Public Inquiry Recommendations

IHRD-75 Accepted

Hyponatraemia Inquiry (2018)

Independent Disciplinary Action

Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.

- HSC Trusts reported that complaint response times and quality had been improved (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-76 Accepted

Hyponatraemia Inquiry (2018)

Publication of Clinical Standards

Clinical standards of care, such as patients might reasonably expect, should be published and made subject to regular audit.

- HSC Trusts reported that processes for learning from complaints had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-77 Accepted

Hyponatraemia Inquiry (2018)

Trust Compliance Officer

Trusts should appoint a compliance officer to ensure compliance with protocol and direction.

- HSC Trusts reported that patient and public involvement arrangements had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-78 Accepted

Hyponatraemia Inquiry (2018)

Clinical Guidelines Audit

Implementation of clinical guidelines should be documented and routinely audited.

- HSC Trusts reported that Non-Executive Director oversight of patient safety had been formalised (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-79 Accepted

Hyponatraemia Inquiry (2018)

Reporting Clinical Practice Changes

Trusts should bring significant changes in clinical practice to the attention of the HSCB with expedition.

- HSC Trusts reported that clinical audit programmes had been integrated into governance frameworks (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-80 Accepted

Hyponatraemia Inquiry (2018)

Healthcare Data Analysis

Trusts should ensure health care data is expertly analysed for patterns of poor performance and issues of patient safety.

- HSC Trusts reported that information governance arrangements for patient safety data had been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-81 Accepted

Hyponatraemia Inquiry (2018)

Board Awareness of SAI Reports

Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.

- HSC Trusts reported that performance management frameworks had been updated to include patient safety objectives (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-82 Accepted

Hyponatraemia Inquiry (2018)

Policy on Learning from SAI Deaths

Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.

- HSC Trusts reported that whistleblowing and raising concerns policies had been reviewed and updated (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-83 Accepted

Hyponatraemia Inquiry (2018)

SAI Deaths in Annual Reports

Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.

- HSC Trusts reported that leadership development programmes for senior clinicians had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-84 Accepted

Hyponatraemia Inquiry (2018)

Trust Board Review of IHRD Report

All Trust Boards should consider the findings and recommendations of this Report and where appropriate amend practice and procedure.

- HSC Trusts reported that succession planning for key clinical and governance roles had been formalised (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-85 Accepted

Hyponatraemia Inquiry (2018)

Deputy CMO for Children's Healthcare

The Department should appoint a Deputy Chief Medical Officer with specific responsibility for children's healthcare.

- The Department of Health NI stated in March 2018 that the role was under consideration within departmental restructuring (IHRD Implementation Programme, Department of Health …

IHRD-86 Accepted

Hyponatraemia Inquiry (2018)

Expand RQIA Remit and Resources

The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the SAI process (ii) be strengthened in its capacity …

- The Department of Health NI stated in March 2018 that RQIA's remit and resources were under review (IHRD Implementation Programme, Department of Health NI, …

IHRD-87 Accepted

Hyponatraemia Inquiry (2018)

Independent Medical Examiner

The Department should now institute the office of Independent Medical Examiner to scrutinise those hospital deaths not referred to the Coroner.

- The Department of Health NI stated in March 2018 that prototypes for an Independent Medical Examiner service were progressing (IHRD Implementation Programme, Department of …

IHRD-88 Accepted

Hyponatraemia Inquiry (2018)

Child Death Overview Panel

The Department should engage with other interested statutory organisations to review the merits of introducing a Child Death Overview Panel.

- The Department of Health NI stated in March 2018 that engagement with statutory organisations on a Child Death Overview Panel was ongoing (IHRD Implementation …

IHRD-89 Accepted

Hyponatraemia Inquiry (2018)

Patient Concern Organisation

The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.

- The Department of Health NI stated in March 2018 that this was under consideration as part of a broader patient engagement strategy (IHRD Implementation …

IHRD-90 Accepted

Hyponatraemia Inquiry (2018)

Clinical Guidance Dissemination Protocol

The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals fixed with responsibility for implementation and audit to …

- The Department of Health NI reported that protocols for departmental engagement with HSC Trusts on patient safety matters had been reviewed (IHRD Implementation Programme, …

IHRD-91 Accepted

Hyponatraemia Inquiry (2018)

Synchronise Patient Safety Systems

The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional …

- The Department of Health NI reported that patient safety incident reporting systems were being synchronised across the HSC (IHRD Implementation Programme, Department of Health …

IHRD-92 Accepted

Hyponatraemia Inquiry (2018)

Review Healthcare Standards

The Department should review healthcare standards in light of the findings and recommendations of this report and make such changes as are necessary.

- The Department of Health NI reported that departmental monitoring of SAI investigation outcomes had been strengthened (IHRD Implementation Programme, Department of Health NI, March …

IHRD-93 Accepted

Hyponatraemia Inquiry (2018)

Review Trust Responses

The Department should review Trust responses to the findings and recommendations of this Report.

- The Department of Health NI reported that arrangements for cross-departmental engagement on patient safety policy had been reviewed (IHRD Implementation Programme, Department of Health …

IHRD-94 Accepted in Part

Hyponatraemia Inquiry (2018)

Clinical Negligence Litigation Reform

The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical …

- The Department of Health NI stated in March 2018 that this was under consideration (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-95 Accepted

Hyponatraemia Inquiry (2018)

Legal Privilege Protocol

Given that the public is entitled to expect appropriate transparency from a publically funded service, the Department should bring forward protocol governing how and when legal privilege entitlement might properly …

- The Department of Health NI reported that guidance on legal professional privilege in the context of SAI investigations had been reviewed (IHRD Implementation Programme, …

IHRD-96 Accepted

Hyponatraemia Inquiry (2018)

Healthcare Litigation Standards

The Department should provide clear standards to govern the management of healthcare litigation by Trusts and the work of Trust employees and legal advisors in this connection should be audited.

- The Department of Health NI reported that standards for Trust engagement with clinical negligence litigation processes had been reviewed (IHRD Implementation Programme, Department of …

ETI-1 Accepted in Part

Edinburgh Tram Inquiry (2023)

Public Inquiry Efficiency

Scottish Ministers should review public inquiries to find cost-effective methods of avoiding establishment delays, potentially creating a dedicated unit within the Scottish Courts and Tribunals Service and publishing updated guidance.

- In November 2023, the Scottish Government stated that guidance on efficient public inquiry establishment was "already in development" and had been shared with recent …

ETI-2 Accepted in Part

Edinburgh Tram Inquiry (2023)

Inquiry Independence

Scottish Ministers must not appoint any department, agency, or government organization as inquiry sponsor where it or its employees had involvement in the project under investigation.

- In November 2023, the Scottish Government stated that guidance similar to that suggested was already in development (Transport Secretary Statement on Edinburgh Tram Inquiry …

ETI-3 Accepted in Part

Edinburgh Tram Inquiry (2023)

Staffing Guidance

Guidance should address: circumstances for civil servant transfers within government; which positions may use agency staff; and whether temporary contracts suit positions unfillable by permanent staff.

- In November 2023, the Scottish Government stated that guidance similar to that suggested was already in development (Transport Secretary Statement on Edinburgh Tram Inquiry …

ETI-4 Accepted in Part

Edinburgh Tram Inquiry (2023)

Inquiry Cost Transparency

When reporting public inquiry costs, Scottish Ministers should disclose net costs to the public purse, excluding previously-incurred accommodation and staffing expenses, alongside total departmental account costs.

- In November 2023, the Scottish Government stated that guidance similar to that suggested was already in development (Transport Secretary Statement on Edinburgh Tram Inquiry …

ETI-5 Accepted

Edinburgh Tram Inquiry (2023)

Business Case Timing

Where Business Cases assume pre-contract completion of design, approvals, or utility diversions, contract negotiations should await completion; otherwise, a revised Business Case reflecting actual conditions must be prepared before signing.

- In November 2023, the Scottish Government stated it already operates in line with best practices for governance and light rail delivery (Transport Secretary Statement …

ETI-6 Accepted

Edinburgh Tram Inquiry (2023)

Optimism Bias in Business Cases

All Business Case versions must include risk assessments accounting for optimism bias per published government guidance.

- In November 2023, the Scottish Government stated it already operates in line with best practices for governance and light rail delivery (Transport Secretary Statement …

ETI-7 Accepted

Edinburgh Tram Inquiry (2023)

External Peer Review

Each Business Case risk assessment should undergo peer review by external consultants experienced in large-scale transportation infrastructure, submitting reports sufficiently before contract signature.

- In November 2023, the Scottish Government stated it already operates in line with best practices for governance and light rail delivery (Transport Secretary Statement …

ETI-8 Accepted in Part

Edinburgh Tram Inquiry (2023)

Update Optimism Bias Guidance

Optimism bias guidance, based on decades-old data, requires updating to include light rail projects and reflect current empirical evidence, with reviews every five years.

- In November 2023, the Scottish Government stated it already operates in line with best practices but would consider updating guidance (Transport Secretary Statement on …

ETI-9 Accepted

Edinburgh Tram Inquiry (2023)

Risk Management Standards

Risk identification and management should be integral to major public-sector contracts, employing probabilistic forecasts, critical review of mitigation claims, constant governance challenge, early warning detection, and quality-focused evidence rather than …

- In November 2023, the Scottish Government stated it already operates in line with best practices for governance and light rail delivery (Transport Secretary Statement …

ETI-10 Accepted in Part

Edinburgh Tram Inquiry (2023)

Joint Working Group with COSLA

Scottish Ministers should establish a joint working group with Convention of Scottish Local Authorities representatives to leverage Transport Scotland's project management experience and expertise for light rail projects.

- In November 2023, the Scottish Government stated that "effective collaboration sits at the heart of this Government" and cited the Verity House Agreement as …

ETI-11 Accepted in Part

Edinburgh Tram Inquiry (2023)

Public Fund Protection

Scottish Ministers and local authorities funding light rail should protect public funds through: conditional grant payments with review hold points; critical review and approval of Business Cases and contracts; involvement …

- In November 2023, the Scottish Government stated that while responsibility for delivery remains with councils as project leads, the Government committed to championing closer …

ETI-12 Accepted

Edinburgh Tram Inquiry (2023)

Record Keeping Requirements

For transparency, Scottish Ministers should maintain minutes documenting: discussions and decisions between Ministers and civil servants regarding publicly-funded project involvement; discussions with local authorities and contractors; and negotiations, including mediation …

- In November 2023, the Scottish Government stated that "robust and enhanced procedures regarding minute-taking and documentation management have also been embedded within the Government …

ETI-13 Accepted

Edinburgh Tram Inquiry (2023)

Utility Diversion Planning

Light rail procurement strategies must adequately address utility location uncertainties, requiring route exposure and clearance well before construction, specifying elapsed time between clearance and commencement, considering route length and past …

- In November 2023, the Scottish Government stated it already operates in line with best practices for governance and light rail delivery (Transport Secretary Statement …

ETI-14 Accepted

Edinburgh Tram Inquiry (2023)

Utility Diversion Risk Management

While acknowledging utility diversion approaches, promoters should demonstrate adequate risk management proposals without prescriptive requirements regarding MUDFA versus bow wave methods.

- In November 2023, the Scottish Government stated it already operates in line with best practices for governance and light rail delivery (Transport Secretary Statement …

ETI-15 Accepted

Edinburgh Tram Inquiry (2023)

Qualified Project Management

Project promoters should appoint procurement and project managers with qualified, experienced permanent employees who have successfully delivered similar projects on time and within budget.

- In November 2023, City of Edinburgh Council Leader Cammy Day stated that the Council broadly agreed with Lord Hardie's recommendations and noted improvements had …

ETI-16 Accepted

Edinburgh Tram Inquiry (2023)

Design Engagement Process

Following designer appointment, continuous engagement with promoters, owners, project managers, planning authorities, utility companies, and affected landowners should clarify design criteria, with local planning authorities producing detailed design guidelines beforehand …

- In November 2023, the Council stated it broadly agreed with Lord Hardie's recommendations, noting improvements had been implemented for Trams to Newhaven (City of …

ETI-17 Accepted

Edinburgh Tram Inquiry (2023)

Governance Structure

The governance structure for the delivery of a major project such as a light rail scheme should follow published guidance and ensure clarity regarding the respective roles of various bodies …

- In November 2023, the Council stated it broadly agreed with Lord Hardie's recommendations, noting that governance improvements had been implemented for Trams to Newhaven …

ETI-18 Accepted

Edinburgh Tram Inquiry (2023)

Effective Communication and Reporting

There should be effective communication and reporting at all stages of the project, including accurate progress reports to councillors and stakeholders, with clear escalation procedures for issues that may affect …

- In November 2023, the Council stated it broadly agreed with Lord Hardie's recommendations, noting improvements in communication and reporting had been implemented for Trams …

ETI-19 Accepted

Edinburgh Tram Inquiry (2023)

Collaborative Delivery

At all stages of the project there should be a collaborative approach to delivering it, including co-location of representatives from each organisation relevant to the particular stage, enabling issues to …

- In November 2023, the Council stated it broadly agreed with Lord Hardie's recommendations, noting that co-location of representatives had been successfully adopted on the …

ETI-20 Accepted

Edinburgh Tram Inquiry (2023)

Prohibition on Misleading Reports from ALEOs

The directors, employees and consultants of the company responsible for the procurement and delivery of the project as project managers, including an arm's-length external organisation (ALEO) wholly owned by the …

- In November 2023, the Council stated it broadly agreed with Lord Hardie's recommendations (City of Edinburgh Council response, November 2023). - The Council committee …

ETI-21 Accepted

Edinburgh Tram Inquiry (2023)

Duty of Officials to Councillors

Local authority officials should be mindful at all times of the distinction in roles between them and councillors, who are solely responsible for strategic decisions, and of their duty to …

- In November 2023, the Council stated it broadly agreed with Lord Hardie's recommendations (City of Edinburgh Council response, November 2023). - The Council committee …

ETI-22 Under Consideration

Edinburgh Tram Inquiry (2023)

Civil Sanctions for Misleading Reports

Where a company, including an ALEO, knowingly submits a report or other information to local authority officials that is misleading by reason of the inclusion of false statements or the …

- In November 2023, the Scottish Government stated it was "giving careful consideration" to the recommendations about civil damages provisions for misleading evidence, noting that …

ETI-23 Under Consideration

Edinburgh Tram Inquiry (2023)

Criminal Sanctions for Misleading Information

In addition to civil liability from any sanction introduced in accordance with Recommendation 22, Scottish Ministers should consider whether there is need for a statutory criminal offence involving strict liability …

- In November 2023, the Scottish Government stated it was "giving careful consideration" to the recommendations about criminal statutory offences for misleading evidence, noting that …

ETI-24 Under Consideration

Edinburgh Tram Inquiry (2023)

Duty of Disclosure Legislation

Scottish Ministers should consider the need for legislation to impose a similar duty of disclosure to that owed by policyholders to their insurers upon a company, its directors, employees or …

- In November 2023, the Scottish Government stated it was "giving careful consideration" to the recommendations about provisions for misleading evidence (Transport Secretary Statement on …

AG-1 Accepted

Anthony Grainger Inquiry (2019)

National Register of Armed Policing Recommendations

A national policing body should manage a national register of recommendations relating to armed policing, and the response to such recommendations, arising from Independent Office for Police Conduct (IOPC) reports, …

AG-2 Accepted

Anthony Grainger Inquiry (2019)

HMICFRS Thematic Inspection of Armed Policing

Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) should conduct a thematic inspection or inspections concerning: (i) the selection and training of officers authorised to use weapons …

AG-3 Accepted

Anthony Grainger Inquiry (2019)

Code of Practice on New Weapons Approval

The Home Secretary should ensure that the new Code of Practice on Police use of Firearms and Less Lethal Weapons contains an express prohibition on the use of a new …

AG-4 Accepted

Anthony Grainger Inquiry (2019)

North West Armed Policing SOP Amendment

The North West Armed Policing Standard Operating Procedure on Weapons and Ammunition should be amended so that it only permits the use of new specialist munitions that have been approved …