Public Inquiry Recommendations

BAHA-42 Accepted

Baha Mousa Inquiry (2011)

Written CPErS Responsibilities

Before any deployed operation, the Commanding Officer must ensure that there is a clear written explanation of unit level responsibilities for CPErS. If responsibilities are changed during an enduring operation …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that requirements for written captured persons responsibilities and …

BAHA-43 Accepted

Baha Mousa Inquiry (2011)

PM(A) Inspection Authority

The PM(A) and those who in his name carry out inspections of the main operational detention facilities should be expressly recognised as having the right and duty to inspect CPErS …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the Provost Marshal (Army) inspection authority had …

BAHA-44 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-45 Accepted

Baha Mousa Inquiry (2011)

Unannounced Inspections

The PM(A) and the in theatre Force Provost Marshal should take account of the in theatre situation in assessing whether any unannounced MPS inspections of forward detention facilities would be …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that procedures for unannounced inspections of forward detention …

BAHA-46 Accepted

Baha Mousa Inquiry (2011)

Lessons Learned Process

The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that lessons learned processes had been improved for …

BAHA-47 Accepted

Baha Mousa Inquiry (2011)

CPErS Training Content

CPErS training should include both theoretical and practical training in what Forces personnel can and should do when handling CPErS. It is important that training is not limited to prohibitions …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that captured persons training had been expanded to …

BAHA-48 Accepted

Baha Mousa Inquiry (2011)

End-to-End CPErS Training

CPErS training should be woven into the full range of military exercises and training. Such training should be 'end to end', not just focused on planning and the actual combat …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that captured persons handling had been incorporated throughout …

BAHA-49 Accepted

Baha Mousa Inquiry (2011)

Consistent Training Materials

Training materials across the Services need to be reviewed to ensure that the messages about all aspects of CPErS handling are clear and consistent. The arrangement whereby the PM(A) will …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training materials had been reviewed and made …

BAHA-50 Accepted

Baha Mousa Inquiry (2011)

MATT 7 Presentation Update

The MATT 7 PowerPoint presentation on the five techniques should be amended to ensure that the definitions of the techniques are consistent with amendments to JDP 1-10; that it is …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the MATT 7 PowerPoint presentation on the …

BAHA-51 Accepted

Baha Mousa Inquiry (2011)

Prisoner Handling DVD Update

The 2005 prisoner handling DVD should be amended to avoid misleading messages about sight deprivation in the context of interrogation, and the inappropriate presentation of the interrogation facility. 'Bagged and …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the prisoner handling DVD had been reviewed …

BAHA-52 Accepted

Baha Mousa Inquiry (2011)

Restraint Positions Guidance

Greater clarity and guidance should be given in training in relation to the concept of 'restraint positions'. More must be done to give practical guidance to help service personnel distinguish …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that clearer guidance on distinguishing unlawful stress positions …

BAHA-53 Accepted

Baha Mousa Inquiry (2011)

Positional Asphyxia Training

MATT 7 and mission specific training for CPErS handling should incorporate suitably pitched training on the risks of positional asphyxia/death by struggle against restraint.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training on positional asphyxia risks had been …

BAHA-54 Accepted

Baha Mousa Inquiry (2011)

MATT 7 Take-up Recording

There needs to be better recording of the take-up of MATT 7 (and equivalent training) to avoid the need to rely upon Reception Staging and Onward Integration (RSOI) training in …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that better systems for recording MATT 7 completion …

BAHA-55 Accepted

Baha Mousa Inquiry (2011)

Operational Law Training Currency

Those responsible for designing the mandatory operational law and values and standards training must keep the training relevant and up-to-date both in its content and in the style and means …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that processes for keeping operational law training current …

BAHA-56 Accepted

Baha Mousa Inquiry (2011)

Operational Law Training Quality

Unit commanders should ensure that the annual operational law training is delivered to the highest standards, so as to avoid it becoming stale or routine. Different media should be used …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that guidance on maintaining high standards in operational …

BAHA-57 Accepted

Baha Mousa Inquiry (2011)

Remove Shock of Capture Language

Training soldiers to maintain or prolong the shock of capture is apt to be misunderstood and should not feature in general training. Phrases such as 'calm, neutral and professional' and …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that references to training soldiers to maintain or …

BAHA-58 Accepted

Baha Mousa Inquiry (2011)

Moral Courage Training

MATT 6 training should include discussion and role play scenarios relevant to moral courage. Training materials should include reference to occasions when UK troops have breached the Law of Armed …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that MATT 6 training had been enhanced to …

BAHA-59 Accepted

Baha Mousa Inquiry (2011)

TQ Training Audit

Enhanced auditing of tactical questioning and interrogation training should be introduced to ensure that the interrogation branch at Chicksands adequately trains students including in the proper limits of approaches.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that enhanced auditing of tactical questioning and interrogation …

BAHA-60 Accepted

Baha Mousa Inquiry (2011)

Annual Legal Review of TQ Training

The annual legal review of training materials planned by Defence Intelligence and Security Centre (DISC) is a necessary step. It must include a rigorous scrutiny of the detail of the …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that annual legal reviews of tactical questioning training …

BAHA-61 Accepted

Baha Mousa Inquiry (2011)

Triennial Legal Review

A more senior and more independent legal review of the kind now being conducted as a one off ad hoc review is also required. Such a review should not be …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that a triennial independent legal review of tactical …

BAHA-62 Accepted Urgent

Baha Mousa Inquiry (2011)

DISC Materials Management

DISC should take immediate remedial action to ensure that: (1) old versions of interrogation branch teaching materials are retained but archived separately; (2) interrogation branch teaching materials are always dated; …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that DISC had implemented improved version control and …

BAHA-63 Accepted

Baha Mousa Inquiry (2011)

Complete TQ Training in Approaches

The tactical questioning and interrogation courses must train students adequately in all approaches that they may be required to use operationally. The current compromise whereby tactical questioning students are given …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that tactical questioning courses now provide complete training …

BAHA-64 Accepted

Baha Mousa Inquiry (2011)

Geneva Convention Compliance in Training

The MoD should give further careful consideration to the examples used in training for bridging between questioning sessions to ensure that they comply with the Geneva Conventions.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training examples for bridging between questioning sessions …

BAHA-65 Accepted

Baha Mousa Inquiry (2011)

Remove Conditioning Terminology

'Conditioning' should cease to be used as an approved Chicksands or HUMINT term. The term is dangerously ambiguous since it can be used to refer to unlawful means of putting …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the term 'conditioning' had been removed from …

BAHA-66 Accepted

Baha Mousa Inquiry (2011)

Remove Shock of Capture from DISC

DISC should give consideration to avoiding the terminology 'maintain the shock of capture' and 'prolong the shock of capture' even in their own courses. As a minimum, students on the …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that DISC courses now warn students against misuse …

BAHA-67 Accepted

Baha Mousa Inquiry (2011)

Resistance Training Warning

All theoretical and practical resistance training must include a warning which explains in terms that the training is to show conduct that can be expected of a non-Geneva Conventions compliant …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that all resistance training now includes clear warnings …

BAHA-68 Accepted

Baha Mousa Inquiry (2011)

SERE DVD Review

When reviewing the current Survive, Evade, Resist and Extract (SERE) DVD, Defence Survival Training Organisation (DSTO) should take into account the latest developments in tactical questioning and interrogation policy. DSTO …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the SERE DVD had been reviewed and …

BAHA-69 Accepted

Baha Mousa Inquiry (2011)

DSTO Sole Provider of Resistance Training

The MoD must make all units aware that, not only is DSTO the only body trained to provide resistance training, but that if any escape and evasion training is carried …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that units had been informed that only the …

BAHA-70 Accepted

Baha Mousa Inquiry (2011)

MCTC Control and Restraint Monitoring

The Military Correction Training Centre (MCTC) should continue to monitor that breakaway, personal protection and control and restraint techniques taught on the All Arms Unit Custody Staff Course (AAUCSC) are …

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the Military Correction Training Centre continues to …

BAHA-71 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-72 Accepted

Baha Mousa Inquiry (2011)

Detention Sergeant Training

Unit Detention Sergeants (see recommendation 41) should be properly trained in CPErS handling practices.

- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training requirements for Detention Sergeants (as established …

BAHA-73 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, …

1 Accepted

Morecambe Bay Investigation (2015)

Admit problems and apologise to affected families

The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and …

- In July 2015, the government stated that the Trust had "formally admitted the extent and nature of the problems that occurred and apologised individually …

2 Accepted

Morecambe Bay Investigation (2015)

Review clinical staff competencies

The University Hospitals of Morecambe Bay NHS Foundation Trust should review the skills, knowledge, competencies and professional duties of care of all obstetric, paediatric, midwifery and neonatal nursing staff, and …

- In July 2015, the government stated that a review of skills, knowledge, competencies and professional duties of care had been "started" and was to …

3 Accepted

Morecambe Bay Investigation (2015)

Deliver staff training and development plans

The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up plans to deliver the training and development of staff identified as a result of the review of maternity, …

- In July 2015, the government stated that the Trust was putting "substantial plans in place" including staff training and development programmes (Learning Not Blaming, …

4 Accepted

Morecambe Bay Investigation (2015)

Establish continuing professional development requirements

Following completion of additional training or experience where necessary, the University Hospitals of Morecambe Bay NHS Foundation Trust should identify requirements for continuing professional development of staff and link this …

- In July 2015, the government stated that the Trust was addressing continuing professional development requirements, to be completed by September 2015 (Learning Not Blaming, …

5 Accepted

Morecambe Bay Investigation (2015)

Promote effective multidisciplinary team-working

The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and develop measures that will promote effective multidisciplinary team-working, in particular between paediatricians, obstetricians, midwives and neonatal staff. These …

- In July 2015, the government stated that the Trust had "started to strengthen multi-disciplinary working - in particular between paediatricians, midwives, obstetricians and neonatal …

6 Accepted

Morecambe Bay Investigation (2015)

Draw up maternity risk assessment protocol

The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of …

- In July 2015, the government stated that the Trust was addressing risk assessment protocols in maternity services (Learning Not Blaming, Cm 9113, Department of …

7 Accepted

Morecambe Bay Investigation (2015)

Audit maternity and paediatric services

The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, …

- In July 2015, the government stated that the Trust was putting plans in place to audit maternity and paediatric services against risk assessment protocols, …

8 Accepted

Morecambe Bay Investigation (2015)

Develop recruitment and retention strategy

The University Hospitals of Morecambe Bay NHS Foundation Trust should identify a recruitment and retention strategy aimed at achieving a balanced and sustainable workforce with the requisite skills and experience. …

- In July 2015, the government stated that the Trust was developing a recruitment and retention strategy, to be completed by January 2016 (Learning Not …

9 Accepted

Morecambe Bay Investigation (2015)

Improve joint working between hospital sites

The University Hospitals of Morecambe Bay NHS Foundation Trust should identify an approach to developing better joint working between its main hospital sites, including the development and operation of common …

- In July 2015, the government stated that the Trust was addressing joint working between its main hospital sites (Learning Not Blaming, Cm 9113, Department …

10 Accepted

Morecambe Bay Investigation (2015)

Establish partner Trust buddying arrangement

The University Hospitals of Morecambe Bay NHS Foundation Trust should seek to forge links with a partner Trust, so that both can benefit from opportunities for learning, mentoring, secondment, staff …

- In July 2015, the government stated that the Trust was establishing partnerships with other trusts for learning and mentoring (Learning Not Blaming, Cm 9113, …

11 Accepted

Morecambe Bay Investigation (2015)

Raise awareness of incident reporting and duty of candour

The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also …

- In July 2015, the government stated that the Trust had "begun to review how investigations into incidents are carried out and started a programme …

12 Accepted

Morecambe Bay Investigation (2015)

Review incident investigation structures

The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning …

- In July 2015, the government stated that the Trust had "begun to review how investigations into incidents are carried out" (Learning Not Blaming, Cm …

13 Accepted

Morecambe Bay Investigation (2015)

Improve complaints handling

The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints …

- In July 2015, the government stated that the Trust was improving complaints handling processes (Learning Not Blaming, Cm 9113, Department of Health, July 2015). …

14 Accepted

Morecambe Bay Investigation (2015)

Review clinical leadership arrangements

The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with …

- In July 2015, the government stated that the Trust had "reviewed clinical leadership in terms of individuals and structures in obstetrics, paediatrics and midwifery" …

15 Accepted

Morecambe Bay Investigation (2015)

Continue governance systems work

The University Hospitals of Morecambe Bay NHS Foundation Trust should continue to prioritise the work commenced in response to the review of governance systems already carried out, including clinical governance, …

- In July 2015, the government stated that the Trust was continuing governance systems work, including clinical governance (Learning Not Blaming, Cm 9113, Department of …

16 Accepted

Morecambe Bay Investigation (2015)

Clarify manager quality responsibilities

As part of the governance systems work, we consider that the University Hospitals of Morecambe Bay NHS Foundation Trust should ensure that middle managers, senior managers and non-executives have the …

- In July 2015, the government stated that the Trust was clarifying manager roles and responsibilities in relation to quality (Learning Not Blaming, Cm 9113, …

17 Accepted

Morecambe Bay Investigation (2015)

Improve Furness General Hospital delivery suite

The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite …

- In July 2015, the government stated that the Trust was addressing the physical environment of the delivery suite at Furness General Hospital (Learning Not …

18 Accepted

Morecambe Bay Investigation (2015)

Ensure external oversight of implementation

All of the previous recommendations should be implemented with the involvement of Clinical Commissioning Groups, and where necessary, the Care Quality Commission and Monitor. In the particular circumstances surrounding the …

- In July 2015, the government stated that the Trust was "working closely with the Care Quality Commission, Monitor, NHS England and others" to implement …