Quality and safety oversight
463 items
2 sources
Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.
Cross-Source Insight
Quality and safety oversight has been flagged across 2 independent accountability sources:
387 inquiry recs
76 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (387)
BAHA-27 — Interrogation Video Audit
Recommendation: The interrogation policy should require, as part of the auditing process, a review of a selection of video recordings of interrogations of the inspector's choosing. Interrogators should know that the recordings of their interrogations may be inspected in this way.
Gov response: Accepted. Video recording review has been incorporated into the interrogation auditing process.
Accepted
Delivered
BAHA-28 — Tactical Questioning Audit Procedure
Recommendation: The tactical questioning policy should be amended to include a clear and simple auditing procedure.
Gov response: Accepted. A clear auditing procedure for tactical questioning has been implemented.
Accepted
Delivered
BAHA-43 — PM(A) Inspection Authority
Recommendation: The PM(A) and those who in his name carry out inspections of the main operational detention facilities should be expressly recognised as having the right and duty to inspect CPErS handling throughout the detention process including during interrogation.
Gov response: Accepted. PM(A) inspection authority has been formally recognised and extended.
Accepted
Delivered
BAHA-45 — Unannounced Inspections
Recommendation: The PM(A) and the in theatre Force Provost Marshal should take account of the in theatre situation in assessing whether any unannounced MPS inspections of forward detention facilities would be feasible and beneficial. The unit detention officer should be able …
Gov response: Accepted. Procedures for unannounced inspections have been developed.
Accepted
Delivered
BAHA-59 — TQ Training Audit
Recommendation: Enhanced auditing of tactical questioning and interrogation training should be introduced to ensure that the interrogation branch at Chicksands adequately trains students including in the proper limits of approaches.
Gov response: Accepted. Enhanced auditing of tactical questioning and interrogation training has been implemented.
Accepted
Delivered
BAHA-61 — Triennial Legal Review
Recommendation: A more senior and more independent legal review of the kind now being conducted as a one off ad hoc review is also required. Such a review should not be necessary on an annual basis but should provide a suitable …
Gov response: Accepted. A triennial independent legal review has been established.
Accepted
Delivered
BRIS-100 — Mandate ethics committee approval for all new untried invasive clinical procedures
Recommendation: Before any new and hitherto untried invasive clinical procedure can be undertaken for the first time, the clinician involved should have to satisfy the relevant local research ethics committee that the procedure is justified and it is in the patient’s …
Unknown
BRIS-101 — Re-form local ethics committees to assess new invasive clinical procedures
Recommendation: Local research ethics committees should be re-formed as necessary so that they are capable of considering applications to undertake new and hitherto untried invasive clinical procedures.
Unknown
BRIS-104 — Professional bodies must adopt flexible, local disciplinary actions for misconduct
Recommendation: In the exercise of their disciplinary function the professional regulatory bodies must adopt a more flexible approach towards what constitutes misconduct. They must deal with cases, as far as possible, at a local level and must have available a range …
Unknown
BRIS-105 — Involve public in all professional regulatory body activities, including discipline
Recommendation: The need to involve the public in the various professional regulatory bodies applies as much to discipline as to all the other activities of these bodies (see Recommendation 42).
Unknown
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-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-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-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-148 — Implement a single, trusted system for collecting clinical and administrative data
Recommendation: The current ‘dual’ system of collecting data in the NHS in separate administrative and multiple clinical systems is wasteful and anachronistic. A single approach to collecting data should be adopted, which clinicians can trust and use and from which information …
Unknown
BRIS-149 — Improve clinician confidence in Patient Administration Systems data through collaboration
Recommendation: Steps should be taken nationally and locally to build the confidence of clinicians in the data recorded in the Patient Administration Systems in trusts (which is subsequently aggregated nationally to form the Hospital Episode Statistics). Such steps should include the …
Unknown
BRIS-150 — Support Hospital Episode Statistics as a reliable national resource for monitoring outcomes
Recommendation: The Hospital Episode Statistics database should be supported as a major national resource which can be used reliably, with care, to undertake the monitoring of a range of healthcare outcomes.
Unknown
BRIS-151 — Improve status, training, and qualifications of clinical coding staff for data accuracy
Recommendation: Systems for clinical audit and for monitoring performance rely on accurate and complete data. Competent staff, trained in clinical coding, and supported in their work are required: the status, training and professional qualifications of clinical coding staff should be improved.
Unknown
BRIS-152 — Review incentives for data quality; include trust performance in validation process
Recommendation: The system of incentives and penalties to encourage trusts to provide complete and validated data of a high quality to the national database should be reviewed. Any new system must include reports of each trust’s performance in terms of the …
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-154 — Invest in world-class IT systems for efficient healthcare data collection and feedback
Recommendation: The need to invest in world-class IT systems must be recognised so that the fundamental principles of data collection, validation and management can be observed: that data be collected only once; that the data be part and parcel of systems …
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-172 — Urgently agree and implement National Service Framework for children's healthcare
Recommendation: The proposed National Service Framework (NSF) for children’s healthcare services must be agreed and implemented as a matter of urgency.
Unknown
BRIS-173 — NSF must establish standards for all children's acute healthcare services
Recommendation: The NSF should include a programme for the establishment of standards in all areas of children’s acute hospital and healthcare services.
Unknown
BRIS-174 — NSF must set obligatory and aspirational standards for children's services
Recommendation: The NSF should set obligatory standards which must be observed, as well as standards to which children’s services should aspire over time.
Unknown
BRIS-175 — NSF must include incentives for improving children's healthcare services, aiding needy trusts
Recommendation: The NSF should include incentives for the improvement of children’s healthcare services, with particular help being given to those trusts most in need.
Unknown
BRIS-176 — NSF must plan regular publication of children's healthcare quality and performance data
Recommendation: The NSF must include plans for the regular publication of information about the quality and performance of children’s healthcare services at national level, at the level of individual trusts, and of individual consultant units.
Unknown
BRIS-181 — Organise children's specialist services for best staff, facilities, and outcomes, prioritising quality
Recommendation: Specialist services for children should be organised so as to provide the best available staff and facilities, thus providing the best possible opportunity for good outcomes. Advice should be sought from experts on the appropriate number of patients to be …
Unknown
BRIS-183 — Validate trusts providing children's acute services for child-centred policies, staff, and facilities
Recommendation: After completion of a pilot exercise, all trusts which provide acute hospital services for children should be subject to a process of validation to ensure that they have appropriate child- and family-centred policies, staff, and facilities to provide a good …
Unknown
BRIS-192 — Develop national standards for all aspects of congenital heart disease care and treatment
Recommendation: National standards should be developed, as a matter of priority, for all aspects of the care and treatment of children with congenital heart disease (CHD). The standards should address diagnosis, surgical and other treatments, and continuing care. They should include …
Unknown
BRIS-193 — Stipulate minimum paediatric cardiac surgery procedure volumes for hospitals to ensure outcomes
Recommendation: With regard to paediatric cardiac surgery, the standards should stipulate the minimum number of procedures which must be performed in a hospital over a given period of time in order to have the best opportunity of achieving good outcomes for …
Unknown
BRIS-194 — Establish minimum weekly operating sessions for paediatric cardiac surgeons to maintain competence
Recommendation: With regard to those surgeons who undertake paediatric cardiac surgery, although not stipulating the number of operating sessions sufficient to maintain competence, it may be that four sessions a week should be the minimum number required. Agreement on this should …
Unknown
BRIS-195 — Require two paediatric surgeons performing 40-50 open-heart operations annually for infants
Recommendation: With regard to the very particular circumstances of open-heart surgery on very young children (including neo-nates and infants), we stipulate that the following standard should apply unless, within six months of the publication of this Report, this standard is varied …
Unknown
BRIS-196 — Mandate paediatric environment, trained staff, and PICU access for children's interventional procedures
Recommendation: The national standards should stipulate that children with CHD who undergo any form of interventional procedure must be cared for in a paediatric environment. This means that all healthcare professionals who care for these children must be trained and qualified …
Unknown
BRIS-197 — Centralise rare paediatric heart condition surgery to maximum two expert-validated units
Recommendation: Surgical services for children with very rare congenital heart conditions, such as Truncus Arteriosus, or involving procedures undertaken very rarely, should only be performed in a maximum of two units, validated as such on the advice of experts. Such arrangements …
Unknown
BRIS-198 — Urgently investigate paediatric cardiac surgery units for unsafe low patient volumes
Recommendation: An investigation should be conducted as a matter of urgency to ensure that PCS is not currently being carried out where the low volume of patients or other factors make it unsafe to perform such surgery.
Unknown
BRIS-69 — Broaden healthcare professional regulation to include education, training, CPD, and revalidation
Recommendation: Regulation of healthcare professionals is not just about disciplinary matters. It should be understood as encapsulating all of the systems which combine to assure the competence of healthcare professionals: education, registration, training, CPD and revalidation as well as disciplinary matters.
Unknown
BRIS-70 — Establish single regulatory bodies for each distinct healthcare professional group
Recommendation: For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine, and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and …
Unknown
BRIS-71 — Establish a single body to coordinate all healthcare professional regulatory bodies
Recommendation: In addition, a single body should be charged with the overall co-ordination of the various professional bodies and with integrating the various systems of regulation. It should be called the Council for the Regulation of Healthcare Professionals. (In effect, this …
Unknown
BRIS-72 — Prioritise establishing statutory Council for Regulation of Healthcare Professionals with broad membership
Recommendation: The Council for the Regulation of Healthcare Professionals should be established as a matter of priority. It should have a statutory basis. It should report to Parliament. It should have a broadly-based membership, consisting of representatives of the bodies which …
Unknown
BRIS-73 — Grant Council powers to enforce good regulation principles and consistent professional body behaviour
Recommendation: The Council for the Regulation of Healthcare Professionals should have formal powers to require bodies which regulate the separate groups of healthcare professionals to conform to principles of good regulation. It should act as a source of guidance and of …
Unknown
BRIS-74 — Council to prioritise promoting common curricula and shared learning across professions
Recommendation: It should be a priority for the Council for the Regulation of Healthcare Professionals to promote common curricula and shared learning across the professions.
Unknown
BRIS-75 — Establish pilot schemes for common first-year undergraduate education for all healthcare professionals
Recommendation: Pilot schemes should be established to develop and evaluate the feasibility of making the first year’s course of undergraduate education common to all those wishing to become healthcare professionals.
Unknown
BRIS-76 — Universities to develop closer links for joint medical and nursing student education
Recommendation: Universities should develop closer links between medical schools and schools of nursing education with a view to providing more joint education between medical and nursing students.
Unknown
BRIS-77 — Universities to link medical/nursing schools with management training for all professionals
Recommendation: Universities should develop closer links between medical and nursing schools and centres for education and training in health service and public sector management, with a view to enabling all healthcare professionals to learn about management.
Unknown
BRIS-81 — Establish Medical Education Standards Board (MESB) under GMC for postgraduate training
Recommendation: In relation to doctors, we endorse the proposal to establish a Medical Education Standards Board (MESB), to co-ordinate postgraduate medical training. The MESB should be part of and answerable to the GMC which should have a wider role. (See Recommendation …
Unknown
BRIS-90 — Council to review revalidation systems and incorporate managers into professional development
Recommendation: The new Council for the Regulation of Healthcare Professionals should take as a further priority an early review of the various systems of revalidation and re-registration to ensure that they are sufficiently rigorous, and in alignment both with each other …
Unknown
BRIS-91 — Subject healthcare managers to regulatory bodies and professional codes of practice
Recommendation: Managers as healthcare professionals should be subject to the same obligations as other healthcare professionals, including being subject to a regulatory body and professional code of practice. (See Recommendation 70.)
Unknown
HIDD-36 — Continue implementing Total Quality Management Initiative and BS5750 quality systems
Recommendation: BR shall continue to press ahead with its Total Quality Management Initiative and the application of British Standard BS5750: Quality systems.
Unknown
HIDD-37 — Urgently implement the Board's existing quality plan within S&T Departments
Recommendation: S&T Departments shall implement the Board's existing quality plan with the greatest urgency.
Unknown
HIDD-38 — Urgently use outside consultants to review safety management and communication issues
Recommendation: The Court endorses the use of outside consultants to review safety management issues within BR and recommends that the consultants proceed with their programme with the greatest urgency looking particularly at problems of communication up and down the organisation.
Unknown
HIDD-39 — Urgently introduce independent monitoring and auditing for all safety-related work
Recommendation: BR shall introduce monitoring and independent auditing systems in all safety-related aspects of work, in particular the S&T Departments, with the greatest urgency, in advance of Total Quality Management as an aid to good management.
Unknown
HIDD-4 — Urgently ensure and document independent wire counts during testing procedures
Recommendation: BR shall urgently ensure that an independent wire count is carried out as a matter of practice during testing. It shall be the responsibility of the person in overall charge of testing to ensure and to document that an independent …
Unknown
HIDD-40 — Prioritise introduction of on-train data recorders for incident investigation assistance
Recommendation: BR shall give a higher priority to the introduction of on-train data recorders to assist investigation of any future incident.
Unknown
HIDD-41 — Utilise on-train data recorder information for systematic safety monitoring procedures
Recommendation: BR shall consider the use of information from on-train data recorders as part of a systematic safety monitoring procedure.
Unknown
HIDD-42 — Report 6-monthly to Railway Inspectorate on accident follow-up and recommendations
Recommendation: BR shall report at 6 monthly intervals to the Railway Inspectorate on its follow-up to the Clapham Junction accident and implementation of its own and this Report's recommendations.
Unknown
HIDD-43 — Prioritise installation of driver-signalman radio communication on all traction units
Recommendation: BR shall implement as a priority its programme to install a system of radio communication between driver and signalman on all traction units. The introduction of this system shall be in addition to signal-post telephones and not automatically entail their …
Unknown
HIDD-44 — Install voice recorders to provide a record of all radio messages
Recommendation: BR shall instal voice recorders for the purpose of providing a record of all radio messages relayed.
Unknown
HIDD-45 — Government allocate sufficient radio frequencies for important safety communication functions
Recommendation: Government, in discussion with BR, shall allocate a sufficient number of frequencies for this important safety function
Unknown
HIDD-46 — Fully implement Automatic Train Protection within five years, prioritising busy lines
Recommendation: The Court welcomes BR's commitment to introduce Automatic Train Protection on a large percentage of its network, but is concerned at the timetable proposed. After the specific type of ATP system has been selected, ATP shall be fully implemented within …
Unknown
HIDD-47 — Report 6-monthly to Railway Inspectorate on Automatic Train Protection implementation progress
Recommendation: BR shall report at 6 monthly intervals to the Railway Inspectorate on its progress in implementing ATP.
Unknown
HIDD-48 — Study appraisal procedures for safety elements in railway investment proposals
Recommendation: The Department of Transport and BRB shall make a thorough study of appraisal procedure for safety elements of investment proposals so that the cost-effectiveness of safe operation of the railway occupies its proper place in a business-led operation.
Unknown
HIDD-49 — Develop system for allocating project priority to prevent safety compromise
Recommendation: BR shall develop an adequate system of allocating priority to projects to ensure that safety standards are not compromised by delay.
Unknown
HIDD-5 — Identify single individual responsible for overall charge of all testing
Recommendation: BR shall ensure that one individual is always identified as the person in overall charge of testing.
Unknown
HIDD-50 — Establish organisational framework to prevent commercial considerations compromising railway safety
Recommendation: BR shall ensure that the organisational framework exists to prevent commercial considerations of a business-led railway from compromising safety.
Unknown
HIDD-51 — Emphasise signalling irregularity definitions and reportable situations during driver training
Recommendation: BR shall ensure that during driver training the definition of a signalling irregularity and situations which are reportable are given greater emphasis.
Unknown
HIDD-52 — Provide appropriate feedback to drivers reporting signalling irregularities on outcomes
Recommendation: BR shall ensure that drivers, reporting on signalling irregularities, are given appropriate feedback on the outcome.
Unknown
HIDD-53 — Eliminate re-use of insulation tape and ensure secure insulation methods
Recommendation: BR shall ensure that the practice of the re-use of insulation tape is eliminated and the method of insulation is secure.
Unknown
HIDD-54 — Complete research programme into structural integrity of rolling stock by April 1991
Recommendation: BR shall carry out its stated programme of research into the structural integrity of its rolling stock within its planned timescale of completion by April 1991.
Unknown
HIDD-55 — Discuss research conclusions with Inspectorate to agree structural changes for rolling stock
Recommendation: On completion of the programme BR shall discuss its conclusions with the Railway Inspectorate and obtain their agreement to the structural changes necessary to strengthen all relevant rolling stock with a subsequent life span of eight years and over.
Unknown
HIDD-56 — Extend research to include dynamic testing for improved passenger furniture design
Recommendation: BR shall extend its programme of research to include dynamic testing or full-scale simulations of collision retardations in order to improve the design of internal furniture under conditions of passenger impact.
Unknown
HIDD-57 — Seek economic dynamic modelling methods for coach collision resistance research
Recommendation: BR shall, as an alternative to full-scale testing, seek economic and practical methods of dynamic modelling during development stages when researching the structural resistance of coaches to collision conditions.
Unknown
HIDD-58 — Expand involvement in European studies on passenger stock performance and collision resistance
Recommendation: BR shall continue and expand its involvement in collaborative European railway studies of performance of passenger stock, including collision resistance.
Unknown
HIDD-59 — Amend Road and Rail Traffic Act 1933 to include rolling stock approval
Recommendation: Government shall seek to amend S.41 of the Road and Rail Traffic Act 1933 to clarify what work has to be approved by the Secretary of State after inspection, if necessary, and to include rolling stock within the terms of …
Unknown
HIDD-6 — Ensure a comprehensive testing plan is drawn up for every commissioning
Recommendation: BR shall ensure that a testing plan is drawn up for every commissioning.
Unknown
HIDD-60 — Achieve and regularly review overall train loading criteria with Department of Transport
Recommendation: BR shall ensure that overall train loading criteria are achieved. The Department of Transport and BR shall keep the criteria under review.
Unknown
HIDD-7 — Require BR to include sufficient, qualified staff in all testing plans
Recommendation: BR shall ensure that sufficient numbers of suitably qualified staff are included in the testing plan.
Unknown
FENN-150 — Consider establishing a single passenger safety inspectorate for all transport
Recommendation: Consideration should be given to the establishment of a single passenger safety inspectorate charged with monitoring and supervising standards in all passenger transport.
Unknown
P2-1 — Establish single construction industry regulator
Recommendation: That the government draw together under a single regulator all the functions relating to the construction industry to which we have referred. (113.6)
Gov response: The government accepts this recommendation in principle. The single regulator will deliver the functions specified in the report with two exceptions. We do not believe it is appropriate for the single regulator to undertake testing …
Accepted in Part
In progress
P2-12 — Clarify BS 9414 limitations requiring fire engineer assessment
Recommendation: BS 9414 should be approached with caution and we recommend that the government make it clear that it should not be used as a substitute for an assessment by a suitably qualified fire engineer. (113.18)
Gov response: The government accepts this recommendation. We will address this through the response to recommendation 5.
Accepted
In progress
P2-13 — Make construction regulator responsible for product conformity certificates
Recommendation: That the construction regulator should be responsible for assessing the conformity of construction products with the requirements of legislation, statutory guidance and industry standards and issuing certificates as appropriate. We should expect such certificates to become pre-eminent in the market. …
Gov response: The government accepts this recommendation in principle. We have published a construction products green paper alongside the response to the Inquiry that addresses this recommendation more effectively, as it will be considered as part of …
Accepted in Part
In progress
P2-14 — Require test results disclosure and transparency for construction products
Recommendation: a) that copies of all test results supporting any certificate issued by the construction regulator be included in the certificate; b) that manufacturers be required to provide the construction regulator with the full testing history of the product or material …
Gov response: The government accepts this recommendation in principle. Any claims made about a product's performance, including statements about its suitability for use in certain situations, must be clear, honest and evidenced. Test results relied on when …
Accepted in Part
In progress
P2-15 — Establish legal recognition and regulation of fire engineer profession
Recommendation: That the profession of fire engineer be recognised and protected by law and that an independent body be established to regulate the profession, define the standards required for membership, maintain a register of members and regulate their conduct. (113.25)
Gov response: The government accepts this recommendation. We recognise the importance of fire engineers in ensuring life safety and will consider how to most effectively protect and regulate the profession.
Accepted
In progress
19 — Nottingham harmful sexual behaviour evaluation
Recommendation: Nottingham City Council and its child protection partners should commission an independent, external evaluation of their practice concerning harmful sexual behaviour, including responses, prevention, assessment, intervention and workforce development. An action plan should be set up to ensure that any …
Gov response: On 29 July 2021, Nottingham City Council stated that the NSPCC undertook an independent external evaluation of its practice in relation to harmful sexual behaviour. The NSPCC identified opportunities for further strengthening and an action …
Accepted
No update 2+ yrs
22 — National chaperone policy for healthcare (England)
Recommendation: The Chair and Panel recommend that the Department of Health and Social Care develops a national policy for the training and use of chaperones in the treatment of children in healthcare services. The Chair and Panel recommend that the Care …
Gov response: DHSC fully supports the use of chaperones for children, young people and adults at risk. DHSC will seek assurance from NHS England and CQC that the relevant organisations have chaperone protocols in place to safeguard …
Accepted
Delivered
23 — National chaperone policy for healthcare (Wales)
Recommendation: The Chair and Panel recommend that the Welsh Government develops a national policy for the training and use of chaperones in the treatment of children in healthcare services. The Chair and Panel recommend that Healthcare Inspectorate Wales considers compliance with …
Gov response: On 6 January 2020, the Welsh Government published guidance for health boards and trusts in respect of good working practice for the use of chaperones during intimate examinations or procedures within NHS Wales.
Accepted
Delivered
58 — Residential schools inspection and guardians registration
Recommendation: The Department for Education and the Welsh Government should: require all residential special schools to be inspected against the quality standards used to regulate children's homes in England and care homes in Wales; reintroduce a duty on boarding schools and …
Gov response: On 30 June 2022, the UK government stated that it was still of the view that the best way to protect children in residential special schools was to strengthen the National Minimum Standards (NMS), and …
Accepted in Part
No update 2+ yrs
74 — Joint inspection of Victims Code compliance
Recommendation: The Chair and Panel recommend that the Ministry of Justice, Home Office and Attorney General commission a joint inspection of compliance with the Victims' Code in relation to victims and survivors of child sexual abuse. The Victims' Commissioner should be …
Gov response: The Victims Strategy commits to hold agencies to account for compliance with the Victims' Code through improved reporting, monitoring and transparency on whether victims are receiving entitlements. The Ministry of Justice is considering the role …
Not Accepted
8 — Expand Ofsted powers for unregistered settings
Recommendation: The government should introduce legislation to: change the definition of full-time education, and to bring any setting that is the pupil's primary place of education within the scope of the definition of a registered educational setting; and provide the Office …
Gov response: On 2 March 2022, the UK government stated that in 2020 it had consulted to legislate to amend the registration requirements for independent education settings. It confirmed that it had considered responses to the consultation …
Accepted in Part
No update 2+ yrs
P1-10 — Regular CCTV review with swipe card data
Recommendation: Maidstone and Tunbridge Wells NHS Trust must ensure that footage from the CCTV is reviewed on a regular basis by appropriately trained staff and examined in conjunction with swipe card data to identify trends that might be of concern.
Gov response: Implemented. CCTV footage is reviewed regularly in conjunction with swipe card access data. Staff have been trained in monitoring procedures. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-11 — Share HTA reports with reliant organisations
Recommendation: Maidstone and Tunbridge Wells NHS Trust must proactively share Human Tissue Authority reports with organisations that rely on Human Tissue Authority licensing for assurance of the service provided by the mortuary.
Gov response: Implemented. The Trust now proactively shares HTA reports with organisations that rely on the mortuary services. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-13 — Board review governance - assurance not reassurance
Recommendation: We have illustrated throughout this Report how Maidstone and Tunbridge Wells NHS Trust relied on reassurance rather than assurance in monitoring its processes. The Board must review its governance structures and function in light of this.
Gov response: Implemented. The Trust Board has reviewed its governance structures to ensure proper assurance mechanisms are in place rather than relying on reassurance. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 …
Accepted
Delivered
P1-14 — Board oversight of licensed mortuary activity
Recommendation: Maidstone and Tunbridge Wells NHS Trust Board must have greater oversight of licensed activity in the mortuary. It must ensure that the Designated Individual is actively involved in reporting to the Board and is supported in this.
Gov response: Implemented. The Board now has direct oversight of licensed mortuary activity. The Designated Individual reports regularly to the Board and is supported in this role. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial …
Accepted
Delivered
P1-15 — Treat HTA compliance as Trust statutory responsibility
Recommendation: Maidstone and Tunbridge Wells NHS Trust should treat compliance with Human Tissue Authority standards as a statutory responsibility for the Trust, notwithstanding the fact that the formal responsibility under the Human Tissue Act 2004 rests with the Designated Individual. The …
Gov response: Implemented. The Trust treats HTA compliance as a corporate statutory responsibility alongside the formal duties of the Designated Individual. Phase 2 recommendations address broader legislative reform. (Source: Trust assurance statement, February 2024; confirmed in Written …
Accepted
Delivered
P1-16 — Chief Nurse responsible for mortuary assurance
Recommendation: The Chief Nurse should be made explicitly responsible for assuring the Maidstone and Tunbridge Wells NHS Trust Board that mortuary management is delivered in such a way that it protects the security and dignity of the deceased.
Gov response: Implemented. The Chief Nurse has explicit responsibility for assuring the Board on mortuary management and protection of the deceased. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-2 — No deceased left out of fridges overnight
Recommendation: Maidstone and Tunbridge Wells NHS Trust must assure itself that all regulatory requirements and standards relating to the mortuary are met and that the practice of leaving deceased people out of mortuary fridges overnight, or while maintenance is undertaken, does …
Gov response: Implemented. The Trust has confirmed compliance with this requirement. Standard Operating Procedures updated to ensure deceased persons are not left out of fridges unnecessarily. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement …
Accepted
Delivered
P1-7 — Audit and monitor mortuary access
Recommendation: Maidstone and Tunbridge Wells NHS Trust must audit implementation of any resulting new policy and must regularly monitor access to restricted areas, including the mortuary, by all staff and contractors.
Gov response: Implemented. Regular audits of mortuary access are now conducted. Access data is monitored and reviewed. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-8 — Security as corporate responsibility
Recommendation: Maidstone and Tunbridge Wells NHS Trust should treat security as a corporate not a local departmental responsibility.
Gov response: Implemented. Security is now treated as a corporate responsibility with board-level oversight. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-9 — CCTV in mortuary including post-mortem room
Recommendation: Maidstone and Tunbridge Wells NHS Trust must install CCTV cameras in the mortuary, including the post-mortem room, to monitor the security of the deceased and safeguard their privacy and dignity.
Gov response: Implemented. Full CCTV coverage has been installed throughout the mortuary including the post-mortem room, with appropriate safeguards for dignity. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P2-1 — NHS trusts commission specialist security review
Recommendation: All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased people, which should include a detailed risk assessment of the potential breaches of security that could occur. The …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-12 — DI attendance at governance forums
Recommendation: NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as well as reporting upwards when required.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-15 — Routine mortuary reporting to trust boards
Recommendation: All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include the presentation of a formal report, by the accountable executive director, to the trust board on a routine …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-16 — Trust boards assure recommendation implementation
Recommendation: Trust boards should assure themselves that the recommendations in this Report have been implemented.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-17 — Recommendations apply to temporary facilities
Recommendation: Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage and care of deceased people.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-18 — Mortuaries treated as regulated activity in governance
Recommendation: Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent regard to other regulated activities within trust governance arrangements.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-2 — CCTV in all NHS mortuaries
Recommendation: All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the doors of body fridges, while maintaining the security and dignity of deceased people by implementing the appropriate safeguards. …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-28 — CQC guidance on hospice inspection scope
Recommendation: To avoid confusion over its remit, the Care Quality Commission should issue clear guidance to inspectors (and others) that hospice inspections should not include areas where deceased people are kept, other than to focus on the needs of bereaved relatives.
Gov response: The Care Quality Commission (CQC) issued a rapid update to reiterate to inspectors the limits of their regulation in relation to mortuaries, and a further update via its internal bulletin to inspectors. CQC is currently …
Accepted
In progress
P2-29 — Hospices in scope for new regulatory regime
Recommendation: Hospices should be considered in scope for the regulatory measures recommended in Chapter 11.
Gov response: This recommendation is under consideration.
Response Unclear
P2-57 — Local authority review third-party contracts
Recommendation: Local authorities must review all contractual arrangements and agreements with third-party providers of services that care for and transport the deceased. This must include consideration of assurance mechanisms, such as key performance indicators, regular reporting, formal contract review meetings, site …
Gov response: This recommendation is under consideration.
Response Unclear
P2-58 — Contractual incident notification requirement
Recommendation: There must be a contractual requirement to formally notify the contract manager and senior local authority officers of any incidents involving the deceased, as well as the outcome of inspections or other action by the Human Tissue Authority or others …
Gov response: This recommendation is under consideration.
Response Unclear
P2-59 — Local authority contractor governance assurance
Recommendation: Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee the services they provide. This should include Standard Operating Procedures that protect the security and dignity of the …
Gov response: This recommendation is under consideration.
Response Unclear
P2-6 — Security breaches reviewed by expert with action plans
Recommendation: All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be reviewed by a security expert who is able to identify any systemic security issues associated with the incident. …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-60 — Care homes in scope for new regulatory regime
Recommendation: The regulatory measures recommended in Chapter 11 should apply to care homes in England. Regulation should cover both systems and professionals where staff are providing care to deceased people in care homes.
Gov response: This recommendation is under consideration.
Response Unclear
P2-61 — Statutory regulation of funeral directors
Recommendation: The UK government should establish an independent statutory regulatory regime for funeral directors in England as a matter of urgency in order to safeguard the security and dignity of the deceased. This regime should include a licensing scheme, mandatory standards …
Gov response: This recommendation is under consideration.
Response Unclear
P2-62 — Regulations consider whole deceased journey
Recommendation: These regulations and standards should be considered within the overall care and journey of the deceased rather than applying in isolation to funeral directors.
Gov response: This recommendation is under consideration.
Response Unclear
P2-63 — Mandatory information from funeral directors
Recommendation: The standards should include details of mandatory information to be given to customers by funeral directors to provide transparency about the care of the deceased, including information on measures to protect their security and dignity, and what should be expected …
Gov response: This recommendation is under consideration.
Response Unclear
P2-64 — Direct cremation in scope for standards
Recommendation: Direct cremation businesses should also be considered in this context, and mandatory standards to protect the security and dignity of the deceased should be applied to these businesses and to any emerging new models of delivery of care for the …
Gov response: This recommendation is under consideration.
Response Unclear
P2-65 — Funeral director regulation benefits outweigh difficulties
Recommendation: While the introduction of a proportionate statutory regulation and inspection regime may require significant adjustment by funeral director organisations, it is the view of the Inquiry that the benefit to customers and the need for public confidence outweigh the difficulties …
Gov response: This recommendation is under consideration.
Response Unclear
P2-66 — Funeral sector in scope for new regulatory regime
Recommendation: The funeral sector in England should be considered in scope for the broader regulatory measures recommended in Chapter 11.
Gov response: This recommendation is under consideration.
Response Unclear
P2-67 — Faith organisations share guidance on deceased care
Recommendation: All faith organisations should consider how to support their members to deliver high standards of care for the deceased, with a focus on the security and dignity of the deceased – for example, by sharing guidance.
Gov response: This recommendation is under consideration.
Response Unclear
P2-68 — Religious building security for deceased
Recommendation: Where deceased people are in a religious building overnight, measures should be taken to ensure that the building is secure, including, for example, CCTV and secure access control for the area in which they are kept.
Gov response: This recommendation is under consideration.
Response Unclear
P2-69 — Formalise multi-organisation arrangements
Recommendation: Where organisations work together to care for people after death, the arrangements should be formalised through contracts or service level agreements. This should include joint Standard Operating Procedures. The parties to the contracts or service level agreements should ensure that …
Gov response: This recommendation is under consideration.
Response Unclear
P2-7 — Body store security standards match HTA-licensed facilities
Recommendation: The NHS should ensure that the security standards required for body stores are the same as those required for facilities licensed by the Human Tissue Authority.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-70 — Chief Coroner review practice consistency
Recommendation: The Chief Coroner should review the difference in practice between coronial areas as soon as possible to ensure that: All coroners are informed of the findings of this Inquiry. All coroners are aware of the prevalence of offending by David …
Gov response: This recommendation is under consideration.
Response Unclear
In progress
P2-71 — New Chief Inspector regulatory regime for deceased
Recommendation: The UK government should establish an independent statutory regulatory regime, headed by a Chief Inspector, for those who store and care for deceased people. The purpose of the regulatory regime should be to ensure that the security and dignity of …
Gov response: This recommendation is under consideration.
Response Unclear
P2-72 — Interim Commissioner for Dignity of Deceased
Recommendation: In the interim, the government should immediately appoint a Commissioner for the Dignity of the Deceased who should immediately issue universal guidance that applies to all those who store and care for deceased people. This guidance should set out expectations …
Gov response: This recommendation is under consideration.
Response Unclear
P2-73 — Amend HT Act for organisational responsibility
Recommendation: The government should amend the Human Tissue Act 2004 so that the organisation holding the licence has primary legal responsibility to ensure that: There is a suitable Designated Individual in place at their establishment. Suitable premises are provided and maintained. …
Gov response: This recommendation is under consideration.
Response Unclear
P2-74 — HTA require suitable qualified staff with enforcement
Recommendation: The Human Tissue Authority, and/or the new inspectorate, should require the organisations it licenses to ensure that any individual who provides care to deceased people is suitably qualified, experienced and supervised. The regulatory regime should set minimum standards on the …
Gov response: This recommendation is under consideration.
Response Unclear
P2-8 — Swipe to exit for mortuaries
Recommendation: All NHS trusts should consider the installation of 'swipe to exit' for mortuary facilities. This would allow trusts to monitor and audit entry and exit, as well as time spent in the mortuary.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-9 — Monitor and review staff access numbers
Recommendation: All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine review.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
IBI-4c(i) — Simplify External Regulation
Recommendation: Regulation: That external regulation of safety in healthcare be simplified. As a first step towards this, there should be a UK wide review by the four health departments of the systems of external regulation, with the aim of addressing all …
Gov response: UK Government In relation to recommendation 4c) i. the Secretary of State for Health and Social Care asked Dr Penny Dash to conduct a review of patient safety in the health and care landscape. The …
Accepted
In progress
IBI-4c(ii) — Safety Management Systems Coordination
Recommendation: Regulation: That the national healthcare administrations in England, Northern Ireland, Scotland and Wales explore, and if appropriate, support the development and implementation of safety management systems (“SMS”s) through SMS coordination groups (as recommended by the HSSIB), and do so as …
Gov response: UK Government In relation to Recommendation 4c) ii., DHSC agrees that it is important to explore approaches for enhancing the safety of services. In 2023, NHS England established an SMS coordination group with partners from …
Accepted
In progress
IBI-9a — Haemophilia Peer Review
Recommendation: That peer review of haemophilia care should continue to occur as presently practised, with any necessary support being provided by NHS Trusts and Health Boards;
Gov response: UK Government Recommendation 9a-9c: Peer review of UK comprehensive care centres has been an essential part of haemophilia services for many years. The triennial audit was replaced in 2019 with a more formal peer review …
Accepted
In progress
IBI-9b — Trust/Board Action on Peer Reviews
Recommendation: That NHS Trusts and Health Boards should be required to deliberate on peer review findings and give favourable consideration to implementing the changes identified with a view to ensuring comprehensive, safe, care.
Gov response: UK Government Recommendation 9a-9c: Peer review of UK comprehensive care centres has been an essential part of haemophilia services for many years. The triennial audit was replaced in 2019 with a more formal peer review …
Accepted
In progress
IBI-9c — Five-Year Peer Review Cycle
Recommendation: A peer review of each centre should take place not less than once every five years.
Gov response: UK Government Recommendation 9a-9c: Peer review of UK comprehensive care centres has been an essential part of haemophilia services for many years. The triennial audit was replaced in 2019 with a more formal peer review …
Accepted
In progress
IHRD-38 — Multi-Disciplinary Peer Review
Recommendation: Investigations should be subject to multi-disciplinary peer review.
Gov response: Multi-disciplinary review processes incorporated into SAI investigation procedures.
Accepted
Delivered
IHRD-39 — Investigation Team Reconvening
Recommendation: Investigation teams should reconvene after an agreed period to assess both investigation and response.
Gov response: Follow-up review processes established for SAI investigations.
Accepted
Delivered
IHRD-40 — SAI Learning Informing Clinical Audit
Recommendation: Learning and trends identified in SAI investigations should inform programmes of clinical audit.
Gov response: Learning from SAI investigations incorporated into clinical audit programmes.
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: Training protocols updated. Competency requirements incorporated into medical education and continuing professional development.
Accepted
Delivered
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-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
LADB-20 — Strengthen safety audit processes and improve communication quality during audits
Recommendation: The safety audit process should be strengthened, and the quality of communication during the process should be improved (para 9.44).
Unknown
LADB-21 — Require audited organisations to disclose all material information to auditors
Recommendation: An organisation the activities of which are being audited should disclose all material and relevant information to the auditor in regard to the area of the activity which is being audited (para 9.46).
Unknown
LADB-32 — Integrate signal sighting committee recommendations into Railtrack's safety management system
Recommendation: It should form part of Railtrack’s safety management system that it is the responsibility of senior Zone operating and signal engineering management to decide whether the recommendations of a signal sighting committee under the Group Standard on SPADs are to …
Unknown
LADB-89 — HSC to review compliance with recommendations and publish review outcomes.
Recommendation: A review of compliance with the above recommendations should be conducted on behalf of the HSC within six months of publication of this report, and further reviews should be put in hand as necessary thereafter. The HSC should publish the …
Unknown
MAI-121 — Consequences for breaching event healthcare standards
Recommendation: The Department of Health and Social Care together with the Care Quality Commission should consider what the consequences of breaching the appropriate standard should be. That should include consideration of whether the sanction should be criminal in nature.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted in Part
In progress
MAI-126 — Assess quality of first responder training
Recommendation: The Home Office and the College of Policing should regularly assess and appraise the training on first responder interventions provided by each police service to ensure that it is of an appropriate quality and that adequate time is allocated to …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-18 — Address BTP systemic failings from Volume 1
Recommendation: BTP should address the systemic failings identified in Volume 1, so as to ensure that they are not repeated.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-50 — Address Arena failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made at the Arena to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-51 — Address Showsec failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made by Showsec to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-61 — Independent inspection regime for LRFs
Recommendation: Local resilience forums have a vital role in the preparation for the response to any Major Incident. The Cabinet Office and the Home Office should consider implementing an independent inspection regime for local resilience forums.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-62 — LRF oversight of lessons from exercises and incidents
Recommendation: Local resilience forums should establish procedures to ensure that they oversee the process of identifying the lessons to be learned from major exercises, or serious incidents, in their areas, and that they are responsible for overseeing the debriefing of those …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-63 — Monitor LRF attendance and flag concerns
Recommendation: Local resilience forums should monitor attendance and participation at their meetings, and flag promptly any concerns about attendance by members to the leadership of the organisation concerned. The Home Office should ensure that this is being done by local resilience …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-89 — CQC regulation of event healthcare standards
Recommendation: That standard needs to be regulated and enforced. The Care Quality Commission is the appropriate body to provide regulation and enforcement. The Department of Health and Social Care should give urgent consideration to making the necessary changes in the law …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
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
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
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
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
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
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
F152 — Medical training
Recommendation: Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the acceptability of training provided by a healthcare provider, must be required to inform the relevant training regulator 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
F153 — Medical training
Recommendation: The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between the deanery, commissioners, the General Medical Council, the Care Quality …
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
F154 — Medical training
Recommendation: The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight of medical training to coordinate their oversight of healthcare organisations which provide regulated training.
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
F155 — Medical training
Recommendation: The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance with the following principles: The Postgraduate Dean should be responsible for managing the process at the level 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
F156 — Medical training
Recommendation: The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.
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
F157 — Matters to be reported to the General Medical Council
Recommendation: The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical Council either routinely or as they arise. Reports should include a description of all relevant activity and findings …
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
F158 — Training and training establishments as a source of safety information
Recommendation: The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers with minimum standards of patient safety and quality of care, …
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
F159 — Training and training establishments as a source of safety information
Recommendation: Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical Council should consult the Care Quality Commission in developing 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
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
F161 — Training and training establishments as a source of safety information
Recommendation: Training visits should make an important contribution to the protection of patients: Obtaining information directly from trainees should remain a valuable source of information – but it should not be the only method used. Visits to, and observation 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
F162 — Training and training establishments as a source of safety information
Recommendation: The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of medical training and education maintains as its first priority the safety of patients. It should also ensure 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
F163 — Safe staff numbers and skills
Recommendation: The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of available staff for the provision of training and to ensure …
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
F164 — Approved Practice Settings
Recommendation: The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision of the same. Consideration should be given to empowering 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
F165 — Approved Practice Settings
Recommendation: The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public.
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
F166 — Approved Practice Settings
Recommendation: The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view in particular to provision for active exchange of relevant 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
F167 — Approved Practice Settings
Recommendation: The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments with a view to ensuring that the General Medical 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
F168 — Approved Practice Settings
Recommendation: The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for post graduate training.
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
F169 — Role of the Department of Health and the National Quality Board
Recommendation: The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation between them and healthcare systems regulators.
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
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
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
F184 — Enforcement by the Care Quality Commission
Recommendation: Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and wilful deception. The Care Quality Commission should be supported 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
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
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
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
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
F221 — Ensuring common standards of competence and compliance
Recommendation: Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards of health service bodies which are not foundation trusts, of equivalent rigour to that applied to foundation 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
F222 — General Medical Council Systemic investigation where needed
Recommendation: The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be made to it, enabling a more proactive approach to monitoring fitness to practise.
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
F223 — Enhanced resources
Recommendation: If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater resources, or better cooperation with the Care Quality Commission and other organisations such as the Royal Colleges 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
F224 — Information sharing
Recommendation: Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue guidance for use by employers of doctors to the same 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
F225 — Peer reviews
Recommendation: The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic way, in order to be advised whether there are individual …
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
F226 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic concerns as well as individual ones. It must be enabled …
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
F227 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide …
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
F228 — Administrative reform
Recommendation: It is of concern that the administration of the Nursing and Midwifery Council, which has not been examined by this Inquiry, is still found by other reviews to be wanting. It is imperative in the public interest that this is …
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
F229 — Revalidation
Recommendation: It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional …
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
F23 — Responsibility for regulating and monitoring compliance
Recommendation: The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include …
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
F230 — Profile
Recommendation: The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable source of information about the conduct of nurses. All patients should be informed, by those providing treatment 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
F231 — Coordination with internal procedures
Recommendation: It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be possible, through cooperation, to allow both to proceed in parallel. …
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
F232 — Employment liaison officers
Recommendation: The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this is impractical, a support network of senior nurse leaders will …
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
F233 — For joint action Profile
Recommendation: While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that patients and other service users are made aware at the point of service provision of their existence, 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
F234 — Cooperation with the Care Quality Commission
Recommendation: Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in many cases there should be joint working to minimise the time taken to resolve issues and maximise 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
F235 — Joint proceedings
Recommendation: The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for dealing consistently and in the public interest with cases arising …
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
F24 — Responsibility for regulating and monitoring compliance
Recommendation: Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted by the public and healthcare professionals.
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
F246 — Comparable quality accounts
Recommendation: Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form to enable comparisons to be made between organisations, to include a minimum of prescribed information about their 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
F247 — Accountability for quality accounts
Recommendation: Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems regulators.
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
F248 — Accountability for quality accounts
Recommendation: Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to use their professional judgement in examining the reliability of all statements in the accounts.
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
F249 — Accountability for quality accounts
Recommendation: Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying that they believe the contents of the account to be true, or alternatively a statement of explanation 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 in Part
F25 — Responsibility for regulating and monitoring compliance
Recommendation: It should be considered the duty of all specialty professional bodies, ideally together with the National Institute for Health and Clinical Excellence, to develop measures of outcome in relation to their work and to assist in the development of measures …
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
F250 — Accountability for quality accounts
Recommendation: It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account are true if it contains a misstatement of fact concerning an item of prescribed information which he/she does …
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
F251 — Regulatory oversight of quality accounts
Recommendation: The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled to require corrections to be issued where appropriate. In the event of an organisation failing to take 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
F258 — Role of the Health and Social Care Information Centre
Recommendation: The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to comparative performance statistics.
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
F259 — Role of the Health and Social Care Information Centre
Recommendation: The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should develop a means of publishing more detailed breakdowns of clinically related complaints.
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
F26 — Responsibility for regulating and monitoring compliance
Recommendation: In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and protocols. The regulatory system should retain 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
F260 — Information standards
Recommendation: The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied …
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
F261 — Information standards
Recommendation: The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.
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
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
F263 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in specialties.
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
F264 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review.
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
F268 — Resources
Recommendation: Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.
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
F269 — Improving and assuring accuracy
Recommendation: The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and where possible improved.
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
F27 — Responsibility for regulating and monitoring compliance
Recommendation: The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental standards; and allowing no place for favourable assumptions, unless there is evidence showing that suspicions are ill-founded 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
F270 — Improving and assuring accuracy
Recommendation: There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the patient outcome statistics, including hospital mortality and other outcome indicators. In particular, there could be benefit from consideration …
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
F271 — Improving and assuring accuracy
Recommendation: To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and the Health and Social Care Information Centre should work towards establishing such status for them or any successor …
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
F272 — Improving and assuring accuracy
Recommendation: There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation scheme has been included in the Health and Social Care Act 2012, it should be used as soon …
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
F275 — Independent medical examiners
Recommendation: It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.
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
F276 — Independent medical examiners
Recommendation: Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.
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
F277 — Death certification
Recommendation: National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, that similar approaches are universal.
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
F278 — Death certification
Recommendation: It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether 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
F279 — Death certification
Recommendation: So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge of a patient's case or treatment.
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
F28 — Sanctions and interventions for non-compliance
Recommendation: Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable to an organisation in the case of a system failure and to individual accountability where individual professionals 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
F282 — Information for and from inquests
Recommendation: Coroners should send copies of relevant Rule 43 reports 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
F283 — Information for and from inquests
Recommendation: Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the death of a patient. This should include contact with the patient's family.
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
F29 — Sanctions and interventions for non-compliance
Recommendation: It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory requirements, or, in any other case of breach, where a warning notice in respect of the breach has …
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
F30 — Interim measures
Recommendation: The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach of fundamental standards, even if it has yet to reach a concluded view or acquire all the evidence. …
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
F31 — Interim measures
Recommendation: Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place policies which ensure that they constantly review whether the need to protect patients requires use of their own …
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
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
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
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
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
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
18 — Ensure external oversight of implementation
Recommendation: All of the previous recommendations should be implemented with the involvement of Clinical Commissioning Groups, and where necessary, the Care Quality Commission and Monitor. In the particular circumstances surrounding the University Hospitals of Morecambe Bay NHS Foundation Trust, NHS England …
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
32 — Reform Local Supervising Authority for midwives
Recommendation: The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation Trust, not only in individual failures of care but also with the systems to investigate them. As with …
Gov response: 83. We accept this recommendation. We will therefore modernise the regulatory regime for midwifery. 84. The statutory supervision of midwives was designed in 1902 to protect the public. It no longer meets the needs of …
Accepted
33 — CQC and Monitor coordination
Recommendation: We considered carefully the effectiveness of separating organisationally the regulation of quality by the Care Quality Commission from the regulation of finance and performance by Monitor, given the close inter-relationship between Trust decisions in each area. However, we were persuaded …
Gov response: 87. We accept this recommendation. Closer working links have been established and will be developed further. 88. An updated Memorandum of Understanding between Monitor and the Care Quality Commission was published on 26 February 2015. …
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
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
WATE-(40) — Develop key indicators to monitor compliance with safeguards for looked after children
Recommendation: Appropriate key indicators of compliance with safeguards for looked after children should be developed, covering particularly:34, 62(i) (a) the allocation of a designated social worker to each looked after child; (b) compliance with fostering and placement regulations; (c) statutory review …
Unknown
WATE-(41) — Require all private children's homes to register with the independent regulatory agency
Recommendation: All private children's homes should be required to register with the independent agency referred to in recommendation (47).
Unknown
WATE-(42) — Mandate governing bodies for larger private children's homes and residential schools
Recommendation: The owner of a private children's home and the owner of a private residential school approved generally for SEN children or receiving SEN children with the consent of the Secretary of State should be required, if the establishment is above …
Unknown
WATE-(43) — Disclose financial information of private children's homes and residential schools to regulators
Recommendation: The accounts and other relevant financial information relating to private children's homes and private residential schools approved generally for SEN children or receiving SEN children with the consent of the Secretary of State should be disclosed to the relevant regulatory …
Unknown
WATE-(44) — Urgently review legislation to establish stricter regulation for private residential schools
Recommendation: There should be an urgent review of the legislation governing the regulation of private residential schools to include particularly:71 (a) approvals and consents under section 347 of the Education Act 1996921 and for provisional registration of schools, (b) the Notice …
Unknown
WATE-(47) — Establish an independent regulatory agency for all children's services in Wales
Recommendation: Without prejudice to the continuing role generally of the Social Services Inspectorate for Wales, an independent regulatory agency for children's services in Wales should be established, with a local base or local bases in North Wales, and charged with the …
Unknown
WATE-(48) — Ensure inspectors of children's services have substantial child care experience
Recommendation: When inspections are made by the agency of homes, schools or services mentioned in recommendation (47) at least one of the inspectors should have substantial experience of child care.
Unknown
WATE-(49) — Mandate joint inspection programmes for educational and welfare oversight of residential schools
Recommendation: The agencies responsible for educational and welfare inspections of private residential schools accommodating children with SEN pursuant to section 347 of the Education Act 1996 should be required to agree joint programmes of inspection and reporting.
Unknown
WATE-(50) — Apply common standards across all sectors for looked after children's services
Recommendation: A common set of standards should be applied to the local authority, voluntary and private sectors in relation to residential provision and other services for looked after children.
Unknown
WATE-(51) — Send local authority children's homes inspection reports to Chief Executives
Recommendation: Copies of the reports of inspections of local authorities' children's homes and services should be sent to the Chief Executives as well as the Directors of Social Services.
Unknown
WATE-(52) — Send private and voluntary care inspection reports to relevant placing authorities
Recommendation: Copies of reports of inspections of private and voluntary children's homes and of private residential schools should be sent to the Director of Social Services of any placing authority with a child at the school and of the authority in …
Unknown
WATE-(53) — Require agency to present annual report on work and constraints
Recommendation: The agency referred to in recommendation (47) should present an annual report on all aspects of its work, including any constraints upon that work and any shortfall in fulfilling its obligations.
Unknown
WATE-(54) — Mandate child care expert on local authority social services management team
Recommendation: There should be at least one full member of a local authority's social services department management team with child care expertise and experience.
Unknown
WATE-(55) — Assign children's services policy and oversight to Assistant Director level manager
Recommendation: The responsibility for policy and service development and for oversight of the delivery of a local authority's children's services should be assigned to one member of the social services department management team of at least Assistant Director status.
Unknown
WATE-(56) — Ensure sufficient intermediate management staff for children's services supervision and support
Recommendation: Staffing resources at intermediate management level for a local authority's children's services should be sufficient in number and quality to enable positive and close supervision and support to be given to residential establishments and the fostering service.
Unknown
POH-3 — Apply full and fair meaning consistently across all schemes
Recommendation: The Post Office, the Department and the Minister shall ensure that all decision makers in HSS, GLOS and OCS/HCRS apply the meaning to be given to the words "full and fair" when assessing the amounts to be awarded to individual …
Gov response: Department for Business and Trade accepts this recommendation. Both DBT and Post Office have agreed to apply the meaning to be given to the words "full and fair" as set out in the public statement …
Accepted
Delivered
POH-5 — Allow 3-month window to accept Fixed Sum Offer after assessment
Recommendation: Any claimant who opts to have a claim assessed when the claim is submitted to the Post Office or the Department may decide to accept the Fixed Sum Offer at any time thereafter up to and including the date which …
Gov response: Department for Business and Trade accepts this recommendation. From 9 October, claimants to HSS and HCRS will have 3 months from receipt of their first detailed assessed offer to revert to accepting the Fixed Sum …
Accepted
Delivered
RHI-32a — Governance Systems Review
Recommendation: The checks and balances within a Department designed to catch problems early failed over many years in DETI to identify certain of the risks of the RHI or their materialisation. All Departments would benefit from reviewing how their governance systems …
Gov response: [Note: The NI Executive responded to recommendations 19-23, 29-33 together as a group under the 'Governance and Financial Controls' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full. It is important …
Accepted
No update 2+ yrs
MACP-3 — Grant Her Majesty's Inspectors full powers to inspect all Police Services.
Recommendation: That Her Majesty's Inspectors of Constabulary (HMIC) be granted full and unfettered powers and duties to inspect all parts of Police Services including the Metropolitan Police Service.
Unknown
MACP-4 — Conduct immediate HMIC inspection of Metropolitan Police Service, including undetected murders.
Recommendation: That in order to restore public confidence an inspection by HMIC of the Metropolitan Police Service be conducted forthwith. The inspection to include examination of current undetected HOLMES based murders and Reviews into such cases.
Unknown
MACP-5 — Apply OFSTED-like standards to Police Service inspections for improved quality and reporting
Recommendation: That principles and standards similar to those of the Office for Standards in Education (OFSTED) be applied to inspections of Police Services, in order to improve standards of achievement and quality of policing through regular inspection, public reporting, and informed …
Unknown
MACP-53 — Implement independent and regular monitoring of all Police Service training
Recommendation: That there should be independent and regular monitoring of training within all Police Services to test both implementation and achievement of such training.
Unknown
MACP-55 — Implement and monitor new police disciplinary and complaints procedures for effectiveness
Recommendation: That the changes to Police Disciplinary and Complaints procedures proposed by the Home Secretary should be fully implemented and closely and publicly monitored as to their effectiveness.
Unknown
MACP-58 — Home Secretary ensure independent investigation of serious complaints against police officers
Recommendation: That the Home Secretary, taking into account the strong expression of public perception in this regard, consider what steps can and should be taken to ensure that serious complaints against police officers are independently investigated. Investigation of police officers by …
Unknown
MACP-59 — Home Office review and monitor police selection and promotion standards for senior officers
Recommendation: That the Home Office review and monitor the system and standards of Police Services applied to the selection and promotion of officers of the rank of Inspector and above. Such procedures for selection and promotion to be monitored and assessed …
Unknown
MACP-6 — Reconsider Metropolitan Police Authority powers to align with other services, including appointments
Recommendation: That proposals as to the formation of the Metropolitan Police Authority be reconsidered, with a view to bringing its functions and powers fully into line with those which apply to other Police Services, including the power to appoint all Chief …
Unknown
MACP-62 — Require police services to monitor, analyse, review, and publish relevant records
Recommendation: That these records should be monitored and analysed by Police Services and Police Authorities, and reviewed by HMIC on inspections. The information and analysis should be published.
Unknown
ICL-4 — Independent Risk Assessment Audit
Recommendation: The current risk assessment system should be improved by the addition of an independent audit process.
Gov response: Stakeholders were strongly opposed (78%) to mandatory independent audits of all risk assessments. A significant majority (62%) were also opposed to such measures for LPG only. The Government does not consider that the case has …
Not Accepted
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
R13 — Clear nursing responsibility line
Recommendation: Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.
Gov response: Section 2.2 of the Scottish Government's response addresses leadership and management structures. It highlights the strengthened role of senior charge nurses through the Leading Better Care initiative, which provides a template for developing their role …
Accepted
R14 — Patient records compliance audit
Recommendation: Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.
Gov response: Section 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear, accurate, and contemporaneous records. While the text does not explicitly state …
Accepted
R33 — Nursing complaint investigation
Recommendation: Health Boards should ensure that where a complaint is made about nursing practice on a ward this complaint is investigated by an independent senior member of Nursing Management.
Gov response: Section 4.1 of the Scottish Government's response acknowledges the report's finding of 'poor complaint management by nursing teams,' which forms the substance of recommendation 33. While the response generally accepts recommendations relating to nursing care, …
Accepted
R44 — IPC staff appraisals
Recommendation: Health Boards should ensure that performance appraisals of infection prevention and control staff take place at least annually.
Gov response: Section 4.1 of the Scottish Government's response outlines that registered health professionals, including nurses and doctors, are regulated by bodies like the NMC and GMC, which set professional standards. While not explicitly stating annual appraisals …
Accepted
R45 — Manager IPC job description
Recommendation: Health Boards should ensure that where a manager has responsibility for oversight of infection prevention control, this is specified in the job description.
Gov response: Section 2.2 of the Scottish Government's response details the specific responsibilities of the Infection Control Manager (ICM), including overall responsibility for coordinating prevention and control of infection throughout the NHS board area and delivering the …
Accepted
R46 — ICM direct responsibility
Recommendation: Health Boards should ensure that the Infection Control Manager has direct responsibility for the infection prevention control service and its staff.
Gov response: Section 2.2 of the Scottish Government's response clearly states that the Infection Control Manager (ICM) has overall responsibility for coordinating prevention and control of infection throughout the NHS board area and delivering the board-approved infection …
Accepted
R47 — ICM reports to CEO
Recommendation: Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive or, at least, to an executive board member.
Gov response: Section 2.2 of the Scottish Government's response explicitly states that the Infection Control Manager (ICM) is accountable directly to the chief executive and the board. Furthermore, the Scottish Government has been working with partners since …
Accepted
R48 — ICM Board HAI reporting
Recommendation: Health Boards should ensure that the ICM is responsible for reporting to the Board on the state of HAI in the organisation.
Gov response: Section 2.2 of the Scottish Government's response specifies that the Infection Control Manager (ICM) is responsible for producing an annual report on the state of HAI, decontamination, and cleaning in the NHS board and releasing …
Accepted
R49 — National ICM role guidance
Recommendation: Scottish Government should re-issue national guidance on the role of the ICM, stipulating that the ICM must be responsible for the management of the infection prevention and control service.
Gov response: Section 2.2 of the Scottish Government's response indicates that the government has been working with partners since 2014/15 to ensure the stipulation that infection control managers have direct lines of communication and accountability to the …
Accepted
R51 — ICT functions as team
Recommendation: Health Boards should ensure that any Infection Control Team functions as a team, with clear lines of communication and regular meetings.
Gov response: Section 2.1 of the Scottish Government's response highlights the role of the national HAI Taskforce, which coordinates, implements, and monitors actions across NHS Scotland to reduce HAIs, working with local teams and existing structures. The …
Accepted
R52 — IPC policy adherence audits
Recommendation: Health Boards should ensure that adherence to infection prevention and control polices, for example C. difficile and Loose Stools Policies, is audited at least annually.
Gov response: Section 3.3 of the Scottish Government's response states that quality improvement uses a range of methods, such as audit, to deliver change and improve outcomes. Section 2.1 details that a robust HAI scrutiny regime is …
Accepted
R56 — Regular IPC group meetings
Recommendation: Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through the management structure.
Gov response: Section 2.2 of the Scottish Government's response notes the recommendation that NHS boards should ensure infection prevention and control is explicitly considered at all clinical governance committee meetings. Section 2.1 describes the national HAI Taskforce, …
Accepted
R57 — IPC committee minutes reporting
Recommendation: Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to the level above in the hierarchy.
Gov response: Section 4.2 of the Scottish Government's response details that registered health professionals must meet professional standards on record-keeping established by their regulatory bodies, and the Scottish Government has its own Records Management: NHS code of …
Accepted
PFD Reports (76)
Linda Books
Concerns: The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, and confusion about Serious Incident Report procedures.
Pending
Mark Foster
Concerns: The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Response: The surgery has appointed a new practice manager and GP partner for governance, implemented a new governance structure, and revised its Significant Event Policy. All staff are now instructed to …
Responded
Ricky Monahan
Concerns: An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines for fire escape protections in such settings.
Response: NHS England states that appropriate national guidance regarding patient safety and risk assessment in mental health settings already exists, implying the issue was with local implementation of environmental risk assessments …
Response: The Environmental Risk Assessment has been updated to include the fire escape, and the Trust has installed new metal fence panels and an eight-foot-high gate on the ground floor and …
Response: The CQC outlines its existing regulatory duties under Regulation 12 regarding safe care and treatment, and explains its inspection processes, but states the issue of national guidelines for fire escape …
Responded
Keith Hankin
Concerns: A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading to fragmented care and potential detriment to patient safety.
Responded
Linda Farmer
Concerns: The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a detailed inquiry, leaving systemic issues unaddressed and risking future patient harm.
Responded
John Tompkins
Concerns: The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in its subsequent investigation.
Responded
Karen Day
Concerns: The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems for internal investigation of patient safety incidents.
Responded
Michael Thompson
Concerns: A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the official investigation failed to address this key issue, hindering learning from deaths.
Responded
Janet Brown Townend
Concerns: The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.
Responded
Phyllis Tromans
Concerns: A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. The subsequent investigation failed to identify the root causes of these critical care gaps.
Responded
Sylvia Prichard
Concerns: The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.
Responded
Elizabeth Holder
Concerns: The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately identified and reflected upon these care failings, preventing effective remediation.
Overdue
Philips Evans
Concerns: The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to recurring patient safety risks.
Responded
Paul Roberts
Concerns: The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient safety.
Responded
Richard Fitzgerald
Concerns: Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation was criticised for its lack of thoroughness.
Responded
Alan Soane
Concerns: A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT meetings, leading to an incorrect cancer diagnosis. This poses a significant widespread risk to patients.
Responded
Jamie Pilkington
Concerns: Mental health teams repeatedly failed to complete suicide risk assessments and thoroughly explore the deceased's suicidal thoughts, research into methods, or support networks. No system changes were assured to prevent future omissions.
Responded
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
Sarah Holmes
Concerns: The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially allowing lethal hazards to persist longer than necessary.
Responded
Michael Bray
Concerns: Ambulance response times for Category 2 calls are persistently and significantly below target, posing a risk of future deaths. Current actions to address these long delays have been demonstrably ineffective.
Responded
Thomas Jayamaha
Concerns: Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation process, raise concerns about effective service improvement.
Responded
Ann Daghlian
Concerns: The nursing and care provider lacked a formal system to trigger multi-disciplinary reviews for patient deterioration or to monitor whether care plans were being met, despite clear signs of refusal for essential care.
Responded
Joan Richardson
Concerns: Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure areas and falls, were absent. Staff training and escalation procedures for deteriorating patients were inadequate, leading to undocumented pressure ulcers.
Overdue
Yvonne Eaves
Concerns: Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the VTE policy, created significant patient risks.
Overdue
Rebecca Begg
Concerns: The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated time for staff to read care plans.
Overdue
Darrell Devlin
Concerns: Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or polydrug exposure.
Responded
Emma Burbury
Concerns: There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.
Responded
Philip Ellis
Concerns: The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.
Responded
Susan Merton
Concerns: The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.
Responded
Kyle Hurst
Concerns: The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.
Responded
Pauline Brumfitt
Concerns: The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Overdue
Rachel Johnston
Concerns: The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Overdue
Elizabeth Robinson
Concerns: Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.
Responded
Frank Medley
Concerns: The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
Responded
Gillian McKinlay
Concerns: There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.
Overdue
Pamela Evans
Concerns: Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.
Responded
Ben Haddon-Cave
Concerns: Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.
Responded
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
Evelyn Swift
Concerns: The medical group had multiple systemic failures, including unsafe patient triage and home visit procedures, insufficient clinical capacity, poor documentation, and a lack of processes for reviewing significant events to learn from them.
Overdue
Kathleen Smith
Concerns: Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
Responded
Sophie Bennett
Concerns: The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
Overdue
Jean Cutler
Concerns: The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.
Responded
Ruth Whitmore
Concerns: Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which failed to thoroughly interview staff or analyse events.
Overdue
Tom Cribley
Concerns: Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.
Overdue
Margaret Evans
Concerns: Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Overdue
Sylvia Davies
Concerns: Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial patient information provided by families create ongoing safety risks.
Overdue
Ester Wood
Concerns: Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
Overdue
Neville Welton
Concerns: The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.
Responded
Lewis Colgan
Concerns: Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and an incomplete Root Cause Analysis further raised concerns.
Overdue
David Sketchley
Concerns: The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Responded
Elaine Bradbrook
Concerns: Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.
Responded
Sarah Kiff
Concerns: GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.
Responded
David Lindsey
Concerns: The Trust failed to adhere to both NICE guidelines and its own internal policies concerning cancer screening, referrals, diagnosis, and treatment.
Overdue
Brian Betterton
Concerns: Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log installation locations or end-user details.
Responded
Sam Crick
Concerns: Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Responded
Doreen Willis
Concerns: Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light of these findings.
Responded
Martyn Watkins
Concerns: Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.
Overdue
Barry Thompson
Concerns: Systemic failures included non-compliance with sepsis protocols, inadequate diabetic patient monitoring, issues with medication administration, and poor record-keeping, leading to fragmented and unreliable care.
Overdue
Norman Beard
Concerns: Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Overdue
Helen Millard
Concerns: The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.
Overdue
Harry Gill
Concerns: The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Responded
Angela Brealey
Concerns: The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.
Overdue
Adrian Smith
Concerns: A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to ensure specialist advice is implemented.
Overdue
Kathleen Neville
Concerns: The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
Overdue
Amanda Ellams
Concerns: Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone system collectively contributed to significant care failures.
Overdue
Maurice Cowling
Concerns: Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.
Responded
Huseyin Erdogan
Concerns: Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.
Overdue
Edwin Thompson
Concerns: A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.
Overdue
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
Concerns: Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.
Responded
Peter White
Concerns: Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.
Overdue
Clive Clinton
Concerns: A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of harm.
Overdue
Derrick Rivers
Concerns: The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Overdue
Mary Waldron
Concerns: Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
Overdue
Kathleen Rosemary Dixon
Concerns: Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Response: The Department of Health reports that the Care Quality Commission (CQC) has already issued two warning notices and published an inspection report identifying shortfalls at Cumbria Partnership NHS Foundation Trust. …
Pending
Walter Gordon Powley
Concerns: Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Response: The CQC acknowledges its inspector did not assess against relevant regulations for premises safety in this case. They are piloting a new inspection methodology that will focus on safety and …
Response: The Health and Safety Executive (HSE) intends to raise concerns about assessing the risk from hot surfaces and pipework at its Social Care Partners Forum and a national local authority …
Response: The Registered Nursing Home Association (RNHA) states the specific care home is not a member, thus they have no regulatory powers. They currently advise their members on the need for …
Responded
Rose Hollingworth
Concerns: The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan and inadequate monitoring of service performance for a vulnerable person.
Responded