Public Inquiry Recommendations

P2-47 Accepted in Part

Fuller Inquiry (2025)

Local authority security breach investigation

There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be reported to director level within the local authority …

- The government stated in December 2025 that this recommendation on incident investigation in local authority mortuaries was accepted in principle. Full government response due …

P2-48 Accepted in Part

Fuller Inquiry (2025)

Local authority annual SOP and HTA audits

There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, with a clear record of authorisation by the …

- The government stated in December 2025 that this recommendation on compliance audits for local authority mortuaries was accepted in principle. Full government response due …

P2-49 Accepted in Part

Fuller Inquiry (2025)

Local authority DI management and oversight review

There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as the Designated Individual, their direct contact with the …

- The government stated in December 2025 that this recommendation on management oversight of local authority mortuaries was accepted in principle. Full government response due …

P2-50 Accepted in Part

Fuller Inquiry (2025)

Local authority mortuary as regulated service

The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must be visible to scrutiny at the relevant statutory …

- The government stated in December 2025 that this recommendation on governance arrangements for local authority mortuaries was accepted in principle. Full government response due …

P2-51 Accepted in Part

Fuller Inquiry (2025)

Local authority biennial audits and peer review

The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal committee regardless of the level of assurance. Local …

- The government stated in December 2025 that this recommendation on professional audits of local authority mortuaries was accepted in principle. Full government response due …

P2-52 Accepted in Part

Fuller Inquiry (2025)

Share mortuary reports with coroner service

All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service (and the Senior Coroner if they wish to …

- The government stated in December 2025 that this recommendation on coroner reporting to local authorities on mortuary standards was accepted in principle. Full government …

P2-53 Accepted in Part

Fuller Inquiry (2025)

Local authority report implementation to committee

The implementation of these recommendations must be reported to the relevant statutory committee.

- The government stated in December 2025 that this recommendation on local authorities reporting on implementation of mortuary standards was accepted in principle. Full government …

P2-54 Accepted in Part

Fuller Inquiry (2025)

Local authority contingent body storage plans

Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local organisations providing mortuary services.

- The government stated in December 2025 that this recommendation on contingency planning for local authority mortuary capacity was accepted in principle. Full government response …

P2-55 Accepted in Part

Fuller Inquiry (2025)

Unlicensed body stores prepared for HTA compliance

Local authorities providing an unlicensed body store must be prepared to comply with the Human Tissue Authority's standards and guidance where applicable, in the event that a Human Tissue Authority …

- The government stated in December 2025 that this recommendation on bringing unlicensed body stores into compliance was accepted in principle. Full government response due …

P2-56 Accepted in Part

Fuller Inquiry (2025)

Unlicensed body stores follow same standards

Where local authorities provide an unlicensed body store, they should do so in line with this Report's recommendations to local authority providers of licensed mortuaries.

- The government stated in December 2025 that this recommendation on minimum standards for unlicensed body stores was accepted in principle. Full government response due …

P2-57 Under Consideration

Fuller Inquiry (2025)

Local authority review third-party contracts

Local authorities must review all contractual arrangements and agreements with third-party providers of services that care for and transport the deceased. This must include consideration of assurance mechanisms, such as …

- The government stated in December 2025 that this recommendation on local authority oversight of mortuary contractors was under consideration. Full government response due Summer …

P2-58 Under Consideration

Fuller Inquiry (2025)

Contractual incident notification requirement

There must be a contractual requirement to formally notify the contract manager and senior local authority officers of any incidents involving the deceased, as well as the outcome of inspections …

- The government stated in December 2025 that this recommendation on contractual standards for mortuary service contractors was under consideration. Full government response due Summer …

P2-59 Under Consideration

Fuller Inquiry (2025)

Local authority contractor governance assurance

Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee the services they provide. This should include Standard …

- The government stated in December 2025 that this recommendation on due diligence requirements for local authority mortuary contractors was under consideration. Full government response …

P2-60 Under Consideration

Fuller Inquiry (2025)

Care homes in scope for new regulatory regime

The regulatory measures recommended in Chapter 11 should apply to care homes in England. Regulation should cover both systems and professionals where staff are providing care to deceased people in …

- The government stated in December 2025 that this recommendation on regulation of care home mortuaries was under consideration. Full government response due Summer 2026 …

P2-61 Under Consideration

Fuller Inquiry (2025)

Statutory regulation of funeral directors

The UK government should establish an independent statutory regulatory regime for funeral directors in England as a matter of urgency in order to safeguard the security and dignity of the …

- The government stated in December 2025 that this recommendation on statutory regulation of the funeral sector was under consideration. Full government response due Summer …

P2-62 Under Consideration

Fuller Inquiry (2025)

Regulations consider whole deceased journey

These regulations and standards should be considered within the overall care and journey of the deceased rather than applying in isolation to funeral directors.

- The government stated in December 2025 that this recommendation on security standards for funeral director premises was under consideration. Full government response due Summer …

P2-63 Under Consideration

Fuller Inquiry (2025)

Mandatory information from funeral directors

The standards should include details of mandatory information to be given to customers by funeral directors to provide transparency about the care of the deceased, including information on measures to …

- The government stated in December 2025 that this recommendation on DBS checks for funeral sector staff was under consideration. Full government response due Summer …

P2-64 Under Consideration

Fuller Inquiry (2025)

Direct cremation in scope for standards

Direct cremation businesses should also be considered in this context, and mandatory standards to protect the security and dignity of the deceased should be applied to these businesses and to …

- The government stated in December 2025 that this recommendation on training requirements for funeral sector staff was under consideration. Full government response due Summer …

P2-65 Under Consideration

Fuller Inquiry (2025)

Funeral director regulation benefits outweigh difficulties

While the introduction of a proportionate statutory regulation and inspection regime may require significant adjustment by funeral director organisations, it is the view of the Inquiry that the benefit to …

- The government stated in December 2025 that this recommendation on a code of practice for the funeral sector was under consideration. Full government response …

P2-66 Under Consideration

Fuller Inquiry (2025)

Funeral sector in scope for new regulatory regime

The funeral sector in England should be considered in scope for the broader regulatory measures recommended in Chapter 11.

- The government stated in December 2025 that this recommendation on a complaints mechanism for the funeral sector was under consideration. Full government response due …

P2-67 Under Consideration

Fuller Inquiry (2025)

Faith organisations share guidance on deceased care

All faith organisations should consider how to support their members to deliver high standards of care for the deceased, with a focus on the security and dignity of the deceased …

- The government stated in December 2025 that this recommendation on faith organisations and the care of deceased persons was under consideration. Full government response …

P2-68 Under Consideration

Fuller Inquiry (2025)

Religious building security for deceased

Where deceased people are in a religious building overnight, measures should be taken to ensure that the building is secure, including, for example, CCTV and secure access control for the …

- The government stated in December 2025 that this recommendation on coroner oversight of mortuary standards was under consideration. Full government response due Summer 2026 …

P2-69 Under Consideration

Fuller Inquiry (2025)

Formalise multi-organisation arrangements

Where organisations work together to care for people after death, the arrangements should be formalised through contracts or service level agreements. This should include joint Standard Operating Procedures. The parties …

- The government stated in December 2025 that this recommendation on coroner powers in relation to mortuary security was under consideration. Full government response due …

P2-70 Under Consideration

Fuller Inquiry (2025)

Chief Coroner review practice consistency

The Chief Coroner should review the difference in practice between coronial areas as soon as possible to ensure that: All coroners are informed of the findings of this Inquiry. All …

- The government stated in December 2025 that this recommendation on coroner reporting on the treatment of the deceased was under consideration. Full government response …

P2-71 Under Consideration

Fuller Inquiry (2025)

New Chief Inspector regulatory regime for deceased

The UK government should establish an independent statutory regulatory regime, headed by a Chief Inspector, for those who store and care for deceased people. The purpose of the regulatory regime …

- The government stated in December 2025 that this recommendation on establishing an independent statutory regulatory regime with a Chief Inspector of Mortuaries was under …

P2-72 Under Consideration

Fuller Inquiry (2025)

Interim Commissioner for Dignity of Deceased

In the interim, the government should immediately appoint a Commissioner for the Dignity of the Deceased who should immediately issue universal guidance that applies to all those who store and …

- The government stated in December 2025 that this recommendation on appointing an interim Commissioner for the Dignity of the Deceased was under consideration. Full …

P2-73 Under Consideration

Fuller Inquiry (2025)

Amend HT Act for organisational responsibility

The government should amend the Human Tissue Act 2004 so that the organisation holding the licence has primary legal responsibility to ensure that: There is a suitable Designated Individual in …

- The government stated in December 2025 that this recommendation on amending the Human Tissue Act 2004 was under consideration. The government noted the complexity …

P2-74 Under Consideration

Fuller Inquiry (2025)

HTA require suitable qualified staff with enforcement

The Human Tissue Authority, and/or the new inspectorate, should require the organisations it licenses to ensure that any individual who provides care to deceased people is suitably qualified, experienced and …

- The government stated in December 2025 that this recommendation on the HTA setting minimum qualification standards for mortuary staff was under consideration. Full government …

P2-75 Accepted

Fuller Inquiry (2025)

Government responsible for implementation monitoring

The government should take responsibility for the implementation of all the recommendations we make in this Report, regardless of the primary organisation they are directed at, and make arrangements to …

- The government stated in December 2025 that this recommendation on the government taking responsibility for overseeing implementation of all Fuller Inquiry recommendations was accepted …

1 Accepted in Part

Paterson Inquiry (2020)

Single consultant data repository

We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data – for …

- The Department of Health and Social Care stated in December 2021 that it was improving data flows to the CQC and GMC to provide …

2 Accepted

Paterson Inquiry (2020)

Patient-focused correspondence

We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, …

- The Academy of Medical Royal Colleges (AoMRC) updated its 'Please write to me' guidance in 2018, stipulating that outpatient letters should be written directly …

3 Accepted

Paterson Inquiry (2020)

Explaining independent sector differences

We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised is explained clearly …

- The available evidence indicates that implementation is in progress but not complete. The government remains committed to publishing the information requested by the recommendation, …

4 Accepted in Part

Paterson Inquiry (2020)

Reflection period for consent

We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and …

- The GMC revised its "Decision making and consent" guidance, effective 9 November 2020, which requires doctors to give patients time to consider information before …

5 Accepted

Paterson Inquiry (2020)

CQC assurance on MDT meetings

We recommend that CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national guidance on MDT meetings, including in breast cancer …

- The government stated in December 2021 that the CQC had updated its inspection methodology to examine MDT functioning and compliance with national guidance (Government …

6a Accepted

Paterson Inquiry (2020)

Communicating complaint escalation

We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and the independent sector.

- The Parliamentary and Health Service Ombudsman issued NHS Complaints Standards in December 2022, which include a model procedure to increase awareness of independent resolution …

6b Accepted in Part

Paterson Inquiry (2020)

Mandatory independent complaint resolution

We recommend that all private patients should have the right to mandatory independent resolution of their complaint.

- The government stated in December 2021 that it was considering whether legislative change is needed to make independent adjudication mandatory for all private healthcare …

7 Accepted

Paterson Inquiry (2020)

UHB patient recall

We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been …

- University Hospitals Birmingham NHS Foundation Trust stated that all known living patients of Ian Paterson had been contacted by August 2020 (Implementation update to …

8 Accepted

Paterson Inquiry (2020)

Spire patient recall

We recommend that Spire should check that all patients of Ian Paterson have been recalled, and to communicate with any who have not been seen, and that they should check …

- Spire Healthcare stated in April 2025 that it had contacted all known living patients of Ian Paterson and completed a comprehensive review (Implementation update …

9 Accepted

Paterson Inquiry (2020)

National patient recall framework

We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated, centred around the needs of the patients and …

- The National Quality Board published the "Patient-Centred Framework for NHS-Led Recalls" on 1 June 2022 to provide guidance on conducting recall processes (Patient-Centred Framework …

10 Accepted in Part

Paterson Inquiry (2020)

Indemnity regulation reform

We recommend that the Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals in light of the serious shortcomings identified by this …

- In March 2024, the government announced that Medical Defence Organisations (MDOs) intended to implement a sector-led Code of Practice for discretionary indemnity by the …

11 Accepted

Paterson Inquiry (2020)

Regulatory system patient safety priority

We recommend that the government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of …

- The Department of Health and Social Care stated in April 2025 that professional regulators are members of the Joint Strategic Oversight Group (JSOG) to …

12a Not Accepted

Paterson Inquiry (2020)

Suspension during investigation

We recommend that if, when a hospital investigates a healthcare professional's behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension …

- The government did not accept the recommendation for automatic suspension, stating that suspension should be based on individual risk assessments (Government Response to the …

12b Accepted in Part

Paterson Inquiry (2020)

Information sharing between providers

We recommend that if the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.

- The GMC updated its guidance to state that patient safety is paramount when deciding whether to share information about doctors with other providers (DHSC …

13 Accepted in Part

Paterson Inquiry (2020)

Independent sector provider responsibility

We recommend that the government addresses, as a matter of urgency, this gap in responsibility and liability.

- The Independent Healthcare Providers Network (IHPN) refreshed the Medical Practitioners Assurance Framework (MPAF) to clarify that independent providers are responsible for the quality of …

14 Accepted

Paterson Inquiry (2020)

Board apologies

We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established a statutory duty of candour for NHS trusts in 2014 and all …

15 Under Consideration

Paterson Inquiry (2020)

Independent sector NHS contract qualification

We recommend that if the government accepts any of the recommendations set out above, it should make arrangements to ensure that these are to be applicable across the whole of …

- The government did not accept this recommendation, stating that different governance models in the NHS and independent sectors require different approaches to achieving change …

SHI-1 Accepted

Scottish Hospitals Inquiry (2025)

Communication strategy for patients and families

Health boards must ensure that in the event of any adverse situation that could affect the wellbeing of patients and their families, there is a communication strategy in place to …

- On 13 March 2025, Cabinet Secretary Neil Gray MSP accepted all 11 recommendations in a parliamentary statement (Scottish Government Parliamentary Statement, 13 March 2025). …

SHI-2 Accepted

Scottish Hospitals Inquiry (2025)

Risk assessment on funding model changes

Accordingly, in situations where the funding model or procurement route changes mid project, a risk assessment should be conducted to assess whether work done on the project up to that …

- On 13 March 2025, Cabinet Secretary Neil Gray MSP accepted this recommendation (Scottish Government Parliamentary Statement, 13 March 2025). - On 17 September 2025, …

SHI-3 Accepted

Scottish Hospitals Inquiry (2025)

Clarity in brief for healthcare facility construction

It is critical that a health board formulates and then presents its requirements for the key building systems in a proposed healthcare facility (its "brief") in terms which are full, …

- On 13 March 2025, Cabinet Secretary Neil Gray MSP accepted this recommendation (Scottish Government Parliamentary Statement, 13 March 2025). - On 17 September 2025, …

SHI-4 Accepted

Scottish Hospitals Inquiry (2025)

Standard form for derogations from guidance

The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use throughout the NHS in Scotland would be beneficial. …

- On 13 March 2025, Cabinet Secretary Neil Gray MSP accepted this recommendation (Scottish Government Parliamentary Statement, 13 March 2025). - No published standard form …