Public Inquiry Recommendations

SHI-5 Accepted

Scottish Hospitals Inquiry (2025)

Streamlining NHS construction quality procedures

A range of procedures now exists to help ensure health board projects meet appropriate standards. One is the NHS Scotland Design Assessment Process ("NDAP"). There is also a Sustainable Design …

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

SHI-6 Accepted

Scottish Hospitals Inquiry (2025)

Information on common construction errors

It is important that common project errors are not repeated. One helpful step is to ensure health boards undertaking projects have information about such common errors, and that this information …

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

SHI-7 Accepted

Scottish Hospitals Inquiry (2025)

Independent validation of hospital construction

It is clearly desirable that a health board has the assurance prior to the handover of a new or refurbished healthcare facility that the facility's specialised ventilation systems have been …

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

SHI-8 Accepted

Scottish Hospitals Inquiry (2025)

IPC role specifications and staffing levels

I accordingly recommend that priority be given to protecting scarce IPC resources. With that objective in view, what is expected of consideration and advice from individual disciplines at various stages …

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

SHI-9 Accepted

Scottish Hospitals Inquiry (2025)

Documentation of technical adviser advice

I accordingly recommend that a similar procedure should be considered when technical advisers (particularly engineers) are providing specific technical advice in relation to a project such as the RHCYP and …

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

SHI-10 Accepted

Scottish Hospitals Inquiry (2025)

Uniform policy for obtaining technical advice

This issue was highlighted in the Grant Thornton report where similar recommendations are made to what is set out above. NHSL has taken steps to address the issue. However, it …

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

SHI-11 Accepted

Scottish Hospitals Inquiry (2025)

Training for IPC professionals engineers and clinicians

I would recommend that IPC professionals should receive some basic training on the recommendations made by the NHS's own guidance for engineering systems, insofar as they are made in the …

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

AFA-1 Response Pending

Urology Services Inquiry (2026)

Patient focus and complaints

The Inquiry recommends that the Trust and Department work together to ensure there is: • A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and …

AFA-2 Response Pending

Urology Services Inquiry (2026)

Organisational development and cultural reform

The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system …

AFA-3 Response Pending

Urology Services Inquiry (2026)

Board and senior leadership development

The Inquiry recommends: • The Department implements and funds a bespoke, regional leadership development programme for Board members and senior leaders, co-designed with external expertise including specific training in patient …

AFA-4 Response Pending

Urology Services Inquiry (2026)

Governance

The Inquiry recommends a programme of work by the Trust to: • Consolidate governance improvements into a clear, prioritised programme overseen by the Board. This will ensure that the large …

AFA-5 Response Pending

Urology Services Inquiry (2026)

Serious Adverse Incidents

We recommend that: • The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in …

AFA-6 Response Pending

Urology Services Inquiry (2026)

Medical leadership and doctors in difficulty

The Inquiry recommends that: • There must be sustained investment in leadership development for doctors at all career stages. Improvements discussed in the Medical Management and Leadership chapter should continue. …

AFA-7A Response Pending

Urology Services Inquiry (2026)

Urology Service

The impact of the Inquiry on the Urology Department has been very significant. The Inquiry recommends that the Urology Service be provided with ongoing specific medical and operational leadership support …

AFA-7B Response Pending

Urology Services Inquiry (2026)

Cancer Services

The Trust has worked through a detailed action plan relating to Cancer Services, specifically in relation to the oversight and support for MDTs and has addressed the issues identified in …

SP1 Accepted

Southport Inquiry (2026)

Single agency for high-risk children

Phase 2 should consider what single agency or structure should be appointed or established to record, monitor and co-ordinate interventions for children and young people who present a high risk …

- The government stated the Chair identified this recommendation for further consideration by the Inquiry in Phase 2, and that the government agrees with all …

SP2 Accepted

Southport Inquiry (2026)

Shared multi-agency risk-assessment tool

Phase 2 should consider the development of a shared multi‑agency risk‑assessment tool that is clear, accessible and suitable for use across public sector services.

- The government stated the Chair identified this recommendation for further consideration by the Inquiry in Phase 2, and that the government agrees with all …

SP3 Accepted

Southport Inquiry (2026)

Internet access restrictions for high-risk children

Phase 2 should consider whether there should be a further ability to restrict or monitor access to the internet on the part of children and young people, if a significant …

- The government stated the Chair identified this recommendation for further consideration by the Inquiry in Phase 2, and that the government agrees with all …

SP4 Accepted

Southport Inquiry (2026)

Taxi driver duty to report criminal activity

The Department for Transport should require local authorities to ensure that all licensed taxi drivers have a clear duty promptly to report any significant criminal activity they witness while working. …

- The Department for Transport stated on 27 November 2025 that it proposed national minimum standards for taxi and private hire vehicle licensing across England, …

SP5 Accepted

Southport Inquiry (2026)

Taxi company and school safeguarding arrangements

The Department for Transport should ensure that local authorities establish effective arrangements between licensed taxi companies and schools. These should enable school safeguarding teams to access taxi booking information where …

- The Department for Transport opened a consultation running from 8 January 2026 to 1 April 2026 on the licensing of taxis and private hire …

SP6 Accepted

Southport Inquiry (2026)

Police use of unarmed officers in immediate threat

All police forces should ensure that their policies, guidance and training address taking on a calculated degree of risk in recognition of the immediate need to protect the public from …

- The government stated this recommendation requires delivery by an organisation outside central government, that it has written to all national, regional and local organisations …

SP7 Accepted

Southport Inquiry (2026)

Second Force Incident Manager support

All police forces that have not implemented a model providing immediate and direct support to Force Incident Managers, ideally through a second Force Incident Manager, should consider adopting such arrangements …

- The government stated this recommendation requires delivery by an organisation outside central government, that it has written to all national, regional and local organisations …

SP8 Accepted

Southport Inquiry (2026)

Ambulance staff training exercise funding

NHS England should review funding, and consider providing additional resources, to enable all emergency response ambulance staff to participate in appropriate training exercises.

- NHS England and the Department for Health and Social Care stated in the response that they are the lead organisations working with the Emergency …

SP9 Accepted

Southport Inquiry (2026)

NWAS Major Incident declaration procedures

North West Ambulance Service should review its procedures for declaring a Major Incident or Major Incident (Standby) to ensure clarity in how declarations are made and how they are communicated …

- NHS England and the Department of Health and Social Care stated that, in the spirit of recommendations 9 and 10, there is an opportunity …

SP10 Accepted

Southport Inquiry (2026)

Police-ambulance terminology interoperability

Merseyside Police and North West Ambulance Service should review the terminology used in their systems and procedures to ensure shared understanding and interoperability. The College of Policing and the National …

- NHS England and the Department of Health and Social Care stated that terminology used in major incident response must be consistent across all ambulance …

SP11 Accepted

Southport Inquiry (2026)

Out-of-school settings guidance update

The Department for Education should update the out‑of‑school settings guidance by reviewing the health and safety section to ensure terminology is clear and consistent, particularly regarding emergency plans and fire/evacuation …

- The Department for Education ran an out-of-school settings safeguarding call for evidence from 29 May 2025, which closed on 21 September 2025, seeking views …

SP12 Accepted

Southport Inquiry (2026)

Detection of concerning online behaviour

Phase 2 should consider systems to detect and report concerning online behaviour and suspicious combinations of purchases. This should include consideration of: 1. Concerning patterns of online browsing and purchasing …

- The government agreed with the recommendation and noted the Chair identified it for further consideration in Phase 2 of the Inquiry (Government Response to …

SP13 Accepted

Southport Inquiry (2026)

Regulation of castor bean sales

The Home Office’s ongoing review of the sale of castor beans should consider regulation of the number of castor beans that can be sold in a single transaction.

- The Home Office stated it completed a targeted review of the sale and availability of castor beans in May 2026, that ministers agreed further …

SP14 Accepted

Southport Inquiry (2026)

Archery bow age verification and restrictions

Phase 2 should consider whether conventional archery bows should be subject to age‑verification prior to sale, delivery restrictions including ID checks, mandatory labelling for deliveries, and industry or trading standards …

- The Crime and Policing Act 2026 contains provisions on the remote sale, letting and delivery of crossbows introducing age and identity verification at point …

SP15 Accepted

Southport Inquiry (2026)

Crossbow prohibition or licensing

Phase 2 should consider, in parallel with the government’s consultation where possible, a prohibition on the sale of crossbows, a licensing scheme similar to firearms, tighter controls on purchasing such …

- The government set out that it will introduce a prohibition on the sale of crossbows, a licensing scheme for existing owners with suitability checks, …

SP16 Accepted

Southport Inquiry (2026)

Guidance on suspicious archery/crossbow purchasers

The Home Office should provide clear guidance to all UK retailers of archery bows and crossbows on identifying and reporting suspicious behaviour, including underage purchasers or those who appear to …

- The Crime and Policing Act 2026 contains provisions on the remote sale, letting and delivery of crossbows, under which the government states statutory guidance …

SP17 Accepted

Southport Inquiry (2026)

Investigation of Ageo Wholesale knife marketing

The Commissioner of Police of the Metropolis should consider an investigation, with input from the Crown Prosecution Service if appropriate, as to whether Ageo Wholesale UK Ltd committed criminal offences …

- The government noted this recommendation requires delivery by an organisation outside central government, that it has written to the relevant organisations to highlight the …

SP18 Accepted

Southport Inquiry (2026)

Online knife retailer compliance with Knives Act

The Home Office should take immediate action to ensure that online knife retailers are complying with the Knives Act 1997, particularly regarding the marketing of knives, machetes, swords and similar …

- A Home Office consultation proposed a licensing scheme for online knife sellers including mandatory age verification, application of Challenge 25 policies, a requirement for …

SP19 Accepted

Southport Inquiry (2026)

Amazon bladed article delivery controls

Amazon should: 1. Improve its measures to prevent children from making purchases, including making the conditions of use and sale more prominent. 2. Improve the labelling on packaging of bladed …

- The government noted this recommendation requires delivery by an organisation outside central government, that it has written to the relevant organisations to highlight the …

SP20 Accepted

Southport Inquiry (2026)

Further knife/bladed item sales measures

Phase 2 should consider further measures relating to knives/bladed items sales, including: 1. Restrictions on sharp‑tipped knives. 2. Prohibiting some online sales (such as machetes). 3. Strengthening online age‑verification and …

- The Crime and Policing Act 2026 introduces stricter age verification for the online sale and delivery of knives, a duty to report bulk sales …

SP21 Accepted

Southport Inquiry (2026)

School monitoring and filtering systems guidance

The Department for Education should review and strengthen its guidance to schools on monitoring and filtering systems, including ensuring that the systems used are appropriate and adequate from a technical …

- A Department for Education consultation sought views on proposed changes to Keeping Children Safe in Education, including a strengthened expectation that schools review the …

SP22 Accepted

Southport Inquiry (2026)

LCC online harms risk assessment review

Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing Service) assess and manage risk and online harms …

- The Department of Health and Social Care published advice for parents on screen use for children aged 0 to 5 on the Best Start …

SP23 Accepted

Southport Inquiry (2026)

Coroner and inquiry Ofcom notification powers

The Department for Science, Innovation and Technology should consider extending the powers under the Online Safety Act 2023 to enable Senior Coroners to make a notification to Ofcom to obtain …

- Ofcom guidance states that from 30 September it can require tech firms to preserve data about a deceased child's activity if requested by the …

SP24 Accepted

Southport Inquiry (2026)

VPN age verification

Phase 2 should consider age verification for the use of Virtual Private Network (VPN) software and other options to avoid VPNs being used to circumvent the age-related protections in the …

- The government agreed with the recommendation and noted the Chair identified it for further consideration in Phase 2 of the Inquiry (Government Response to …

SP25 Accepted

Southport Inquiry (2026)

Operation Encompass cross-border extension

Lancashire Constabulary should consider extending Operation Encompass to share automatically relevant information with schools in bordering areas. The Department for Education should consider national implementation. This is because children will …

- The Home Office introduced a statutory duty on police in England and Wales to notify a child's educational setting when officers attend a domestic …

SP26 Accepted

Southport Inquiry (2026)

Recording words and behaviour of high-risk individuals

Lancashire Constabulary, and the College of Policing nationally, should ensure that forms and training emphasise the importance of recording, as precisely as possible, the words and behaviour of individuals who …

- The government response states this recommendation requires delivery by an organisation outside central government, that the government has written to the responsible organisations to …

SP27 Accepted

Southport Inquiry (2026)

Cross-force information sharing review

Lancashire Constabulary and Merseyside Police should review the effectiveness of their information‑sharing systems and consider whether a more robust process is required. Findings should be shared with the National Police …

- The government response states this recommendation requires delivery by an organisation outside central government, that the government has written to the responsible organisations to …

SP28 Accepted

Southport Inquiry (2026)

Recording case information on police systems

Lancashire Constabulary should ensure its training and systems address the risks associated with failing to record case information on police systems so it is readily available to others. The National …

- The government response states this recommendation requires delivery by an organisation outside central government, that the government has written to the responsible organisations to …

SP29 Accepted

Southport Inquiry (2026)

Risks posed by children and young people

Lancashire Constabulary should ensure its procedures and training sufficiently addresses the risks children and young people may pose to others and the options for addressing that risk. The College of …

- The government response states this recommendation requires delivery by an organisation outside central government, that the government has written to the responsible organisations to …

SP30 Accepted

Southport Inquiry (2026)

Autism spectrum disorder police training

1. Lancashire Constabulary should strengthen its autism spectrum disorder‑related training for new officers and through continuous development. 2. National policing bodies, with input from the Department of Health and Social …

- The government response states that options for improving guidance or training on autism for police have been provided by the Department of Health and …

SP31 Accepted

Southport Inquiry (2026)

Response officer access to case information technology

1. Lancashire Constabulary should ensure response officers have access to effective technology providing clear, essential case information. 2. The National Police Chiefs’ Council, College of Policing and Home Office should …

- The Home Office published a White Paper announcing a National Police Service, national standards and investment in data, which the government response states included …

SP32 Accepted

Southport Inquiry (2026)

Prevent training on online activity assessment

While training for Counter Terrorism Policing, staff involved in Prevent currently cover the importance of understanding a referred individual’s online activity and the practical steps required to assess it, the …

- The Interim Independent Prevent Commissioner's review, examining the Prevent interactions of the Southport perpetrator, found that Prevent needs rapidly to adapt to the online …

SP33 Accepted

Southport Inquiry (2026)

CT Policing online activity analysis capability

Counter Terrorism Policing’s capability to access and analyse data relating to a referred person’s online activity should be reviewed in the context of Prevent referrals, to determine whether staff have …

- The government response states the Prevent National Referral Form was updated in 2024 to request an individual's social media handle, that the Prevent Assessment …

SP34 Accepted

Southport Inquiry (2026)

Neurodiversity training for Prevent practitioners

Counter Terrorism Policing Headquarters should review its neurodiversity training for Prevent practitioners (including, where appropriate, drawing in wider healthcare advice) to ensure that they sufficiently equip practitioners with a proper …

- The Home Office stated that an internal strategic policy review of mental ill-health and neurodivergence in Prevent has been undertaken, and that the findings …

SP35 Accepted

Southport Inquiry (2026)

Balancing vulnerability with professional curiosity

Counter Terrorism Policing Headquarters should review and where necessary strengthen the training that Counter Terrorism officers involved in Prevent already receive to ensure that they understand the importance of balancing …

- The Home Office stated it updated the Prevent National Referral Form in 2024 to request an individual's social media handle, and rolled out the …