Public Inquiry Recommendations

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- The Department of Health and Social Care stated in April 2025 that this recommendation was superseded by actions related to recommendation 252 (DHSC and …

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 Department of Health and Social Care stated in April 2025 that the Federated Data Platform, Consultant Outcomes Publication, and National Consultant Information Programme …

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 Department of Health and Social Care stated in April 2025 that 99% of Trusts in England were enrolled in the National Consultant Information …

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 Department of Health and Social Care stated in April 2025 that statistics on treatment effectiveness are published by NHS Digital and the National …

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 Department of Health and Social Care stated in April 2025 that the NHS Standard Contract requires providers to publish services in the e-Referral …

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 Department of Health and Social Care stated in April 2025 that NHS England conducts public consultations on statistical reports and proposed changes to …

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 Department of Health and Social Care stated in April 2025 that patient outcome statistics are available via NHS Digital, CQC inspection reports, and …

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 Department of Health and Social Care stated in April 2025 that resources had been allocated to support data collection and publication (DHSC and …

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 Department of Health and Social Care stated in April 2025 that the Data Quality Maturity Index (DQMI) is published monthly to provide transparency …

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 …

- NHS England stated in April 2025 that patient outcome statistics are publicly available through its website, Care Quality Commission inspection reports, and public portals …

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 …

- NHS England stated in April 2025 that the Summary Hospital-Level Mortality Indicator (SHMI) is produced and published monthly as an Accredited Official Statistic (DHSC …

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 …

- NHS England stated in April 2025 that the Data Alliance Partnership Board (DAPB) assures the quality of information standards to ensure data can be …

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 …

- Schedule 5 of the Coroners and Justice Act 2009 confers power on coroners to order the disclosure of evidence, including written statements and documents …

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 National Medical Examiner stated in April 2025 that records of medical examiner scrutiny should be shared with bereaved families where possible, following an …

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.

- NHS England stated in April 2025 that operational arrangements at NHS bodies must support the independent role of medical examiners and that combining these …

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.

- NHS England stated in April 2025 that all acute NHS Trusts have established medical examiner offices and have been asked to ensure they have …

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 Department of Health and Social Care published guidance on completing the new Medical Cause of Death Certificate (MCCD) as part of the 2024 …

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 …

- Regulation 6 of the Medical Certificate of Cause of Death Regulations 2024 requires medical examiners to carry out a proportionate review of medical records …

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 Department of Health and Social Care stated in April 2025 that it is the responsibility of the consultant in charge of a patient's …

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 Medical Examiner system became statutory on 9 September 2024, requiring independent scrutiny of all deaths not referred to a coroner (The Medical Examiners …

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 Medical Examiners (England) Regulations 2024 require medical examiners to undertake training to ensure they have the skills to carry out their functions (The …

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.

- NHS England stated in April 2025 that Regulation 28 reports (formerly Rule 43) are shared with the CQC when it is a named respondent …

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 …

- DHSC and NHS England stated in April 2025 that the Judicial College provides induction and annual training for coroners and their officers, and the …

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.

- DHSC and NHS England stated in April 2025 that action was taken regarding the appointment of assistant coroners following the conclusion of the Mid-Staffordshire …

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.

- DHSC and NHS England stated in April 2025 that the Thirlwall Inquiry has noted action taken in response to this recommendation regarding the appearance …

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 …

- DHSC and NHS England stated in April 2025 that an impact assessment was conducted for the Health and Care Act 2022 (DHSC and NHS …

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 Care Quality Commission introduced fundamental standards of care in 2015 as part of its regulatory framework (Health and Social Care Act 2008 (Regulated …

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.

- DHSC and NHS England stated in April 2025 that senior clinical advice is embedded through roles including the Chief Medical Officer, Chief Nursing Officer, …

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 Department of Health and Social Care stated in April 2025 that the Connecting Programme was established in June 2013, requiring senior civil servants …

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 Department of Health and Social Care stated in April 2025 that transparency measures include a statutory duty of candour, a national learning from …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

LIT-1 Accepted

Litvinenko Inquiry (2016)

Closed Recommendation

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

LIT-2 Accepted

Litvinenko Inquiry (2016)

Asset Freezes on Suspects

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

LIT-3 Accepted

Litvinenko Inquiry (2016)

Maintain Arrest Warrants

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

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.

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.

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 …

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 …

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 …

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 …

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 …

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 …