Public Inquiry Recommendations

19 Accepted

Morecambe Bay Investigation (2015)

Professional bodies review conduct of registrants

In light of the evidence we have heard during the Investigation, we consider that the professional regulatory bodies should review the findings of this Report in detail with a view …

- In July 2015, the government stated: "We accept this recommendation. Action is under way" and confirmed that the GMC and NMC had "reviewed the …

20 Accepted

Morecambe Bay Investigation (2015)

National review of maternity care in challenging circumstances

There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should …

- In July 2015, the government stated: "We accept this recommendation" and confirmed that NHS England had begun a national review of maternity care chaired …

21 Accepted

Morecambe Bay Investigation (2015)

Consider extending review to other rural services

The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care and paediatrics. We recommend that NHS England consider …

- In July 2015, the government stated: "We accept this recommendation in principle" and described the establishment of Vanguard sites to explore new care models …

22 Accepted

Morecambe Bay Investigation (2015)

Recognise educational opportunities in smaller units

We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and …

- In July 2015, the government stated: "We accept this recommendation in principle" and confirmed that Health Education England had established a working group to …

23 Accepted

Morecambe Bay Investigation (2015)

Clear standards for incident reporting in maternity

Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and …

- In July 2015, the government stated: "We accept this recommendation in principle" and announced a new Independent Patient Safety Investigation Service to supplement existing …

24 Accepted

Morecambe Bay Investigation (2015)

Involve patients and relatives in incident investigation

We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious …

- In July 2015, the government stated: "We accept this recommendation" and confirmed that the organisational duty of candour was now in force as a …

25 Accepted

Morecambe Bay Investigation (2015)

Duty to report external investigation findings

We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the …

- In July 2015, the government stated: "We accept these recommendations" (covering recs 25 and 42) and described existing reporting requirements and plans to extend …

26 Accepted

Morecambe Bay Investigation (2015)

Clear national whistleblowing policy

We commend the introduction of a clear national policy on whistleblowing. As well as protecting the interests of whistleblowers, we recommend that this is implemented in a way that ensures …

- In July 2015, the government stated: "We accept this recommendation" and described measures to implement the Freedom to Speak Up principles (Learning Not Blaming, …

27 Accepted

Morecambe Bay Investigation (2015)

Professional duty to report concerns

Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do …

- In July 2015, the government stated: "We accept this recommendation" and noted that a review of professional codes was under way (Learning Not Blaming, …

28 Accepted

Morecambe Bay Investigation (2015)

National standards for clinical leads

Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 28 and 29) and described work between the Department of …

29 Accepted

Morecambe Bay Investigation (2015)

Standards for manager quality responsibilities

Clear national standards should be drawn up setting out the responsibilities for clinical quality of other managers, including executive directors, middle managers and non-executives. All Trusts should provide evidence to …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 28 and 29) and described the renewed focus on leadership …

30 Accepted

Morecambe Bay Investigation (2015)

National protocol on duties relating to inquests

A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the …

- In July 2015, the government stated: "We accept this recommendation in principle" and said it would "give further thought, with the Ministry of Justice …

31 Accepted

Morecambe Bay Investigation (2015)

Fundamental review of NHS complaints system

The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the …

- In July 2015, the government stated: "We accept this recommendation in principle" but stated it did "not believe that another fundamental review will help" …

32 Accepted

Morecambe Bay Investigation (2015)

Reform Local Supervising Authority for midwives

The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation Trust, not only in individual failures of care …

- In July 2015, the government stated: "We accept this recommendation. We will therefore modernise the regulatory regime for midwifery" (Learning Not Blaming, Cm 9113, …

33 Accepted

Morecambe Bay Investigation (2015)

CQC and Monitor coordination

We considered carefully the effectiveness of separating organisationally the regulation of quality by the Care Quality Commission from the regulation of finance and performance by Monitor, given the close inter-relationship …

- In July 2015, the government stated: "We accept this recommendation" and noted that an updated Memorandum of Understanding between Monitor and the CQC had …

34 Accepted

Morecambe Bay Investigation (2015)

CQC and PHSO memorandum of understanding

The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between …

- In July 2015, the government stated: "We accept this recommendation" and confirmed that a new Memorandum of Understanding between the CQC and PHSO had …

35 Accepted

Morecambe Bay Investigation (2015)

Clarify oversight responsibilities

The division of responsibilities between the Care Quality Commission and other parts of the NHS for oversight of service quality and the implementation of measures to correct patient safety failures …

- In July 2015, the government stated: "We accept this recommendation in principle" and described actions to clarify oversight responsibilities (Learning Not Blaming, Cm 9113, …

36 Accepted

Morecambe Bay Investigation (2015)

Impact assessment of policy changes

The cumulative impact of new policies and processes, particularly the perceived pressure to achieve Foundation Trust status, together with organisational reconfiguration, placed significant pressure on the management capacity of the …

- In July 2015, the government stated: "We accept this recommendation in principle" and acknowledged that "the pursuit of Foundation Trust status distorted management capacity …

37 Accepted

Morecambe Bay Investigation (2015)

Protocol for organisational change transitions

Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting …

- In July 2015, the government stated: "We accept this recommendation" and referenced existing guidance issued in September 2011 on management of records during organisational …

38 Accepted

Morecambe Bay Investigation (2015)

Improve perinatal mortality recording

Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place …

- In July 2015, the government stated: "We accept this recommendation" and confirmed that MBRRACE-UK had established a system to systematically collect and report surveillance …

39 Accepted

Morecambe Bay Investigation (2015)

Implement medical examiner system

There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly …

- The available evidence indicates partial implementation. A statutory medical examiner system now scrutinises non-coronial deaths in England, but the 2025 report does not separately …

40 Accepted

Morecambe Bay Investigation (2015)

Extend medical examiners to stillbirths

Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 39 and 40) but noted that "medical examiners would scrutinise …

41 Accepted

Morecambe Bay Investigation (2015)

Guidance for external service reviews

We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS …

- In July 2015, the government stated: "We accept this recommendation" and noted that the Serious Incident Framework (March 2015) set out details of when …

42 Accepted

Morecambe Bay Investigation (2015)

Register external reviews with CQC

We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that the Care Quality Commission develops a system to …

- In July 2015, the government stated: "We accept these recommendations" (covering recs 25 and 42) and stated it would "consult on proposals to extend …

43 Accepted

Morecambe Bay Investigation (2015)

Maintain focus on quality

We strongly endorse the emphasis placed on the quality of NHS services that began with the Darzi review, High Quality Care for All, and gathered importance with the response to …

- In July 2015, the government stated: "We accept this recommendation, and strongly agree that the emphasis on quality of care must be maintained" (Learning …

44 Accepted

Morecambe Bay Investigation (2015)

Establish framework for future investigations

This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, …

- In July 2015, the government stated: "We accept this recommendation in principle" and announced the establishment of the Independent Patient Safety Investigation Service (Learning …

IHRD-1 Accepted Urgent

Hyponatraemia Inquiry (2018)

Statutory Duty of Candour

A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all …

- The available evidence indicates that this recommendation is not implemented. The February 2026 Being Open Framework expressly says that it does not create the …

IHRD-2 Accepted in Part

Hyponatraemia Inquiry (2018)

Criminal Liability for Candour Breach

Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.

- The Department of Health NI stated in March 2018 that criminal liability for breach of the duty of candour was under review (IHRD Implementation …

IHRD-3 Accepted in Part

Hyponatraemia Inquiry (2018)

Guidance on Statutory Duty of Candour

Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.

- The Department of Health NI stated in March 2018 that guidance was being developed in conjunction with the statutory duty of candour legislation (IHRD …

IHRD-4 Accepted

Hyponatraemia Inquiry (2018)

Trust Awareness of Duty of Candour

Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of …

- The Department of Health NI reported that work to raise awareness of the duty of candour among healthcare staff was being taken forward (IHRD …

IHRD-5 Accepted

Hyponatraemia Inquiry (2018)

Employment Contracts and Duty of Candour

Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.

- The Department of Health NI reported that contractual obligations relating to the duty of candour were under development (IHRD Implementation Programme, Department of Health …

IHRD-6 Accepted

Hyponatraemia Inquiry (2018)

Support for Candour Compliance

Support and protection should be given to those who properly fulfil their duty of candour.

- The Department of Health NI reported that support mechanisms for staff exercising the duty of candour were being developed (IHRD Implementation Programme, Department of …

IHRD-7 Accepted

Hyponatraemia Inquiry (2018)

Monitoring Candour Compliance

Trusts should monitor compliance and take disciplinary action against breach.

- The Department of Health NI reported that compliance monitoring for the duty of candour was being considered (IHRD Implementation Programme, Department of Health NI, …

IHRD-8 Accepted

Hyponatraemia Inquiry (2018)

RQIA Compliance Review Powers

Regulation and Quality Improvement Authority ('RQIA') should review overall compliance and consideration should be given to granting it the power to prosecute in cases of serial non-compliance or serious and …

- The Department of Health NI stated in March 2018 that expanded oversight powers for RQIA were under consideration (IHRD Implementation Programme, Department of Health …

IHRD-9 Accepted

Hyponatraemia Inquiry (2018)

Leadership Development

The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.

- The Department of Health NI reported that leadership development programmes had been implemented across the HSC (IHRD Implementation Programme, Department of Health NI, March …

IHRD-10 Accepted

Hyponatraemia Inquiry (2018)

Age-Appropriate Hospital Settings

Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in age-appropriate hospital settings.

- HSC Trusts reported that children are treated in age-appropriate settings with appropriately trained staff (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-11 Accepted

Hyponatraemia Inquiry (2018)

Patient Transfer Protocol

There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.

- HSC Trusts reported that consultant-led ward rounds are conducted regularly on paediatric wards (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-12 Accepted

Hyponatraemia Inquiry (2018)

Senior Paediatric Responsibility

Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.

- HSC Trusts reported that bedside name boards identifying the responsible consultant and named nurse are in place on paediatric wards (IHRD Implementation Programme, Department …

IHRD-13 Accepted in Part

Hyponatraemia Inquiry (2018)

Foundation Doctors in Children's Wards

Foundation doctors should not be employed in children's wards.

- HSC Trusts reported that care plans are available at each child's bedside for reference by parents and carers (IHRD Implementation Programme, Department of Health …

IHRD-14 Accepted

Hyponatraemia Inquiry (2018)

Clinician Competence Assessment

The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.

- HSC Trusts reported that fluid management protocols for children have been reviewed and updated (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-15 Accepted

Hyponatraemia Inquiry (2018)

Consultant Notification on Admission

A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept informed of the patient's condition, to ensure senior …

- HSC Trusts reported that specific protocols for the recognition and management of hyponatraemia in children have been implemented (IHRD Implementation Programme, Department of Health …

IHRD-16 Accepted

Hyponatraemia Inquiry (2018)

Bedside Display of Responsible Staff

The names of both the consultant responsible and the accountable nurse should be prominently displayed at the bed in order that all can know who is in charge and responsible.

- HSC Trusts reported that Paediatric Early Warning Scoring systems are in use across paediatric settings (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-17 Accepted

Hyponatraemia Inquiry (2018)

Recording Changes in Accountability

Any change in clinical accountability should be recorded in the notes.

- HSC Trusts reported that nurse-to-patient ratios on paediatric wards have been reviewed in line with professional standards (IHRD Implementation Programme, Department of Health NI, …

IHRD-18 Accepted

Hyponatraemia Inquiry (2018)

On-Call Consultant Display

The names of all on-call consultants should be prominently displayed in children's wards.

- HSC Trusts reported that clinical handover processes on paediatric wards have been standardised (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-19 Accepted

Hyponatraemia Inquiry (2018)

Senior Lead Nurse in Children's Wards

To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating …

- HSC Trusts reported that arrangements for paediatric consultant cover out of hours have been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-20 Accepted

Hyponatraemia Inquiry (2018)

Consultant-Led Ward Rounds

Children's ward rounds should be led by a consultant and occur every morning and evening.

- HSC Trusts reported that processes for escalation of clinical concerns about children have been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-21 Accepted

Hyponatraemia Inquiry (2018)

Nurse Attendance at Clinical Interactions

The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.

- HSC Trusts reported that clinical documentation standards for paediatric care have been improved (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-22 Accepted

Hyponatraemia Inquiry (2018)

Parental Knowledge in Care Plans

Clinicians should respect parental knowledge and expertise in relation to a child's care needs and incorporate the same into their care plans.

- HSC Trusts reported that discharge planning processes for children have been reviewed and strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-23 Accepted

Hyponatraemia Inquiry (2018)

Care Plan Availability at Bedside

The care plan should be available at the bed and the reasons for any change in treatment should be recorded.

- HSC Trusts reported that arrangements for parent and carer involvement in clinical decision-making have been formalised (IHRD Implementation Programme, Department of Health NI, March …

IHRD-24 Accepted

Hyponatraemia Inquiry (2018)

Blood Test Result Documentation

All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should …

- HSC Trusts reported that medication prescribing and administration protocols for children have been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). - …