Public Inquiry Recommendations

R97 Response Pending

Muckamore Abbey Inquiry (2026)

Funded access to primary care

The SPPG must ensure that commissioning includes provision for people with learning disabilities and autistic people cared for in any facility to have fully funded access to primary care services. …

R98 Response Pending

Muckamore Abbey Inquiry (2026)

AHP and social care workforce recruitment

The DoH must devise ways to recruit and retain more allied health professionals and social care staff in the community for autistic people and people with learning disabilities.

R99 Response Pending

Muckamore Abbey Inquiry (2026)

Key individual for resettlement communication

Communication between the HSCTs and/or resettlement service providers and families and people with learning disabilities should be more open and transparent. Each service user/family should have appointed to them a …

R100 Response Pending

Muckamore Abbey Inquiry (2026)

Person-centred day activities and supported employment

Trusts, private and 3rd sector care providers must ensure that person-centred day activities (including supported employment where appropriate) should be available and offered to all people with learning disabilities and …

R101 Response Pending

Muckamore Abbey Inquiry (2026)

Whole-system commissioning with cross-agency risk assessment

Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole system (including primary care, housing, benefits and independent …

R102 Response Pending

Muckamore Abbey Inquiry (2026)

Centralised workforce intelligence function

DoH should establish a comprehensive, centralised workforce intelligence function, similar to those in the rest of the UK, within 12 months of the publication of this report. The learning disability …

R103 Response Pending

Muckamore Abbey Inquiry (2026)

Public learning disability performance dashboard within 12 months

A live dashboard of performance, quality and safety indicators within learning disabilities must be developed and made publicly available within 12 months of the publication of this report.

R104 Response Pending

Muckamore Abbey Inquiry (2026)

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 …

R105 Response Pending

Muckamore Abbey Inquiry (2026)

Reverse burden for organisational failure to prevent harm

Consideration should be given to a different approach to the prosecution of organisations for failing to prevent deliberate harm being caused by their employees, such as by applying a reverse …

R106 Response Pending

Muckamore Abbey Inquiry (2026)

Redress working party for MAH victims

In relation to direct redress, including consideration of financial compensation, we recommend that the DoH set up a small working party to consult with patients, service user groups and individuals …

R1 Accepted

Bichard Inquiry (2004)

National IT system for police intelligence

A national IT system for England and Wales to support police intelligence should be introduced as a matter of urgency. The Home Office should take the lead and report by …

R2 Accepted

Bichard Inquiry (2004)

PLX system introduction

The PLX system, which flags that intelligence is held about someone by particular police forces, should be introduced in England and Wales by 2005.

R3 Accepted

Bichard Inquiry (2004)

Police IT procurement review

The procurement of IT systems by the police should be reviewed to ensure that, wherever possible, national solutions are delivered to national problems.

R4 Accepted

Bichard Inquiry (2004)

PNC investment

Investment should be made available by Government to secure the PNC's medium and long-term future, given its importance to intelligence-led policing and to the criminal justice system as a whole. …

R5 Accepted

Bichard Inquiry (2004)

PNC Code of Practice implementation

The new Code of Practice, made under the Police Reform Act 2002, dealing with the quality and timeliness of PNC data input, should be implemented as soon as possible.

R6 Accepted

Bichard Inquiry (2004)

PNC data quality inspection

The quality and timeliness of PNC data input should be routinely inspected as part of the Policing Performance Assessment Framework (PPAF) and the Baseline Assessments, which are being developed by …

R7 Accepted

Bichard Inquiry (2004)

Court results PNC transfer

The transfer of responsibility for inputting court results onto the PNC should be reaffirmed by the Court Service and the Home Office and, if possible, accelerated ahead of the 2006 …

R8 Accepted

Bichard Inquiry (2004)

Information management Code of Practice

A Code of Practice should be produced covering record creation, review, retention, deletion and information sharing. This should be made under the Police Reform Act 2002 and needs to be …

R9 Accepted

Bichard Inquiry (2004)

Key principles of information management

The Code of Practice must clearly set out the key principles of good information management (capture, review, retention, deletion and sharing), having regard to policing purposes, the rights of the …

R10 Accepted

Bichard Inquiry (2004)

Information management standards

The Code of Practice must set out the standards to be met in terms of systems (including IT), accountability, training, resources and audit. These standards should be capable of being …

R11 Accepted

Bichard Inquiry (2004)

Sexual offences intelligence retention

The Code of Practice should have particular regard to the factors to be considered when reviewing the retention or deletion of intelligence in cases of sexual offences.

R12 Accepted

Bichard Inquiry (2004)

Police notification of child offences

The Government should reaffirm the guidance in Working Together to Safeguard Children so that the police are notified as soon as possible when a criminal offence has been committed, or …

R13 Accepted

Bichard Inquiry (2004)

Criteria for police notification

National guidance should be produced to inform the decision as to whether or not to notify the police. This guidance could usefully draw upon the criteria included in a local …

R14 Accepted

Bichard Inquiry (2004)

Recording non-referral decisions

The Integrated Children's System should record those cases where a decision is taken not to refer to the police.

R15 Accepted

Bichard Inquiry (2004)

Inspection of non-referral decisions

The Commission for Social Care Inspection should, as part of any social services inspection, review whether decisions not to inform the police have been properly taken.

R16 Accepted

Bichard Inquiry (2004)

Interview training for headteachers

Head teachers and school governors should receive training on how to ensure that interviews to appoint staff reflect the importance of safeguarding children.

R17 Accepted

Bichard Inquiry (2004)

Trained panel member requirement

From a date to be agreed, no interview panel to appoint staff working in schools should be convened without at least one member being properly trained.

R18 Accepted

Bichard Inquiry (2004)

Inspection of school recruitment

The relevant inspection bodies should, as part of their inspection, review the existence and effectiveness of a school's selection and recruitment arrangements.

R19 Accepted

Bichard Inquiry (2004)

Registration scheme for working with children

New arrangements should be introduced requiring those who wish to work with children, or vulnerable adults, to be registered. This register – perhaps supported by a card or licence – …

R20 Accepted

Bichard Inquiry (2004)

Standards for police vetting checks

HMIC should develop, with ACPO and the CRB, the standards to be observed by police forces in carrying out vetting checks. These should cover the intelligence databases to be searched, …

R21 Accepted

Bichard Inquiry (2004)

Enhanced Disclosure for school staff

All posts, including those in schools, that involve working with children, and vulnerable adults, should be subject to the Enhanced Disclosure regime.

R22 Accepted

Bichard Inquiry (2004)

Identity checking responsibilities

The Registered Bodies' precise responsibilities for checking identities need to be clarified urgently.

R23 Accepted

Bichard Inquiry (2004)

Database access for identity verification

Registered Bodies, or the CRB, should be able to check passports and driving licences presented as proof of identity against the Passport Service and Driver and Vehicle Licensing Agency (DVLA) …

R24 Accepted

Bichard Inquiry (2004)

Photograph requirement for identity documents

There should be an expectation that documents produced to confirm identity should, wherever possible, include a photograph.

R25 Accepted

Bichard Inquiry (2004)

Fingerprints for identity verification

Fingerprints should be used as a means of verifying identity.

R26 Accepted

Bichard Inquiry (2004)

Address verification guidance

Guidance should be issued to Registered Bodies on how to verify that applicants have given a full and accurate account of their current and past addresses.

R27 Accepted

Bichard Inquiry (2004)

Information verification confirmation

Registered Bodies should be required to confirm that they have checked the information on the 'Police Check Form' in accordance with CRB guidance.

R28 Accepted

Bichard Inquiry (2004)

Broader consent on Police Check Form

The consents that applicants currently give on the 'Police Check Form' should be sufficiently broad to enable the requisite checks to be undertaken.

R29 Accepted

Bichard Inquiry (2004)

Incomplete applications returned to Registered Body

Incomplete or withdrawn applications should in future be returned to the Registered Body, and not to the applicant.

R30 Accepted

Bichard Inquiry (2004)

Overseas applicant checking

Proposals should be brought forward as soon as possible to improve the checking of people from overseas who want to work with children and vulnerable adults.

R31 Accepted

Bichard Inquiry (2004)

Additional database access for CRB

As a priority, legislation should be brought forward to enable the CRB to access the following additional databases for the purpose of vetting: Her Majesty's Customs & Excise; National Criminal …

ICL-1 Accepted Urgent

ICL Inquiry (2009)

Replace Buried Metallic LPG Pipes

An urgent programme of replacement of buried metallic LPG pipework with polyethylene piping should be implemented.

ICL-2 Accepted

ICL Inquiry (2009)

New LPG Safety Regime

A new safety regime should be put in place governing the installation, maintenance, monitoring and replacement of all LPG systems.

ICL-3 Accepted in Part

ICL Inquiry (2009)

LPG Supplier Registration

A new scheme should be introduced requiring all LPG suppliers to be registered and accredited.

ICL-4 Not Accepted

ICL Inquiry (2009)

Independent Risk Assessment Audit

The current risk assessment system should be improved by the addition of an independent audit process.

ICL-5 Accepted

ICL Inquiry (2009)

Polyethylene Piping Research

Research into the safety of polyethylene piping should be conducted to ensure long-term reliability.

ICL-6 Accepted

ICL Inquiry (2009)

LPG Safety Communications

There should be prompt and effective communication between all interested parties of all technical developments in matters of LPG safety.

ICL-7 Accepted

ICL Inquiry (2009)

Legal Responsibility Awareness

Awareness of legal responsibilities should be raised among LPG suppliers and consumers.

PENROSE-1 Accepted

Penrose Inquiry (2015)

HCV Testing for Pre-1991 Transfusion Recipients

The Scottish Government takes all reasonable steps to offer an HCV test to everyone in Scotland who had a blood transfusion before September 1991 and who has not been tested …

- The Scottish Government established a Short-Life Working Group in 2015, comprising representatives from the Scottish Government, Scottish National Blood Transfusion Service, and Health Protection …

R1 Accepted

Vale of Leven Inquiry (2014)

HEI ward closure powers

Scottish Government should ensure that the Healthcare Environment Inspectorate (HEI) has the power to close a ward to new admissions if the HEI concludes that there is a real risk …

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …