Patient safety governance
375 items
2 sources
Lack of well-protected and defined resources for national patient safety agencies and insufficient awareness among healthcare professionals of the Duty of Candour.
Cross-Source Insight
Patient safety governance has been flagged across 2 independent accountability sources:
269 inquiry recs
106 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (269)
BRIS-106 — Establish independent National Patient Safety Agency for healthcare safety and quality
Recommendation: We support and endorse the broad framework of recommendations advocated in the report ‘An Organisation with a Memory’ by the Chief Medical Officer’s expert group on learning from adverse events in the NHS. The National Patient Safety Agency proposed as …
Unknown
BRIS-108 — Conduct priority studies to establish baseline of NHS sentinel events
Recommendation: Major studies should, as a matter of priority, be carried out to investigate the extent and type of sentinel events in the NHS to establish a baseline against which improvements can be made and measured.
Unknown
BRIS-109 — Create single, unified system for reporting and analysing sentinel events
Recommendation: There should a single, unified, accessible system for reporting and analysing sentinel events, with clear protocols indicating the categories of information which must be reported to a national database.
Unknown
BRIS-110 — National Patient Safety Agency to manage national sentinel events database
Recommendation: The national database of sentinel events should be managed by the National Patient Safety Agency, so as to ensure that a high degree of confidence is placed in the system by the public.
Unknown
BRIS-111 — Require National Patient Safety Agency to inform trusts and publish reports
Recommendation: The National Patient Safety Agency, in the exercise of its function of surveillance of sentinel events, should be required to inform all trusts of the need for immediate action, in the light of occurrences reported to it. The Agency should …
Unknown
BRIS-112 — Conduct structured analysis of sentinel events considering organisational factors
Recommendation: All sentinel events should be subject to a form of structured analysis in the trust where they occur, which takes into account not only the conduct of individuals, but also the wider contributing factors within the organisation which may have …
Unknown
BRIS-113 — Make reporting of sentinel events easy using all communication means
Recommendation: The reporting of sentinel events must be made as easy as possible, using all available means of communication (including a confidential telephone reporting line).
Unknown
BRIS-120 — NPSA to urgently apply engineering design approaches to reduce sentinel events.
Recommendation: The proposed National Patient Safety Agency should, as a matter of urgency, bring together managers in the NHS, representatives of the pharmaceutical companies and manufacturers of medical equipment, members of the healthcare professions and the public, to seek to apply …
Unknown
BRIS-121 — Assign executive and non-executive board members responsibility for clinical safety strategy.
Recommendation: At the level of individual trusts, an executive member of the board should have the responsibility for putting into operation the trust’s strategy and policy on safety in clinical care. Further, a non-executive director should be given specific responsibility for …
Unknown
BRIS-122 — Designate NICE as sole body for national clinical standards coordination and review.
Recommendation: One body should be responsible for co-ordinating all action relating to the setting, issuing and keeping under review of national clinical standards: this should be NICE, suitably structured so as to give it the necessary independence and authority.
Unknown
BRIS-123 — Grant NICE exclusive authority to issue national clinical standards to NHS.
Recommendation: Once the recommended system is in place, only NICE should be permitted to issue national clinical standards to the NHS. The DoH (as the headquarters of the NHS) while issuing, for example, National Service Frameworks and supplementary guidance, should not …
Unknown
BRIS-124 — NICE to involve public, patients, professionals in clinical standards development and review.
Recommendation: NICE should pursue vigorously its current policy of involving as wide a community as possible, including the public, patients and carers, in the work to develop and keep under review clinical standards. In particular, the special expertise of the Royal …
Unknown
BRIS-125 — Formulate national clinical standards from patient-centred perspective, based on best evidence.
Recommendation: National standards of clinical care should reflect the commitment to patient-centred care and thus in future be formulated from the perspective of the patient. The standards should address the quality of care that a patient with a given illness or …
Unknown
BRIS-126 — Clearly distinguish between obligatory and aspirational national clinical care standards.
Recommendation: Such standards for clinical care as are established should distinguish clearly between those which are obligatory and must be observed, and those to which the NHS should aspire over time.
Unknown
BRIS-127 — Publish and revise timetable for national clinical standards development, including target dates.
Recommendation: A timetable over the short, medium and long term should be published, and revised periodically, for the development of national clinical standards, so that the public may be consulted and kept aware of those areas of healthcare which are covered …
Unknown
BRIS-128 — Provide NICE with resources and statutory authority for national clinical standards role.
Recommendation: Resources, and any necessary statutory authority, must be made available to NICE to allow it to perform its role of developing, issuing and keeping under review national clinical standards.
Unknown
BRIS-129 — Make public the national clinical care standards patients expect from NHS.
Recommendation: Standards of clinical care which patients are entitled to expect to receive in the NHS should be made public.
Unknown
BRIS-130 — Establish single, coherent set of generic standards for safe, quality care.
Recommendation: There must be a single, coherent, co-ordinated set of generic standards: that is, standards relating to the patient’s experience and the systems for ensuring that care is safe and of good quality (for example corporate management, clinical governance, risk management, …
Unknown
BRIS-131 — Replace trust inspection system with supportive, flexible validation and revalidation.
Recommendation: The current system of inspection of trusts and primary care trusts should be changed to become a system of validation4 and periodic revalidation of these trusts. The system should be supportive and flexible. Its aim should be to promote continued …
Unknown
BRIS-132 — Designate CHI as sole body for validating and revalidating NHS trusts.
Recommendation: One body should be responsible for validating and re-validating NHS trusts and primary care trusts. This body should be CHI, suitably structured so as to give it the necessary independence and authority. Other bodies (for example the NHS Litigation Authority) …
Unknown
BRIS-133 — Base trust validation on compliance with generic standards for safe, quality care.
Recommendation: Validation and revalidation of trusts should be based upon compliance with the generic standards which relate to the patient’s experience and the systems for ensuring that care is safe and of good quality.
Unknown
BRIS-134 — Make public the trust validation standards and revalidation results.
Recommendation: The standards against which trusts are to be validated, and the results of the process of validation or revalidation, should be made public.
Unknown
BRIS-135 — Require private and voluntary NHS providers to meet national standards
Recommendation: Any organisation in the voluntary or private sector which provides services to NHS patients should be required to meet the standards for systems, facilities and staff which organisations in the NHS must meet. The aim should be that, wherever care …
Unknown
BRIS-136 — Empower validating body to suspend or withdraw trust validation for failing standards
Recommendation: The validating body should have the power to withdraw, withhold or suspend a trust’s validation if standards fall such as to threaten the quality of care or the safety of patients. Any trust or organisation whose validation may be affected …
Unknown
BRIS-137 — CHI should integrate existing trust accreditation programmes into its validation process
Recommendation: CHI should consider how it might work with the providers of those programmes of accreditation already adopted by a significant number of trusts. In the future, where required standards are met, CHI should accept as part of its validation process …
Unknown
BRIS-138 — Pilot and evaluate extending trust validation to discrete, identifiable services
Recommendation: The process of validation of trusts should, in time, be extended to cover discrete, identifiable services within trusts. This extension of validation should first be piloted and evaluated.
Unknown
BRIS-139 — Include children's acute and paediatric cardiac services in discrete validation pilot
Recommendation: The pilot exercise for this form of validation should include children’s acute hospital services and paediatric cardiac surgery.
Unknown
BRIS-140 — Prioritise specialist services for validation if discrete services pilot is successful
Recommendation: Should the pilot exercise be successful, the category of discrete services which should be a priority for this form of validation are those specialist services which are currently funded or meet the criteria for funding by the National Specialist Commissioning …
Unknown
BRIS-141 — Require discrete services to meet current standards or cease offering the service
Recommendation: For discrete services, whether specialist services or otherwise, to be validated trusts they must be able to demonstrate that all relevant aspects of the service can currently be met, rather than that the trust aims to develop so as to …
Unknown
BRIS-142 — Prioritise quality and safety for specialist services; fund patient travel and accommodation
Recommendation: Where the interests of securing quality of care and the safety of patients require that there be only a small number of centres offering a specialist service, the requirements of quality and safety should prevail over considerations of ease of …
Unknown
BRIS-143 — Establish multidisciplinary clinical audit as the core of local performance monitoring
Recommendation: The process of clinical audit, which is now widely practised within trusts, should be at the core of a system of local monitoring of performance. Clinical audit should be multidisciplinary.
Unknown
BRIS-144 — Trusts must fully support clinical audit with resources and a central co-ordinating office
Recommendation: Clinical audit must be fully supported by trusts. They should ensure that healthcare professionals have access to the necessary time, facilities, advice and expertise in order to conduct audit effectively. All trusts should have a central clinical audit office which …
Unknown
BRIS-145 — Make clinical audit compulsory for all healthcare professionals and part of contracts
Recommendation: Clinical audit should be compulsory for all healthcare professionals providing clinical care and the requirement to participate in it should be included as part of the contract of employment.
Unknown
BRIS-146 — Consolidate national clinical performance monitoring into a new CHI Office
Recommendation: The monitoring of clinical performance at a national level should be brought together and co-ordinated in one body: an independent Office for Information on Healthcare Performance. This Office should be part of CHI.
Unknown
BRIS-147 — New Office to co-ordinate national audits and provide early performance surveillance
Recommendation: The Office for Information on Healthcare Performance should supplant the current fragmentation of approach through a programme of activities involving the co-ordination of the various national audits. In addition to its other responsibilities, the new system should provide a mechanism …
Unknown
BRIS-153 — Develop clear, high-quality national healthcare performance indicators comprehensible to the public
Recommendation: At national level, the indicators of performance should be comprehensible to the public as well as to healthcare professionals. They should be fewer and of high quality, rather than numerous but of questionable or variable quality.
Unknown
BRIS-155 — Ensure patients and public can access trust and consultant unit performance information
Recommendation: Patients and the public must be able to obtain information as to the relative performance of the trust and the services and consultant units within the trust.
Unknown
BRIS-156 — Require trust boards to publicly report compliance with national clinical standards
Recommendation: As part of their Annual Reports trust boards should be required to report on the extent of their compliance with the national clinical standards. These reports should be made public and be made available to CHI.
Unknown
BRIS-157 — Embed public and patient perspectives into all NHS healthcare decision-making structures
Recommendation: The involvement of the public in the NHS must be embedded in its structures: the perspectives of patients and of the public must be heard and taken into account wherever decisions affecting the provision of healthcare are made.
Unknown
BRIS-158 — Require non-NHS regulatory bodies to involve the public in healthcare decisions
Recommendation: Organisations which are not part of the NHS but have an impact on it, such as Royal Colleges, the GMC, the Nursing and Midwifery Council and the body responsible for regulating the professions allied to medicine, must involve the public …
Unknown
BRIS-159 — Ensure transparent public involvement processes in NHS organisations, reported annually
Recommendation: The processes for involving patients and the public in organisations in the NHS must be transparent and open to scrutiny: the annual report of every organisation in the NHS should include a section setting out how the public has been …
Unknown
BRIS-160 — Focus public involvement on NHS service development, delivery, safety, and quality regulation
Recommendation: The public’s involvement in the NHS should particularly be focused on the development and planning of healthcare services and on the operation and delivery of healthcare services, including the regulation of safety and quality, the competence of healthcare professionals, and …
Unknown
BRIS-161 — Ensure Patients' Forums and Councils include wider public, not just patient groups
Recommendation: Proposals to establish Patients’ Forums and Patients’ Councils must allow for the involvement of the wider public and not be limited only to patients or to patients’ groups. They must be seen as an addition to the process of involving …
Unknown
BRIS-162 — Routinely evaluate NHS public involvement mechanisms based on evidence of effectiveness
Recommendation: The mechanisms for the involvement of the public in the NHS should be routinely evaluated. These mechanisms should draw on the evidence of what works.
Unknown
BRIS-163 — Provide training and guidance to properly support public involvement processes
Recommendation: The process of public involvement must be properly supported, through for example, the provision of training and guidance.
Unknown
BRIS-164 — Provide financial resources to support public involvement, covering costs like childcare
Recommendation: Financial resources must be made available to enable members of the public to become involved in NHS organisations: this should include provision for payments to cover, for example, the costs of childcare, or loss of earnings.
Unknown
BRIS-165 — NHS Modernisation Agency to advise on achieving widest public and patient involvement
Recommendation: The involvement of the public, particularly of patients, should not be limited to the representatives of patients’ groups, or to those representing the interests of patients with a particular illness or condition: the NHS Modernisation Agency should advise the NHS …
Unknown
BRIS-166 — PCTs must involve public in commissioning hospital services and gather feedback
Recommendation: Primary care trusts (and groups), given their capacity to influence the quality of care in hospitals, must involve patients and the public, for example through each PCG/T’s Patient and Advocacy Liaison Service. They must make efforts systematically to gather views …
Unknown
BRIS-27 — Provide patients with performance information for trusts, specialties, and consultant units
Recommendation: Patients should be referred to information relating to the performance of the trust, of the specialty and of the consultant unit (a consultant and the team of doctors who work under his or her supervision). (See further the Recommendations on …
Unknown
BRIS-28 — Routinely seek, act on, and publish patient feedback and experience surveys across NHS
Recommendation: Patients must be given the opportunity to pass on views on the service which they have received: all parts of the NHS should routinely seek and act on feedback from patients as to their views of the service. In addition, …
Unknown
BRIS-29 — Require trusts to provide clear patient access to information and explanation
Recommendation: NHS trusts and primary care trusts must have systems which ensure that patients know where and to whom to go when they need further information or explanation.
Unknown
BRIS-30 — Implement and securely fund Patient Advocacy and Liaison Services in all NHS trusts
Recommendation: We endorse the initiative in ‘The NHS Plan’ to establish a Patient Advocacy and Liaison Service in every NHS trust and primary care trust. The establishment of this service should be implemented in full as quickly as possible. Once established, …
Unknown
BRIS-31 — Require trusts to publish periodic reports on patient views and actions
Recommendation: Trusts and primary care trusts must have systems for publishing periodic reports on patients’ views and suggestions, including information about the action taken in the light of them. (See further the Recommendations on care of an appropriate standard.)
Unknown
BRIS-35 — Create a 'one-stop shop' system in every trust for patient concerns
Recommendation: There should be a clear system, in the form of a ‘one-stop shop’ in every trust, for addressing the concerns of a patient about the care provided by, or the conduct of, a healthcare professional.
Unknown
BRIS-36 — Establish independent, swift, and thorough complaints handling with advocacy for patients
Recommendation: Complaints should be dealt with swiftly and thoroughly, keeping the patient (and carer) informed. There should be a strong independent element, not part of the trust’s management or board, in any body considering serious complaints which require formal investigation. An …
Unknown
BRIS-38 — Make DoH roles explicit: NHS headquarters and independent regulatory framework
Recommendation: The DoH’s roles in relation to the NHS must in future be made explicit. The DoH should have two roles. It should be the headquarters of the NHS. It should also establish an independent framework of regulation which will assure …
Unknown
BRIS-39 — Create two independent councils for healthcare quality and professional regulation
Recommendation: The framework of regulation must consist of two overarching organisations, independent of government, which bring together the various bodies which regulate healthcare. A Council for the Quality of Healthcare should be created to bring together those bodies which regulate healthcare …
Unknown
BRIS-40 — Ensure independent Councils report to DoH and Parliament with DoH oversight
Recommendation: The two Councils should be independent of government and report both to the DoH and to Parliament. There should be close collaboration between the two Councils. The DoH should establish and fund the Councils and set their strategic framework, and …
Unknown
BRIS-41 — Ensure all healthcare quality and professional competence bodies are independent of DoH
Recommendation: The various bodies whose purpose it is to assure the quality of care in the NHS (for example, CHI and NICE) and the competence of healthcare professionals (for example, the GMC and the Nursing and Midwifery Council) must themselves be …
Unknown
BRIS-42 — Regulatory bodies must be independent and reflect interests of patients and professionals
Recommendation: All the various bodies and organisations concerned with regulation, besides being independent of government, must involve and reflect the interests of patients, the public and healthcare professionals, as well as the NHS and government.
Unknown
1 — Single consultant data repository
Recommendation: We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data – for example, how many times a consultant has performed a particular …
Gov response: Accepted in principle. The government is improving data flows to CQC and GMC to give them better oversight of consultants' full scope of practice. NHS England is developing a workforce repository and working with partner …
Accepted in Part
No update 2+ yrs
11 — Regulatory system patient safety priority
Recommendation: We recommend that the government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry.
Gov response: Accepted. Government is strengthening regulatory collaboration. CQC and GMC have improved information sharing arrangements. The Professional Standards Authority oversees healthcare regulators. Regulatory reform programme underway to ensure patient safety is paramount. Health and Care Act …
Accepted
No update 2+ yrs
12a — Suspension during investigation
Recommendation: 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 of that healthcare professional.
Gov response: Not accepted. Government does not support blanket automatic suspension. Suspension should be decided case-by-case based on risk assessment. Automatic suspension could deter reporting and be disproportionate. Existing guidance from NHS Employers and professional regulators provides …
Not Accepted
12b — Information sharing between providers
Recommendation: We recommend that if the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Gov response: Accepted in principle. Government supports principle of sharing concerns between employers. CQC registration conditions require providers to share relevant information. GMC guidance requires doctors to disclose concerns about their practice. NHS England working with independent …
Accepted in Part
No update 2+ yrs
15 — Independent sector NHS contract qualification
Recommendation: We recommend that if the government accepts any of the recommendations set out above, it should make arrangements to ensure that these are to be applicable across the whole of the independent sector's workload, where relevant, and not only to …
Gov response: Not accepted but kept under review. Government concerned about proportionality and unintended consequences. NHS Standard Contract already requires providers to meet certain standards. CQC registration applies to all providers regardless of funding source. Government monitoring …
Response Unclear
No update 2+ yrs
3 — Explaining independent sector differences
Recommendation: We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised is explained clearly to patients, so that they understand how the engagement of …
Gov response: Accepted. CQC now requires independent healthcare providers to ensure patients understand these arrangements as part of their registration conditions. The Private Healthcare Information Network (PHIN) also provides comparative information. Independent providers should explain consultant engagement …
Accepted
No update 2+ yrs
5 — CQC assurance on MDT meetings
Recommendation: We recommend that CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national guidance on MDT meetings, including in breast cancer care, and that patients are not at risk of harm …
Gov response: Accepted. CQC has updated its inspection methodology to specifically look at MDT functioning and compliance with national guidance. Inspectors examine whether MDT processes are effective and whether all relevant cases are discussed. CQC works with …
Accepted
No update 2+ yrs
7 — UHB patient recall
Recommendation: We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen.
Gov response: Accepted and implemented. University Hospitals Birmingham has undertaken extensive patient recall programmes. Over 12,000 patients were recalled for review. Ongoing support is provided to affected patients. Trust has confirmed all identifiable patients have been contacted …
Accepted
Delivered
8 — Spire patient recall
Recommendation: We recommend that Spire should check that all patients of Ian Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in …
Gov response: Accepted and implemented. Spire Healthcare has undertaken comprehensive patient recall. All identifiable former patients of Paterson have been contacted and offered clinical review. Spire has provided ongoing treatment plans and support to affected patients, consistent …
Accepted
Delivered
9 — National patient recall framework
Recommendation: We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated, centred around the needs of the patients and applicable in both the independent sector and the NHS.
Gov response: Accepted and implemented. NHS England published the National Quality Board Recall Framework on 1 June 2022, developed with input from Paterson patients. The framework establishes principles for patient-centred recall in secondary care across both NHS …
Accepted
Delivered
P2-26 — HTA require anatomy adverse incidents reported as HTARIs
Recommendation: The Human Tissue Authority should change its guidance to require that relevant adverse incidents in the anatomy sector are formally reported as Human Tissue Authority Reportable Incidents (HTARIs).
Gov response: The Human Tissue Authority has expanded the scope of its adverse events and reportable incidents systems in the Post-Mortem sector to include the Anatomy sector. The HTA has issued formal guidance to ensure that adverse …
Accepted
Delivered
IBI-10a(i) — Patient Satisfaction in Clinical Audits
Recommendation: A clinical audit should as a matter of routine include measures of patient satisfaction or concern, and these should be reported to the board of the body concerned. Success in this will be measured by comparing the measure of satisfaction …
Gov response: UK Government The Health Secretary, the Rt Hon Wes Streeting MP, in setting out his mission for saving the NHS earlier this year, stated his aim to return to the “highest patient satisfaction in history”. …
Accepted
In progress
IHRD-55 — Board Member Training on Patient Safety
Recommendation: Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.
Gov response: Training programmes implemented for Board members on scrutiny of patient safety performance.
Accepted
Delivered
IHRD-56 — Board Member Induction Training
Recommendation: All Trust Board Members should receive induction training in their statutory duties.
Gov response: Induction training programmes established for Trust Board members.
Accepted
Delivered
IHRD-71 — Children's Healthcare Governance
Recommendation: All Trust Boards should ensure that appropriate governance mechanisms are in place to assure the quality and safety of the healthcare services provided for children and young people.
Gov response: Governance mechanisms for children's healthcare services established across Trusts.
Accepted
Delivered
IHRD-76 — Publication of Clinical Standards
Recommendation: Clinical standards of care, such as patients might reasonably expect, should be published and made subject to regular audit.
Gov response: Clinical standards published and audit programmes established.
Accepted
Delivered
IHRD-77 — Trust Compliance Officer
Recommendation: Trusts should appoint a compliance officer to ensure compliance with protocol and direction.
Gov response: Compliance roles established within Trust governance structures.
Accepted
Delivered
IHRD-78 — Clinical Guidelines Audit
Recommendation: Implementation of clinical guidelines should be documented and routinely audited.
Gov response: Clinical guideline implementation documentation and audit processes established.
Accepted
Delivered
IHRD-79 — Reporting Clinical Practice Changes
Recommendation: Trusts should bring significant changes in clinical practice to the attention of the HSCB with expedition.
Gov response: Procedures established for reporting significant clinical practice changes to HSCB.
Accepted
Delivered
IHRD-8 — RQIA Compliance Review Powers
Recommendation: Regulation and Quality Improvement Authority ('RQIA') should review overall compliance and consideration should be given to granting it the power to prosecute in cases of serial non-compliance or serious and wilful deception.
Gov response: RQIA remit under review. Consideration being given to expanded oversight powers but prosecution powers not yet granted.
Accepted in Part
Delivered
IHRD-80 — Healthcare Data Analysis
Recommendation: Trusts should ensure health care data is expertly analysed for patterns of poor performance and issues of patient safety.
Gov response: Healthcare data analysis capabilities enhanced across Trusts.
Accepted
No update 2+ yrs
IHRD-81 — Board Awareness of SAI Reports
Recommendation: Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.
Gov response: Procedures established for ensuring Board members receive all SAI-related reports.
Accepted
Delivered
IHRD-82 — Policy on Learning from SAI Deaths
Recommendation: Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.
Gov response: Trusts have published policies on responding to and learning from SAI-related deaths.
Accepted
Delivered
IHRD-83 — SAI Deaths in Annual Reports
Recommendation: Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.
Gov response: SAI-related death reporting incorporated into Trust annual reports.
Accepted
No update 2+ yrs
IHRD-84 — Trust Board Review of IHRD Report
Recommendation: All Trust Boards should consider the findings and recommendations of this Report and where appropriate amend practice and procedure.
Gov response: Trust Boards have considered the IHRD Report findings and initiated implementation programmes.
Accepted
Delivered
IHRD-86 — Expand RQIA Remit and Resources
Recommendation: The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the SAI process (ii) be strengthened in its capacity to investigate and review individual cases or groups of cases, …
Gov response: RQIA remit and resources under review. Some expanded oversight implemented.
Accepted
No update 2+ yrs
IHRD-87 — Independent Medical Examiner
Recommendation: The Department should now institute the office of Independent Medical Examiner to scrutinise those hospital deaths not referred to the Coroner.
Gov response: Prototypes to determine the most appropriate way to operate such a service are progressing. Learning will inform proposals for an IME service in Northern Ireland.
Accepted
No update 2+ yrs
IHRD-88 — Child Death Overview Panel
Recommendation: The Department should engage with other interested statutory organisations to review the merits of introducing a Child Death Overview Panel.
Gov response: Engagement with statutory organisations on Child Death Overview Panel ongoing.
Accepted
No update 2+ yrs
IHRD-89 — Patient Concern Organisation
Recommendation: The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.
Gov response: Under consideration as part of broader patient engagement strategy.
Accepted
No update 2+ yrs
IHRD-90 — Clinical Guidance Dissemination Protocol
Recommendation: The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals fixed with responsibility for implementation and audit to ensure accountability. (ii) The identification of specific training requirements necessary …
Gov response: Protocol development for clinical guidance dissemination progressing.
Accepted
No update 2+ yrs
IHRD-91 — Synchronise Patient Safety Systems
Recommendation: The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional information.
Gov response: Work progressing on synchronisation of patient safety incident systems across organisations.
Accepted
No update 2+ yrs
IHRD-92 — Review Healthcare Standards
Recommendation: The Department should review healthcare standards in light of the findings and recommendations of this report and make such changes as are necessary.
Gov response: Healthcare standards reviewed in light of IHRD recommendations.
Accepted
No update 2+ yrs
IHRD-93 — Review Trust Responses
Recommendation: The Department should review Trust responses to the findings and recommendations of this Report.
Gov response: Department reviewing Trust responses to IHRD recommendations through Implementation Programme.
Accepted
No update 2+ yrs
F1 — Implementing the recommendations
Recommendation: It is recommended that: All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this report and decide how to apply them to their own work; Each such organisation should announce at the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F10 — Fundamental standards of behaviour
Recommendation: The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as those produced by the National Institute for Health and Clinical Excellence and, where relevant, the Care Quality Commission, …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F101 — National Patient Safety Agency functions
Recommendation: While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it should be possible to organise for mutual peer review inspections or the inclusion in Patient Environment Action Team …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F102 — Transparency use and sharing of information
Recommendation: Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others facilitated in that task.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F103 — Transparency use and sharing of information
Recommendation: The National Patient Safety Agency or its successor should regularly share information with Monitor.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F104 — Transparency use and sharing of information
Recommendation: The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency or its successor to assist it in identifying areas for focusing its attention. There needs to be a …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F113 — Complaints handling
Recommendation: The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F114 — Complaints handling
Recommendation: Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F115 — Investigations
Recommendation: 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 incident; Subject matter involving clinically related issues is not capable …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F118 — Learning and information from complaints
Recommendation: Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F119 — Learning and information from complaints
Recommendation: Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F12 — Fundamental standards of behaviour
Recommendation: Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F120 — Learning and information from complaints
Recommendation: Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F121 — Learning and information from complaints
Recommendation: The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints and the detail underlying them.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F122 — Handling large-scale complaints
Recommendation: Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to very distressed and anxious members of the public; Swift identification of persons of independence, authority and expertise to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F123 — Responsibility for monitoring delivery of standards and quality
Recommendation: GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F124 — Duty to require and monitor delivery of fundamental standards
Recommendation: The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in respect of each item of service it is commissioning. In relation to each such standard, it should agree …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F125 — Responsibility for requiring and monitoring delivery of enhanced standards
Recommendation: In addition to their duties with regard to the fundamental standards, commissioners should be enabled to promote improvement by requiring compliance with enhanced standards or development towards higher standards. They can incentivise such improvements either financially or by other means …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F126 — Preserving corporate memory
Recommendation: The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This code should cover both transitions between commissioners, for example as …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F127 — Resources for scrutiny
Recommendation: The NHS Commissioning Board and local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny of its providers' services, based on sound commissioning contracts, while ensuring providers remain responsible and accountable for the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F128 — Expert support
Recommendation: Commissioners must have access to the wide range of experience and resources necessary to undertake a highly complex and technical task, including specialist clinical advice and procurement expertise. When groups are too small to acquire such support, they should collaborate …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F129 — Ensuring assessment and enforcement of fundamental standards through contracts
Recommendation: In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard patients and to ensure that at least fundamental safety and quality standards are maintained. This requires close engagement …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F13 — The nature of standards
Recommendation: Standards should be divided into: Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations. …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F130 — Relative position of commissioner and provider
Recommendation: Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be provided, and for that purpose will have to consult clinicians both from potential providers and elsewhere, and to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F131 — Development of alternative sources of provision
Recommendation: Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken on behalf of consortia of commissioning groups to provide the negotiating weight necessary to achieve a negotiating balance …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F132 — Monitoring tools
Recommendation: Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: Such monitoring may include requiring quality information generated by the provider. Commissioners must also have the capacity to undertake …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F133 — Role of commissioners in complaints
Recommendation: Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, while respecting the principle that it is the provider who …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F134 — Role of commissioners in provision of support for complainants
Recommendation: Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F135 — Public accountability of commissioners and public engagement
Recommendation: Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should be a membership system whereby eligible members of the public …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F136 — Public accountability of commissioners and public engagement
Recommendation: Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of technical support. Effective local commissioning can only work with effective local monitoring, and that cannot be done without …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F137 — Intervention and sanctions for substandard or unsafe services
Recommendation: Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other measures necessary to protect patients from the risk of harm. In the provision of the commissioned services, such …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F138 — Local scrutiny
Recommendation: Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at risk from substandard or unsafe services.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F139 — The need to put patients first at all times
Recommendation: The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient safety and quality standards are being met. Such an organisation must require convincing evidence to be available before …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F14 — The nature of standards
Recommendation: In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance with fundamental standards, and the provision and publication of accurate information about compliance with the fundamental and enhanced …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F140 — Performance managers working constructively with regulators
Recommendation: Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant information with the relevant regulator, including information about its judgement as to the safety of patients of the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F141 — Taking responsibility for quality
Recommendation: Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its retained individual responsibility to take whatever action within its power …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F142 — Clear lines of responsibility supported by good information flows
Recommendation: For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the performance manager is not in ignorance of the reality.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F143 — Clear metrics on quality
Recommendation: Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms to be established so that outliers or progression to poor performance can be identified and accepted as needing …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F144 — Need for ownership of quality metrics at a strategic level
Recommendation: The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing the performance of providers, and retain oversight of these through its regional offices, if appropriate.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F145 — Structure of Local Healthwatch
Recommendation: There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter 6: Patient and public local involvement and scrutiny.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F146 — Finance and oversight of Local Healthwatch
Recommendation: Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the money. Transparent respect for the independence of Local Healthwatch should …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F147 — Coordination of local public scrutiny bodies
Recommendation: Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F148 — Training
Recommendation: 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.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F149 — Expert assistance
Recommendation: Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F15 — The nature of standards
Recommendation: All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it is being used to good effect.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F150 — Inspection powers
Recommendation: Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger and follow up inspections where appropriate, rather than receiving reports …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F16 — Responsibility for setting standards
Recommendation: The Government, through regulation, but after so far as possible achieving consensus between the public and professional representatives, should provide for the fundamental standards which should define outcomes for patients that must be avoided. These should be limited to those …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F17 — Responsibility for setting standards
Recommendation: The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. Failure to comply with such standards should be a matter for performance management by commissioners rather than the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F170 — Health Education England
Recommendation: Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F171 — Deans
Recommendation: All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F173 — Principles of openness transparency and candour
Recommendation: Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F174 — Candour about harm
Recommendation: Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F18 — Responsibility for setting standards
Recommendation: It is essential that professional bodies in which doctors and nurses have confidence are fully involved in the formulation of standards and in the means of measuring compliance.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F19 — Gaps between the understood functions of separate regulators
Recommendation: There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards for all trusts.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F192 — Strong nursing voice
Recommendation: The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and accountable to, the Nursing and Midwifery Council.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F198 — Measuring cultural health
Recommendation: Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience and feedback of nursing staff using a robust methodology, such …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F2 — Putting the patient first
Recommendation: The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority in everything done. This requires: A common set of core values and standards shared throughout the system; Leadership …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F20 — Responsibility for regulating and monitoring compliance
Recommendation: The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the indicators by which it intends to monitor compliance with those standards. It should be responsible not for directly …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F205 — Strengthening the nursing professional voice
Recommendation: Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety of any proposed major change to nurse staffing arrangements or …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F206 — Strengthening the nursing professional voice
Recommendation: The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a recognised leading representative of the nursing profession as a whole, able and empowered to give independent professional advice …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F21 — Responsibility for regulating and monitoring compliance
Recommendation: The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. The regulator must be willing to consider individual cases of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F214 — Shared training
Recommendation: 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 and management as a profession; administer an accreditation scheme to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F215 — Shared code of ethics
Recommendation: A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the code and their employers to enforce it.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F216 — Leadership framework
Recommendation: The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health service. This could be done by, for example, creating a separate domain for managing safety, or by defining …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F218 — Enforcement of standards and accountability
Recommendation: Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be fit and proper persons to hold such positions by a …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F219 — A regulator as an alternative
Recommendation: An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up an independent professional regulator. The need for this would be greater if it were thought appropriate to extend …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F22 — Responsibility for regulating and monitoring compliance
Recommendation: The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical means of compliance, and indicators by which compliance with both fundamental and enhanced standards can be measured. These …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F220 — Accreditation
Recommendation: 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 require all leadership posts to be filled by persons who …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F245 — Board accountability
Recommendation: Each provider organisation should have a board level member with responsibility for information.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F252 — Access to data
Recommendation: It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F253 — Access to quality and risk profile
Recommendation: The information behind the quality and risk profile – as well as the ratings and methodology – should be placed in the public domain, as far as is consistent with maintaining any legitimate confidentiality of such information, together with appropriate …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F257 — Role of the Health and Social Care Information Centre
Recommendation: 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 information functions previously held by the National Patient Safety …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F262 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on the performance of each of their services against patient safety and minimum quality standards; Effective real-time information of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F265 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to consider how best to develop comparative statistics on the efficacy of treatment in that specialty, for publication and …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F266 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and the specialty organisations should seek and have regard to the views of patient groups and the public about …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F267 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F287 — Impact assessments before structural change
Recommendation: The Department of Health should together with healthcare systems regulators take the lead in developing through obtaining consensus between the public and healthcare professionals, a coherent, and easily accessible structure for the development and implementation of values, fundamental, enhanced and …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F288 — Clinical input
Recommendation: The Department of Health should ensure that there is senior clinical involvement in all policy decisions which may impact on patient safety and well-being.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F289 — Experience on the front line
Recommendation: Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who have suffered poor experiences. The Department of Health could also be assisted in its work by involving patient/service …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F290 — Experience on the front line
Recommendation: The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making information publicly available about performance at the most detailed level …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F3 — Clarity of values and principles
Recommendation: The NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system's common values, as well as the respective rights, legitimate expectations and obligations of patients.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F32 — Interim measures
Recommendation: Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F33 — Interim measures
Recommendation: Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F34 — Interim measures
Recommendation: Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F35 — Need to share information between regulators
Recommendation: Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F36 — Use of information for effective regulation
Recommendation: A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F37 — Use of information about compliance by regulator from: Quality accounts
Recommendation: Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent that it is not practical in a written report to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F38 — Use of information about compliance by regulator from: Complaints
Recommendation: The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F39 — Use of information about compliance by regulator from: Complaints
Recommendation: The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F4 — Clarity of values and principles
Recommendation: The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients are put first, and everything done by the NHS and everyone associated with it should be informed by …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F40 — Use of information about compliance by regulator from: Complaints
Recommendation: It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F41 — Use of information about compliance by regulator from: Patient safety alerts
Recommendation: The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F42 — Use of information about compliance by regulator from: Serious untoward incidents
Recommendation: Strategic Health Authorities/their successors should
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F43 — Use of information about compliance by regulator from: Media
Recommendation: Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F44 — Use of information about compliance by regulator from: Media
Recommendation: Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F45 — Use of information about compliance by regulator from: Inquests
Recommendation: The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F46 — Use of information about compliance by regulator from: Quality and risk profiles
Recommendation: The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important that this is explained carefully and clearly as and when the public are given access to the information.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F47 — Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
Recommendation: The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current 'sounding board events'.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F48 — Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
Recommendation: The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F49 — Enhancement of monitoring and the importance of inspection
Recommendation: Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained from: The Quality and Risk Profile; Quality Accounts; Reports from …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F5 — Clarity of values and principles
Recommendation: In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; They will do everything in their power to protect patients from avoidable harm; They will be honest and …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F50 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F51 — Enhancement of monitoring and the importance of inspection
Recommendation: 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 such inspectors who should have the support of a team, …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F52 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F53 — Care Quality Commission independence strategy and culture
Recommendation: Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F54 — Care Quality Commission independence strategy and culture
Recommendation: Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission's statutory role.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F55 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined in this report.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F56 — Care Quality Commission independence strategy and culture
Recommendation: The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F57 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F58 — Care Quality Commission independence strategy and culture
Recommendation: Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a patient …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F59 — Care Quality Commission independence strategy and culture
Recommendation: Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F6 — Clarity of values and principles
Recommendation: The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their significance.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F60 — Consolidation of regulatory functions
Recommendation: The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F61 — Consolidation of regulatory functions
Recommendation: A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a justification for reduction of the resources allocated to this area …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F62 — Improved patient focus
Recommendation: For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F63 — Improved transparency
Recommendation: Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F64 — Authorisation of foundation trusts
Recommendation: The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F65 — Quality of care as a pre-condition for foundation trust applications
Recommendation: The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support for a foundation trust application.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F66 — Improving contribution of stakeholder opinions
Recommendation: The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is sought on the fitness of a potential applicant NHS trust …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F67 — Focus on compliance with fundamental standards
Recommendation: The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as a priority focus a review of the standard of service …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F68 — Focus on compliance with fundamental standards
Recommendation: No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F69 — Focus on compliance with fundamental standards
Recommendation: The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality standards at the same time as complying with the financial and corporate governance requirements of a foundation trust.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F7 — Clarity of values and principles
Recommendation: All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts of employment.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F70 — Duty of utmost good faith
Recommendation: A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant information material to the application and to ensure that any information is complete and accurate. This duty should …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F71 — Role of Secretary of State
Recommendation: The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a service to patients which is, at the time of his consideration, safe, effective and compliant with all relevant …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F72 — Assessment process for authorisation
Recommendation: The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas as well as all wards to determine whether it is compliant with fundamental safety and quality standards.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F73 — Need for constructive working with other parts of the system
Recommendation: The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with the Department of Health and whether the appropriate degree of clarity of understanding of the scope of their …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F74 — Enhancement of role of governors
Recommendation: Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation to account to the public, and in particular in arranging for communication with the public served by the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F75 — Enhancement of role of governors
Recommendation: The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its obligations and to represent the public interest. They should produce …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F76 — Enhancement of role of governors
Recommendation: Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large – it is important that regular and constructive contact between governors and the public is maintained.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F77 — Enhancement of role of governors
Recommendation: 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 challenge deficiencies in the quality of the foundation trust's services.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F78 — Enhancement of role of governors
Recommendation: The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in relation to compliance with healthcare standards as will be available for compliance issues in relation to breach of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F79 — Accountability of providers' directors
Recommendation: There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper persons for the role. Such a test should include a …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F8 — Clarity of values and principles
Recommendation: Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for these purposes do so as well. These requirements could be included in the terms on which providers are …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F80 — Accountability of providers' directors
Recommendation: A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications in the standard terms of a foundation trust's constitution.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F81 — Accountability of providers' directors
Recommendation: 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.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F82 — Accountability of providers' directors
Recommendation: Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom the regulator is satisfied is not or is no longer a fit and proper person, regardless of whether …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F83 — Accountability of providers' directors
Recommendation: If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would exercise its power to require the removal or suspension or disqualification of directors who did not fulfil it, …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F84 — Accountability of providers' directors
Recommendation: Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is not a fit and proper person to hold such a …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F85 — Accountability of providers' directors
Recommendation: Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event of an executive or non-executive director being found to have been guilty of serious failure in the performance …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F87 — Ensuring the utility of a health and safety function in a clinical setting
Recommendation: The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should be given power to prosecute 1974 Act offences or a new offence containing comparable provisions should be created …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F88 — Information sharing
Recommendation: The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order to provide a check on the consistency of trusts' practice …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F89 — Information sharing
Recommendation: Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F9 — Fundamental standards of behaviour
Recommendation: The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F90 — Assistance in deciding on prosecutions
Recommendation: In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences for any victims, that the public interest requires individuals or organisations to be brought to account for their …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F91 — NHS Litigation Authority Improvement of risk management
Recommendation: The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority scheme, to have and to comply with risk management standards …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F92 — NHS Litigation Authority Improvement of risk management
Recommendation: The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F93 — NHS Litigation Authority Improvement of risk management
Recommendation: The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F94 — Evidence-based assessment
Recommendation: As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider development of a relatively simple database containing the same information.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F96 — Information sharing
Recommendation: The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of its standards assessments and of the reliance which can be placed on them.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F97 — National Patient Safety Agency functions
Recommendation: The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this valuable function to a systems regulator.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F98 — National Patient Safety Agency functions
Recommendation: Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F99 — National Patient Safety Agency functions
Recommendation: The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
15 — Continue governance systems work
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should continue to prioritise the work commenced in response to the review of governance systems already carried out, including clinical governance, so that the Board has adequate assurance of the quality …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
34 — CQC and PHSO memorandum of understanding
Recommendation: The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between the Care Quality Commission and the Parliamentary and Health Service …
Gov response: 90. We accept this recommendation. The Investigation found that the lack of co ordination between the Care Quality Commission and the Parliamentary and Health Service Ombudsman was a contributory factor to the ongoing inability of …
Accepted
35 — Clarify oversight responsibilities
Recommendation: The division of responsibilities between the Care Quality Commission and other parts of the NHS for oversight of service quality and the implementation of measures to correct patient safety failures was not clear, and we are concerned that potential ambiguity …
Gov response: 92. We accept this recommendation in principle. Patient safety is a critical element of an effective, patient-focused health system and we agree that it is important to be clear about who is responsible for patient …
Accepted
39 — Implement medical examiner system
Recommendation: There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith …
Gov response: 106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical …
Accepted
40 — Extend medical examiners to stillbirths
Recommendation: Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, thereby ensuring that appropriate recommendations are made to coroners concerning …
Gov response: 106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical …
Accepted
41 — Guidance for external service reviews
Recommendation: We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS Foundation Trust. We recommend that systematic guidance be drawn up …
Gov response: 109. We accept this recommendation, and there are actions in train, which go some way to meeting it. For example, the Serious Incident Framework published by NHS England and updated in March 2015, sets out …
Accepted
42 — Register external reviews with CQC
Recommendation: We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that the Care Quality Commission develops a system to collate learning from reviews and disseminate it to other Trusts. …
Gov response: 43. We accept these recommendations. A new national, Independent Patient Safety Investigation Service will improve local standards of investigation and openness. 44. During the 10-year period in which serious incidents were occurring at Morecambe Bay, …
Accepted
43 — Maintain focus on quality
Recommendation: We strongly endorse the emphasis placed on the quality of NHS services that began with the Darzi review, High Quality Care for All, and gathered importance with the response to the events at the Mid Staffordshire NHS Foundation Trust. Our …
Gov response: 111. We accept this recommendation, and strongly agree that the emphasis on quality of care must be maintained, and that service changes should put the safety and quality of patient care as central objectives. Indeed …
Accepted
COVID-M3.1 — IPC Structures and Transmission Risk
Recommendation: The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready to be convened at the outset of any future pandemic, to consider and draft infection prevention and control …
Gov response: No formal response published by this government.
Unknown
COVID-M3.7 — ICU Resource Allocation Framework
Recommendation: The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of adult intensive care resources in the extreme event that they are saturated during a pandemic. That framework must: …
Gov response: No formal response published by this government.
Unknown
R1 — HEI ward closure powers
Recommendation: Scottish Government should ensure that the Healthcare Environment Inspectorate (HEI) has the power to close a ward to new admissions if the HEI concludes that there is a real risk to the safety of patients.
Gov response: Section 2.1 of the Scottish Government's response describes the Healthcare Environment Inspectorate (HEI) as providing independent and rigorous scrutiny and assurance of NHS Scotland hospitals. The HEI carries out inspections and issues 'requirements' for action …
Accepted
R59 — Priority attendance at IPC meetings
Recommendation: Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority.
Gov response: Section 2.1 of the Scottish Government's response states that reducing HAI is a priority, leading to a wide range of measures driven by the national HAI Taskforce. This Taskforce has been restructured to provide efficient, …
Accepted
R6 — Service change continuity plans
Recommendation: Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place for continuity of safe patient care.
Gov response: Section 2.1 of the Scottish Government's response details the intention to develop a longer-term plan for health and social care, and the integration of health and social care services. This integration aims to improve care, …
Accepted
R61 — Unannounced inspections with lay representation
Recommendation: Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay representation.
Gov response: Section 2.1 of the Scottish Government's response highlights the role of the Healthcare Environment Inspectorate (HEI), established in April 2009, which conducts at least 30 unannounced inspections annually in acute and other healthcare settings. To …
Accepted
R62 — Senior manager clinical visits
Recommendation: Health Boards should ensure that senior managers accompanied by IPC staff visit clinical areas at least weekly to verify that proper attention is being paid to IPC.
Gov response: Section 3.1 of the Scottish Government's response details the 10 Patient Safety Essentials, which include leadership walk-rounds. These walk-rounds involve leaders, including executive and non-executive directors, and frontline staff discussing and reducing barriers to reliably …
Accepted
R64 — Cohorting only exceptional
Recommendation: Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in exceptional circumstances.
Gov response: Section 3.1 of the Scottish Government's response outlines a policy to increase single-room accommodation in hospitals. All planned new-build hospitals are now required to provide 100% single-room accommodation, and refurbished hospital builds must ensure at …
Accepted
R7 — Reorganisation due diligence
Recommendation: In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the Board or Boards responsible.
Gov response: Section 2.2 of the Scottish Government's response describes the 'Governance for Quality Healthcare in Scotland - an Agreement' and a 'clinical and care governance framework for integrated health and social care services' to ensure good …
Accepted
R72 — Internal investigation independence
Recommendation: Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.
Gov response: Section 3.2 notes that the report addresses issues in NHS boards relating to internal investigations (recommendation 72). While the "Our current position" section discusses feedback, complaints, and the introduction of a statutory duty of candour …
Accepted
R74 — Review of UK IPC reports
Recommendation: Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports published in the UK and in other relevant jurisdictions on infection prevention and control and patient safety are …
Gov response: Section 2.1 notes the report's call for the Scottish Government to ensure timely review and implementation of relevant measures from existing inquiry reports, including those from other jurisdictions, as a matter of standard practice (recommendation …
Accepted
R75 — Health Board review of IPC reports
Recommendation: Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or otherwise) should be put in place.
Gov response: Section 2.1 highlights the report's recommendation for NHS boards to review existing inquiry reports from the UK and other jurisdictions to learn lessons and implement necessary measures (recommendation 75). While the response details how NHS …
Accepted
R8 — Reorganisation management structure
Recommendation: In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable management structure is in place.
Gov response: Section 2.2 of the Scottish Government's response emphasizes that leaders and managers at all levels are responsible for quality of care and that investment is needed in leadership and management. Work is ongoing locally and …
Accepted
R9 — IPC clinical governance meetings
Recommendation: Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.
Gov response: Section 2.2 and 3.2 of the Scottish Government's response confirm that the infection control manager is an integral member of the organisation's infection prevention control, clinical governance, and risk management committees. Section 3.2 further states …
Accepted
LAMI-82 — Examine feasibility of clinical governance for children at risk of deliberate harm.
Recommendation: The Department of Health should examine the feasibility of bringing the care of children about whom there are concerns about deliberate harm within the framework of clinical governance.
Unknown
PFD Reports (106) — showing 100 most recent
Janet Tripp
Concerns: Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
Pending
Rory Williams
Concerns: The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the corporate risk register.
Response: The Health Board has actively recruited medical and nursing staff for gastroenterology and endoscopy services, secured additional endoscopy capacity through insourcing and private providers, and reviewed and strengthened clinical pathways …
Responded
Ashana Charles
Concerns: Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between manufacturers and health providers.
Response: NHS England notes the British Pharmaceutical Nutrition Group (BPNG) has issued a position statement recommending 1.2 μm filters for all parenteral nutrition admixtures and has written to BAPEN and RCN …
Overdue
Antonio Galisi-Swallow
Concerns: There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.
Response: NICE declines to develop national guidance on propofol use for sedation in children, stating it is not the appropriate organisation. They advise that existing product information contains contraindications and local …
Responded
Steven Davidson
Concerns: Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during prisoner health assessments, indicating training deficiencies.
Response: HCRG has amended its training provision to include mandatory structured SystmOne training for all new staff during induction and refresher training for existing staff. They are also embedding this training …
Responded
John Rust
Concerns: Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all current and future clinical staff receive essential training on critical equipment.
Response: The response text is truncated; therefore, no actions taken or planned regarding mandatory training for CSF drainage systems can be identified.
Responded
Melanie Walker
Concerns: Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other hospitals.
Response: The Greater Manchester ICB has reconfigured heart monitor alarms so that 'ECG leads off' alerts will visually flash and re-alarm audibly every three minutes if not reconnected, whereas previously they …
Response: Philips reset the 'ECG Leads Off' alarm at the specific hospital to its factory default medium priority. However, Philips disputes the need for wider changes to their product's default settings, …
Response: The Department noted that Philips has already issued a Field Safety Notice for its IntelliVue Patient Monitors, clarifying that alarm functions are user-reconfigurable and must be confirmed as 'alarm on'. …
Responded
Mohammad Asghar
Concerns: The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines and an inability to learn from adverse events.
Overdue
Pamela Honeybone
Concerns: Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to pose a significant risk to patient safety across hospital sites.
Responded
Tony Jackson
Concerns: A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for investigation, hindering learning and remediation of sub-optimal practice.
Responded
Mabel Williams
Concerns: The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents are unacceptably slow and reactive.
Overdue
Charles Stonley
Concerns: Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their risk of self-harm and death.
Overdue
Chloe Barber
Concerns: Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of Mental Health Act aftercare provisions.
Overdue
Jessica Smithson
Concerns: The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied support, challenges in police response, and limited integration with NHS mental health pathways.
Responded
Tracey Ostler
Concerns: A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.
Responded
Maureen Batchelor
Concerns: The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing efforts, posing an unacceptable risk to patient safety.
Overdue
Margaret McNaughton
Concerns: The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse incidents, as current policies and communications are insufficient to embed these critical safety practices.
Responded
Joanne Stones
Concerns: The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected to consult specialists, leading to significant delays and inappropriate treatment.
Responded
Jason Clemens
Concerns: The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a previous report.
Responded
David Bateman
Concerns: Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied since the incident.
Responded
Kenneth Foster
Concerns: The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a significant incident, risking future deaths from unaddressed sub-optimal practice.
Responded
Mary Pomeroy
Concerns: A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to implement required enhanced observations for a high-risk patient.
Responded
Ida Lock
Concerns: The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure to learn from past incidents, unreliable data, and inadequate reporting of serious harms.
Responded
Sheridan Pickett
Concerns: No specific coroner's concerns regarding systemic issues or risks to prevent future deaths were identified in the provided text.
Responded
Andrea Mann
Responded
Paul Dunne
Concerns: Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record systems prevented crucial information sharing between departments.
Overdue
Mark-Anthony Summersett
Concerns: A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate risk assessment and timely action for a vulnerable patient.
Responded
Eden Street
Concerns: Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.
Responded
Michael Jervis
Concerns: Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and the absence of a digital alert system.
Responded
Keith Foord
Concerns: Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category 1 is necessary to prevent future deaths.
Responded
John Doyle
Concerns: Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and inconsistent access to protocols for treating kidney transplant patients.
Responded
Darren Hope
Concerns: Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, leading to unaddressed discrepancies and potential safety risks during unescorted leave.
Responded
Joan Knight
Concerns: The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.
Responded
Tamara Davis
Concerns: The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during major incidents.
Responded
Janet Rice
Concerns: A significantly delayed and incomplete patient safety investigation failed to adequately address systemic failures in anticoagulant administration and capacity assessments across hospital transfers, hindering timely learning and comprehensive training.
Responded
Nicola Lacey
Concerns: The provided text describes the deceased's intentions related to suicide but does not detail any specific systemic failures or risks of future deaths identified by the coroner.
Responded
Margaret Clement
Concerns: Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical reviews and urgent clinical assistance for a patient with a significant bleed.
Responded
Elvon Morton
Concerns: Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance failed to identify and review a serious incident, compromising patient safety.
Responded
Olayemi Kehinde
Concerns: Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure to conduct a proper governance investigation into the incident.
Responded
Paz Ogbe-Millar
Concerns: Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Responded
Elizabeth Roberts
Concerns: Persistent, nationally unresolvable staffing shortages within the District Nursing Service continue to impact patient care delivery at a local trust level.
Responded
Hazel Pearson
Concerns: Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a serious risk.
Responded
Kevin O’Hara
Concerns: Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk assessment follow-ups, results in missed opportunities to identify and address safety issues.
Responded
Maxwell Frame
Concerns: The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe practices across hospitals. A standardised national policy is needed to ensure patient safety.
Responded
Bavaniammah Theiventhiran
Concerns: The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. This non-compliance significantly increases patients' risk of early death due to delayed intervention.
Overdue
Madeleine Lawrence
Concerns: Southmead Hospital had serious patient safety deficiencies. Concerns remain regarding the adequacy of current staff training and the measures in place for ongoing training of new staff.
Overdue
Sasha Mishabi
Concerns: St. Andrew's Healthcare displayed chronic non-compliance with its pressure ulcer prevention policy, including failures in assessments, daily skin inspections, and incident reporting. This indicates systemic governance and quality assurance deficiencies.
Responded
Riya Hirani
Concerns: A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent concerns. There was also no clear mechanism for families to obtain a second medical opinion.
Responded
Lynsey Smalley
Concerns: Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical records across mental health teams risks lost notes and poor continuity of patient care.
Responded
Cherry Garland
Concerns: The provided text indicates an extremely important concern was identified, but its specific nature or the risks it poses for future deaths are not detailed.
Responded
Peter Fleming
Concerns: No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that action should be taken to prevent future deaths.
Responded
Raniya Khan
Concerns: The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, raising serious concerns about continued risks.
Responded
Zachary Klement
Concerns: The deceased had a long history of complex mental health conditions, including Autistic Spectrum Disorder, indicating challenges in managing his specific needs.
Responded
Joan Ferguson
Concerns: The report provides no specific details regarding the matters of concern, only a placeholder indicating that concerns (1), (2), and (3) exist.
Responded
Peter Pearson
Concerns: A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and medication records, and staff lacked sufficient patient knowledge, indicating severe systemic failures.
Overdue
Gordon Hendley
Concerns: Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in A&E and ward care. Covid restrictions also hindered family advocacy.
Overdue
Elizabeth Mills
Responded
Edward Akroyd
Concerns: No specific concerns identified within the provided text, which details a critical condition and subsequent death following an expedited delivery due to abnormal CTG tracing.
Responded
Surekha Shivalkar
Concerns: A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's early departure contributed to a failure to identify a critically ill patient.
Overdue
William Doleman, Anita Burkey, Peter Sellars and Carol Cole
Concerns: There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
Responded
Brian Rochell
Concerns: Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. This delay in addressing competence issues poses a risk to future patients.
Overdue
Eva Hayden
Concerns: No specific concerns were detailed in the provided text.
Responded
Amarbai Bhudia
Concerns: Poor communication of medical instructions, inadequate training for nursing and agency staff on NG tube management, and a failure to properly escalate concerns about its function were identified.
Overdue
Stanley Babbs
Concerns: Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients.
Responded
Sarah Gibbs
Concerns: Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.
Responded
Martin Barrett
Concerns: When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative treatment or support.
Responded
Karen Jane Winn
Concerns: Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of anticoagulation decisions on records posed significant risks.
Responded
Roger Wood
Concerns: A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct automatic referral, risking similar failures.
Overdue
Sylvia Scully
Concerns: The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment model, causing significant delays in senior doctor assessment and critical treatment for walk-in patients.
Responded
John Cheetham
Concerns: The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national issue," but provides no specific details on remaining concerns or identified risks.
Responded
Bethan Harris
Concerns: Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions implemented.
Responded
Theo Young
Concerns: Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.
Overdue
Harry Richford
Concerns: The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
Overdue
Clive Miles
Concerns: The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.
Responded
Jean Waghorn
Concerns: The Trust repeatedly ignored its own transfer policy, leading to unnecessary patient movements, and failed to implement promised improvements from previous PFD reports concerning transfer protocols.
Overdue
Daniel Williams
Concerns: Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial care failures on the transferring ward.
Responded
Daphne Wigley
Concerns: The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.
Overdue
Alistair McDonald
Concerns: Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was not assessed by a consultant psychiatrist, nor given clear advice for persistent suicidal feelings.
Overdue
Lewis Doyle
Concerns: Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to a lack of critical information for original prescribers regarding suspended medications.
Overdue
Archie Grieves
Concerns: No specific concerns were detailed in the provided text.
Overdue
Marcie Tadman
Concerns: No specific matters of concern were detailed in the provided text.
Overdue
Graham Tailby
Concerns: No specific concerns were detailed in the provided text.
Responded
Peter Knight
Concerns: The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by the agreed deadline.
Responded
Geoffrey Jackson
Concerns: The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Overdue
Joseph Page
Concerns: Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
Overdue
Lea Hunsley
Concerns: The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Responded
Annette Krasinsky-Lloyd
Concerns: Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.
Overdue
Anna Walker
Concerns: Post-operative checks were not compliant with protocol, leading to delayed detection of a bleed, due to failures in portering, ward nurse responsibilities, and unclear clinical accountability. The incident was also inappropriately downgraded.
Overdue
Kathleen Cooper
Concerns: Persistent, unaddressed systemic failures at the Trust include poor communication, inadequate supervision, incorrect early warning scores, and delayed action on patient deterioration, compounded by challenges from split-site operations.
Overdue
Michael Parke
Concerns: Repeated deaths from misplaced nasogastric tubes exposed systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous "Never Events."
Responded
Amanda Coulthard
Concerns: Multiple deaths from misplaced nasogastric tubes highlight systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous "Never Events."
Responded
Milly Zemmel
Concerns: There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.
Responded
Dorothy Imisson
Concerns: The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
Overdue
Lincoln Brady
Concerns: Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Responded
Alwyn Head
Concerns: Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Responded
June Parkes
Concerns: Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.
Overdue
Lana-Liza Chervonenko
Concerns: High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Overdue
Jean James
Concerns: Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Responded
Natasha Raghoo
Concerns: Critical failures included inadequate staff training in resuscitation, sporadic and incomplete patient observations, and failure to perform essential diagnostic tests like ECGs. Poor communication during staff handovers and with families also compromised care.
Overdue
Barry Dillion
Concerns: Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
Overdue