Public Inquiry Recommendations

R52 Accepted

Vale of Leven Inquiry (2014)

IPC policy adherence audits

Health Boards should ensure that adherence to infection prevention and control polices, for example C. difficile and Loose Stools Policies, is audited at least annually.

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

R53 Accepted

Vale of Leven Inquiry (2014)

Surveillance systems fit for purpose

Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time.

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

R54 Accepted

Vale of Leven Inquiry (2014)

Surveillance system training

Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to use and respond to the data available.

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

R55 Accepted

Vale of Leven Inquiry (2014)

CDI reporting to CEO and Board

Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the Chief Executive and the Board.

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

R56 Accepted

Vale of Leven Inquiry (2014)

Regular IPC group meetings

Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through the management structure.

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

R57 Accepted

Vale of Leven Inquiry (2014)

IPC committee minutes reporting

Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to the level above in the hierarchy.

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

R58 Accepted

Vale of Leven Inquiry (2014)

Lay representation on IPC committee

Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy on public involvement.

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

R59 Accepted

Vale of Leven Inquiry (2014)

Priority attendance at IPC meetings

Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority.

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

R60 Accepted

Vale of Leven Inquiry (2014)

Cleanliness Champions implementation

Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as Cleanliness Champions Programme, are implemented without undue delay.

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

R61 Accepted

Vale of Leven Inquiry (2014)

Unannounced inspections with lay representation

Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay representation.

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

R62 Accepted

Vale of Leven Inquiry (2014)

Senior manager clinical visits

Health Boards should ensure that senior managers accompanied by IPC staff visit clinical areas at least weekly to verify that proper attention is being paid to IPC.

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

R63 Accepted

Vale of Leven Inquiry (2014)

Effective CDI patient isolation

Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior management.

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

R64 Accepted

Vale of Leven Inquiry (2014)

Cohorting only exceptional

Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in exceptional circumstances.

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

R65 Accepted

Vale of Leven Inquiry (2014)

Isolation for infectious diarrhoea

Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.

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

R66 Accepted

Vale of Leven Inquiry (2014)

Healthcare environment maintenance

Health Boards should ensure that the healthcare environment does not compromise effective IPC, and that poor maintenance practices are not tolerated.

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

R67 Accepted

Vale of Leven Inquiry (2014)

Link Nurse training

Health Boards should ensure that, where a local Link Nurse system is in place as part of the IPS system, the Link Nurses have specific training for that role.

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

R68 Accepted

Vale of Leven Inquiry (2014)

Consultant involvement in death certificates

Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patients care is involved in completion of the death certificate wherever practicable.

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

R69 Accepted

Vale of Leven Inquiry (2014)

Explanation to relatives on CDI death

Health boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a …

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

R70 Accepted

Vale of Leven Inquiry (2014)

COPFS death reporting guidance review

Crown Office and the Procurator Fiscal service (COPFS) should review its guidance on the reporting of deaths regularly and at least every two years.

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

R71 Accepted

Vale of Leven Inquiry (2014)

National CDI death monitoring

Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.

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

R72 Accepted

Vale of Leven Inquiry (2014)

Internal investigation independence

Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.

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

R73 Accepted

Vale of Leven Inquiry (2014)

OCT report detail sufficiency

Health Boards should ensure that OCT3 reports provide sufficient details of the key factors in the spread of infection to allow a proper audit to be carried out.

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

R74 Accepted

Vale of Leven Inquiry (2014)

Review of UK IPC reports

Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports published in the UK and in other relevant …

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

R75 Accepted

Vale of Leven Inquiry (2014)

Health Board review of IPC reports

Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or otherwise) should be put in place.

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

FP1 Accepted

Fingerprint Inquiry (2011)

Fingerprint evidence as opinion

Fingerprint evidence should be recognised as opinion evidence, not fact, and those involved in the criminal justice system need to assess it as such on its merits.

FP3 Accepted

Fingerprint Inquiry (2011)

Discontinue certainty claims

Examiners should discontinue reporting conclusions on identification or exclusion with a claim to 100% certainty or on any other basis suggesting that fingerprint evidence is infallible.

FP5 Accepted

Fingerprint Inquiry (2011)

Basis of conclusions

Experts should list all variables considered and state whether the conclusion has been reached through training and personal experience or on any other basis such as statistical analysis.

FP9 Accepted

Fingerprint Inquiry (2011)

Features demonstrable to lay persons

Features on which examiners rely should be demonstrable to a lay person with normal eye sight as observable in the mark.

FP16-18 Accepted

Fingerprint Inquiry (2011)

Academic study requirement

Expert opinion should be informed by proper academic study of the subject.

FP53 Accepted

Fingerprint Inquiry (2011)

Note-taking general practice

Note-taking as to the detail found on analysis and the process of comparison, though not mandatory, should become the general practice for all fingerprint comparison work.

FP60 Accepted

Fingerprint Inquiry (2011)

Disclosure of opinion basis - recording

Experts should record and properly disclose all of the basis of their opinion to enable a court to understand it and the defence to assess it.

FP66 Accepted

Fingerprint Inquiry (2011)

Unable to exclude findings

Before a finding of 'unable to exclude' is led in evidence, careful consideration will require to be given to (a) the types of mark for which such a finding is …

FP-COMPLEX Accepted

Fingerprint Inquiry (2011)

Complex marks examination

Processes should be developed to ensure that complex marks such as those in question are treated differently, by examination by three suitably qualified examiners who reach their conclusion independently, make …

RHI-1 Accepted

RHI Inquiry (2020)

Policy Skills Assessment

A new policy at its earliest stage should be subject to a rigorous process to determine whether the Northern Ireland devolved administration has (or is prepared to assign) the necessary …

- In October 2021, the NI Executive accepted this recommendation in full, stating that some elements were addressed in existing guidance (NI Executive Response to …

RHI-2 Accepted

RHI Inquiry (2020)

Novel Policy Scrutiny

Novel, potentially volatile and untested initiatives should in future be scrutinised thoroughly, well ahead of ministerial and business case approval. The Inquiry commends processes such as a 'starting point Gateway …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-3 Accepted

RHI Inquiry (2020)

Policy Skills Training

As far as practicable, Northern Ireland Civil Service teams working on policies, particularly new and untested initiatives, should be trained and supported so that they have the skills to do …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-4 Accepted

RHI Inquiry (2020)

Quality of Ministerial Advice

A lesson from the RHI experience is that action is needed to raise and sustain the quality of advice to Ministers and the clarity with which it is expressed. Options …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-5 Accepted

RHI Inquiry (2020)

Ministerial Training and Support

One role of Ministers in a democratic system is to decide on policies and they can only do so effectively if they are prepared, in appropriate cases, to question and …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-6 Accepted

RHI Inquiry (2020)

Special Adviser Role Clarity

(i) Under existing arrangements, Northern Ireland Ministers should be responsible for their Special Advisers. (ii) New or returning Ministers should be invited to convey to the relevant Permanent Secretary, and …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-7 Accepted

RHI Inquiry (2020)

Special Adviser Induction

There should be a clearly defined induction process for new Special Advisers, shared by the appointing Minister and the relevant Permanent Secretary, in the course of which the structure and …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-8 Accepted

RHI Inquiry (2020)

Job-Specific Recruitment

A fundamental shift is needed in the approach used within the Northern Ireland Civil Service with regard to recruitment and selection for government jobs. This must involve an up-front assessment …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-9 Accepted

RHI Inquiry (2020)

Commercial Awareness

Commercial and business awareness amongst policy officials, particularly those working in roles relating to the economy of Northern Ireland, must be improved. It is important that the leadership of the …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-10 Accepted

RHI Inquiry (2020)

External Consultants Guidance

The Northern Ireland Civil Service should consider what changes are needed to its guidance and practices on the use of external consultants arising from the experience of RHI. Specific recommendations …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-11 Accepted

RHI Inquiry (2020)

Project Management Disciplines

Best practice project and risk management disciplines should be the default practice within the Northern Ireland Civil Service when developing novel and complex policies and managing their implementation. These disciplines …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-12 Accepted

RHI Inquiry (2020)

Invest NI and SIB Collaboration

The leaders of the Northern Ireland Civil Service should work with Invest Northern Ireland and the Strategic Investment Board to consider how both organisations can better contribute their expertise to …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-13 Accepted

RHI Inquiry (2020)

External Expertise on Project Boards

Project boards are an essential element of project management oversight and must include individuals who can challenge and who are not directly responsible for the day-to-day delivery of the project. …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-14 Accepted

RHI Inquiry (2020)

Risk Tracking and Reporting

The risks involved in implementation of an initiative must be tracked, re-considered regularly and used to manage, improve and adjust the project in real time. How the risks are being …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-15 Accepted

RHI Inquiry (2020)

Programme Boards for Sector Coordination

Co-ordination of groups of projects aiming to achieve change in a particular sector – e.g. renewable energy projects – would be stronger through use of high level Programme Boards. Such …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-16 Accepted

RHI Inquiry (2020)

Third Party Governance

Where other government bodies, such as Ofgem, or contractors or other third parties are involved in the implementation of a project, the 'home' Department must retain overall control and overall …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …

RHI-17 Accepted

RHI Inquiry (2020)

Professional Development

The Northern Ireland Civil Service should take steps to draw on best practice from other jurisdictions to provide more support for professions within the civil service. The Inquiry specifically recommends: …

- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …