Investigation
Recommendations related to investigation
35
Recommendations
83% accepted
Government Response
Accepted (20)Accepted in Part (9)Not Accepted (1)Under Review (1)Awaiting Response (4)
Recommendations in This Theme
recommendation across 16 inquiries
Across 16 inquiries
Tagged Recommendations
35 total
R42
Response Pending
Muckamore Abbey Inquiry
Regular updates on complaint progress
Complainants must be regularly updated and informed of the progress of any investigation, including when the process concludes without a specific finding.
Northern Ireland Executi…
R74
Response Pending
Muckamore Abbey Inquiry
Staffing review in safeguarding investigations
Consideration of staffing (including skill mix as well as total numbers) should be a mandatory part of safeguarding investigations in all settings.
Northern Ireland Executi…
R88
Response Pending
Muckamore Abbey Inquiry
PSNI investigation file review processes
PSNI needs to improve its processes for the review of live investigation files, and have an effective escalation process when progress is delayed. PSNI should consider how it assures the …
Northern Ireland Executi…
P2-47
Accepted in Part
Fuller Inquiry
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 …
Ministry of Housing, Com…
ANG-24
No Response
Angiolini Inquiry
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 …
Home Office
22
Accepted in Part
Brook House Inquiry
Update healthcare complaints handling guidance
The Home Office must review and update Detention Services Order 03/2015: Handling of Complaints to ensure that appropriate guidance is given to healthcare providers on the investigation and handling of …
- In March 2024, the Home Office stated that a comprehensive review of complaints processes, including medical complaints, was underway in consultation with residents, IMBs, …
Home Office
29
Accepted in Part
Brook House Inquiry
Improve Professional Standards Unit investigation procedures and training
The Home Office must update Detention Services Order 03/2015: Handling of Complaints to clarify that, in investigations carried out by the Professional Standards Unit into allegations of serious misconduct against …
- In March 2024, the Home Office stated that the PSU had updated its training to reflect Brook House Inquiry findings, including training in interviewing …
Home Office
31
Accepted in Part
Brook House Inquiry
Update whistleblowing DSO with anonymous reporting mechanisms
The Home Office must update Detention Services Order 03/2020: Whistleblowing – The Public Interest Disclosure Act 1998 to require contractors that run immigration removal centres to: have a whistleblowing policy …
- In March 2024, the Home Office committed to including whistleblowing process improvements in its comprehensive complaints and DSO review (Government Response to the Brook …
Home Office
82
Accepted
IICSA
Metropolitan Police investigation into Lambeth Council
The Metropolitan Police Service should consider whether there are grounds for a criminal investigation into Lambeth Council's actions when providing information to the coroner about the circumstances surrounding LA-A2's death.
- The Metropolitan Police Service accepted this recommendation, stating it would consider whether there are grounds for a criminal investigation into Lambeth Council's actions regarding …
Metropolitan Police Serv…
JB-15.23
Under Consideration
Jermaine Baker Inquiry
Written questions as alternative to face-to-face IOPC interviews
Consideration should be given to the introduction of a practice requiring, as an alternative to a face-to-face interview, the submission of a list of questions for written answer within a …
- The IOPC has called for fundamental reform of the police complaints and disciplinary system (IOPC). - The government announced its intention to commission a …
Independent Office for P…
DM-1
Accepted
Daniel Morgan Panel
Forensic analysis of Daniel Morgan's diary
The Panel has received advice from an independent forensic science expert it consulted, Dr Kathryn Mashiter that useful work could still be carried out on this document. It therefore recommends …
Metropolitan Police Serv…
DM-2
Accepted
Daniel Morgan Panel
DNA samples from Police Officer Z31's relatives
The Panel recommends that the Metropolitan Police consider the desirability and explore the possibility of obtaining samples of DNA from former Police Officer Z31's relatives, to compare it with the …
Metropolitan Police Serv…
DM-4
Accepted
Daniel Morgan Panel
Review HOLMES system resources
The HOLMES system is both an investigative tool and a quality assurance mechanism, but it requires significant resources if it is to be used properly. The Panel recommends that the …
Metropolitan Police Serv…
RHI-34
Accepted
RHI Inquiry
Rapid Response Capacity
The Northern Ireland Civil Service should have regard to best practice elsewhere about how to respond effectively when serious problems emerge, such as those that did so with the non-domestic …
- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …
Northern Ireland Executi…
12a
Not Accepted
Paterson Inquiry
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 …
Department of Health and…
IHRD-10
Accepted
Hyponatraemia Inquiry
Age-Appropriate Hospital Settings
Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in age-appropriate hospital settings.
- HSC Trusts reported that children are treated in age-appropriate settings with appropriately trained staff (IHRD Implementation Programme, Department of Health NI, March 2018). - …
Northern Ireland Executi…
HSC Trusts
IHRD-33
Accepted
Hyponatraemia Inquiry
CEO Responsibility for Investigations
Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.
- The Department of Health NI reported that CEO accountability for SAI investigation quality and timeliness had been strengthened in revised SAI procedures (IHRD Implementation …
HSC Trusts
IHRD-34
Accepted in Part
Hyponatraemia Inquiry
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 …
Department of Health NI
IHRD-35
Accepted
Hyponatraemia Inquiry
Non-Cooperation as Disciplinary Offence
Failure to co-operate with investigation should be a disciplinary offence.
- The Department of Health NI reported that SAI investigation teams now include members with appropriate clinical expertise for the incident under review (IHRD Implementation …
HSC Trusts
IHRD-36
Accepted
Hyponatraemia Inquiry
Separation of Investigation and Litigation
Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.
- The Department of Health NI reported that SAI investigation training for panel members had been developed and delivered (IHRD Implementation Programme, Department of Health …
HSC Trusts
IHRD-37
Accepted
Hyponatraemia Inquiry
Family Involvement in SAI Investigations
Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all …
- The Department of Health NI reported that standardised terms of reference for SAI investigations had been developed (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
IHRD-38
Accepted
Hyponatraemia Inquiry
Multi-Disciplinary Peer Review
Investigations should be subject to multi-disciplinary peer review.
- The Department of Health NI reported that timescales for completion of SAI investigations had been set and were being monitored (IHRD Implementation Programme, Department …
HSC Trusts
IHRD-39
Accepted
Hyponatraemia Inquiry
Investigation Team Reconvening
Investigation teams should reconvene after an agreed period to assess both investigation and response.
- The Department of Health NI reported that family engagement in the SAI process had been formalised through the SAI Engagement Platform (IHRD Implementation Programme, …
HSC Trusts
IHRD-6
Accepted
Hyponatraemia Inquiry
Support for Candour Compliance
Support and protection should be given to those who properly fulfil their duty of candour.
- The Department of Health NI reported that support mechanisms for staff exercising the duty of candour were being developed (IHRD Implementation Programme, Department of …
Northern Ireland Executi…
HSC Trusts
IHRD-65
Accepted
Hyponatraemia Inquiry
SAI Investigator Training
Training in SAI investigation methods and procedures should be provided to those employed to investigate.
- HSC Trusts reported that training on complaints handling and family engagement had been enhanced (IHRD Implementation Programme, Department of Health NI, March 2018). - …
HSC Trusts
24
Accepted
Morecambe Bay Investigation
Involve patients and relatives in incident investigation
We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious …
- In July 2015, the government stated: "We accept this recommendation" and confirmed that the organisational duty of candour was now in force as a …
CQC
AS-4
Accepted
Al-Sweady Inquiry
Shooting Incident Policy
A Shooting Incident Policy should be drafted which is achievable in practice in Theatre, which is compliant with Article 2 of the ECHR and which enables the ascertainment of the …
Ministry of Defence
R72
Accepted
Vale of Leven Inquiry
Internal investigation independence
Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …
NHS Health Boards (Scotl…
F112
Accepted
Mid Staffs Inquiry
Lowering barriers
Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as …
- The Parliamentary and Health Service Ombudsman defines a complaint as any expression of dissatisfaction, whether spoken or written, that requires a response (NHS Complaint …
Healthcare providers
F114
Accepted
Mid Staffs Inquiry
Complaints handling
Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 mandate that NHS bodies investigate and respond to complaints regarding health …
Healthcare providers
F115
Accepted in Part
Mid Staffs Inquiry
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 …
Healthcare providers
F227
Accepted in Part
Mid Staffs Inquiry
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, …
NMC
L18
Accepted in Part
Leveson Inquiry
Investigation Powers
The Board, being an independent self-regulatory body, should have authority to examine issues on its own initiative and have sufficient powers to carry out investigations both into suspected serious or …
- The Prime Minister stated on 29 November 2012 that he accepted the principles for independent self-regulation including own-initiative investigations (Oral Statement to Parliament, Prime …
Press
L39
Accepted in Part
Leveson Inquiry
Ring-fenced Enforcement Fund
A new regulatory body should establish a ring-fenced enforcement fund, into which receipts from fines could be paid, for the purpose of funding investigations.
- The Prime Minister stated on 29 November 2012 that he accepted the principles for independent self-regulation including enforcement (Oral Statement to Parliament, Prime Minister's …
Press
BAHA-16
Accepted
Baha Mousa Inquiry
Death in Custody Checklist
JDP 1-10 should include a simple checklist for actions on a death in custody. Where there is a death in custody, particularly one that is sudden or unexplained, prompt checks …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that a death in custody checklist had been …
Ministry of Defence