Public Inquiry Recommendations

F161 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Training visits should make an important contribution to the protection of patients: Obtaining information directly from trainees should remain a valuable source of information – but it should not be …

- The GMC stated in April 2025 that it conducts quality activities including visits and talking to students and trainees to check how organisations address …

F162 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of medical training and education maintains as its first …

- DHSC and NHS England stated in April 2025 that the GMC uses an enhanced monitoring process for training institutions where persistent and serious patient …

F163 Accepted

Mid Staffs Inquiry (2013)

Safe staff numbers and skills

The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of …

- DHSC and NHS England stated in April 2025 that the GMC published standards for medical education and training in July 2015, specifically requirement R1.7 …

F164 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision …

- DHSC and NHS England stated in April 2025 that Approved Practice Setting requirements were introduced by the GMC in June 2014 (DHSC/NHS England implementation …

F165 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public.

- DHSC and NHS England stated in April 2025 that the GMC introduced Approved Practice Setting requirements in June 2014 (DHSC/NHS England implementation update to …

F166 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view …

- DHSC and NHS England stated in April 2025 that the GMC introduced Approved Practice Setting requirements in June 2014 (DHSC/NHS England implementation update to …

F167 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments …

- DHSC and NHS England stated in April 2025 that the GMC embedded Approved Practice Setting arrangements within the Responsible Officer Regulations in June 2014, …

F168 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for …

- DHSC and NHS England stated in April 2025 that the Approved Practice Setting scheme was incorporated into the regulatory framework via the Responsible Officer …

F169 Accepted in Part

Mid Staffs Inquiry (2013)

Role of the Department of Health and the National Quality Board

The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation …

- DHSC and NHS England stated in April 2025 that a Patient Safety Syllabus and associated training courses have been published for providers and regulators …

F170 Accepted

Mid Staffs Inquiry (2013)

Health Education England

Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.

- Health Education England merged with NHS England on 1 April 2023 (Health and Care Act 2022, July 2022). - DHSC and NHS England stated …

F171 Accepted

Mid Staffs Inquiry (2013)

Deans

All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education.

- The Department of Health and Social Care and NHS England stated in April 2025 that Local Education Training Boards (LETBs) have been replaced by …

F172 Accepted

Mid Staffs Inquiry (2013)

Proficiency in the English language

The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required …

- The Department of Health and Social Care and NHS England stated in April 2025 that professional regulators, including the Nursing and Midwifery Council and …

F173 Accepted

Mid Staffs Inquiry (2013)

Principles of openness transparency and candour

Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never …

- The Department of Health and Social Care and NHS England stated in April 2025 that a statutory Duty of Candour was introduced in 2014 …

F174 Accepted

Mid Staffs Inquiry (2013)

Candour about harm

Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any …

- The Department of Health and Social Care and NHS England stated in April 2025 that the statutory Duty of Candour and the Patient Safety …

F175 Accepted

Mid Staffs Inquiry (2013)

Candour about harm

Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled …

- The Department of Health and Social Care and NHS England stated in April 2025 that the joint duty of candour guidance by the Nursing …

F176 Accepted

Mid Staffs Inquiry (2013)

Openness with regulators

Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.

- The Department of Health and Social Care and NHS England stated in April 2025 that the statutory Duty of Candour applies to statements made …

F177 Accepted

Mid Staffs Inquiry (2013)

Openness in public statements

Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Standard contract includes requirements to ensure submissions …

F178 Accepted in Part

Mid Staffs Inquiry (2013)

Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and candour

The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, …

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Constitution was updated in February 2024 to …

F179 Accepted

Mid Staffs Inquiry (2013)

Restrictive contractual clauses

"Gagging clauses" or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona …

- The Department of Health and Social Care and NHS England stated in April 2025 that NHS Employers has published guidance on the use of …

F180 Accepted

Mid Staffs Inquiry (2013)

Candour about incidents

Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.

- The Department of Health and Social Care and NHS England stated in April 2025 that the 'Being Open' guidance has been superseded by the …

F181 Accepted in Part

Mid Staffs Inquiry (2013)

Enforcement of the duty Statutory duties of candour in relation to harm to patients

A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has …

- Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established a statutory duty of candour for all CQC-regulated providers …

F182 Accepted

Mid Staffs Inquiry (2013)

Statutory duty of openness and transparency

There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf …

- The Department of Health and Social Care stated in April 2025 that this recommendation is addressed through the statutory Duty of Candour and the …

F183 Not Accepted

Mid Staffs Inquiry (2013)

Criminal liability

It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an authorised or registered healthcare organisation: Knowingly to obstruct …

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

F184 Accepted

Mid Staffs Inquiry (2013)

Enforcement by the Care Quality Commission

Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and …

- The Department of Health and Social Care stated in April 2025 that the CQC has implemented this recommendation and it remains an ongoing piece …

F185 Accepted

Mid Staffs Inquiry (2013)

Focus on culture of caring

There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures …

- The Nursing and Midwifery Council (NMC) updated its pre-registration nursing and midwifery education standards in 2018 and 2019 to emphasize compassionate, person-centred care (NMC …

F186 Accepted

Mid Staffs Inquiry (2013)

Practical hands-on training and experience

Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.

- The Nursing and Midwifery Council stated in April 2025 that all education programmes require 50% of time to be spent in practice learning and …

F187 Accepted

Mid Staffs Inquiry (2013)

Practical hands-on training and experience

There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision …

- The Nursing and Midwifery Council stated in April 2025 that 50% of education hours (2,300 hours) must be spent in practice learning, with a …

F188 Accepted in Part

Mid Staffs Inquiry (2013)

Aptitude test for compassion and caring

The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in …

- The Nursing and Midwifery Council stated in April 2025 that its pre-registration standards negate the need for a specific aptitude test (DHSC and NHS …

F189 Accepted in Part

Mid Staffs Inquiry (2013)

Consistent training

The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.

- The Nursing and Midwifery Council stated in April 2025 that it reviewed the use of aptitude tests and common examinations but identified affordability, scalability, …

F190 Accepted in Part

Mid Staffs Inquiry (2013)

National standards

There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it performs Education Quality Assurance to ensure nursing education programmes meet standards for …

F191 Accepted

Mid Staffs Inquiry (2013)

Recruitment for values and commitment

Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should …

- The Department of Health and Social Care stated in April 2025 that the NHS operates a values-based recruitment approach to align employee behaviours with …

F192 Accepted in Part

Mid Staffs Inquiry (2013)

Strong nursing voice

The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and accountable to, the Nursing and Midwifery Council.

- The government stated in April 2025 that the specific role of a "Responsible Officer" for nursing was not introduced, but the NMC established a …

F193 Accepted in Part

Mid Staffs Inquiry (2013)

Standards for appraisal and support

Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which responsible officers would be obliged to comply. They …

- The government stated in April 2025 that the Nursing and Midwifery Council has introduced a revalidation process for all nurses and midwives to maintain …

F194 Accepted in Part

Mid Staffs Inquiry (2013)

Standards for appraisal and support

As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of nursing practice …

- The government stated in April 2025 that the NMC revalidation process requires nurses to demonstrate continuing professional development (CPD), reflective discussions, and declarations of …

F195 Accepted in Part

Mid Staffs Inquiry (2013)

Nurse leadership

Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. …

- The government stated in April 2025 that this recommendation was superseded by Royal College of Nursing (RCN) Workforce Standards and the rollout of Professional …

F196 Accepted

Mid Staffs Inquiry (2013)

Nurse leadership

The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient care and, in particular, to the priority to …

- The government stated in April 2025 that the Knowledge and Skills Framework is no longer updated by NHS Employers and has been superseded by …

F197 Accepted in Part

Mid Staffs Inquiry (2013)

Nurse leadership

Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all …

- The government stated in April 2025 that eight national development programmes are available through the NHS Leadership Academy, training approximately 20,000 participants annually (DHSC …

F198 Accepted

Mid Staffs Inquiry (2013)

Measuring cultural health

Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience …

- The government stated in April 2025 that the NHS Staff Survey and NHS People Pulse provide a standardised framework for measuring employee experience and …

F199 Accepted

Mid Staffs Inquiry (2013)

Key nurses

Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for each allocated patient. The named key nurse on …

- The Department of Health and Social Care and NHS England stated in April 2025 that the role of the Named Nurse is used within …

F200 Accepted in Part

Mid Staffs Inquiry (2013)

Key nurses

Consideration should be given to the creation of a status of Registered Older Person's Nurse.

- The Department of Health and Social Care and NHS England stated in April 2025 that Health Education England funded an Older Persons Fellowship for …

F201 Accepted

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

The Royal College of Nursing should consider whether it should formally divide its "Royal College" functions and its employee representative/trade union functions between two bodies rather than behind internal "Chinese …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Royal College of Nursing (RCN) continues to act …

F202 Accepted

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff to undertake this role, and employers and unions …

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Terms and Conditions Handbook (Part 4, Section …

F203 Accepted

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of coordinating the leadership of the nursing profession.

- The Department of Health and Social Care and NHS England stated in April 2025 that the Chief Nursing Officer (CNO) for England provides professional …

F204 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as …

- The National Health Service Trusts (Membership and Procedure) Regulations require Trust and Foundation Trust Boards to include a nurse or midwife executive director (The …

F205 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety …

- The Department of Health and Social Care and NHS England stated in April 2025 that all Boards are required to have a nurse/midwife executive …

F206 Accepted

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a recognised leading representative of the nursing profession as …

- The Department of Health and Social Care and NHS England stated in April 2025 that the Chief Nursing Officer (CNO) reports directly to the …

F207 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening identification of healthcare support workers and nurses

There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.

- DHSC and NHS England stated in April 2025 that the development of local uniform policy remains the responsibility of local organisations (DHSC and NHS …

F208 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening identification of healthcare support workers and nurses

Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse.

- DHSC and NHS England stated in April 2025 that provider organisations are responsible for local uniform policies and that uniforms and name badges should …

F209 Not Accepted

Mid Staffs Inquiry (2013)

Registration of healthcare support workers

A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of …

- The government did not accept the recommendation to create a registration system for healthcare support workers (Hard Truths: the journey to putting patients first …

F210 Accepted

Mid Staffs Inquiry (2013)

Code of conduct for healthcare support workers

There should be a national code of conduct for healthcare support workers.

- The Care Certificate, launched in April 2015, includes 15 standards that serve as a national code of conduct and training standard for healthcare assistants …