Training

Recommendations requiring staff training

135
Recommendations
87% accepted
Government Response
Accepted (106)Accepted in Part (12)Not Accepted (3)Under Review (2)Awaiting Response (12)
Recommendations in This Theme

recommendation across 20 inquiries

Across 20 inquiries
Al-Sweady Inquiry Angiolini Inquiry Anthony Grainger Inquiry Baha Mousa Inquiry Brook House Inquiry COVID-19 Inquiry Cranston Inquiry Fingerprint Inquiry Fuller Inquiry Grenfell Tower Inquiry Hyponatraemia Inquiry IICSA Jermaine Baker Inquiry Mid Staffs Inquiry Morecambe Bay Investigation Muckamore Abbey Inquiry RHI Inquiry Scottish Hospitals Inquiry Urology Services Inquiry Vale of Leven Inquiry
Tagged Recommendations
135 total
SHI-11 Accepted
Scottish Hospitals Inquiry
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, …
Scottish Government
COVID-M5.8 No Published Response
COVID-19 Inquiry
Training in Emergency Procurement and Distribution
The UK government and devolved administrations should each establish a pool of officials who are trained in the emergency procurement and distribution of healthcare equipment. Completion of the training should …
- An implementation status cannot yet be assessed. No government response or recommendation-specific delivery evidence was located by 23 July 2026, so the absence of …
Department of Health and…
AFA-6 Response Pending
Urology Services Inquiry
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. …
Department of Health NI
R17 Response Pending
Muckamore Abbey Inquiry
Co-production training
Creating a co-produced care environment, where people with learning disabilities, families and professionals work collaboratively, requires a fundamental shift in practice. As well as organisational commitments, staff will need education …
Department of Health NI
R31 Response Pending
Muckamore Abbey Inquiry
Restraint education effectiveness metrics
The effectiveness of the education programme for staff in relation to restraint reduction should be measured through defined data metrics. This is to ensure that every instance of restraint is …
Northern Ireland Executi…
R37 Response Pending
Muckamore Abbey Inquiry
Human rights-based restrictive practices training
Education and training on the use of restrictive practices should be grounded in human rights principles and the dedicated human rights specialist appointed in accordance with Recommendation 21 (R21) should …
Northern Ireland Executi…
R71 Response Pending
Muckamore Abbey Inquiry
Specialist training for healthcare assistants
All healthcare assistants working with people with learning disabilities and autistic people should be provided with training, which should include specialist learning disability training as well as basic positive behaviour …
Department of Health NI
R76 Response Pending
Muckamore Abbey Inquiry
NED with clinical governance expertise
NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as …
Northern Ireland Executi…
R79 Response Pending
Muckamore Abbey Inquiry
Board member learning framework
The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in …
Department of Health NI
CR15 Response Pending
Cranston Inquiry
Joint training exercises plan
HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved in maritime search and rescue in the English …
HM Coastguard
CR4 Response Pending
Cranston Inquiry
Training on normalcy bias
HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one being the need to avoid normalcy bias, in …
HM Coastguard
CR6 Response Pending
Cranston Inquiry
Joint exercises on triage procedure
Those involved in maritime search and rescue should continue to undertake joint exercises on the application of the Mass Persons in the Water Triage procedure.
HM Coastguard
P2-19 Accepted in Part
Fuller Inquiry
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 …
NHS England
P2-25 Under Consideration
Fuller Inquiry
Postgraduate training governance clarity
Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include …
- The government stated in December 2025 that this recommendation on governance of postgraduate anatomy training was under consideration. Full government response due Summer 2026 …
Department of Health and…
P2-31 Accepted
Fuller Inquiry
Ambulance policy on crew position with deceased
Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should include reference to the risk of abuse of …
- The government stated in December 2025 that this recommendation on ambulance seating policies to protect the dignity of deceased persons was accepted in full. …
NHS England
P2-70 Under Consideration
Fuller Inquiry
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 …
Ministry of Justice
P1-11 Accepted
Grenfell Tower Inquiry
Train incident commanders on control room communications
All officers who may be expected to act as incident commanders (i.e. all those above the rank of Crew Manager) receive training directed to the specific requirements of communication with …
- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-12 Accepted
Grenfell Tower Inquiry
Train control room operators on incident commander communications
All control room operators of Assistant Operations Manager rank and above receive training directed to the specific requirements of communication with the incident commander.
- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-15 Accepted
Grenfell Tower Inquiry
Regular refresher training for control room operators
The LFB provide regular and more effective refresher training to control room operators at all levels, including supervisors.
- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - The government's Phase …
London Fire Brigade
P1-19 Accepted
Grenfell Tower Inquiry
Train control room staff on evacuation advice changes
Control room staff receive training directed specifically to handling such a change of advice and conveying it effectively to callers.
- NFCC accepted all Phase 1 recommendations directed to it (NFCC Response, 2020). - The government's Phase 1 progress report stated this recommendation is complete, …
National Fire Chiefs Cou…
P1-2 Accepted
Grenfell Tower Inquiry
Train fire personnel on external wall fire risks
All fire and rescue services ensure that their personnel at all levels understand the risk of fire taking hold in the external walls of high-rise buildings and know how to …
- NFCC accepted all Phase 1 recommendations directed to it, committing to develop national guidance across all 43 fire and rescue services in England (NFCC …
National Fire Chiefs Cou…
P1-22 Accepted
Grenfell Tower Inquiry
LFB improve deployment control policies
The LFB develop policies and training to ensure better control of deployments and the use of resources.
- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-23 Accepted
Grenfell Tower Inquiry
Improve crew debrief information systems
The LFB develop policies and training to ensure that better information is obtained from crews returning from deployments and that the information is recorded in a form that enables it …
- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-27 Accepted
Grenfell Tower Inquiry
Command support system operational on all units
Urgent steps be taken to ensure that the command support system is fully operative on all command units and that crews are trained in its use.
- LFB accepted all Phase 1 recommendations in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - LFB Commissioner stated …
London Fire Brigade
P1-29 Accepted
Grenfell Tower Inquiry
Fire services develop evacuation policies and training
Fire and rescue services develop policies for partial and total evacuation of high-rise residential buildings and training to support them.
- NFCC accepted all Phase 1 recommendations directed to it (NFCC Response, 2020). - National Evacuation Guidelines were published on 5 February 2024 (National Evacuation …
National Fire Chiefs Cou…
P1-3 Accepted
Grenfell Tower Inquiry
LFB to review PN633 Appendix 1
The LFB review, and revise as appropriate, Appendix 1 to PN633 to ensure that it fully reflects the principles in GRA 3.2.
- LFB accepted all Phase 1 recommendations directed to it in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - …
London Fire Brigade
P1-4 Accepted
Grenfell Tower Inquiry
Train LFB officers on high-rise inspections
The LFB ensure that all officers of the rank of Crew Manager and above are trained in carrying out the requirements of PN633 relating to the inspection of high-rise buildings.
- LFB accepted all Phase 1 recommendations directed to it in January 2020 (LFB Response to Grenfell Tower Inquiry Phase 1 Report, January 2020). - …
London Fire Brigade
P2-18 Accepted
Grenfell Tower Inquiry
Develop fire engineering courses for construction professionals
That the government, working in collaboration with industry and professional bodies, encourage the development of courses in the principles of fire engineering for construction professionals and members of the fire …
- The government accepted this recommendation in February 2025, committing to work with industry and professional bodies to encourage fire engineering courses for construction professionals …
UK Government
P2-19 Accepted
Grenfell Tower Inquiry
Review architect education and training for fire safety
We recognise that both the Architects Registration Board (ARB) and the Royal Institute of British Architects (RIBA) have taken steps since the Grenfell Tower fire to improve the education and …
- ARB and RIBA accepted this recommendation in February 2025, noting both had taken steps since the Grenfell Tower fire to improve education and training …
ARB/RIBA
P2-29 Accepted in Part
Grenfell Tower Inquiry
Establish independent College of Fire and Rescue
That the government establish [an independent College of Fire and Rescue] immediately with sufficient resources to provide the following services nationally: a) practical training at all levels supplementary to that …
- The government accepted this recommendation in principle in February 2025, recognising the importance of fire and rescue service training and noting HMICFRS also recommended …
UK Government
P2-30 Accepted in Part
Grenfell Tower Inquiry
College to have permanent staff and training facilities
That [the college] should have a permanent staff of sufficient size to manage its operations and develop its functions in response to the demands of fire and rescue services nationally …
- The government accepted this recommendation in principle in February 2025, linking it to the College of Fire and Rescue consultation (Government Response to Grenfell …
UK Government
P2-32 Accepted
Grenfell Tower Inquiry
Inspect London Fire Brigade incident commander training
That as soon as reasonably possible the Inspectorate inspect the London Fire Brigade to examine and report on the arrangements it has in place for assessing the training of incident …
- HMICFRS accepted this recommendation in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, MHCLG, February 2025). - HMICFRS Round 3 inspection …
HM Inspectorate of Const…
P2-37 Accepted
Grenfell Tower Inquiry
Train firefighters on communications loss response
Since radio communications are inherently unreliable in certain environments, we recommend that firefighters be trained to respond appropriately to the loss of communications and to understand how to restore them. …
- NFCC accepted this recommendation on behalf of all fire and rescue services in February 2025, having reviewed national operational guidance content (Government Response to …
National Fire Chiefs Cou…
P2-38 Accepted
Grenfell Tower Inquiry
Provide water supply system training to all firefighters
That basic training on the structure and operation of the water supply system, including the different types of hydrants in use and their functions, be given to all firefighters. Training …
- NFCC accepted this recommendation on behalf of all fire and rescue services in February 2025, having reviewed national operational guidance on water supply training …
National Fire Chiefs Cou…
P2-41 Accepted
Grenfell Tower Inquiry
Consider guidance on firefighter initiative deviations
That National Fire Chiefs Council consider whether, and if so in what circumstances, firefighters should be discouraged from departing from their instructions on their own initiative and provide appropriate training …
- NFCC accepted this recommendation in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, MHCLG, February 2025). - The government's annual report …
National Fire Chiefs Cou…
P2-46 Accepted
Grenfell Tower Inquiry
Revise London Gold arrangements guidance
Events demonstrated, however, that there is a need for a clearer understanding of the nature of the London Gold arrangements, in particular in situations in which a single borough is …
- The government expressed support for this recommendation directed at London local authorities in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, …
London Authorities
P2-48 Accepted in Part
Grenfell Tower Inquiry
Verify training quality of Category 1 responders
That a mechanism be introduced for independently verifying the frequency and quality of training provided by local authorities and other Category 1 responders. (113.71)
- The government accepted this recommendation in principle in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, MHCLG, February 2025). - The …
UK Government
P2-49 Accepted
Grenfell Tower Inquiry
Train all local authority employees on resilience
That local authorities train all their employees, including chief executives, to regard resilience as an integral part of their responsibilities. (113.73)
- The government expressed support for this recommendation directed at local authorities in February 2025 (Government Response to Grenfell Tower Inquiry Phase 2 Report, MHCLG, …
Local Authorities
ANG-2 Accepted
Angiolini Inquiry
Improve guidance and training on indecent exposure
By December 2024, the College of Policing, in collaboration with the National Police Chiefs' Council, should improve guidance and training on indecent exposure, in order to improve the quality of …
- The government accepted this recommendation on 25 March 2024, with the NPCC and College of Policing committing to address recommendations on police culture and …
College of Policing
ANG-27 No Response
Angiolini Inquiry
Perpetrator focus and interventions
Immediately, the Home Office, as the lead department for the response to violence against women and girls, in conjunction with the Ministry of Justice, the Department for Transport, and national …
- This is a Part 2 recommendation from the Angiolini Inquiry Part 2 First Report, published 2 December 2025, calling for immediate prioritisation of prevention …
Home Office
12 Accepted in Part
Brook House Inquiry
Annual training on Rule 40 and Rule 42 segregation powers
The Home Office and contractors operating immigration removal centres must provide regular training, at least annually, on the operation of Rule 40 and Rule 42 of the Detention Centre Rules …
- In March 2024, the Home Office committed to including staff training requirements and compliance auditing as part of the substantive DSO revision on Rule …
Home Office
19 Not Accepted
Brook House Inquiry
Healthcare staff guidance and training on use of force incidents
The Home Office must ensure that guidance is issued to healthcare staff in immigration removal centres clarifying their role in use of force incidents. It must liaise as necessary with …
- In March 2024, the government rejected this recommendation, stating that NHS England commissions healthcare services and that it is their responsibility, alongside the Care …
Home Office
24 Accepted in Part
Brook House Inquiry
Mandatory staff training on mental health and trauma-informed approaches
The Home Office, in conjunction with contractors, must ensure that all relevant immigration removal centre staff receive mandatory introductory and annual training on: mental health; race and diversity; a trauma-informed …
- In March 2024, the Home Office stated that the Initial Training Course for all new contracted service provider staff was undergoing a full review, …
Home Office
28 Accepted in Part
Brook House Inquiry
Address barriers to detainee complaints including fear of repercussions
The Home Office and its contractors operating immigration removal centres must take steps to identify and address the barriers to making complaints that are faced by detained people, including a …
- In March 2024, the Home Office committed to a comprehensive review of complaints processes, including barriers faced by detainees, in consultation with residents, IMBs, …
Home Office
8 Accepted in Part
Brook House Inquiry
Mandatory comprehensive Rule 34 and Rule 35 training
The Home Office (in collaboration with NHS England as required) must ensure that comprehensive training on Rule 34 and Rule 35 of the Detention Centre Rules 2001 is rolled out …
- In March 2024, the Home Office committed to reviewing Adults at Risk policy and Detention Centre Rules 34 and 35, and stated that NHS …
Home Office
31 Accepted
IICSA
DBS and training compliance for Church officers
Individuals engaged in regulated activity who have failed to undergo a Disclosure and Barring Service check or complete compulsory training should not be permitted to hold voluntary offices within the …
- In June 2019, the Church of England agreed that those in regulated roles who have failed to undergo a DBS check or complete compulsory …
Church of England
26 Accepted
IICSA
Youth Custody Service safeguarding training
The Chair and Panel recommend that the Youth Custody Service takes steps to ensure that its training provides staff with an appropriate understanding of safeguarding in the context of the …
- In July 2019, the Ministry of Justice stated that the Youth Custody Service would review mandatory training for frontline staff including safeguarding components (Government …
Youth Custody Service
22 Accepted
IICSA
National chaperone policy for healthcare (England)
The Chair and Panel recommend that the Department of Health and Social Care develops a national policy for the training and use of chaperones in the treatment of children in …
- In July 2019, the UK government stated that NHS England had developed chaperone guidance notes setting out principles of chaperoning and practical guidance for …
Department of Health and…
23 Accepted
IICSA
National chaperone policy for healthcare (Wales)
The Chair and Panel recommend that the Welsh Government develops a national policy for the training and use of chaperones in the treatment of children in healthcare services. The Chair …
- On 6 January 2020, the Welsh Government published guidance for health boards and trusts on good working practice for the use of chaperones in …
Welsh Government
77 Not Accepted
IICSA
CSA experience for Chief Officer progression
The Chair and Panel recommend that any police officer (or staff equivalent) who wants to progress to the Chief Officer cadre must first be required to: have operational policing experience …
- In July 2019, the UK government stated that the Home Office and College of Policing had drawn up a programme of non-legislative changes to …
Home Office
95 Accepted
IICSA
CICA specialist caseworker training
The Chair and Panel recommend that the Criminal Injuries Compensation Authority ensures that claims relating to child sexual abuse are only considered by caseworkers who have specific and detailed training …
- In December 2018, the UK government stated that all Criminal Injuries Compensation Authority operational staff are given training on handling sexual offences and child …
Criminal Injuries Compen…
53 Accepted
IICSA
Lambeth councillor safeguarding training
All Lambeth Council elected members should receive training on: (i) safeguarding and (ii) corporate parenting. Newly elected members should receive training on these matters as soon as possible following their …
- On 27 July 2021, Lambeth Council stated that all councillors are required to complete safeguarding training as well as training on corporate parenting responsibilities, …
London Borough of Lambeth
55 Accepted
IICSA
Religious organisation child protection policies
All religious organisations should have a child protection policy and supporting procedures, which should include advice and guidance on responding to disclosures of abuse and the needs of victims and …
- Between January and March 2022, the Methodist Church, Triratna Buddhist Order and Community, and the United Reformed Church stated that they had updated their …
Religious Organisations
48 Accepted
IICSA
Mandatory Catholic safeguarding training
The Catholic Bishops' Conference of England and Wales should ensure that safeguarding training is mandatory for all staff and volunteers in roles where they work with children or victims and …
- On 30 April 2021, the Catholic Council for the Inquiry stated that it had mandated that clergy and parish safeguarding representatives must undergo basic …
Catholic Bishops Confere…
JB-15.1 Accepted
Jermaine Baker Inquiry
Clarify separation of SIO and firearms commander roles
There should be clearer guidance from the MPS, College of Policing and/or the NPCC on the separation of roles between the Senior Investigating Officer (SIO) and the Tactical and Strategic …
- The Metropolitan Police Service stated on 28 October 2022 that MO19 had commenced an internal review in July 2021 and that DAC Barbara Gray …
College of Policing
JB-15.10 Accepted
Jermaine Baker Inquiry
Training on clear intelligence communication
When intelligence is being provided, the use of any language that is capable of misinterpretation is to be avoided. Training to address this point should be provided to all officers …
- The Metropolitan Police Service stated on 28 October 2022 that it was actively reviewing steps to address consistency of language between firearms officers and …
College of Policing
JB-15.11 Accepted
Jermaine Baker Inquiry
Training requirement for covert monitoring post officers
Only those officers who have received the requisite training and accreditation should be posted to a Covert Monitoring Post (CMP).
- The Metropolitan Police Service stated on 28 October 2022 that significant CMP training improvements had been made, with 172 H2-trained staff and 350 CMP …
College of Policing
JB-15.13 Accepted
Jermaine Baker Inquiry
Training on note-taking for covert monitoring officers
The training referred to in paragraph 15.11 must emphasise the importance of covert monitoring officers (CMOs) making accurate notes of: (a) what they have heard; and (b) what they have …
- The Metropolitan Police Service stated on 28 October 2022 that H2 training and the CMP operatives awareness course comprehensively covered accurate note-taking and dissemination …
College of Policing
JB-15.18 Accepted
Jermaine Baker Inquiry
Mandatory CLIO system training for command officers
Training should be made mandatory for command officers in the use of the Computer Logging of Intelligence Operations (CLIO) system and the Serious Organised Crime Tasking and Briefing (SOCTAB) system …
- The Metropolitan Police Service stated on 28 October 2022 that MO3 had led work on CLIO training at command level and that SOCTAB CLIO …
College of Policing
JB-15.19 Accepted
Jermaine Baker Inquiry
Guidance on uniformity of firearms commands
Advice should be given by the College of Policing about the benefits of uniformity in instructions and commands. Ultimate discretion as to what is said must be left to the …
- The Metropolitan Police Service stated on 28 October 2022 that it was in consultation with the College of Policing on uniformity of commands and …
College of Policing
JB-15.2 Accepted
Jermaine Baker Inquiry
Require multidimensional risk assessments throughout operations
Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those risk assessments should assess the future threat and …
- The Metropolitan Police Service stated on 28 October 2022 that firearms trainers were required to watch Inquiry hearing recordings and that particular focus had …
College of Policing
JB-15.22 Accepted
Jermaine Baker Inquiry
Training for officers presenting firearms court applications
There should be training of those who are authorised by reason of rank to present such applications at court, and no-one should act as a substitute for a properly authorised …
- The College of Policing updated APP-AP in August 2023, addressing training for officers authorised to present firearms presence applications at court (College of Policing …
College of Policing
JB-15.5 Accepted
Jermaine Baker Inquiry
Compulsory training on firearms authorisation forms
Appropriate training and refresher courses on the usage and completion of FA (and equivalent) forms should be made compulsory for firearms commanders and Tactical Advisors.
- The Metropolitan Police Service stated on 28 October 2022 that it had taken steps to set aside time during training days to focus trainees …
College of Policing
JB-15.8 Accepted
Jermaine Baker Inquiry
National guidance on recording firearms planning meetings
The NPCC and/or College of Policing should ensure that these amendments are reflected in the guidance and training given to forces nationally.
- The Metropolitan Police Service stated on 28 October 2022 that it understood the College of Policing would review APP-AP in respect of the amendments …
National Police Chiefs C…
RHI-3 Accepted
RHI Inquiry
Policy Skills Training
As far as practicable, Northern Ireland Civil Service teams working on policies, particularly new and untested initiatives, should be trained and supported so that they have the skills to do …
- 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…
RHI-30 Accepted
RHI Inquiry
Budget Holder Financial Training
Civil servants who are responsible for holding and monitoring a budget should have to demonstrate core requirements in financial literacy and an understanding of how public spending operates, including what …
- In October 2021, the NI Executive accepted this recommendation in full (NI Executive Response to RHI Inquiry, Department of Finance, October 2021). - The …
Department of Finance
RHI-5 Accepted
RHI Inquiry
Ministerial Training and Support
One role of Ministers in a democratic system is to decide on policies and they can only do so effectively if they are prepared, in appropriate cases, to question and …
- 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…
RHI-7 Accepted
RHI Inquiry
Special Adviser Induction
There should be a clearly defined induction process for new Special Advisers, shared by the appointing Minister and the relevant Permanent Secretary, in the course of which the structure and …
- 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…
RHI-9 Accepted
RHI Inquiry
Commercial Awareness
Commercial and business awareness amongst policy officials, particularly those working in roles relating to the economy of Northern Ireland, must be improved. It is important that the leadership of the …
- 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…
AG-2 Accepted
Anthony Grainger Inquiry
HMICFRS Thematic Inspection of Armed Policing
Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) should conduct a thematic inspection or inspections concerning: (i) the selection and training of officers authorised to use weapons …
HM Inspectorate of Const…
AG-6 Accepted
Anthony Grainger Inquiry
MASTS Documentation and Training Clarity
All documents and training relating to Mobile Armed Support to Surveillance (MASTS) should: clearly differentiate between MASTS as an operational method of supporting surveillance (and delivering a standard range of …
National Police Chiefs C…
IHRD-31 Accepted
Hyponatraemia Inquiry
SAI Reporting Understanding
Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').
- The Department of Health NI reported that work to improve staff understanding of SAI processes and their purpose had been taken forward (IHRD Implementation …
HSC Trusts
IHRD-4 Accepted
Hyponatraemia Inquiry
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 …
Northern Ireland Executi… HSC Trusts
IHRD-55 Accepted
Hyponatraemia Inquiry
Board Member Training on Patient Safety
Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.
- HSC Trusts reported that training programmes for Board members on scrutiny of patient safety had been implemented (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
IHRD-56 Accepted
Hyponatraemia Inquiry
Board Member Induction Training
All Trust Board Members should receive induction training in their statutory duties.
- HSC Trusts reported that Board-level governance arrangements for patient safety had been strengthened, including standing agenda items on patient safety at Board meetings (IHRD …
HSC Trusts
IHRD-57 Accepted
Hyponatraemia Inquiry
Clinical Training for Guidelines
Specific clinical training should always accompany the implementation of important clinical guidelines.
- HSC Trusts reported that mandatory training for clinical staff on fluid management in children had been implemented (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
IHRD-58 Accepted
Hyponatraemia Inquiry
Paediatric Fluid Management Training
HSC Trusts should ensure that all nurses caring for children have facilitated access to e-learning on paediatric fluid management and hyponatraemia.
- HSC Trusts reported that training on the recognition and management of the deteriorating child had been strengthened (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
IHRD-59 Accepted
Hyponatraemia Inquiry
Post-Mortem Request Form Training
There should be training in the completion of the post-mortem examination request form.
- HSC Trusts reported that communication skills training for clinical staff working with children and families had been enhanced (IHRD Implementation Programme, Department of Health …
HSC Trusts
IHRD-60 Accepted
Hyponatraemia Inquiry
Coroner Communication Training
There should be training in the communication of appropriate information and documentation to the Coroner's office.
- HSC Trusts reported that training on open disclosure and candour principles had been provided to clinical staff (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
IHRD-61 Accepted
Hyponatraemia Inquiry
Paediatric Communication Training
Clinicians caring for children should be trained in effective communication with both parents and children.
- HSC Trusts reported that training on consent processes for paediatric care had been reviewed and updated (IHRD Implementation Programme, Department of Health NI, March …
HSC Trusts
IHRD-62 Accepted
Hyponatraemia Inquiry
Adverse Incident Communication Training
Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.
- HSC Trusts reported that training on clinical record-keeping standards had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …
HSC Trusts
IHRD-64 Accepted
Hyponatraemia Inquiry
Parental Involvement in Training
Parents should be involved in the preparation and provision of any such training programme.
- HSC Trusts reported that training on SAI investigation processes had been delivered to relevant staff (IHRD Implementation Programme, Department of Health NI, March 2018). …
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
IHRD-68 Accepted
Hyponatraemia Inquiry
Using Investigations for Training
Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.
- HSC Trusts reported that multidisciplinary team training for paediatric care had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …
HSC Trusts
IHRD-9 Accepted
Hyponatraemia Inquiry
Leadership Development
The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.
- The Department of Health NI reported that leadership development programmes had been implemented across the HSC (IHRD Implementation Programme, Department of Health NI, March …
Northern Ireland Executi… Department of Health NI
14 Accepted
Morecambe Bay Investigation
Review clinical leadership arrangements
The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with …
- In July 2015, the government stated that the Trust had "reviewed clinical leadership in terms of individuals and structures in obstetrics, paediatrics and midwifery" …
University Hospitals of …
2 Accepted
Morecambe Bay Investigation
Review clinical staff competencies
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the skills, knowledge, competencies and professional duties of care of all obstetric, paediatric, midwifery and neonatal nursing staff, and …
- In July 2015, the government stated that a review of skills, knowledge, competencies and professional duties of care had been "started" and was to …
University Hospitals of …
22 Accepted
Morecambe Bay Investigation
Recognise educational opportunities in smaller units
We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and …
- In July 2015, the government stated: "We accept this recommendation in principle" and confirmed that Health Education England had established a working group to …
NHS England
28 Accepted
Morecambe Bay Investigation
National standards for clinical leads
Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads …
- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 28 and 29) and described work between the Department of …
NHS England
3 Accepted
Morecambe Bay Investigation
Deliver staff training and development plans
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up plans to deliver the training and development of staff identified as a result of the review of maternity, …
- In July 2015, the government stated that the Trust was putting "substantial plans in place" including staff training and development programmes (Learning Not Blaming, …
University Hospitals of …
AS-3 Accepted
Al-Sweady Inquiry
Training Material Dating and Archiving
All training material should be dated, appropriately retained and archived in such a way that it can easily be established when the training material was composed, when it came into …
Ministry of Defence
R23 Accepted
Vale of Leven Inquiry
TVN training and qualification
Health Boards should ensure that a nurse appointed as Tissue Viability Nurse (TVN) is appropriately trained and possesses, or is working towards, a recognised specialist post-registration qualification.
- 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…
R42 Accepted
Vale of Leven Inquiry
Mandatory IPC training
Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention control training that includes CDI on appointment.
- 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…
R43 Accepted
Vale of Leven Inquiry
IPC staff regular training
Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control of which a record should be kept.
- 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…
R54 Accepted
Vale of Leven Inquiry
Surveillance system training
Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to use and respond to the data available.
- 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…
R60 Accepted
Vale of Leven Inquiry
Cleanliness Champions implementation
Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as Cleanliness Champions Programme, are implemented without undue delay.
- 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…
R67 Accepted
Vale of Leven Inquiry
Link Nurse training
Health Boards should ensure that, where a local Link Nurse system is in place as part of the IPS system, the Link Nurses have specific training for that role.
- 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…
F108 Accepted
Mid Staffs Inquiry
Support for other agencies
Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers' infection …
- The Department of Health and Social Care and NHS England stated in April 2025 that the review of support and training for local oversight …
F148 Accepted
Mid Staffs Inquiry
Training
The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.
- DHSC stated in April 2025 that Healthwatch England continues to offer a range of training and resources for local Healthwatch staff and volunteers (DHSC/NHS …
F185 Accepted
Mid Staffs Inquiry
Focus on culture of caring
There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures …
- The Nursing and Midwifery Council (NMC) updated its pre-registration nursing and midwifery education standards in 2018 and 2019 to emphasize compassionate, person-centred care (NMC …
NMC
F186 Accepted
Mid Staffs Inquiry
Practical hands-on training and experience
Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.
- The Nursing and Midwifery Council stated in April 2025 that all education programmes require 50% of time to be spent in practice learning and …
NMC
F187 Accepted
Mid Staffs Inquiry
Practical hands-on training and experience
There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision …
- The Nursing and Midwifery Council stated in April 2025 that 50% of education hours (2,300 hours) must be spent in practice learning, with a …
NMC
F189 Accepted in Part
Mid Staffs Inquiry
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, …
NMC
F190 Accepted in Part
Mid Staffs Inquiry
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 …
NMC
F197 Accepted in Part
Mid Staffs Inquiry
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 …
NHS
F211 Accepted
Mid Staffs Inquiry
Training standards for healthcare support workers
There should be a common set of national standards for the education and training of healthcare support workers.
- The Care Certificate was introduced on 1 April 2015 as the national standard for the education and training of healthcare support workers (Care Certificate, …
Department of Health and…
F214 Accepted
Mid Staffs Inquiry
Shared training
A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and leadership to potential senior staff; promote healthcare leadership …
- The NHS Leadership Academy provides national leadership and management training programmes for staff at all levels (DHSC and NHS England implementation update provided to …
F220 Accepted in Part
Mid Staffs Inquiry
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 …
F281 Accepted
Mid Staffs Inquiry
Appropriate and sensitive contact with bereaved families
It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how to undertake this sensitive task in a manner …
- The Medical Examiners (England) Regulations 2024 require medical examiners to undertake training to ensure they have the skills to carry out their functions (The …
Department of Health and…
F51 Accepted
Mid Staffs Inquiry
Enhancement of monitoring and the importance of inspection
The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by …
- The Department of Health and Social Care and NHS England stated in April 2025 that the Care Quality Commission retains specialist inspectors for hospitals, …
CQC
F77 Accepted
Mid Staffs Inquiry
Enhancement of role of governors
Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and …
- NHS England published an updated Code of Governance for NHS provider trusts in April 2023, which requires governors to receive appropriate induction and regular …
NHS England
F81 Accepted
Mid Staffs Inquiry
Accountability of providers' directors
Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.
- Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 established requirements for directors to possess the qualifications, competence, skills, …
CQC
F86 Accepted
Mid Staffs Inquiry
Requirement of training of directors
A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.
- NHS England published an updated Code of Governance for NHS provider trusts in April 2023, stating that all directors should receive appropriate induction and …
NHS Trusts
FP16-18 Accepted
Fingerprint Inquiry
Academic study requirement
Expert opinion should be informed by proper academic study of the subject.
SPA Forensic Services
BAHA-14 Accepted
Baha Mousa Inquiry
Communicating Sight Deprivation Reasons
JDP 1-10 should include guidance that where practicable CPErS should be told the reason why sight deprivation is being applied. Suitable simple phrases in relation to sight deprivation should be …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that guidance on communicating with captured persons about …
Ministry of Defence
BAHA-23 Not Accepted
Baha Mousa Inquiry
Ban Harsh Approach in Tactical Questioning
The harsh approach should no longer have a place in tactical questioning. The MoD should forbid tactical questioners from using what is currently known as the harsh approach and this …
- The Defence Secretary stated on 8 September 2011 that the government did not accept this recommendation. The Defence Secretary decided to retain the ability …
Ministry of Defence
BAHA-46 Accepted
Baha Mousa Inquiry
Lessons Learned Process
The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that lessons learned processes had been improved for …
Ministry of Defence
BAHA-47 Accepted
Baha Mousa Inquiry
CPErS Training Content
CPErS training should include both theoretical and practical training in what Forces personnel can and should do when handling CPErS. It is important that training is not limited to prohibitions …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that captured persons training had been expanded to …
Ministry of Defence
BAHA-48 Accepted
Baha Mousa Inquiry
End-to-End CPErS Training
CPErS training should be woven into the full range of military exercises and training. Such training should be 'end to end', not just focused on planning and the actual combat …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that captured persons handling had been incorporated throughout …
Ministry of Defence
BAHA-49 Accepted
Baha Mousa Inquiry
Consistent Training Materials
Training materials across the Services need to be reviewed to ensure that the messages about all aspects of CPErS handling are clear and consistent. The arrangement whereby the PM(A) will …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training materials had been reviewed and made …
Ministry of Defence
BAHA-50 Accepted
Baha Mousa Inquiry
MATT 7 Presentation Update
The MATT 7 PowerPoint presentation on the five techniques should be amended to ensure that the definitions of the techniques are consistent with amendments to JDP 1-10; that it is …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the MATT 7 PowerPoint presentation on the …
Ministry of Defence
BAHA-51 Accepted
Baha Mousa Inquiry
Prisoner Handling DVD Update
The 2005 prisoner handling DVD should be amended to avoid misleading messages about sight deprivation in the context of interrogation, and the inappropriate presentation of the interrogation facility. 'Bagged and …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the prisoner handling DVD had been reviewed …
Ministry of Defence
BAHA-52 Accepted
Baha Mousa Inquiry
Restraint Positions Guidance
Greater clarity and guidance should be given in training in relation to the concept of 'restraint positions'. More must be done to give practical guidance to help service personnel distinguish …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that clearer guidance on distinguishing unlawful stress positions …
Ministry of Defence
BAHA-53 Accepted
Baha Mousa Inquiry
Positional Asphyxia Training
MATT 7 and mission specific training for CPErS handling should incorporate suitably pitched training on the risks of positional asphyxia/death by struggle against restraint.
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training on positional asphyxia risks had been …
Ministry of Defence
BAHA-55 Accepted
Baha Mousa Inquiry
Operational Law Training Currency
Those responsible for designing the mandatory operational law and values and standards training must keep the training relevant and up-to-date both in its content and in the style and means …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that processes for keeping operational law training current …
Ministry of Defence
BAHA-56 Accepted
Baha Mousa Inquiry
Operational Law Training Quality
Unit commanders should ensure that the annual operational law training is delivered to the highest standards, so as to avoid it becoming stale or routine. Different media should be used …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that guidance on maintaining high standards in operational …
Ministry of Defence
BAHA-57 Accepted
Baha Mousa Inquiry
Remove Shock of Capture Language
Training soldiers to maintain or prolong the shock of capture is apt to be misunderstood and should not feature in general training. Phrases such as 'calm, neutral and professional' and …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that references to training soldiers to maintain or …
Ministry of Defence
BAHA-58 Accepted
Baha Mousa Inquiry
Moral Courage Training
MATT 6 training should include discussion and role play scenarios relevant to moral courage. Training materials should include reference to occasions when UK troops have breached the Law of Armed …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that MATT 6 training had been enhanced to …
Ministry of Defence
BAHA-60 Accepted
Baha Mousa Inquiry
Annual Legal Review of TQ Training
The annual legal review of training materials planned by Defence Intelligence and Security Centre (DISC) is a necessary step. It must include a rigorous scrutiny of the detail of the …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that annual legal reviews of tactical questioning training …
Ministry of Defence
BAHA-63 Accepted
Baha Mousa Inquiry
Complete TQ Training in Approaches
The tactical questioning and interrogation courses must train students adequately in all approaches that they may be required to use operationally. The current compromise whereby tactical questioning students are given …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that tactical questioning courses now provide complete training …
Ministry of Defence
BAHA-64 Accepted
Baha Mousa Inquiry
Geneva Convention Compliance in Training
The MoD should give further careful consideration to the examples used in training for bridging between questioning sessions to ensure that they comply with the Geneva Conventions.
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training examples for bridging between questioning sessions …
Ministry of Defence
BAHA-66 Accepted
Baha Mousa Inquiry
Remove Shock of Capture from DISC
DISC should give consideration to avoiding the terminology 'maintain the shock of capture' and 'prolong the shock of capture' even in their own courses. As a minimum, students on the …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that DISC courses now warn students against misuse …
Ministry of Defence
BAHA-67 Accepted
Baha Mousa Inquiry
Resistance Training Warning
All theoretical and practical resistance training must include a warning which explains in terms that the training is to show conduct that can be expected of a non-Geneva Conventions compliant …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that all resistance training now includes clear warnings …
Ministry of Defence
BAHA-70 Accepted
Baha Mousa Inquiry
MCTC Control and Restraint Monitoring
The Military Correction Training Centre (MCTC) should continue to monitor that breakaway, personal protection and control and restraint techniques taught on the All Arms Unit Custody Staff Course (AAUCSC) are …
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that the Military Correction Training Centre continues to …
Ministry of Defence
BAHA-72 Accepted
Baha Mousa Inquiry
Detention Sergeant Training
Unit Detention Sergeants (see recommendation 41) should be properly trained in CPErS handling practices.
- The Defence Secretary stated on 8 September 2011 that the government accepted this recommendation and stated that training requirements for Detention Sergeants (as established …
Ministry of Defence