibiting the use of the five techniques.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and that JDP 1-10 had been updated to require standard …

BAHA-3 Accepted

Baha Mousa Inquiry (2011)

Broaden Stress Position Definition

The definition of stress positions in JDP 1-10 and elsewhere should be broadened so that it is not dependent upon the intention of the person enforcing the position.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the definition had been broadened so that …

BAHA-4 Accepted

Baha Mousa Inquiry (2011)

Hooding Guidance

The essence of guidance on hooding should be that it is prohibited at any time for whatever purpose to place a sandbag or other cover over a CPErS' head.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and that guidance had been updated to make clear that …

BAHA-5 Accepted

Baha Mousa Inquiry (2011)

Noise Prohibition Definition

The definition of the prohibition on subjecting CPErS to noise should be broadened. It should prohibit subjecting CPErS to any unnecessary excessive noise.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the definition had been broadened to prohibit …

BAHA-6 Accepted

Baha Mousa Inquiry (2011)

Redacted Recommendation

[REDACTED - This recommendation has been redacted from the public version of the report]

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation (Government Response to the Baha Mousa Inquiry, Ministry of Defence, …

BAHA-7 Accepted

Baha Mousa Inquiry (2011)

Five Techniques Communication

The MoD should give careful consideration as to whether referring to the five techniques as being prohibited 'as an aid to interrogation' remains the most effective means of communicating the …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that language had been clarified to ensure the …

BAHA-8 Accepted

Baha Mousa Inquiry (2011)

Five Techniques Placement in Doctrine

The prohibition on the five techniques should not appear only within the Tactical Questioning and interrogation section of JDP 1-10 since it has a wider application and importance.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the prohibition now appears in multiple relevant …

BAHA-9 Accepted

Baha Mousa Inquiry (2011)

Five Techniques in JTTP

The prohibition on the five techniques should appear in the Joint Tactics, Techniques and Procedures guidance as well as in the main body of JDP 1-10.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the prohibition on the five techniques had …