Public Inquiry Recommendations

F79 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established the 'fit and proper person' requirement for directors (Health …

F80 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications …

- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 mandates that directors must not have been responsible for, or …

F84 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability of providers' directors

Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is …

- NHS England published a standardised board member reference template in August 2023 as part of the Fit and Proper Person Test Framework (Fit and …

F87 Accepted in Part

Mid Staffs Inquiry (2013)

Ensuring the utility of a health and safety function in a clinical setting

The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should be given power to prosecute 1974 Act offences …

- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 granted the Care Quality Commission powers to prosecute providers for breaches related to …

F88 Accepted in Part

Mid Staffs Inquiry (2013)

Information sharing

The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order …

- The Care Quality Commission and the Health and Safety Executive (HSE) maintain a Memorandum of Understanding (MoU) that covers the sharing of statutory notifications, …

F89 Accepted in Part

Mid Staffs Inquiry (2013)

Information sharing

Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.

- The Patient Safety Incident Response Framework (PSIRF), which became mandatory for NHS-funded secondary care providers in Autumn 2023, requires patient safety incident reports to …

F91 Accepted in Part

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority …

- The Department of Health and Social Care stated in April 2025 that NHS Resolution has moved away from assessment against risk management standards (DHSC …

F93 Accepted in Part

Mid Staffs Inquiry (2013)

NHS Litigation Authority Improvement of risk management

The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based …

- The Department of Health and Social Care stated in April 2025 that NHS Resolution considers staffing and activity levels in maternity care by incorporating …

F97 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this valuable function to a systems regulator.

- The National Patient Safety Agency (NPSA) was abolished and its functions were transferred to the NHS Commissioning Board (NHS England) on 1 June 2012 …

F98 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part …

- The Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS) for recording and analyzing patient safety events (Learn …

F99 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has …

- The Learn from Patient Safety Events (LFPSE) service uses machine learning to analyze safety events and includes recording forms for primary care settings (Learn …

F100 Accepted in Part

Mid Staffs Inquiry (2013)

National Patient Safety Agency functions

Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that …

- In April 2025, DHSC and NHS England stated that the designation of 'serious incident' had been abolished and replaced by the Learn from Patient …

F115 Accepted in Part

Mid Staffs Inquiry (2013)

Investigations

Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward …

- The Health Services Safety Investigations Body (HSSIB) was established as an independent statutory body in October 2023 to conduct system-focused patient safety investigations (Health …

F117 Accepted in Part

Mid Staffs Inquiry (2013)

Support for complainants

A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.

- The Department of Health and Social Care stated in April 2025 that local authorities are required under the Local Government and Public Involvement in …

F118 Accepted in Part

Mid Staffs Inquiry (2013)

Learning and information from complaints

Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In …

- The Department of Health and Social Care stated in April 2025 that it had not taken forward the recommendation to publish summaries of every …

F120 Accepted in Part

Mid Staffs Inquiry (2013)

Learning and information from complaints

Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This …

- The Department of Health and Social Care stated in April 2025 that GP practices are required to produce annual complaint reports and provide them …

F122 Accepted in Part

Mid Staffs Inquiry (2013)

Handling large-scale complaints

Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to very distressed and anxious members of the public; …

- The Department of Health and Social Care stated in April 2025 that the government had rejected part of this recommendation in the 2013 'Hard …

F124 Accepted in Part

Mid Staffs Inquiry (2013)

Duty to require and monitor delivery of fundamental standards

The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in respect of each item of service it is …

- The NHS Standard Contract 2024/25 includes service condition 37, which allows commissioners and providers to agree on local quality requirements and enhanced standards (DHSC …

F133 Accepted in Part

Mid Staffs Inquiry (2013)

Role of commissioners in complaints

Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, …

- The Parliamentary and Health Service Ombudsman (PHSO) introduced the NHS Complaint Standards in 2022 to provide a consistent approach to complaint handling across the …

F135 Accepted in Part

Mid Staffs Inquiry (2013)

Public accountability of commissioners and public engagement

Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should …

- The Health and Care Act 2022 established Integrated Care Boards (ICBs) to replace Clinical Commissioning Groups (Health and Care Act 2022). - DHSC and …

F141 Accepted in Part

Mid Staffs Inquiry (2013)

Taking responsibility for quality

Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its …

- The Health Services Safety Investigations Body (HSSIB) was launched in October 2023 as an independent statutory body with powers of entry, inspection, and seizure …

F146 Accepted in Part

Mid Staffs Inquiry (2013)

Finance and oversight of Local Healthwatch

Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the …

- The government stated in November 2013 that it did not accept that local authorities should be required to pass over centrally provided funds, leaving …

F150 Accepted in Part

Mid Staffs Inquiry (2013)

Inspection powers

Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger …

- DHSC stated in April 2025 that this recommendation has not yet been actioned (DHSC/NHS England implementation update to the Thirlwall Inquiry, April 2025). - …

F151 Accepted in Part

Mid Staffs Inquiry (2013)

Complaints to MPs

MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns …

- DHSC stated in April 2025 that this recommendation has not yet been actioned and provided no further update (DHSC/NHS England implementation update to the …

F153 Accepted in Part

Mid Staffs Inquiry (2013)

Medical training

The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between …

- The DHSC and NHS England stated in April 2025 that implementation was ongoing and that action taken following the Inquiry had been reviewed (DHSC …

F164 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision …

- DHSC and NHS England stated in April 2025 that Approved Practice Setting requirements were introduced by the GMC in June 2014 (DHSC/NHS England implementation …

F165 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public.

- DHSC and NHS England stated in April 2025 that the GMC introduced Approved Practice Setting requirements in June 2014 (DHSC/NHS England implementation update to …

F166 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view …

- DHSC and NHS England stated in April 2025 that the GMC introduced Approved Practice Setting requirements in June 2014 (DHSC/NHS England implementation update to …

F167 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments …

- DHSC and NHS England stated in April 2025 that the GMC embedded Approved Practice Setting arrangements within the Responsible Officer Regulations in June 2014, …

F168 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for …

- DHSC and NHS England stated in April 2025 that the Approved Practice Setting scheme was incorporated into the regulatory framework via the Responsible Officer …

F169 Accepted in Part

Mid Staffs Inquiry (2013)

Role of the Department of Health and the National Quality Board

The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation …

- DHSC and NHS England stated in April 2025 that a Patient Safety Syllabus and associated training courses have been published for providers and regulators …

F178 Accepted in Part

Mid Staffs Inquiry (2013)

Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and candour

The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, …

- The Department of Health and Social Care and NHS England stated in April 2025 that the NHS Constitution was updated in February 2024 to …

F181 Accepted in Part

Mid Staffs Inquiry (2013)

Enforcement of the duty Statutory duties of candour in relation to harm to patients

A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has …

- Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established a statutory duty of candour for all CQC-regulated providers …

F188 Accepted in Part

Mid Staffs Inquiry (2013)

Aptitude test for compassion and caring

The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in …

- The Nursing and Midwifery Council stated in April 2025 that its pre-registration standards negate the need for a specific aptitude test (DHSC and NHS …

F189 Accepted in Part

Mid Staffs Inquiry (2013)

Consistent training

The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.

- The Nursing and Midwifery Council stated in April 2025 that it reviewed the use of aptitude tests and common examinations but identified affordability, scalability, …

F190 Accepted in Part

Mid Staffs Inquiry (2013)

National standards

There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it performs Education Quality Assurance to ensure nursing education programmes meet standards for …

F192 Accepted in Part

Mid Staffs Inquiry (2013)

Strong nursing voice

The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and accountable to, the Nursing and Midwifery Council.

- The government stated in April 2025 that the specific role of a "Responsible Officer" for nursing was not introduced, but the NMC established a …

F193 Accepted in Part

Mid Staffs Inquiry (2013)

Standards for appraisal and support

Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which responsible officers would be obliged to comply. They …

- The government stated in April 2025 that the Nursing and Midwifery Council has introduced a revalidation process for all nurses and midwives to maintain …

F194 Accepted in Part

Mid Staffs Inquiry (2013)

Standards for appraisal and support

As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of nursing practice …

- The government stated in April 2025 that the NMC revalidation process requires nurses to demonstrate continuing professional development (CPD), reflective discussions, and declarations of …

F195 Accepted in Part

Mid Staffs Inquiry (2013)

Nurse leadership

Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. …

- The government stated in April 2025 that this recommendation was superseded by Royal College of Nursing (RCN) Workforce Standards and the rollout of Professional …

F197 Accepted in Part

Mid Staffs Inquiry (2013)

Nurse leadership

Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all …

- The government stated in April 2025 that eight national development programmes are available through the NHS Leadership Academy, training approximately 20,000 participants annually (DHSC …

F200 Accepted in Part

Mid Staffs Inquiry (2013)

Key nurses

Consideration should be given to the creation of a status of Registered Older Person's Nurse.

- The Department of Health and Social Care and NHS England stated in April 2025 that Health Education England funded an Older Persons Fellowship for …

F204 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as …

- The National Health Service Trusts (Membership and Procedure) Regulations require Trust and Foundation Trust Boards to include a nurse or midwife executive director (The …

F205 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening the nursing professional voice

Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety …

- The Department of Health and Social Care and NHS England stated in April 2025 that all Boards are required to have a nurse/midwife executive …

F207 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening identification of healthcare support workers and nurses

There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.

- DHSC and NHS England stated in April 2025 that the development of local uniform policy remains the responsibility of local organisations (DHSC and NHS …

F208 Accepted in Part

Mid Staffs Inquiry (2013)

Strengthening identification of healthcare support workers and nurses

Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse.

- DHSC and NHS England stated in April 2025 that provider organisations are responsible for local uniform policies and that uniforms and name badges should …

F217 Accepted in Part

Mid Staffs Inquiry (2013)

Common selection criteria

A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn could inform a list of competences a leader …

- The Department of Health and Social Care stated in April 2025 that a Leadership Competency Framework has been developed for board members (DHSC and …

F219 Accepted in Part

Mid Staffs Inquiry (2013)

A regulator as an alternative

An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up an independent professional regulator. The need for this …

- The Department of Health and Social Care stated in April 2025 that an independent professional regulator for managers has not yet been actioned (DHSC …

F220 Accepted in Part

Mid Staffs Inquiry (2013)

Accreditation

A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, at least initally, the objective should be to …

- The Department of Health and Social Care stated in April 2025 that the NHS Leadership Academy provides eight national development programmes for entry-level to …

F223 Accepted in Part

Mid Staffs Inquiry (2013)

Enhanced resources

If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater resources, or better cooperation with the Care Quality …

- The Department of Health and Social Care stated in April 2025 that the General Medical Council entered an information-sharing agreement with the Academy of …