Public Inquiry Recommendations

F226 Accepted in Part

Mid Staffs Inquiry (2013)

Nursing and Midwifery Council Investigation of systemic concerns

To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it has established Memorandums of Understanding (MoUs) and joint working protocols with the …

F227 Accepted in Part

Mid Staffs Inquiry (2013)

Nursing and Midwifery Council Investigation of systemic concerns

The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give …

- The Nursing and Midwifery Council (NMC) stated in April 2025 that it introduced a new internal Pre-case enquiries and referrals policy in January 2024, …

F235 Accepted in Part

Mid Staffs Inquiry (2013)

Joint proceedings

The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for …

- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation has not yet been actioned (DHSC and …

F245 Accepted in Part

Mid Staffs Inquiry (2013)

Board accountability

Each provider organisation should have a board level member with responsibility for information.

- The Records Management Code of Practice published by NHS England states that records management should be a specific corporate responsibility with a designated member …

F249 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability for quality accounts

Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying that they believe the contents of the account …

- The government stated in April 2025 that this recommendation was superseded, as the review of quality accounts determined that local Healthwatch challenge was a …

F250 Accepted in Part

Mid Staffs Inquiry (2013)

Accountability for quality accounts

It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account are true if it contains a misstatement of …

- DHSC and NHS England stated in April 2025 that action had been taken in response to this recommendation following the 2013 inquiry (DHSC and …

F251 Accepted in Part

Mid Staffs Inquiry (2013)

Regulatory oversight of quality accounts

The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled to require corrections to be issued where appropriate. …

- Section 9 of the Health Act 2009 requires providers to republish Quality Accounts with corrections within 21 days if notified of an error by …

F257 Accepted in Part

Mid Staffs Inquiry (2013)

Role of the Health and Social Care Information Centre

The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the agreement of the devolved governments, the United Kingdom. …

- The Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS) and was fully implemented by June 2024 (NHS …

F260 Accepted in Part

Mid Staffs Inquiry (2013)

Information standards

The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It …

- The Department of Health and Social Care and NHS England stated in April 2025 that information regarding patient safety events is managed through the …

F273 Accepted in Part

Mid Staffs Inquiry (2013)

Information to coroners

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a …

- Schedule 5 of the Coroners and Justice Act 2009 confers power on coroners to order the disclosure of evidence, including written statements and documents …

F275 Accepted in Part

Mid Staffs Inquiry (2013)

Independent medical examiners

It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.

- NHS England stated in April 2025 that operational arrangements at NHS bodies must support the independent role of medical examiners and that combining these …

IHRD-2 Accepted in Part

Hyponatraemia Inquiry (2018)

Criminal Liability for Candour Breach

Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.

- The Department of Health NI stated in March 2018 that criminal liability for breach of the duty of candour was under review (IHRD Implementation …

IHRD-3 Accepted in Part

Hyponatraemia Inquiry (2018)

Guidance on Statutory Duty of Candour

Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.

- The Department of Health NI stated in March 2018 that guidance was being developed in conjunction with the statutory duty of candour legislation (IHRD …

IHRD-4 Accepted in Part

Hyponatraemia Inquiry (2018)

Trust Awareness of Duty of Candour

Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of …

- The Department of Health NI reported that work to raise awareness of the duty of candour among healthcare staff was being taken forward (IHRD …

IHRD-13 Accepted in Part

Hyponatraemia Inquiry (2018)

Foundation Doctors in Children's Wards

Foundation doctors should not be employed in children's wards.

- HSC Trusts reported that care plans are available at each child's bedside for reference by parents and carers (IHRD Implementation Programme, Department of Health …

IHRD-34 Accepted in Part

Hyponatraemia Inquiry (2018)

Independent SAI Investigation

The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.

- The Department of Health NI stated in March 2018 that independent investigation arrangements had been strengthened (IHRD Implementation Programme, Department of Health NI, March …

IHRD-94 Accepted in Part

Hyponatraemia Inquiry (2018)

Clinical Negligence Litigation Reform

The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical …

- The Department of Health NI stated in March 2018 that this was under consideration (IHRD Implementation Programme, Department of Health NI, March 2018). - …

ETI-1 Accepted in Part

Edinburgh Tram Inquiry (2023)

Public Inquiry Efficiency

Scottish Ministers should undertake a review of public inquiries to determine the most cost-effective method of avoiding delay in the establishment of an inquiry, including consideration of establishing a dedicated …

- In November 2023, the Scottish Government stated that guidance on efficient public inquiry establishment was "already in development" and had been shared with recent …

ETI-2 Accepted in Part

Edinburgh Tram Inquiry (2023)

Inquiry Independence

In any event Scottish Ministers should not appoint as the sponsor of any public inquiry any department, agency or other government organisation where it, or any of its employees, has …

- In November 2023, the Scottish Government stated that guidance similar to that suggested was already in development (Transport Secretary Statement on Edinburgh Tram Inquiry …

ETI-3 Accepted in Part

Edinburgh Tram Inquiry (2023)

Staffing Guidance

The guidance mentioned in the first recommendation should include: advice concerning the circumstances in which civil servants in the inquiry team may properly transfer to posts, other than promoted posts, …

- In November 2023, the Scottish Government stated that guidance similar to that suggested was already in development (Transport Secretary Statement on Edinburgh Tram Inquiry …

ETI-4 Accepted in Part

Edinburgh Tram Inquiry (2023)

Inquiry Cost Transparency

In reporting the cost of a public inquiry Scottish Ministers should report its net cost to the public purse, after discounting expenditure already incurred on accommodation, staff and other resources, …

- In November 2023, the Scottish Government stated that guidance similar to that suggested was already in development (Transport Secretary Statement on Edinburgh Tram Inquiry …

ETI-8 Accepted in Part

Edinburgh Tram Inquiry (2023)

Update Optimism Bias Guidance

The existing Guidance on optimism bias was based on empirical data available almost two decades ago and should be revised to take into account the additional data that is now …

- In November 2023, the Scottish Government stated it already operates in line with best practices but would consider updating guidance (Transport Secretary Statement on …

ETI-10 Accepted in Part

Edinburgh Tram Inquiry (2023)

Joint Working Group with COSLA

In the interests of protecting the public purse and maximising the benefits from public expenditure on major projects, the Scottish Ministers should contemplate establishing a joint working group consisting of …

- In November 2023, the Scottish Government stated that "effective collaboration sits at the heart of this Government" and cited the Verity House Agreement as …

ETI-11 Accepted in Part

Edinburgh Tram Inquiry (2023)

Public Fund Protection

The Scottish Ministers and local authorities responsible for funding light rail projects should be mindful at all times of their obligation to protect public funds and to obtain value for …

- In November 2023, the Scottish Government stated that while responsibility for delivery remains with councils as project leads, the Government committed to championing closer …

ICL-3 Accepted in Part

ICL Inquiry (2009)

LPG Supplier Registration

A new scheme should be introduced requiring all LPG suppliers to be registered and accredited.

RHI-38 Accepted in Part

RHI Inquiry (2020)

Assembly Committee Scrutiny

The Northern Ireland Assembly should consider what steps are needed to strengthen its scrutiny role, particularly as conducted by Assembly Committees, in the light of lessons from the RHI. While …

- In October 2021, the NI Executive noted that this recommendation was the responsibility of the NI Assembly, not the Executive, and that the Chairpersons' …

P2-1 Accepted in Part

Fuller Inquiry (2025)

NHS trusts commission specialist security review

All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased people, which should include a detailed risk assessment …

- The government stated in December 2025 that this recommendation on conducting a strategic review of NHS mortuary security was accepted in principle. Work to …

P2-2 Accepted in Part

Fuller Inquiry (2025)

CCTV in all NHS mortuaries

All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the doors of body fridges, while maintaining the security …

- The government stated in December 2025 that this recommendation on installing CCTV in all NHS mortuaries was accepted in principle. The government noted that …

P2-3 Accepted in Part

Fuller Inquiry (2025)

Audit access data for deceased storage

All NHS trusts should routinely audit the access data of all facilities used to store deceased people.

- The government stated in December 2025 that this recommendation on auditing access to NHS mortuaries was accepted in principle. Standards and guidance to be …

P2-4 Accepted in Part

Fuller Inquiry (2025)

End shared swipe cards

The practice of using shared electronic swipe cards for specific staff groups should cease immediately.

- The government stated in December 2025 that this recommendation on ending shared swipe cards and generic access credentials in NHS mortuaries was accepted in …

P2-5 Accepted in Part

Fuller Inquiry (2025)

Operational barriers including device restrictions

All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. An example of this would be implementation of …

- The government stated in December 2025 that this recommendation on implementing operational barriers to restrict access within NHS mortuaries was accepted in principle. Full …

P2-6 Accepted in Part

Fuller Inquiry (2025)

Security breaches reviewed by expert with action plans

All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be reviewed by a security expert who is able …

- The government stated in December 2025 that this recommendation on recording and investigating security incidents in NHS mortuaries was accepted in principle. Full government …

P2-7 Accepted in Part

Fuller Inquiry (2025)

Body store security standards match HTA-licensed facilities

The NHS should ensure that the security standards required for body stores are the same as those required for facilities licensed by the Human Tissue Authority.

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

P2-8 Accepted in Part

Fuller Inquiry (2025)

Swipe to exit for mortuaries

All NHS trusts should consider the installation of 'swipe to exit' for mortuary facilities. This would allow trusts to monitor and audit entry and exit, as well as time spent …

- The government stated in December 2025 that this recommendation on requiring swipe-to-exit controls in NHS mortuaries was accepted in principle. Full government response due …

P2-9 Accepted in Part

Fuller Inquiry (2025)

Monitor and review staff access numbers

All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine review.

- The government stated in December 2025 that this recommendation on monitoring staff access patterns in NHS mortuaries was accepted in principle. Full government response …

P2-10 Accepted in Part

Fuller Inquiry (2025)

Designated Individuals adequate time and resource

NHS trusts should ensure that Designated Individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.

- The government stated in December 2025 that this recommendation on ensuring Designated Individuals have adequate time and resources for their HTA oversight role was …

P2-11 Accepted in Part

Fuller Inquiry (2025)

Senior managers understand DI role and accountability

NHS trusts should ensure that senior managers, including the Chief Executive, have a clear understanding of the role of the Designated Individual, their lines of accountability, and the individual legal …

- The government stated in December 2025 that this recommendation on ensuring senior managers understand the Designated Individual role was accepted in principle. Full government …

P2-12 Accepted in Part

Fuller Inquiry (2025)

DI attendance at governance forums

NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as well as reporting upwards when required.

- The government stated in December 2025 that this recommendation on establishing DI governance forums was accepted in principle. Full government response due Summer 2026 …

P2-13 Accepted in Part

Fuller Inquiry (2025)

Mortuary Manager professional background prerequisite

A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.

- The government stated in December 2025 that this recommendation on minimum qualifications for Mortuary Managers was accepted in principle. Full government response due Summer …

P2-14 Accepted in Part

Fuller Inquiry (2025)

Mortuary Manager adequate resources and support

NHS trusts should assure themselves that the Mortuary Manager has adequate resources and support to perform their role effectively, including meeting any reporting requirements.

- The government stated in December 2025 that this recommendation on ensuring Mortuary Managers have adequate resources was accepted in principle. Full government response due …

P2-15 Accepted in Part

Fuller Inquiry (2025)

Routine mortuary reporting to trust boards

All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include the presentation of a formal report, by the …

- The government stated in December 2025 that this recommendation on routine board reporting on mortuary operations was accepted in principle. Full government response due …

P2-16 Accepted in Part

Fuller Inquiry (2025)

Trust boards assure recommendation implementation

Trust boards should assure themselves that the recommendations in this Report have been implemented.

- The government stated in December 2025 that this recommendation on board assurance of implementation of mortuary standards was accepted in principle. Full government response …

P2-17 Accepted in Part

Fuller Inquiry (2025)

Recommendations apply to temporary facilities

Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage and care of deceased people.

- The government stated in December 2025 that this recommendation on standards for temporary mortuary facilities was accepted in principle. Full government response due Summer …

P2-18 Accepted in Part

Fuller Inquiry (2025)

Mortuaries treated as regulated activity in governance

Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent regard to other regulated activities within trust governance …

- The government stated in December 2025 that this recommendation on treating the mortuary as a regulated service within the NHS was accepted in principle. …

P2-19 Accepted in Part

Fuller Inquiry (2025)

Deceased included in safeguarding training and policy

NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.

- The government stated in December 2025 that this recommendation on safeguarding training for staff with access to deceased persons was accepted in principle. Full …

P2-20 Accepted in Part

Fuller Inquiry (2025)

Chief Nurse responsibility for deceased safeguarding

The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased people in NHS mortuaries and body stores.

- The government stated in December 2025 that this recommendation on assigning Chief Nurse responsibility for mortuary services was accepted in principle. Full government response …

P2-21 Accepted in Part

Fuller Inquiry (2025)

NHS England incorporate deceased in safeguarding framework

NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.

- The government stated in December 2025 that this recommendation on NHS England developing a safeguarding framework for the deceased was accepted in principle. Full …

P2-35 Accepted in Part

Fuller Inquiry (2025)

Local authority mortuary access review

There should be a process to routinely review who is permitted to access the mortuary unsupervised.

- The government stated in December 2025 that this recommendation on reviewing access controls in local authority mortuaries was accepted in principle. The government is …

P2-36 Accepted in Part

Fuller Inquiry (2025)

Local authority individualised access controls

Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary and restrict access to specific areas of the …

- The government stated in December 2025 that this recommendation on electronic access controls in local authority mortuaries was accepted in principle. Full government response …

P2-37 Accepted in Part

Fuller Inquiry (2025)

Local authority visitor supervision

Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must be limited to specific areas required for the …

- The government stated in December 2025 that this recommendation on restricting visitor access to local authority mortuaries was accepted in principle. Full government response …