Public Inquiry Recommendations

ANG-11 Accepted

Angiolini Inquiry (2024)

Strengthen information-sharing practices

By December 2024, the College of Policing, in collaboration with force vetting and recruitment units, should ensure that information-sharing practices, including data retention policies, are strengthened in order to prevent …

- The government accepted this recommendation on 25 March 2024, with the NPCC and College of Policing committing to address vetting robustness (Government accepts all …

ANG-12 Accepted

Angiolini Inquiry (2024)

Officers held to higher standard with fettered privacy rights

With immediate effect, police forces should convey to all existing and prospective officers and staff that they must be held to a higher standard of behaviour and accountability than members …

- The government accepted this recommendation on 25 March 2024, with the NPCC Chair confirming all recommendations were accepted (Government accepts all recommendations made by …

ANG-13 Accepted

Angiolini Inquiry (2024)

Stronger vetting aftercare and randomised re-vetting

By December 2024, the College of Policing, in collaboration with all force vetting units, should develop a stronger approach to force vetting aftercare in order to monitor an individual effectively …

- The government accepted this recommendation on 25 March 2024, with the NPCC and College of Policing committing to address vetting robustness (Government accepts all …

ANG-14 Accepted

Angiolini Inquiry (2024)

Public commitment to anti-sexist anti-racist organisation

With immediate effect, every police force should commit publicly to being an anti-sexist, anti-misogynistic, anti-racist organisation in order to address, understand and eradicate sexism, racism and misogyny, contributing to a …

- The government accepted this recommendation on 25 March 2024, with the NPCC Chair confirming all recommendations were accepted (Government accepts all recommendations made by …

ANG-15 Accepted

Angiolini Inquiry (2024)

Remove barriers to reporting sexual offences by colleagues

With immediate effect, all police forces should take action to understand and confront the barriers that police officers and staff face when reporting sexual offences committed by a person that …

- The government accepted this recommendation on 25 March 2024, with the NPCC Chair confirming all recommendations were accepted (Government accepts all recommendations made by …

ANG-16 Accepted

Angiolini Inquiry (2024)

Improve conditions for female officers

By September 2024, the College of Policing and the National Police Chiefs' Council should review and examine the conditions of female officers and staff in order to encourage more women …

- The government accepted this recommendation on 25 March 2024, with the NPCC and College of Policing committing to address recommendations on police culture (Government …

ANG-17 No Response

Angiolini Inquiry (2025)

Collection and sharing of data at national and local levels

Immediately, the Home Office should lead work, coordinated by the National Centre for Violence Against Women and Girls and Public Protection, to significantly increase both the collection and use of …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for significantly increased data collection …

ANG-18 No Response

Angiolini Inquiry (2025)

Increased use of police Designing Out Crime Officers

By November 2026, the Government should explore how to improve the impact that the safety advice provided by police Designing Out Crime Officers could have on the prevention of sexually …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, with a deadline of November 2026 …

ANG-19 No Response

Angiolini Inquiry (2025)

Targeted and consistent public messaging

By March 2026, the Home Office, as the lead department for the response to violence against women and girls, should agree funding for a multi-year series of public information campaigns …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for agreed funding for multi-year …

ANG-20 No Response

Angiolini Inquiry (2025)

Empowering and engaging citizens to take action

The public has a pivotal role to play in the prevention of sexually motivated crimes against women in public spaces. In recognition of that: a. By April 2026, the Home …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for agreed funding for active …

ANG-21 No Response

Angiolini Inquiry (2025)

National roll-out of Project Vigilant

By April 2026, the Home Office, the National Centre for Violence Against Women and Girls and Public Protection, and the National Police Chiefs' Council should roll out Project Vigilant nationally …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for national rollout of Project …

ANG-22 No Response

Angiolini Inquiry (2025)

Information and early intervention for men and boys

By September 2026, the Home Office (as the lead department for the response to violence against women and girls), working closely with the Department for Education, the Ministry of Justice, …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for increased and improved information, …

ANG-23 No Response Urgent

Angiolini Inquiry (2025)

Police prioritisation of prevention

Immediately, Chief Constables and Police and Crime Commissioners should ensure that the prevention of sexually motivated crimes against women in public spaces is an essential part of: (i) their violence …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for Chief Constables and PCCs …

ANG-24 No Response

Angiolini Inquiry (2025)

Implementation of Operation Soteria

By March 2026, the Home Office, working with the National Police Chiefs' Council, and the National Centre for Violence Against Women and Girls and Public Protection, should agree plans for …

- The government announced in February 2024 that Operation Soteria was already being funded and implemented nationally across all police forces and prosecutors in England …

ANG-25 No Response

Angiolini Inquiry (2025)

Whole-system approach to preventing sexually motivated crimes

By June 2026, building on the wider violence against women and girls strategy, the Government should publish a comprehensive, multi-year and whole-system prevention strategy, which specifically targets the perpetrators of …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for a comprehensive multi-year prevention …

ANG-26 No Response

Angiolini Inquiry (2025)

Improved mechanism for converting initiatives from local to national

By March 2026, the College of Policing, working with the National Police Chiefs' Council including the Office of the Police Chief Scientific Adviser, the Home Office, HM Inspectorate of Constabulary …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for improved mechanisms to identify, …

ANG-27 No Response Urgent

Angiolini Inquiry (2025)

Perpetrator focus and interventions

Immediately, the Home Office, as the lead department for the response to violence against women and girls, in conjunction with the Ministry of Justice, the Department for Transport, and national …

- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for immediate prioritisation of prevention …

ANG-28 No Response

Angiolini Inquiry (2025)

Improvement of the investigation of sexually motivated crimes

By March 2026, the College of Policing and the National Centre for Violence Against Women and Girls and Public Protection, working with the National Police Chiefs' Council and the Crown …

- This recommendation was made in the Angiolini Inquiry Part 2 First Report, published 2 December 2025, with a deadline of March 2026 (Angiolini Inquiry …

ANG-29 No Response Urgent

Angiolini Inquiry (2025)

Government prioritisation of prevention

Immediately, the Government should take action to make it clearer that preventing sexually motivated offences against women in public is an essential part of tackling violence against women and girls. …

- This recommendation was made in the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for immediate government action to clarify that …

CR1 Response Pending

Cranston Inquiry (2026)

Network flexing risk mitigation

Given the risks associated with HM Coastguard's use of network flexing for small boat search and rescue – whereby its workforce is split between different geographical locations – HM Coastguard …

CR2 Response Pending

Cranston Inquiry (2026)

Technology for duplicate incident reconciliation

HM Coastguard should seek, at pace, to invest in the technology required to support its ability to reconcile duplicate small boat incidents. Where this cannot be accommodated within the existing …

CR3 Response Pending

Cranston Inquiry (2026)

Regular assessment of assets and resources

There should be regular assessments by HM Coastguard of the adequacy of the available assets and human resources to respond to both current and reasonably foreseeable levels of small boat …

CR4 Response Pending

Cranston Inquiry (2026)

Training on normalcy bias

HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one being the need to avoid normalcy bias, in …

CR5 Response Pending

Cranston Inquiry (2026)

Mass Persons in Water Triage procedure

Those involved in maritime search and rescue should adopt formally the Mass Persons in the Water Triage procedure to govern the operational response to a maritime search and rescue incident …

CR6 Response Pending

Cranston Inquiry (2026)

Joint exercises on triage procedure

Those involved in maritime search and rescue should continue to undertake joint exercises on the application of the Mass Persons in the Water Triage procedure.

CR7 Response Pending

Cranston Inquiry (2026)

IMO recommendation on triage tool

The Department for Transport must consider recommending to the International Maritime Organization that it consider incorporating an in-water mass casualty triage tool within its policies and procedures.

CR8 Response Pending

Cranston Inquiry (2026)

Survivability advice to persons in distress

HM Coastguard should amend its existing policies to incorporate the need to provide more comprehensive advice about survivability to people in distress at sea.

CR9 Response Pending

Cranston Inquiry (2026)

Cold water survivability modelling

HM Coastguard should examine whether it is using the most appropriate modelling for survivability in cold water. HM Coastguard should amend its existing policies to ensure that they consistently identify …

CR10 Response Pending

Cranston Inquiry (2026)

Equipment and techniques development

HM Coastguard must continue to liaise with search and rescue partners in the UK and abroad to identify opportunities for the development or deployment of equipment and techniques to assist …

CR11 Response Pending

Cranston Inquiry (2026)

Coastguard role in legislation

The role and functions of HM Coastguard should be set out in up-to-date legislation.

CR12 Response Pending

Cranston Inquiry (2026)

Independent external oversight body

An independent external body should be given responsibility for the regular assessment of the effectiveness and efficiency of HM Coastguard. Consideration should be given to extending the remit of His …

CR13 Response Pending

Cranston Inquiry (2026)

Reconsider Border Force SAR function

The government should reconsider Mr Downer's recommendation in his independent review of Border Force that Border Force Maritime should not be providing an ongoing search and rescue function in the …

CR14 Response Pending

Cranston Inquiry (2026)

MoU between Coastguard and Border Force

For so long as the current arrangements in relation to search and rescue in the English Channel remain in place, the roles and responsibilities of HM Coastguard and Border Force …

CR15 Response Pending

Cranston Inquiry (2026)

Joint training exercises plan

HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved in maritime search and rescue in the English …

CR16 Response Pending

Cranston Inquiry (2026)

Mass rescue operation plan

HM Coastguard should develop a mass rescue operation plan that includes command and control, co-ordination, external stakeholders, medical and law enforcement roles, and public and external affairs.

CR17 Response Pending

Cranston Inquiry (2026)

Protocol for duty to assist referrals

HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard Agency's regulatory compliance investigations team, identifying the threshold …

CR18 Response Pending

Cranston Inquiry (2026)

MAIB publication of implementation measures

The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details of implementation measures taken by those to whom …

P1-1 Accepted

Fuller Inquiry (2023)

Non-mortuary staff accompanied in mortuary

Maidstone and Tunbridge Wells NHS Trust must ensure that non-mortuary staff and contractors, including maintenance staff employed by the Trust's external facilities management provider, are always accompanied by another staff …

- MTW Trust stated in February 2024 that it had implemented accompaniment requirements for non-mortuary staff and contractors visiting the mortuary (MTW Trust Assurance Statement, …

P1-2 Accepted

Fuller Inquiry (2023)

No deceased left out of fridges overnight

Maidstone and Tunbridge Wells NHS Trust must assure itself that all regulatory requirements and standards relating to the mortuary are met and that the practice of leaving deceased people out …

- MTW Trust stated in February 2024 that it had strengthened procedures to ensure regulatory requirements are met and that the deceased are not left …

P1-3 Accepted

Fuller Inquiry (2023)

Criminal record checks compliance

Maidstone and Tunbridge Wells NHS Trust must assure itself that it is compliant with its own current policy on criminal record checks and re-checks for staff. The Trust should ensure …

- MTW Trust stated in February 2024 that it had implemented enhanced criminal record checks for mortuary staff, including DBS checks at the appropriate level …

P1-4 Accepted

Fuller Inquiry (2023)

Mortuary Managers qualified and supported

Maidstone and Tunbridge Wells NHS Trust must assure itself that its Mortuary Managers are suitably qualified and have relevant anatomical pathology technologist experience. The Mortuary Manager should have a clear …

- MTW Trust stated in February 2024 that it had reviewed the qualifications required for the Mortuary Manager role and ensured the post-holder meets the …

P1-5 Accepted

Fuller Inquiry (2023)

Mortuary Manager as full-time dedicated role

The role of Mortuary Manager at Maidstone and Tunbridge Wells NHS Trust should be protected as a full-time dedicated role, in recognition of the fact that this is a complex …

- MTW Trust stated in February 2024 that it had established the Mortuary Manager as a full-time dedicated role (MTW Trust Assurance Statement, February 2024). …

P1-6 Accepted

Fuller Inquiry (2023)

Review policies on mortuary access

Maidstone and Tunbridge Wells NHS Trust must review its policies to ensure that only those with appropriate and legitimate access can enter the mortuary.

- MTW Trust stated in February 2024 that it had implemented a comprehensive mortuary access policy restricting entry to authorised personnel only (MTW Trust Assurance …

P1-7 Accepted

Fuller Inquiry (2023)

Audit and monitor mortuary access

Maidstone and Tunbridge Wells NHS Trust must audit implementation of any resulting new policy and must regularly monitor access to restricted areas, including the mortuary, by all staff and contractors.

- MTW Trust stated in February 2024 that it had implemented audit procedures to monitor access to restricted areas within the mortuary (MTW Trust Assurance …

P1-8 Accepted

Fuller Inquiry (2023)

Security as corporate responsibility

Maidstone and Tunbridge Wells NHS Trust should treat security as a corporate not a local departmental responsibility.

- MTW Trust stated in February 2024 that mortuary security had been elevated to a corporate responsibility with board-level oversight (MTW Trust Assurance Statement, February …

P1-9 Accepted

Fuller Inquiry (2023)

CCTV in mortuary including post-mortem room

Maidstone and Tunbridge Wells NHS Trust must install CCTV cameras in the mortuary, including the post-mortem room, to monitor the security of the deceased and safeguard their privacy and dignity.

- MTW Trust stated in February 2024 that CCTV had been installed in the mortuary covering all areas where the deceased are stored or examined …

P1-10 Accepted

Fuller Inquiry (2023)

Regular CCTV review with swipe card data

Maidstone and Tunbridge Wells NHS Trust must ensure that footage from the CCTV is reviewed on a regular basis by appropriately trained staff and examined in conjunction with swipe card …

- MTW Trust stated in February 2024 that it had implemented regular review of CCTV footage from the mortuary as part of routine security procedures …

P1-11 Accepted

Fuller Inquiry (2023)

Share HTA reports with reliant organisations

Maidstone and Tunbridge Wells NHS Trust must proactively share Human Tissue Authority reports with organisations that rely on Human Tissue Authority licensing for assurance of the service provided by the …

- MTW Trust stated in February 2024 that HTA inspection reports are now shared with relevant Trust boards and governance committees (MTW Trust Assurance Statement, …

P1-12 Accepted

Fuller Inquiry (2023)

Local authorities examine contractual arrangements

Kent County Council and East Sussex County Council should examine their contractual arrangements with Maidstone and Tunbridge Wells NHS Trust to ensure that they are effective in protecting the safety …

- MTW Trust stated in February 2024 that it had reviewed contracts with Kent County Council and East Sussex County Council for mortuary services (MTW …

P1-13 Accepted

Fuller Inquiry (2023)

Board review governance - assurance not reassurance

We have illustrated throughout this Report how Maidstone and Tunbridge Wells NHS Trust relied on reassurance rather than assurance in monitoring its processes. The Board must review its governance structures …

- MTW Trust stated in February 2024 that it had strengthened board governance to ensure "assurance not reassurance" in relation to mortuary operations (MTW Trust …