Staff training and development
1,517 items
2 sources
Lack of effective systems to ensure staff receive appropriate training, ongoing support, professional development, supervision, and appraisal.
Cross-Source Insight
Staff training and development has been flagged across 2 independent accountability sources:
490 inquiry recs
1027 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (490)
ANG-2 — Improve guidance and training on indecent exposure
Recommendation: By December 2024, the College of Policing, in collaboration with the National Police Chiefs' Council, should improve guidance and training on indecent exposure, in order to improve the quality of investigations and management of indecent exposure cases. In particular, the …
Gov response: Home Secretary James Cleverly said: "The act of pure evil committed against Sarah shocked the nation to its core. My heart goes out to Sarah's family and to all the brave victims who came forward …
Accepted
In progress
BAHA-14 — Communicating Sight Deprivation Reasons
Recommendation: JDP 1-10 should include guidance that where practicable CPErS should be told the reason why sight deprivation is being applied. Suitable simple phrases in relation to sight deprivation should be included in mission specific language training.
Gov response: Accepted. Guidance on communicating with CPErS about sight deprivation has been added, including language training requirements.
Accepted
Delivered
BAHA-15 — Unit Holding Area Checklist
Recommendation: JDP 1-10 should include a simple checklist covering both the principles and practicalities of accommodation for unit holding areas.
Gov response: Accepted. A checklist for unit holding area accommodation has been developed and included.
Accepted
Delivered
BAHA-2 — Standard Orders Prohibiting Five Techniques
Recommendation: Joint Doctrine Publication (JDP) 1-10 should include the requirement for standard orders to be issued for each operation prohibiting the use of the five techniques.
Gov response: Accepted. JDP 1-10 has been updated to require standard orders prohibiting the five techniques for each operation.
Accepted
Delivered
BAHA-20 — Doctrine Usability Review
Recommendation: The MoD should ensure that Development Concepts and Doctrine Centre (DCDC) reviews whether its protocols for layout and pagination of joint doctrine really serve the end user.
Gov response: Accepted. DCDC has reviewed and improved the layout and accessibility of joint doctrine publications.
Accepted
Delivered
BAHA-21 — Generic CPErS Handling SOI
Recommendation: Permanent Joint Headquarters (PJHQ) should complete work on a generic theatre-level Standard Operating Instruction (SOI) for CPErS handling. This should stand as the starting template for CPErS handling on future operations.
Gov response: Accepted. A generic theatre-level SOI for CPErS handling has been developed.
Accepted
Delivered
BAHA-22 — Tactical Questioning Policy Clarity
Recommendation: Urgent consideration must be given to amending the tactical questioning policy to make clear what approaches are and are not authorised for use in tactical questioning. In future all tactical questioning and interrogational policies should descend to greater detail on …
Gov response: Accepted. The tactical questioning policy has been amended to provide detailed guidance on authorised approaches.
Accepted
Delivered
BAHA-23 — Ban Harsh Approach in Tactical Questioning
Recommendation: The harsh approach should no longer have a place in tactical questioning. The MoD should forbid tactical questioners from using what is currently known as the harsh approach and this should be made clear in the tactical questioning policy and …
Gov response: Not accepted. The Defence Secretary decided not to accept this recommendation. The MoD retained the ability to use the harsh approach in tactical questioning, subject to strict parameters and safeguards.
Not Accepted
BAHA-24 — Harsh Approach Parameters
Recommendation: To the extent that the MoD considers that the harsh approach can still lawfully be used in interrogation: (1) there is a need for very clear guidance to be given within the interrogation policy; (2) the approach should be given …
Gov response: Accepted. Guidance on the harsh approach has been clarified, renamed, and requires Ministerial approval for operational use.
Accepted
Delivered
BAHA-26 — Guidance on Exploiting Pressures
Recommendation: The tactical questioning and interrogation policies should give more detailed guidance on the extent to which tactical questioners and interrogators may seek to exploit self and system induced pressures.
Gov response: Accepted. More detailed guidance on self and system induced pressures has been provided.
Accepted
Delivered
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-29 — Medical Personnel Role
Recommendation: Armed Forces medical personnel can and should be involved in providing advice that a CPErS is not fit for detention or questioning. Alternatively, the medic may validly advise that no specific intervention different from the normal process is required. Medics …
Gov response: Accepted. The role of medical personnel has been clarified to focus on identifying unfitness rather than certifying fitness.
Accepted
Delivered
BAHA-3 — Broaden Stress Position Definition
Recommendation: The definition of stress positions in JDP 1-10 and elsewhere should be broadened so that it is not dependent upon the intention of the person enforcing the position.
Gov response: Accepted. The definition has been broadened to: 'Any physical posture which a captured person is deliberately required to maintain will be a stress position if it becomes painful, extremely uncomfortable or exhausting to maintain.'
Accepted
Delivered
BAHA-30 — CPErS Medical Examination Policy
Recommendation: The medical policy for CPErS should include: (1) CPErS must undergo a medical examination within four hours of capture, unless there are compelling circumstances; (2) CPErS should be examined by a qualified doctor as soon as reasonably practicable; (3) the …
Gov response: Accepted. Medical examination requirements have been updated in line with these recommendations.
Accepted
Delivered
BAHA-31 — Update SOI J3-9 Definitions
Recommendation: The definitions of the prohibited techniques contained in SOI J3-9 should be updated to reflect the recommendations made in respect of JDP 1-10.
Gov response: Accepted. SOI J3-9 has been updated to reflect the revised definitions.
Accepted
Delivered
BAHA-32 — SOI J3-9 Sight Deprivation
Recommendation: SOI J3-9 should reflect the greater emphasis that is given in the latest draft of JDP 1-10 to avoiding in the first place, where practicable, circumstances in which sight deprivation may be necessary. More generally, it should reflect the five …
Gov response: Accepted. SOI J3-9 has been updated to emphasise avoiding sight deprivation where practicable.
Accepted
Delivered
BAHA-33 — Communicating Deprivation Reasons
Recommendation: Where practicable CPErS who are subjected to sight deprivation or hearing deprivation should be told the reason for it. If being deprived of their sight for some or part of a journey by road or air, CPErS should be told …
Gov response: Accepted. Requirements to communicate with CPErS about sensory deprivation have been implemented.
Accepted
Delivered
BAHA-34 — Consistent Sight Deprivation Terminology
Recommendation: Theatre level detention instructions and guidance should be reviewed to ensure that references to the means of permissible sight deprivation are consistent. The clearest wording is likely to be 'sight deprivation by blacked-out goggles'.
Gov response: Accepted. Terminology has been standardised to 'sight deprivation by blacked-out goggles'.
Accepted
Delivered
BAHA-36 — CPErS Documentation
Recommendation: CPErS documents should be as few in number as possible but they require amendment to ensure that those involved in detention are guided more accurately on what to record. Current CPERS documents have no obvious place for soldiers to record …
Gov response: Accepted. CPErS documentation has been amended to include recording of sensory deprivation use.
Accepted
Delivered
BAHA-38 — Single Comprehensive CPErS Order
Recommendation: The MoD should continue its recent practice of ensuring that theatre level instructions and procedures for CPErS are contained within a single comprehensive order that is kept up to date and which can be easily handed over to incoming formations …
Gov response: Accepted. The practice of maintaining a single comprehensive CPErS order has been continued and reinforced.
Accepted
Delivered
BAHA-39 — Review Goggles Use in THF
Recommendation: The Provost Marshal (Army) should formally review whether the current practice of using blacked out goggles for all movement of CPErS within Temporary Holding Facilities is strictly necessary and ensure that it is not being used in circumstances that are …
Gov response: Accepted. PM(A) has reviewed the use of blacked-out goggles in THF and updated guidance.
Accepted
Delivered
BAHA-4 — Hooding Guidance
Recommendation: The essence of guidance on hooding should be that it is prohibited at any time for whatever purpose to place a sandbag or other cover over a CPErS' head.
Gov response: Accepted. Guidance updated to make clear that placing any cover over a CPErS' head is prohibited at any time.
Accepted
Delivered
BAHA-40 — Battlegroup Detention Officer
Recommendation: Each Battlegroup should have a 'Detention Officer' being a commissioned officer within Battlegroup Headquarters. The role should encompass coordination and management of CPErS; acting as a focus on CPErS matters during mission specific training; ensuring correct handling of CPErS; assisting …
Gov response: Accepted. The role of Battlegroup Detention Officer has been established.
Accepted
Delivered
BAHA-41 — Detention Sergeant Role
Recommendation: On operations where CPErS may be taken there should be a Senior Non-Commissioned Officer (NCO) who acts as the 'Detention Sergeant' who has responsibility for the administrative aspects of CPErS handling. In most cases, it would be appropriate for the …
Gov response: Accepted. The Detention Sergeant role has been established for operations involving CPErS.
Accepted
Delivered
BAHA-42 — Written CPErS Responsibilities
Recommendation: Before any deployed operation, the Commanding Officer must ensure that there is a clear written explanation of unit level responsibilities for CPErS. If responsibilities are changed during an enduring operation this should be recorded.
Gov response: Accepted. Requirements for written CPErS responsibilities have 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-47 — CPErS Training Content
Recommendation: CPErS training should include both theoretical and practical training in what Forces personnel can and should do when handling CPErS. It is important that training is not limited to prohibitions but conveys good practice.
Gov response: Accepted. CPErS training has been expanded to include positive guidance on good practice.
Accepted
Delivered
BAHA-48 — End-to-End CPErS Training
Recommendation: CPErS training should be woven into the full range of military exercises and training. Such training should be 'end to end', not just focused on planning and the actual combat side of the operation, but including what happens after a …
Gov response: Accepted. CPErS handling has been incorporated throughout the exercise and training cycle.
Accepted
Delivered
BAHA-49 — Consistent Training Materials
Recommendation: Training materials across the Services need to be reviewed to ensure that the messages about all aspects of CPErS handling are clear and consistent. The arrangement whereby the PM(A) will act as a coordinator and validator of prisoner handling training …
Gov response: Accepted. Training materials have been reviewed and made consistent across Services.
Accepted
Delivered
BAHA-5 — Noise Prohibition Definition
Recommendation: The definition of the prohibition on subjecting CPErS to noise should be broadened. It should prohibit subjecting CPErS to any unnecessary excessive noise.
Gov response: Accepted. The definition has been broadened to prohibit subjecting CPErS to any unnecessary excessive noise, with guidance on facility design and use of ear defenders.
Accepted
Delivered
BAHA-50 — MATT 7 Presentation Update
Recommendation: The MATT 7 PowerPoint presentation on the five techniques should be amended to ensure that the definitions of the techniques are consistent with amendments to JDP 1-10; that it is clear that the techniques are not only prohibited as aids …
Gov response: Accepted. The MATT 7 presentation has been updated to reflect current definitions and prohibitions.
Accepted
Delivered
BAHA-51 — Prisoner Handling DVD Update
Recommendation: The 2005 prisoner handling DVD should be amended to avoid misleading messages about sight deprivation in the context of interrogation, and the inappropriate presentation of the interrogation facility. 'Bagged and tagged' is an ambiguous phrase which should not be used.
Gov response: Accepted. The prisoner handling DVD has been reviewed and updated.
Accepted
Delivered
BAHA-52 — Restraint Positions Guidance
Recommendation: Greater clarity and guidance should be given in training in relation to the concept of 'restraint positions'. More must be done to give practical guidance to help service personnel distinguish between unlawful stress positions and the legitimate use of force.
Gov response: Accepted. Clearer guidance on distinguishing stress positions from legitimate restraint has been developed.
Accepted
Delivered
BAHA-53 — Positional Asphyxia Training
Recommendation: MATT 7 and mission specific training for CPErS handling should incorporate suitably pitched training on the risks of positional asphyxia/death by struggle against restraint.
Gov response: Accepted. Training on positional asphyxia risks has been incorporated into MATT 7 and mission specific training.
Accepted
Delivered
BAHA-54 — MATT 7 Take-up Recording
Recommendation: There needs to be better recording of the take-up of MATT 7 (and equivalent training) to avoid the need to rely upon Reception Staging and Onward Integration (RSOI) training in CPErS handling.
Gov response: Accepted. Better systems for recording MATT 7 completion have been implemented.
Accepted
Delivered
BAHA-55 — Operational Law Training Currency
Recommendation: Those responsible for designing the mandatory operational law and values and standards training must keep the training relevant and up-to-date both in its content and in the style and means of delivery.
Gov response: Accepted. Processes for keeping operational law training current have been strengthened.
Accepted
Delivered
BAHA-56 — Operational Law Training Quality
Recommendation: Unit commanders should ensure that the annual operational law training is delivered to the highest standards, so as to avoid it becoming stale or routine. Different media should be used to keep the materials fresh and up-to-date.
Gov response: Accepted. Guidance on maintaining high standards in operational law training has been provided.
Accepted
Delivered
BAHA-57 — Remove Shock of Capture Language
Recommendation: Training soldiers to maintain or prolong the shock of capture is apt to be misunderstood and should not feature in general training. Phrases such as 'calm, neutral and professional' and 'firm, fair and efficient' can properly be used as shorthand …
Gov response: Accepted. References to 'shock of capture' have been removed from general training materials.
Accepted
Delivered
BAHA-58 — Moral Courage Training
Recommendation: MATT 6 training should include discussion and role play scenarios relevant to moral courage. Training materials should include reference to occasions when UK troops have breached the Law of Armed Conflict to avoid any risk of complacency about the conduct …
Gov response: Accepted. MATT 6 training has been enhanced to include moral courage scenarios and historical breaches.
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-60 — Annual Legal Review of TQ Training
Recommendation: The annual legal review of training materials planned by Defence Intelligence and Security Centre (DISC) is a necessary step. It must include a rigorous scrutiny of the detail of the presentations and speaking notes used on the tactical questioning and …
Gov response: Accepted. Annual legal reviews of TQ training materials have 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
BAHA-62 — DISC Materials Management
Recommendation: DISC should take immediate remedial action to ensure that: (1) old versions of interrogation branch teaching materials are retained but archived separately; (2) interrogation branch teaching materials are always dated; (3) when legal advice or policy changes require changes to …
Gov response: Accepted. DISC has implemented improved version control and archiving for teaching materials.
Accepted
Delivered
BAHA-63 — Complete TQ Training in Approaches
Recommendation: The tactical questioning and interrogation courses must train students adequately in all approaches that they may be required to use operationally. The current compromise whereby tactical questioning students are given an idea of the harsh approach but not trained fully …
Gov response: Accepted. TQ courses now provide complete training in all authorised approaches.
Accepted
Delivered
BAHA-64 — Geneva Convention Compliance in Training
Recommendation: The MoD should give further careful consideration to the examples used in training for bridging between questioning sessions to ensure that they comply with the Geneva Conventions.
Gov response: Accepted. Training examples have been reviewed for Geneva Convention compliance.
Accepted
Delivered
BAHA-65 — Remove Conditioning Terminology
Recommendation: 'Conditioning' should cease to be used as an approved Chicksands or HUMINT term. The term is dangerously ambiguous since it can be used to refer to unlawful means of putting pressure on a prisoner as well the intended meaning of …
Gov response: Accepted. The term 'conditioning' has been removed from approved terminology.
Accepted
Delivered
BAHA-66 — Remove Shock of Capture from DISC
Recommendation: DISC should give consideration to avoiding the terminology 'maintain the shock of capture' and 'prolong the shock of capture' even in their own courses. As a minimum, students on the TQ and interrogation courses should be expressly warned of the …
Gov response: Accepted. DISC courses now warn against misuse of 'shock of capture' terminology.
Accepted
Delivered
BAHA-67 — Resistance Training Warning
Recommendation: All theoretical and practical resistance training must include a warning which explains in terms that the training is to show conduct that can be expected of a non-Geneva Conventions compliant enemy and does not reflect the standards required of British …
Gov response: Accepted. All resistance training now includes clear warnings about different standards.
Accepted
Delivered
BAHA-68 — SERE DVD Review
Recommendation: When reviewing the current Survive, Evade, Resist and Extract (SERE) DVD, Defence Survival Training Organisation (DSTO) should take into account the latest developments in tactical questioning and interrogation policy. DSTO should seek to ensure that ambiguity of terms is avoided …
Gov response: Accepted. The SERE DVD has been reviewed and updated to avoid terminology confusion.
Accepted
Delivered
BAHA-69 — DSTO Sole Provider of Resistance Training
Recommendation: The MoD must make all units aware that, not only is DSTO the only body trained to provide resistance training, but that if any escape and evasion training is carried out it must under no circumstances involve the use of …
Gov response: Accepted. Units have been informed that only DSTO may provide resistance training.
Accepted
Delivered
BAHA-7 — Five Techniques Communication
Recommendation: The MoD should give careful consideration as to whether referring to the five techniques as being prohibited 'as an aid to interrogation' remains the most effective means of communicating the prohibited techniques. Hooding prisoners is prohibited in all circumstances. It …
Gov response: Accepted. Language clarified to ensure prohibition is understood to apply in all circumstances, not just interrogation.
Accepted
Delivered
BAHA-70 — MCTC Control and Restraint Monitoring
Recommendation: The Military Correction Training Centre (MCTC) should continue to monitor that breakaway, personal protection and control and restraint techniques taught on the All Arms Unit Custody Staff Course (AAUCSC) are appropriate having regard to a realistic assessment of the number …
Gov response: Accepted. MCTC continues to monitor control and restraint training appropriateness.
Accepted
Delivered
BAHA-72 — Detention Sergeant Training
Recommendation: Unit Detention Sergeants (see recommendation 41) should be properly trained in CPErS handling practices.
Gov response: Accepted. Training requirements for Detention Sergeants have been established.
Accepted
Delivered
BAHA-8 — Five Techniques Placement in Doctrine
Recommendation: The prohibition on the five techniques should not appear only within the Tactical Questioning and interrogation section of JDP 1-10 since it has a wider application and importance.
Gov response: Accepted. The prohibition now appears in multiple relevant sections of JDP 1-10.
Accepted
Delivered
BAHA-9 — Five Techniques in JTTP
Recommendation: The prohibition on the five techniques should appear in the Joint Tactics, Techniques and Procedures guidance as well as in the main body of JDP 1-10.
Gov response: Accepted. The prohibition has been included in Joint Tactics, Techniques and Procedures guidance.
Accepted
Delivered
BRIS-103 — Royal College of Surgeons to develop training and explore surgeon age limits
Recommendation: The Royal College of Surgeons of England should, in partnership with university medical schools and the NHS, be enabled to develop its unit for the training of surgeons, particularly in new techniques. It should also explore the question of whether …
Unknown
BRIS-118 — Integrate sentinel event reporting into all NHS trust staff training and communications.
Recommendation: The process of reporting of sentinel events should be integrated into every trust’s internal communications, induction training and other staff training. Staff must know what is expected of them, to whom to report and what systems are in place to …
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-190 — Mandate specific communication skills training for professionals caring for children and parents
Recommendation: Healthcare professionals intending to care for children should be trained in the particular skills necessary to communicate with parents and with children.
Unknown
BRIS-2 — Integrate patient-professional partnership principles into all healthcare professional education and training
Recommendation: The education and training of all healthcare professionals should be imbued with the idea of partnership between the healthcare professional and the patient.
Unknown
BRIS-43 — Redefine trust-consultant contracts to specify resources and explicit work commitments
Recommendation: The contractual relationship between trusts and consultants should be redefined. The trust must provide the consultant with the time, space and the necessary tools to do the job. Consultants must accept that the time spent in the hospital and what …
Unknown
BRIS-44 — Examine Distinction Awards for consultants to incentivise quality care and extend to juniors
Recommendation: The system of Distinction Awards for hospital consultants should be examined to determine whether it could be used to provide greater incentives than exist at present for providing good quality of care to patients. The possibility of its extension to …
Unknown
BRIS-45 — Incorporate doctors' professional practice code into employment contracts and GP terms
Recommendation: The doctors’ Code of Professional Practice, as set down in the GMC’s ‘Good Medical Practice’, should be incorporated into the contract of employment between doctors and trusts. In the case of GPs, the terms of service should be amended to …
Unknown
BRIS-46 — Incorporate professional codes of practice into contracts for nurses, allied professions, managers
Recommendation: The relevant codes of practice for nurses, for professions allied to medicine and for managers should be incorporated into their contracts of employment with hospital trusts or primary care trusts.
Unknown
BRIS-50 — Create training and support for clinicians seeking executive director roles
Recommendation: The NHS Leadership Centre, in conjunction with trusts, should develop programmes of training and support for clinicians and others who seek to become executive directors.
Unknown
BRIS-52 — Implement induction programme for new non-executive directors via Leadership Centre
Recommendation: Newly appointed non-executive directors of trusts, health authorities and primary care trusts should receive a programme of induction: this should refer to the principles and values of the NHS and their duties and responsibilities with regard to the quality of …
Unknown
BRIS-54 — Provide ongoing training, support, advice for non-executive directors via Leadership Centre
Recommendation: Throughout their period of tenure, non-executive directors should be provided with training, support and advice organised and co-ordinated through the NHS Leadership Centre.
Unknown
BRIS-55 — Establish independent advice and mentorship for trust board Chairs
Recommendation: The Chairs of trust boards should have a source of independent advice (or mentor) during their period of office, drawn from a pool of experts assembled by the NHS Leadership Centre.
Unknown
BRIS-57 — Prioritise non-clinical skills in healthcare professional education and development
Recommendation: Greater priority than at present should be given to non-clinical aspects of care in six key areas in the education, training and continuing professional development of healthcare professionals: (cid:2) skills in communicating with patients and with colleagues; (cid:2) education about …
Unknown
BRIS-58 — Formally assess non-clinical patient care competence for initial professional qualification
Recommendation: Competence in non-clinical aspects of caring for patients should be formally assessed as part of the process of obtaining an initial professional qualification, whether as a doctor, a nurse or some other healthcare professional.
Unknown
BRIS-59 — Make communication skills education essential for all healthcare professionals
Recommendation: Education in communication skills must be an essential part of the education of all healthcare professionals. Communication skills include the ability to engage with patients on an emotional level, to listen, to assess how much information a patient wants to …
Unknown
BRIS-60 — Include inter-professional engagement and respect in communication skills training
Recommendation: Communication skills must also include the ability to engage with and respect the views of fellow healthcare professionals.
Unknown
BRIS-61 — Implement joint inter-professional courses in healthcare professional education and training
Recommendation: The education, training and Continuing Professional Development (CPD) of all healthcare professionals should include joint courses between the professions.
Unknown
BRIS-62 — Increase opportunities for multi-professional teams to learn and train together
Recommendation: There should be more opportunities than at present for multi-professional teams to learn, train and develop together.
Unknown
BRIS-63 — Provide healthcare management education for all aspiring clinical professionals
Recommendation: All those preparing for a career in clinical care should receive some education in the management of healthcare, the health service and the skills required for management.
Unknown
BRIS-64 — Create shadowing opportunities for managers and clinicians to understand roles
Recommendation: Greater opportunities should be created for managers and clinicians to ‘shadow’ one another for short periods to learn about their respective roles and work pressures.
Unknown
BRIS-65 — NHS Leadership Centre to issue guidelines on acceptable leadership styles and practices
Recommendation: An early priority for the new NHS Leadership Centre should be to offer guidelines as to leadership styles and practices which are acceptable and to be encouraged within the NHS, and those which are not.
Unknown
BRIS-66 — Identify and train potential NHS leaders, investing in leadership skills development
Recommendation: Steps should be taken to identify and train those within the NHS who have the potential to exercise leadership. There needs be a sustained investment in developing leadership skills at all levels in the NHS.
Unknown
BRIS-67 — Focus NHS leadership investment on joint, multi-professional training for all staff
Recommendation: The NHS’s investment in developing and funding programmes in leadership skills should be focused on supporting joint education and multi-professional training, open to nurses, doctors, managers and other healthcare professionals.
Unknown
BRIS-68 — Involve NHS Leadership Centre in all healthcare professional education and development stages
Recommendation: The NHS Leadership Centre should be involved in all stages of the education, training and continuing development of all healthcare professionals.
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-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-78 — Widen medical school access for diverse academic and socio-economic backgrounds
Recommendation: Access to medical schools should be widened to include people from diverse academic and socio-economic backgrounds. Those with qualifications in other areas of healthcare and those with an educational background in subjects other than science, who have the ability and …
Unknown
BRIS-79 — GMC's 'Good Medical Practice' to inform medical school selection and curricula
Recommendation: The attributes of a good doctor, as set down in the GMC’s ‘Good Medical Practice’, must inform every aspect of the selection criteria and curricula of medical schools.
Unknown
BRIS-80 — Involve NHS and public in establishing selection criteria for healthcare professionals
Recommendation: The NHS and the public should be involved in (a) establishing the criteria for selection and (b) the selection of those to be educated as doctors, nurses and as other healthcare professionals.
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-82 — Make Continuing Professional Development (CPD) compulsory for all healthcare professionals
Recommendation: CPD, being fundamental to the quality of care provided to patients, should be compulsory for all healthcare professionals.
Unknown
BRIS-83 — Provide incentives, funding, and time for healthcare professional continuous professional development
Recommendation: Trusts and primary care trusts should provide incentives to encourage healthcare professionals to maintain and develop their skills. The contract (or, in the case of GPs, other relevant mechanism) between the trust and the healthcare professional should provide for the …
Unknown
BRIS-84 — Trusts must ensure CPD resources meet patient needs and professional aspirations
Recommendation: Trusts and primary care trusts must take overall responsibility through an agreed plan for their employees’ use of the time allocated to CPD. They must seek to ensure that the resources deployed for CPD contribute towards meeting the needs of …
Unknown
BRIS-85 — Mandate periodic appraisal for all healthcare professionals in employment contracts
Recommendation: Periodic appraisal should be compulsory for all healthcare professionals. The requirement to participate in appraisal should be included in the contract of employment.
Unknown
BRIS-86 — Expedite implementation of regular appraisal for all hospital consultants
Recommendation: The commitment in ‘The NHS Plan’ to introduce regular appraisal for hospital consultants must be implemented as soon as possible.
Unknown
BRIS-87 — Incorporate periodic appraisal requirement into General Practitioners' terms of service
Recommendation: The requirement to undergo periodic appraisal should also be incorporated into GPs’ terms of service.
Unknown
BRIS-88 — Mandate periodic revalidation for all healthcare professionals in employment contracts
Recommendation: Periodic revalidation, whereby healthcare professionals demonstrate that they remain fit to practise in their chosen profession, should be compulsory for all healthcare professionals. The requirement to participate in periodic revalidation should be included in the contract of employment.
Unknown
BRIS-89 — Involve public, employers, and professional groups in revalidation processes
Recommendation: The public, as well as the employer and the relevant professional group, must be involved in the processes of revalidation.
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
BRIS-92 — Provide protected time for clinicians undertaking managerial roles beyond clinical practice
Recommendation: Where clinicians hold managerial roles which extend beyond their immediate clinical practice, sufficient protected time in the form of allocated sessions must be made available for them to carry out that managerial role.
Unknown
BRIS-93 — Require managerial competence for clinicians appointed to managerial roles with training
Recommendation: Any clinician, before appointment to a managerial role, must demonstrate the managerial competence to undertake what is required in that role: training and support should be made available by trusts and primary care trusts.
Unknown
BRIS-95 — Review incentives for senior clinicians in managerial roles, enabling return to practice
Recommendation: The professional and financial incentives for senior clinicians to undertake full-time senior managerial roles should be reviewed: the aim should be to enable senior clinicians to move into a full-time managerial role, and subsequently, if they so wish, to move …
Unknown
BRIS-96 — Establish minimum clinical practice levels for clinicians in part-time managerial roles
Recommendation: To protect patients, in the case of clinicians who take on managerial roles but wish to continue to practise as clinicians, experts together with managers from the NHS should issue advice as to the minimum level of regular clinical practice …
Unknown
BRIS-97 — Differentiate revalidation for managers maintaining clinical practice and those restarting after retraining
Recommendation: To facilitate the movement of clinicians in and out of managerial positions, the proposed systems for the revalidation (and re-registration) of doctors, nurses and professions allied to medicine should distinguish between professionals who are managers and also maintaining a clinical …
Unknown
BRIS-99 — Mandate direct supervision for clinicians performing new clinical procedures until expert
Recommendation: Any clinician carrying out any clinical procedure for the first time must be directly supervised by colleagues who have the necessary skill, competence and experience until such time as the relevant degree of expertise has been acquired.
Unknown
12 — Annual training on Rule 40 and Rule 42 segregation powers
Recommendation: The Home Office and contractors operating immigration removal centres must provide regular training, at least annually, on the operation of Rule 40 and Rule 42 of the Detention Centre Rules 2001, which must include: that Rules 40 and 42 are …
Gov response: The substantive DSO revision on Rule 40/42 includes examination of staff training requirements and compliance auditing.
Accepted in Part
No update 2+ yrs
17 — Mandatory use of force debrief training and multi-level review process
Recommendation: The Home Office must ensure, as a matter of urgency, that training is delivered on how to conduct an effective use of force incident debrief, ensuring that issues of detained person and staff welfare, as well as training needs, are …
Gov response: Training and escalation systems for use of force incidents are referenced in the government response. The Service Improvement Plan references use of force monthly meetings and formal review processes.
Accepted in Part
No update 2+ yrs
19 — Healthcare staff guidance and training on use of force incidents
Recommendation: The Home Office must ensure that guidance is issued to healthcare staff in immigration removal centres clarifying their role in use of force incidents. It must liaise as necessary with NHS England and any relevant medical regulators. The Home Office …
Gov response: The government does not accept this recommendation. The government stated that NHS England commissions healthcare services and it is their responsibility, alongside the Care Quality Commission, to assure the quality of health service provision within …
Not Accepted
24 — Mandatory staff training on mental health and trauma-informed approaches
Recommendation: The Home Office, in conjunction with contractors, must ensure that all relevant immigration removal centre staff receive mandatory introductory and annual training on: mental health; race and diversity; a trauma-informed approach; their own resilience; drug awareness; and the purpose of …
Gov response: The Initial Training Course for all new contractor staff is undergoing a full review covering 'AaR, mental health awareness, racial awareness and safeguarding children', with a mentorship phase and annual refresher training.
Accepted in Part
Delivered
HIDD-1 — BR to rigorously implement cutting, insulating, securing redundant wires before commissioning
Recommendation: BR shall ensure that there is rigorous implementation of the practice of cutting back redundant wires, insulating, and securing them, so that there is no risk of wires coming into contact with working circuitry. Cutting back must be done before …
Unknown
HIDD-10 — BR to audit resources and authority for national signal testing instruction implementation
Recommendation: BR shall ensure through its system of audit that the necessary resources and authority are available to Regional Signal Engineers to implement the national testing instruction.
Unknown
HIDD-11 — Ensure independence of testing and commissioning engineers from new works staff
Recommendation: BR shall ensure that the Testing & Commissioning Engineer must be independent of the line of command between Area Signalling Engineer and new works staff, but able to call on new works staff to assist him in his testing duties.
Unknown
HIDD-12 — Establish effective systems for personal distribution of departmental instructions to all employees
Recommendation: BR shall ensure that there are effective systems for distributing Departmental Instructions on a personal basis to all relevant employees and that provision is made for the situation where an employee moves to a new post.
Unknown
HIDD-13 — Require staff to understand, re-read, and biennially confirm understanding of instructions
Recommendation: BR shall ensure, as a matter of practice, that all staff understand and regularly re-read the Departmental Instructions relevant to their posts. In addition, every two years, those staff involved in an annual appraisal interview, shall sign a statement to …
Unknown
HIDD-14 — Provide necessary technical training for all staff to ensure safe practices
Recommendation: BR shall give technical training as necessary to ensure that efficient and safe practices are carried out by all technical staff.
Unknown
HIDD-15 — Provide mandatory refresher courses for installers at least every five years
Recommendation: BR shall provide refresher courses for installers at intervals of not more than five years.
Unknown
HIDD-16 — Urgently progress and monitor training, certification, and refresher courses for testers
Recommendation: BR shall urgently progress and monitor training and certification of testers. Refresher courses shall be evolved.
Unknown
HIDD-17 — Regularly review the structure and content of all training courses
Recommendation: BR shall ensure that the structure and content of courses are regularly reviewed.
Unknown
HIDD-18 — Monitor staff overtime to prevent individuals working excessive levels
Recommendation: BR shall ensure that overtime is monitored so that no individual is working excessive levels of overtime.
Unknown
HIDD-19 — Introduce scheduled hours for Signals and Telecommunications weekend work with unions
Recommendation: BR, in conjunction with the Unions, shall introduce the concept of scheduled hours within the Signals and Telecommunications Department in order to make better provision for work which has to be carried out at weekends.
Unknown
HIDD-2 — Establish national responsibility for updating and creating new installation standards
Recommendation: BR at national level shall be responsible for updating and creating new standards of installation.
Unknown
HIDD-20 — Monitor and forecast skilled S&T staff to ensure safe recruitment and retention
Recommendation: BR shall monitor and forecast wastage and recruitment of skilled S&T staff and take urgent steps to ensure that sufficient numbers of skilled staff are retained and recruited to match work requirements safely.
Unknown
HIDD-21 — Consider recruiting staff at assistant technician level and above
Recommendation: BR, in reviewing recruitment and retention levels, shall also consider recruiting staff at levels at and above assistant technician.
Unknown
HIDD-22 — Provide clear job descriptions for all staff grades and posts
Recommendation: BR shall provide all grades with job descriptions for their particular post so that staff know what is expected of them
Unknown
HIDD-23 — Extend simplified annual appraisal system to include senior technician level
Recommendation: The annual appraisal system, albeit in a simplified form, shall be extended to senior technician level.
Unknown
HIDD-24 — Establish continuous system to identify employees who would benefit from additional training
Recommendation: BR shall ensure that there is an effective system in place on a continuous basis to identify which employees would benefit from additional training.
Unknown
HIDD-25 — Introduce system for reporting, classifying, and monitoring all WSFs to Board level
Recommendation: BR shall introduce, within S&T Departments, a system of reporting and reviewing all WSFs and shall ensure that they are classified according to potential for danger, and that they are monitored up to and including Board level.
Unknown
HIDD-26 — Thoroughly investigate unprotected WSFs with danger potential to learn wider lessons
Recommendation: BR shall ensure that any unprotected WSF with potential for danger shall be thoroughly investigated with a view to learning and acting upon wider lessons.
Unknown
HIDD-27 — Report unprotected WSFs as "dangerous occurrences" to the Railway Inspectorate
Recommendation: Unprotected WSFs shall be reportable to the Railway Inspectorate as a "dangerous occurrence" and reported on by the Chief Inspecting Officer in his annual report.
Unknown
HIDD-3 — Enforce tighter control on Design Office procedures for accurate working drawings
Recommendation: BR shall enforce tighter control on Design Office procedures for the production, issue and amendment of documents to ensure that all working drawings are complete and are an accurate representation of the system to be worked on and of the …
Unknown
HIDD-33 — Provide necessary training resources for wider management down to supervisor level
Recommendation: BR shall make available necessary training resources for wider management training down to supervisor level.
Unknown
HIDD-34 — Require future reorganisations to be properly planned, resourced, and timely implemented
Recommendation: BR shall require that any future reorganisation shall be properly planned, effectively resourced and implemented to an agreed timetable which takes account of all relevant problems.
Unknown
HIDD-35 — Implement improved procedures to prevent unallocated staff during reorganisations
Recommendation: BR shall implement improved procedures to replace the cumbersome arrangements on reorganisations which allow staff to be displaced and to remain unallocated.
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-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-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-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-64 — Ensure emergency alert lines receive incoming calls only and are tested weekly
Recommendation: Hospitals shall ensure that emergency alert telephone lines receive incoming calls only and are tested weekly. Switchboard operators shall be fully trained in their use and procedure.
Unknown
HIDD-65 — Implement training for Medical Incident Officers in radio communications usage
Recommendation: The LAS shall implement its proposal to train prospective Medical Incident Officers in the use of radio communications.
Unknown
HIDD-66 — Require hospitals to provide Medical Incident Officer training for relevant staff
Recommendation: Hospitals shall provide training in the duties of Medical Incident Officer for staff who could be called upon to act as such in the event of an accident.
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
HIDD-71 — Require ambulance staff qualified in intubation to wear 'Millar trained' badges
Recommendation: Ambulance services shall require staff properly qualified in intubation and infusion to wear "Millar trained" badges prominently displayed, including on protective clothing.
Unknown
HIDD-8 — Require BR to provide and monitor full documentation for proper testing
Recommendation: BR shall ensure that full documentation is provided and later monitored in order that proper testing is carried out.
Unknown
HIDD-81 — BR to equip signal boxes with direct lines and emergency dialling systems
Recommendation: BR shall complete its programme of equipping major signal boxes with direct lines to the appropriate electrical control and equipping other signal boxes with priority emergency dialling systems. Those direct lines and emergency dialling systems shall be logged and tested …
Unknown
HIDD-82 — BR to review and test communication systems with emergency services weekly
Recommendation: BR shall review its communication systems with the emergency services to ensure that efficient methods exist to provide and disseminate early information requiring immediate action. In the course of the review BR shall look particularly at communication between signal boxes …
Unknown
HIDD-83 — BR to ensure proper training and clear instructions for new communication systems
Recommendation: BR shall ensure that those likely to use such systems in recommendations 81 and 82 above shall be properly trained in their use. Instructions in the use of these systems must be clearly drafted, prominently displayed and regularly checked for …
Unknown
HIDD-86 — Produce updated accident procedure manual and provide staff with appropriate training
Recommendation: BR shall produce an up-to-date manual on Accident Procedure to replace such incomplete and out-of-date documents as the Southern Region Accident Procedure booklet of November 1984. BR shall ensure that all staff are given appropriate training in such procedures.
Unknown
HIDD-87 — Develop and regularly exercise effective emergency plans for all station staff
Recommendation: BR shall ensure that each area manager, station manager and all senior station staff have an effective emergency plan for their area that is understood by all their staff and is the subject of regular exercises.
Unknown
HIDD-9 — Introduce national testing instruction with workforce explanation, monitoring, and auditing
Recommendation: BR shall introduce a national testing instruction with all speed. Such introduction shall be accompanied by a full explanation to the workforce, including workshops or seminars as necessary. Implementation must be monitored and audited.
Unknown
CR4 — Training on normalcy bias
Recommendation: HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one being the need to avoid normalcy bias, in particular, assumptions about exaggeration in calls from small boats.
Response Pending
CR6 — Joint exercises on triage procedure
Recommendation: Those involved in maritime search and rescue should continue to undertake joint exercises on the application of the Mass Persons in the Water Triage procedure.
Response Pending
CR8 — Survivability advice to persons in distress
Recommendation: HM Coastguard should amend its existing policies to incorporate the need to provide more comprehensive advice about survivability to people in distress at sea.
Response Pending
CR9 — Cold water survivability modelling
Recommendation: HM Coastguard should examine whether it is using the most appropriate modelling for survivability in cold water. HM Coastguard should amend its existing policies to ensure that they consistently identify the key variables about which information is to be collected …
Response Pending
DUNB-28 — Develop Scottish Vocational Qualification for work with children and protection
Recommendation: Consideration should be given to the development of a Scottish Vocational Qualification in respect of work with children, including the organisation of clubs and child development and protection (para 11.47).
Unknown
DUNB-3 — Provide comprehensive training and guidance for firearm enquiry officers
Recommendation: Enquiry officers should be given as much training and guidance for their work as is practicable (para 8.13).
Unknown
DM-3 — Prevent replication of Abelard Two management failures
Recommendation: It is recommended that the Metropolitan Police introduce systems to ensure that the management arrangements which applied during the Abelard Two Investigation can never be replicated in any future investigation, and that proper management arrangements, in compliance with the Association …
Gov response: The MPS has given assurances that the management arrangements during this particular investigation (Abelard Two) would not happen under current structures and have updated the relevant conflict of interest declaration and policy. The new National …
Accepted
Delivered
DM-4 — Review HOLMES system resources
Recommendation: The HOLMES system is both an investigative tool and a quality assurance mechanism, but it requires significant resources if it is to be used properly. The Panel recommends that the Metropolitan Police conduct an investigation into the adequacy of resources …
Gov response: The MPS has conducted a capacity and capability review of resources deployed to HOLMES, with consideration of national guidance. The review was concluded in January 2022 which concluded there is sufficient resourcing for the management …
Accepted
Delivered
FENN-100 — Provide familiarisation training for all emergency services on London Underground
Recommendation: London Underground shall provide familiarisation training for members of all the emergency services.
Unknown
FENN-101 — Enforce smoking prohibition and review prosecution criteria on London Underground
Recommendation: London Underground and the British Transport Police must decide the most effective way to enforce the smoking prohibition and then train staff and officers accordingly. The criteria for prosecutions should be reviewed.
Unknown
FENN-103 — Institute Health and Safety training for London Underground middle and senior management
Recommendation: London Underground shall reconsider and take advice on the Health and Safety at Work etc Act 1974, and institute a series of training courses for middle and senior management.
Unknown
FENN-104 — Review electrician standards and provide appropriate training for London Underground.
Recommendation: London Underground shall review the standards of its electricians and provide appropriate training where necessary.
Unknown
FENN-106 — Encourage London Underground staff training with financial incentives and uniform distinctions.
Recommendation: London Underground shall encourage staff to undergo further training by offering financial incentives and appropriate marks of distinction on uniforms.
Unknown
FENN-108 — Review British Transport Police King's Cross performance and provide additional fire training.
Recommendation: The British Transport Police should review the performance of its officers in the King's Cross emergency and give additional fire training.
Unknown
FENN-109 — Improve London Fire Brigade operational staff fire prevention and safety training.
Recommendation: The London Fire Brigade shall improve the training of its operational staff in fire prevention and safety and provide experience.
Unknown
FENN-112 — Regularly inspect, label, and report defective London Underground communications equipment for repair.
Recommendation: London Underground shall regularly inspect communications equipment. Where it is out of order it must be clearly labelled. Defective equipment must be immediately reported for repair.
Unknown
FENN-113 — Provide a new, properly equipped operations room at King's Cross station.
Recommendation: A new station operations room must be provided at King's Cross suitably located and properly equipped.
Unknown
FENN-114 — Improve station CCTV coverage and provide monitoring for British Transport Police.
Recommendation: Closed circuit television equipment shall be improved to allow coverage in colour of wider areas of stations. Monitoring facilities shall be provided in the British Transport Police L Division information room and line controllers' rooms.
Unknown
FENN-115 — Clearly mark station telephones, PA controls, and expand public payphone provision.
Recommendation: Platform and kiosk telephones, together with controls for public address equipment, must be clearly marked. At all telephone points there should be a list of key telephone numbers. An aide memoire of important telephone numbers should be issued to London …
Unknown
FENN-116 — Issue radios to station staff and ensure compatibility with tunnel equipment.
Recommendation: Station staff shall be issued with radios. Station radio equipment shall be made compatible with that used in the running tunnels.
Unknown
FENN-117 — Consider paging equipment as an alternative to personal radios for junior staff.
Recommendation: Paging equipment for junior station staff may be considered as an alternative to personal radios.
Unknown
FENN-118 — Provide public address equipment on all trains for crew and controller use.
Recommendation: There shall be public address equipment on all trains for use by the crew and the line controller.
Unknown
FENN-119 — Improve London Fire Brigade radio communications for firefighters operating below ground.
Recommendation: The London Fire Brigade must improve the means of radio communications between fire-fighters below ground.
Unknown
FENN-13 — Regularly test water fog equipment and train staff in its use.
Recommendation: Water fog equipment must be regularly tested and staff trained in its use.
Unknown
FENN-14 — Agree principles for location and equipping of station operations rooms.
Recommendation: Principles for the location and equipping of station operations rooms must be agreed by all those concerned and followed by London Underground in their future planning.
Unknown
FENN-143 — Trade unions to appoint safety representatives and establish station safety committees
Recommendation: The trade unions shall appoint safety representatives as necessary under 'The Safety Representatives and Safety Committees Regulations 1977' [SI 1977 No 5001 to provide a comprehensive system of safety committees covering all stations.
Unknown
FENN-144 — Increase employee participation in London Underground safety programme preparation and execution
Recommendation: There must be more employee participation in the preparation and execution of London Underground's safety programmes in accordance with section 2(6) of the Health and Safety at Work etc. Act 1974.
Unknown
FENN-18 — Provide distinctive uniforms indicating rank for all station staff
Recommendation: Station staff, including booking office staff, shall have distinctive uniforms which give a clear indication of rank.
Unknown
FENN-27 — Review LFB policy and training for alternative underground fire access
Recommendation: The London Fire Brigade shall review its policy and training on the use of alternative means of access to an underground fire.
Unknown
FENN-29 — Ensure LFB officers are familiar with underground station geography and layout
Recommendation: The London Fire Brigade shall ensure that its officers are made familiar with the geography and layout of underground stations on their own and adacent fireground lerritories.
Unknown
FENN-30 — Review LFB instructions and training for command and control
Recommendation: The London Fire Brigade shall review its instructions and training arrangements for command and control.
Unknown
FENN-39 — Implement regular escalator cleaning, improving access and protective clothing for staff
Recommendation: Escalators shall be manually cleaned at least every six months until the rewiring of machine rooms is completed. Thereafter they shall be mechanically cleaned in accordance with the programme determined under Recommendation 38. Escalator steps must be removed as necessary, …
Unknown
FENN-40 — Require station supervisors to inspect escalators and machine rooms every two hours
Recommendation: Station supervisors must personally inspect escalators, and both upper and lower machine rooms, every two hours until wooden parts have been removed.
Unknown
FENN-44 — Encourage trade union participation in all internal inquiries
Recommendation: Trade union participation in internal inquiries shall be encouraged.
Unknown
FENN-45 — Regularly examine fire equipment, report defects, and ensure immediate remedy
Recommendation: London Underground shall regularly examine fire equipment and ensure that defects are reported and remedied at once or alternative arrangements made.
Unknown
FENN-47 — Ensure keys and communication equipment for unmanned locked station exit gates
Recommendation: Keys must always be readily available for unmanned locked gates at station exits. There shall be communication equipment or remote monitoring equipment at these gates.
Unknown
FENN-50 — Maintain formal health and safety monitoring system at all management levels
Recommendation: London Underground shall maintain a formal system for health and safety monitoring at all levels of management.
Unknown
FENN-55 — Review fire section scope, effectiveness, and station fire equipment organisation
Recommendation: The Senior Fire Officer of London Underground, under the direction of the new Chief Safety Inspector, shall review the scope, effectiveness and organisation of the fire section and station fire equipment in consultation with the London Fire Brigade.
Unknown
FENN-57 — Survey stations to recommend optimal equipment and staff for safety levels
Recommendation: In consultation with the emergency services the Chief Safety Inspector shall carry out a survey of each station in order to recommend the means of achieving satisfactory safety levels. The survey must particularly address the most effective combination of equipment …
Unknown
FENN-71 — Implement job specifications and inspection for all maintenance and cleaning activities
Recommendation: Proper job specification and inspection arrangements shall be put in place for all maintenance and cleaning activities.
Unknown
FENN-72 — Institute and maintain cleaning and maintenance standards for London Underground
Recommendation: London Underground must institute and maintain a set of standards for cleaning and maintenance.
Unknown
FENN-73 — Require engineers to maintain and repair lift and escalator shaft lighting
Recommendation: The lift and escalator engineer shall maintain and repair the lighting systems in lift and escalator shafts.
Unknown
FENN-80 — Ensure adequate staffing by suitably trained personnel in station operations rooms
Recommendation: Station operations rooms shall always be adequately staffed by suitably trained personnel.
Unknown
FENN-81 — Establish continuing fire and safety instruction for station staff by supervisors
Recommendation: London Underground shall establish a programme of continuing instruction at work by supervisors for station staff in fire and safety with the assistance of the London Fire Brigade and British Transport Police. At stations equipped with water fog equipment supervisors …
Unknown
FENN-82 — Provide biennial refresher training for management and supervisors on station emergency control
Recommendation: Every two years all management and supervisory staff shall receive refresher training in controlling station emergencies, and the use of fire and communications equipment.
Unknown
FENN-83 — Provide biannual fire and safety training for non-supervisory and shop staff
Recommendation: Every six months fire and safety training must be provided for non-supervisory staff and booking clerks. Staff must be given site familiarisation training before they are permitted to take part in the running of the station. Specific provision shall be …
Unknown
FENN-84 — Re-draft fire brigade calling instructions for staff in plain English
Recommendation: Instructions to staff as to the calling of the fire brigade shall be re-drafted in plain English. They must contain only relevant matter.
Unknown
FENN-85 — Provide fire safety training for cleaning and engineering staff on stations
Recommendation: Fire safety training for cleaning and engineering staff working on stations shall be provided. London Underground must obtain expert advice.
Unknown
FENN-86 — Review station staff fire and safety training based on consultant advice
Recommendation: Fire and safety training for station staff shall be reviewed in the light of the advice from consultants.
Unknown
FENN-87 — Make detailed staff training records locally available to station supervisors
Recommendation: Detailed records of all training given to individual staff shall be available locally to station supervisors.
Unknown
FENN-89 — Train all staff in emergency use of public address systems
Recommendation: All staff shall be trained in the emergency use of public address and other communications systems.
Unknown
FENN-9 — Agree station emergency instructions with LFB for staff training
Recommendation: Station instructions for emergencies and closure must be agreed with the London Fire Brigade and used in training station staff.
Unknown
FENN-90 — Train and practice London Underground incident officers in their duties
Recommendation: Potential London Underground incident officers must be trained and practised in their duties.
Unknown
FENN-91 — Appoint and train station 'landlords' with total management responsibility
Recommendation: A station 'landlord' shall be appointed and trained to have total management responsibility at each major station or group of smaller stations.
Unknown
FENN-92 — Appoint only qualified relief supervisory staff to stations
Recommendation: Relief supervisory staff shall only be appointed to a station for which they are qualified.
Unknown
FENN-93 — Engage consultants to rewrite rule book and create staff information materials
Recommendation: London Underground shall engage consultants: (i) to rewrite the rule book and its appendices in plain English; (ii) to produce check lists for station supervisory staff and duty cards for members of staff; (iii) to produce relevant extracts from the …
Unknown
FENN-94 — Consult Railway Inspectorate and LFB before issuing safety documents
Recommendation: London Underground shall consult the Railway Inspectorate and the London Fire Brigade before issuing these documents and any future revisions.
Unknown
FENN-95 — Train LFB personnel on station technical features and electrical isolation
Recommendation: London Underground shall train London Fire Brigade Personnel on technical features of stations, such as escalator and lift equipment, electrical controls and the means of isolating the electrical supply.
Unknown
FENN-97 — Train potential station supervisors in station evacuation and closure procedures
Recommendation: Potential station supervisors must be trained in the evacuation and closure of stations.
Unknown
FENN-98 — Train area and group managers on health and safety responsibilities
Recommendation: Area and group managers must be trained to discharge their responsibility under health and safety legislation.
Unknown
FENN-99 — British Transport Police to review London Underground officer training appropriateness
Recommendation: The British Transport Police shall review the training given by London Underground to its officers to ensure that it is appropriate to their responsibilities.
Unknown
FLIX-209 (iv) — Clarify British Standard for pipework test pressure and design pressure definition
Recommendation: That the British Standard referring to the pressure to which pipe work should be tested (see paragraph 73 above) should be clarified. At present it is ambiguous in its reference to testing to 1 -3 x the “design pressure”. It …
Unknown
FLIX-209 (v) — Make compliance with British Standard hydraulic testing requirements obligatory
Recommendation: That compliance with the British Standard requirement for hydraulic testing (paragraph 73 above) should be obligatory. The by-pass was tested pneumatically to 9 kg/cm2 for leaks without any previous test at all. Had it burst there might well have been …
Unknown
FLIX-210 (ii) — Broaden engineer training to include elements of other engineering branches
Recommendation: That the training of engineers should be more broadly based. Although it may well be that the occasion to use such knowledge will not arise in acute form until an engineer has to take executive responsibility it is impossible at …
Unknown
P1-11 — Train incident commanders on control room communications
Recommendation: All officers who may be expected to act as incident commanders (i.e. all those above the rank of Crew Manager) receive training directed to the specific requirements of communication with the control room.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-12 — Train control room operators on incident commander communications
Recommendation: All control room operators of Assistant Operations Manager rank and above receive training directed to the specific requirements of communication with the incident commander.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-15 — Regular refresher training for control room operators
Recommendation: The LFB provide regular and more effective refresher training to control room operators at all levels, including supervisors.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-19 — Train control room staff on evacuation advice changes
Recommendation: Control room staff receive training directed specifically to handling such a change of advice and conveying it effectively to callers.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-2 — Train fire personnel on external wall fire risks
Recommendation: All fire and rescue services ensure that their personnel at all levels understand the risk of fire taking hold in the external walls of high-rise buildings and know how to recognise it when it occurs.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-4 — Train LFB officers on high-rise inspections
Recommendation: The LFB ensure that all officers of the rank of Crew Manager and above are trained in carrying out the requirements of PN633 relating to the inspection of high-rise buildings.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P2-16 — Increase Masters-level fire engineering course places
Recommendation: That the government take urgent steps to increase the number of places on high-quality masters level courses in fire engineering accredited by the professional regulator. (113.25)
Gov response: The government accepts this recommendation. We recognise the value that more masters level courses in fire engineering could bring and will consider how to most effectively increase their number and take-up.
Accepted
In progress
P2-17 — Define competent fire engineer knowledge and skills
Recommendation: That the government convene a group of practitioner and academic fire engineers and such other professionals as it thinks fit to produce an authoritative statement of the knowledge and skills to be expected of a competent fire engineer. Such a …
Gov response: The government accepts this recommendation. We will convene a panel of academics and industry experts to consider what should be expected of a competent fire engineer. The panel will also support and advise on the …
Accepted
Delivered
P2-18 — Develop fire engineering courses for construction professionals
Recommendation: That the government, working in collaboration with industry and professional bodies, encourage the development of courses in the principles of fire engineering for construction professionals and members of the fire and rescue services as part of their continuing professional development. …
Gov response: The government accepts this recommendation. We recognise the importance that the principles of fire engineering can have for these professions and others. We will work with industry and professional bodies to consider how best to …
Accepted
In progress
P2-19 — Review architect education and training for fire safety
Recommendation: We recognise that both the Architects Registration Board (ARB) and the Royal Institute of British Architects (RIBA) have taken steps since the Grenfell Tower fire to improve the education and training of architects. We recommend that they should review the …
Gov response: ARB and RIBA accept this recommendation. The Inquiry's report notes that both the regulator, the Architects Registration Board (ARB), and the professional body, the Royal Institute of British Architects (RIBA), have taken steps since the …
Accepted
In progress
P2-29 — Establish independent College of Fire and Rescue
Recommendation: That the government establish [an independent College of Fire and Rescue] immediately with sufficient resources to provide the following services nationally: a) practical training at all levels supplementary to that provided by individual fire and rescue services; b) education in …
Gov response: The government accepts this recommendation in principle. We recognise the importance of making sure that fire and rescue services are appropriately trained and that high standards are maintained. The creation of a college was also …
Accepted in Part
In progress
P2-30 — College to have permanent staff and training facilities
Recommendation: That [the college] should have a permanent staff of sufficient size to manage its operations and develop its functions in response to the demands of fire and rescue services nationally and the requirements of the board. The college will need …
Gov response: The government accepts this recommendation in principle. See recommendation 29. This will be captured by the consultation on the most appropriate functions for the college to fulfil and how it could best be structured and …
Accepted in Part
In progress
P2-31 — Inspect London Fire Brigade control room operations
Recommendation: That His Majesty's Inspectorate of Constabulary and Fire and Rescue Services (the Inspectorate) inspect the London Fire Brigade as soon as reasonably possible to assess and report on: a) the extent to which the control room is now integrated into …
Gov response: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) accepts this recommendation. HMICFRS most recently inspected London Fire Brigade in February 2024 on their effectiveness, efficiency and people management. The findings were published …
Accepted
Delivered
P2-32 — Inspect London Fire Brigade incident commander training
Recommendation: That as soon as reasonably possible the Inspectorate inspect the London Fire Brigade to examine and report on the arrangements it has in place for assessing the training of incident commanders at all levels and their continuing competence, whether by …
Gov response: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) accepts this recommendation. See recommendation 31.
Accepted
Delivered
P2-33 — Inspect London Fire Brigade information management systems
Recommendation: That as soon as reasonably practicable the Inspectorate inspect the LFB to examine and report on its arrangements for collecting, storing and distributing information in accordance with section 7(2)(d) of the Fire and Rescue Services Act 2004, and in particular …
Gov response: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) accepts this recommendation. See recommendation 31.
Accepted
Delivered
P2-41 — Consider guidance on firefighter initiative deviations
Recommendation: That National Fire Chiefs Council consider whether, and if so in what circumstances, firefighters should be discouraged from departing from their instructions on their own initiative and provide appropriate training in how to respond to a situation of that kind. …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation. Firefighters operate in an extremely high-risk and dynamic environment where responding to changes is essential to safe working practice. The ability to communicate changes in the …
Accepted
In progress
P2-48 — Verify training quality of Category 1 responders
Recommendation: That a mechanism be introduced for independently verifying the frequency and quality of training provided by local authorities and other Category 1 responders. (113.71)
Gov response: The government accepts this recommendation made towards Category 1 responders in principle. There are a number of regulatory and inspectorate bodies across the range of responder organisations to support them to meet their responsibilities under …
Accepted in Part
In progress
P2-49 — Train all local authority employees on resilience
Recommendation: That local authorities train all their employees, including chief executives, to regard resilience as an integral part of their responsibilities. (113.73)
Gov response: The government supports this recommendation made towards local authorities. We expect all relevant staff to be provided with the necessary training. Local authorities should be empowered to determine which of their staff should undertake training …
Accepted
In progress
SHEE-55 — Emphasise clear orders, strict discipline, and effective communication for ship safety
Recommendation: This Court need say no more than stress the need for: (a) Clear and concise orders. (b) Strict discipline. (c) Attention at all times to all matters affecting the safety of the ship and those on board. There must be …
Unknown
26 — Youth Custody Service safeguarding training
Recommendation: The Chair and Panel recommend that the Youth Custody Service takes steps to ensure that its training provides staff with an appropriate understanding of safeguarding in the context of the secure estate, and that this is regularly reviewed and updated.
Gov response: On 23 July 2019, the Ministry of Justice stated that the Youth Custody Service would review the mandatory training for all its frontline staff – including at management level – alongside a review of the …
Accepted
No update 2+ yrs
47 — Catholic lead clergy for safeguarding
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious in England and in Wales should each nominate a lead member of the clergy for safeguarding to provide leadership and oversight on safeguarding matters to their respective …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that the role description for the Lead Bishop for the Catholic Bishops' Conference of England and Wales was approved and Bishop Paul Mason was …
Accepted
Delivered
59 — National LADO standards
Recommendation: The Department for Education and the Welsh Government should: introduce a set of national standards for local authority designated officers in England and in Wales to promote consistency; and clarify in statutory guidance that the local authority designated officer can …
Gov response: On 30 June 2022, the UK government stated that it was considering the scope and timetable for a review of the statutory guidance Working Together to Safeguard Children. It stated that it will consider revised …
Accepted in Part
No update 2+ yrs
63 — Extend TRA jurisdiction to teaching assistants
Recommendation: The Department for Education should amend the Teachers' Disciplinary (England) Regulations 2012 to bring all teaching assistants, learning support staff and cover supervisors within the misconduct jurisdiction of the Teaching Regulation Agency. The Department for Education and the Welsh Government …
Gov response: On 30 June 2022, the UK government stated that anyone undertaking teaching work can be referred to the Teaching Regulation Agency (TRA) and this could include teaching assistants and learning support staff. The TRA does …
Accepted in Part
Delivered
64 — Welsh independent school standards update
Recommendation: The Welsh Government should: update the Independent School Standards as a matter of urgency; update the national minimum standards for boarding schools as a matter of urgency; legislate so that all residential special schools are judged against the quality standards …
Gov response: On 30 June 2022, the Welsh Government stated that it will amend and strengthen the independent school regulations, and that work is ongoing to draft the legislation. The Welsh Government also stated that it will …
Accepted
Delivered
77 — CSA experience for Chief Officer progression
Recommendation: The Chair and Panel recommend that any police officer (or staff equivalent) who wants to progress to the Chief Officer cadre must first be required to: have operational policing experience in preventing and responding to child sexual abuse; and achieve …
Gov response: The Home Office agrees that there is a need within the police to raise the profile and status of work to tackle child sexual abuse. However, the Home Office is concerned that the Inquiry's recommendation …
Not Accepted
95 — CICA specialist caseworker training
Recommendation: The Chair and Panel recommend that the Criminal Injuries Compensation Authority ensures that claims relating to child sexual abuse are only considered by caseworkers who have specific and detailed training in the nature and impact of child sexual abuse.
Gov response: CICA continues to look for opportunities to work with stakeholders to improve its understanding of victims' experiences. Since the abolition of the pre-1979 same roof rule, CICA is providing specialist application support and named caseworkers …
Accepted
Delivered
P1-4 — Mortuary Managers qualified and supported
Recommendation: Maidstone and Tunbridge Wells NHS Trust must assure itself that its Mortuary Managers are suitably qualified and have relevant anatomical pathology technologist experience. The Mortuary Manager should have a clear line of accountability within the Trust's management structure and must …
Gov response: Implemented. The Trust has reviewed Mortuary Manager arrangements and ensured appropriate qualifications and support are in place with clear lines of accountability. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 …
Accepted
Delivered
P1-5 — Mortuary Manager as full-time dedicated role
Recommendation: The role of Mortuary Manager at Maidstone and Tunbridge Wells NHS Trust should be protected as a full-time dedicated role, in recognition of the fact that this is a complex regulated service, based across two sites, that requires the appropriate …
Gov response: Implemented. The Mortuary Manager role is now protected as a dedicated full-time position. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P2-10 — Designated Individuals adequate time and resource
Recommendation: NHS trusts should ensure that Designated Individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.
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
P2-11 — Senior managers understand DI role and accountability
Recommendation: NHS trusts should ensure that senior managers, including the Chief Executive, have a clear understanding of the role of the Designated Individual, their lines of accountability, and the individual legal responsibility associated with being a Designated Individual.
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
P2-13 — Mortuary Manager professional background prerequisite
Recommendation: A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.
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
P2-14 — Mortuary Manager adequate resources and support
Recommendation: NHS trusts should assure themselves that the Mortuary Manager has adequate resources and support to perform their role effectively, including meeting any reporting requirements.
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-3a — Medical Education - Curriculum
Recommendation: The General Medical Council, and NHS Education for Scotland, Health Education and Improvement Wales, Northern Ireland Medical and Dental Training Agency and NHS England, should take steps to ensure that those “lessons to be learned” which relate to clinical practice …
Gov response: Medicine is constantly evolving and it is crucial that doctor’s training is kept up to date. The Inquiry’s May 2024 report is a valuable resource in learning the lessons of the past, recognising that those …
Accepted
In progress
IBI-3b — Medical Education - Training Materials
Recommendation: They should look favourably upon putting together a package of training materials, with excerpts from oral and written testimony, to underpin what can happen in healthcare, and must be avoided in future.
Gov response: A combined working group established by NHS England is developing training materials. The Inquiry website will be maintained with full functionality to support educational use.
Accepted
In progress
IBI-7c — Transfusion Laboratory Staffing
Recommendation: Transfusion laboratories: Transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions.
Gov response: UK Government Work is ongoing to determine the current status of transfusion staffing, reviewing best practice from other areas including nursing, and developing an evidence base to inform minimum staffing level standards. The data for …
Accepted in Part
In progress
IBI-7d — Training in Transfusion Medicine
Recommendation: Training in Transfusion Medicine: That those bodies concerned with undergraduate and postgraduate training across the UK of those people who are, or intend to be, working in the NHS ensure that they are adequately trained in transfusion, that the standards …
Gov response: UK Government The stakeholder group, including a range of professional and statutory bodies, have been working together to review and propose educational and training requirements. The group is currently collating patient safety e-learning material to …
Accepted in Part
In progress
IHRD-19 — Senior Lead Nurse in Children's Wards
Recommendation: To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating to each patient, be visible to both patients and staff …
Gov response: Senior lead nurse roles established in children's wards across Trusts.
Accepted
Delivered
IHRD-56 — Board Member Induction Training
Recommendation: All Trust Board Members should receive induction training in their statutory duties.
Gov response: Induction training programmes established for Trust Board members.
Accepted
Delivered
IHRD-57 — Clinical Training for Guidelines
Recommendation: Specific clinical training should always accompany the implementation of important clinical guidelines.
Gov response: Training incorporated into clinical guideline implementation processes.
Accepted
Delivered
IHRD-58 — Paediatric Fluid Management Training
Recommendation: HSC Trusts should ensure that all nurses caring for children have facilitated access to e-learning on paediatric fluid management and hyponatraemia.
Gov response: E-learning on paediatric fluid management and hyponatraemia made available to nursing staff.
Accepted
Delivered
IHRD-59 — Post-Mortem Request Form Training
Recommendation: There should be training in the completion of the post-mortem examination request form.
Gov response: Training provided on post-mortem examination request form completion.
Accepted
Delivered
IHRD-60 — Coroner Communication Training
Recommendation: There should be training in the communication of appropriate information and documentation to the Coroner's office.
Gov response: Training provided on communication with the Coroner's office.
Accepted
Delivered
IHRD-61 — Paediatric Communication Training
Recommendation: Clinicians caring for children should be trained in effective communication with both parents and children.
Gov response: Communication skills training provided for clinicians caring for children.
Accepted
Delivered
IHRD-62 — Adverse Incident Communication Training
Recommendation: Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.
Gov response: Specific training provided on communication with families following adverse incidents.
Accepted
Delivered
IHRD-63 — Evaluation of Parental Involvement
Recommendation: The practice of involving parents in care and the experience of parents and families should be routinely evaluated and the information used to inform training and improvement.
Gov response: Parental involvement evaluation mechanisms established.
Accepted
No update 2+ yrs
IHRD-64 — Parental Involvement in Training
Recommendation: Parents should be involved in the preparation and provision of any such training programme.
Gov response: Parents involved in development of relevant training programmes.
Accepted
No update 2+ yrs
IHRD-65 — SAI Investigator Training
Recommendation: Training in SAI investigation methods and procedures should be provided to those employed to investigate.
Gov response: SAI investigation training provided to designated investigators.
Accepted
Delivered
IHRD-66 — Time for SAI Learning
Recommendation: Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
Gov response: Protected time for learning from SAI investigations incorporated into practice.
Accepted
No update 2+ yrs
IHRD-67 — Informing Teaching Authorities
Recommendation: Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.
Gov response: Mechanisms established for informing teaching authorities of relevant investigation findings.
Accepted
Delivered
IHRD-68 — Using Investigations for Training
Recommendation: Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.
Gov response: Information from investigations and complaints assessed for training purposes.
Accepted
Delivered
IHRD-69 — Executive Director Responsibilities
Recommendation: Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI related patient deaths.
Gov response: Executive Director responsibilities assigned for candour, child healthcare and SAI learning.
Accepted
Delivered
IHRD-73 — GMC Code in Employment Contracts
Recommendation: General Medical Council ('GMC') 'Good Medical Practice' Code requirements should be incorporated into contracts of employment for doctors.
Gov response: GMC Good Medical Practice requirements incorporated into doctor employment contracts.
Accepted
Delivered
IHRD-74 — Professional Codes in Employment Contracts
Recommendation: Likewise, professional codes governing nurses and other healthcare professionals should be incorporated into contracts of employment.
Gov response: Professional code requirements incorporated into healthcare professional employment contracts.
Accepted
Delivered
IHRD-9 — Leadership Development
Recommendation: The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.
Gov response: Leadership development programmes implemented across HSC. Training provided to Board members.
Accepted
No update 2+ yrs
IHRD-90 — Clinical Guidance Dissemination Protocol
Recommendation: The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals fixed with responsibility for implementation and audit to ensure accountability. (ii) The identification of specific training requirements necessary …
Gov response: Protocol development for clinical guidance dissemination progressing.
Accepted
No update 2+ yrs
JB-15.1 — Clarify separation of SIO and firearms commander roles
Recommendation: There should be clearer guidance from the MPS, College of Policing and/or the NPCC on the separation of roles between the Senior Investigating Officer (SIO) and the Tactical and Strategic Firearms Commanders (TFC and SFC). The guidance should be clear …
Gov response: MPS formally responded on 28 October 2022 (paras 5-6). MO19 internal review commenced July 2021; DAC Barbara Gray authorised interim position separating SFC from investigation team. Chief Inspector Tom Williams led formal MO19 recommendations paper …
Accepted
Delivered
JB-15.10 — Training on clear intelligence communication
Recommendation: When intelligence is being provided, the use of any language that is capable of misinterpretation is to be avoided. Training to address this point should be provided to all officers and staff directly or indirectly involved in armed operations.
Gov response: MPS formally responded on 28 October 2022 (para 22). MPS actively reviewing steps to address consistency of language between firearms officers and other staff in armed operations.
Accepted
Delivered
JB-15.11 — Training requirement for covert monitoring post officers
Recommendation: Only those officers who have received the requisite training and accreditation should be posted to a Covert Monitoring Post (CMP).
Gov response: MPS formally responded on 28 October 2022 (paras 23-27). Significant CMP training improvements. MO3 and MO5 working to ensure training quality. 172 H2 trained staff; 350 CMP operatives awareness-trained; 130 more since.
Accepted
Delivered
JB-15.12 — Written guidance for covert monitoring posts
Recommendation: There should be clear and unequivocal written guidance for the CMP from the TFC as to the key information and intelligence that is being sought.
Gov response: MPS formally responded on 28 October 2022 (para 29). Recommendation reviewed by National CMP Working Group. Amended Surveillance MoS in draft addressing this under NPCC governance.
Accepted
Delivered
JB-15.13 — Training on note-taking for covert monitoring officers
Recommendation: The training referred to in paragraph 15.11 must emphasise the importance of covert monitoring officers (CMOs) making accurate notes of: (a) what they have heard; and (b) what they have passed on.
Gov response: MPS formally responded on 28 October 2022 (para 28). H2 training and CMP operatives awareness course comprehensively cover accurate note-taking and dissemination systems.
Accepted
Delivered
JB-15.14 — Require trained CMP manager for covert monitoring posts
Recommendation: CMPs should not be established without the appointment of a properly trained CMP manager, whose responsibility it should be to appoint a team of CMOs, once satisfied from proper assessment as to their qualifications and ability.
Gov response: MPS formally responded on 28 October 2022 (paras 24-25). Guidance issued reaffirming Surveillance MoS 2021 position: only trained officers may perform CMP roles; no CMP without accredited CMP Manager.
Accepted
Delivered
JB-15.15 — SOP for covert monitoring post evidence recording
Recommendation: When a CMP is being used to gather evidence or intelligence, the MPS (and other forces) should consider developing an SOP to ensure that the information is adequately recorded to provide a clear audit trail.
Gov response: MPS formally responded on 28 October 2022 (para 30). MPS has not yet developed SOP pending national D-DaCS system. Reinforcing national Surveillance MoS via internal guidance and training.
Accepted
No update 2+ yrs
JB-15.17 — Police medic training on catastrophic haemorrhage
Recommendation: Police medic training should emphasise that, in cases of catastrophic external torso haemorrhage, the immediate action is to apply direct pressure and then progress directly to using haemostatic gauze. Chest seals should only be used where there is no evidence …
Gov response: MPS formally responded on 28 October 2022 (paras 32-34). Senior First Aid Advisor Sue Warner reviewed training September 2021; confirmed no gap. Specific scenario on upper chest/neck catastrophic bleed now included in training.
Accepted
Delivered
JB-15.18 — Mandatory CLIO system training for command officers
Recommendation: Training should be made mandatory for command officers in the use of the Computer Logging of Intelligence Operations (CLIO) system and the Serious Organised Crime Tasking and Briefing (SOCTAB) system (a firearms version of CLIO which has specific tabs created …
Gov response: MPS formally responded on 28 October 2022 (paras 35-36). MO3 led work on CLIO training at command level. SOCTAB CLIO Build available to relevant MPS staff. National D-DaCS project integrating these capabilities.
Accepted
Delivered
JB-15.19 — Guidance on uniformity of firearms commands
Recommendation: Advice should be given by the College of Policing about the benefits of uniformity in instructions and commands. Ultimate discretion as to what is said must be left to the CTSFOs, based on the situation that confronts them, but the …
Gov response: MPS formally responded on 28 October 2022 (para 37). MPS in consultation with College of Policing on uniformity of commands and instructions.
Accepted
Delivered
JB-15.2 — Require multidimensional risk assessments throughout operations
Recommendation: Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those risk assessments should assess the future threat and risk at all stages of the operation.
Gov response: MPS formally responded on 28 October 2022 (paras 7-8). Firearms trainers required to watch Inquiry hearing recordings. Particular focus now on multidimensionality at all stages of operational planning. MO19 supporting College of Policing on improved …
Accepted
Delivered
JB-15.22 — Training for officers presenting firearms court applications
Recommendation: There should be training of those who are authorised by reason of rank to present such applications at court, and no-one should act as a substitute for a properly authorised person unless they have been appropriately trained. In any event, …
Gov response: College of Policing updated APP-AP in August 2023. Training implementation ongoing.
Accepted
No update 2+ yrs
JB-15.5 — Compulsory training on firearms authorisation forms
Recommendation: Appropriate training and refresher courses on the usage and completion of FA (and equivalent) forms should be made compulsory for firearms commanders and Tactical Advisors.
Gov response: MPS formally responded on 28 October 2022 (para 13). MPS has taken steps to set aside time during training days to focus trainees on FA form usage and completion.
Accepted
Delivered
JB-15.7 — Recording and documentation of firearms planning meetings and briefings
Recommendation: MPS Armed Policing Standard Operating Procedure (SOP) to be amended so that: a. Notes and/or audio recordings should be made of all meetings in relation to general strategy where it is envisaged that firearms may or will be deployed during …
Gov response: MPS formally responded on 28 October 2022 (paras 17-20). Internal guidance issued to all SFCs and TFCs on comprehensive minutes for planning meetings. PUoF SOP consistent with APP-AP. Recording of firearms briefings still under review …
Accepted
No update 2+ yrs
JB-15.8 — National guidance on recording firearms planning meetings
Recommendation: The NPCC and/or College of Policing should ensure that these amendments are reflected in the guidance and training given to forces nationally.
Gov response: No formal NPCC response published. MPS response (28 October 2022, paras 17-20) confirms NPCC governance of amended Surveillance Manual of Standards now in draft. College of Policing to review APP-AP in respect of recording of …
Accepted
Delivered
JB-15.9 — Intelligence briefing requirements during operations
Recommendation: The College of Policing's Authorised Professional Practice – Armed Policing (APP-AP) should clarify that, during the course of an operation, any relevant intelligence should be briefed out to the firearms officers even if it is appropriate, in the circumstances, to …
Gov response: MPS formally responded on 28 October 2022 (para 21). MPS conveyed willingness to assist College of Policing in review of APP-AP on intelligence briefing during operations.
Accepted
Delivered
LADB-11 — Implement joint training for signallers and drivers to improve understanding
Recommendation: Signallers and drivers should jointly attend away days and other training processes to develop their mutual understanding (para 9.28).
Unknown
LADB-12 — Increase driver briefing frequency with safety as primary agenda item
Recommendation: Thames Trains should increase the frequency of the briefing of drivers with a view to ensuring that each driver has a face to face meeting with his or her driver standards manager at least monthly, if not more often, and …
Unknown
LADB-13 — Endorse adoption of defensive driving teaching and practice by TOCs
Recommendation: The adoption by TOCs of the teaching and practice of defensive driving is endorsed (para 9.39).
Unknown
LADB-14 — Review driver competence system effectiveness and retest drivers every three years
Recommendation: TOCs should review the effectiveness of the systems in place to deliver the required level of driver competence at least once every three years, and should retest the driver against the revised systems at the same frequency (para 9.49).
Unknown
LADB-18 — Establish specific, validated criteria and pass standards for driver training
Recommendation: Thames Trains and other TOCs should ensure that their driver training and testing programmes adequately reflect the need for specific, relevant and validated criteria. Drivers should be tested against these criteria, and a definite pass standard should be established. Consideration …
Unknown
LADB-19 — Conduct further research on human factors relating to train driving
Recommendation: Further research should be carried out to develop the understanding of human factors as they relate to train driving (para 9.66).
Unknown
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-24 — Involve human factors experts in revising the signal sighting standard
Recommendation: Human factors experts should be involved in the revision of the standard on signal sighting (para 11.13).
Unknown
LADB-31 — Ensure adequate supply and training of signal sighters for workload
Recommendation: Railtrack, in consultation with the TOCs, should examine the availability of signal sighters to meet the expected workload and take all necessary steps to ensure that there is an adequate supply of trained signal sighters and an adequate range of …
Unknown
LADB-35 — Train SPAD investigators in human factors and root cause analysis
Recommendation: Persons who investigate, and make recommendations as a consequence of, SPADs should be trained in the identification of human factors and in root cause analysis. Their competence in these areas should be formally recorded, and renewed by refresher courses. The …
Unknown
LADB-36 — Clarify and consolidate signaller SPAD response instructions into a single set
Recommendation: The instructions for signallers as to their response to a SPAD should be: (a) clarified; and (b) set out in a single set of instructions, while if there are matters which are specific to a particular area they should be …
Unknown
LADB-37 — Explicitly state signallers must immediately assess and act after a SPAD
Recommendation: The instructions for signallers should state explicitly that the signaller is expected, in the event of a SPAD, to make an assessment and to take action immediately (para 12.10).
Unknown
LADB-38 — Provide signallers with emergency stop options and regular situational briefings on use
Recommendation: The instructions for signallers should provide a set of options, including the use of the CSR (where it is available) either to send an emergency stop message to a particular train or a general stop message. This range of options …
Unknown
LADB-39 — Establish system for signaller briefing and information sharing after SPAD incidents
Recommendation: Railtrack should institute a system whereby all signallers in the signal box (or centre) are briefed by their line manager following a SPAD in their area, and there is appropriate dissemination of information which may be of assistance to signallers …
Unknown
LADB-40 — Ensure SPAD reports include signaller's actions and reasons for them
Recommendation: Railtrack should ensure that the reports which are made to the Zone about a SPAD should include a report by the signaller as to the actions taken by him or her and the reasons for such actions (para 12.13).
Unknown
LADB-41 — Utilise simulators for effective signaller training in emergency situations
Recommendation: The use of simulators in providing fully effective training of signallers in dealing with emergencies is endorsed (para 12.15).
Unknown
LADB-42 — Promote mutual understanding of work demands between signallers and drivers
Recommendation: Railtrack and the TOCs should take steps to ensure that signallers and drivers obtain a full appreciation of the nature and demands of each other’s work (para 12.16).
Unknown
LADB-43 — Eliminate non-essential tasks performed by signallers at their workstations
Recommendation: Railtrack should review the work done by signallers to identify all non-essential tasks and eliminate them from the work which is performed by them while they are in charge of a workstation (para 12.17).
Unknown
LADB-44 — Employ continuous supervisor to ensure effective operation of signaller workstations
Recommendation: A supervisor should be employed on a continual basis to ensure that the workstations are operated in the most effective way (para 12.17).
Unknown
LADB-45 — Ensure signallers regularly practise controlling train movements
Recommendation: Signallers should take the opportunity from time to time to practise the controlling of train movements (para 12.18).
Unknown
LADB-46 — Establish and apply criteria for signallers exceeding maximum 72-hour work week
Recommendation: Railtrack management should set out the criteria for allowing signallers, in exceptional circumstances, to exceed the maximum of 72 hours of work per week, and ensure that these criteria are, and continue to be, correctly applied (para 12.19).
Unknown
LADB-84 — Train all on-board train staff in evacuation and protection procedures.
Recommendation: All members of the on-board train staff (including persons working under contract) should be persons who have been trained in train evacuation and protection (para 14.62).
Unknown
MAI-100 — Event healthcare staff trained in first responder interventions
Recommendation: The Department of Health and Social Care and the Care Quality Commission should consider introducing guidelines to ensure that all event healthcare staff who work at events are trained in first responder interventions.
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-102 — Enhanced care training for HART personnel
Recommendation: The Department of Health and Social Care and the National Ambulance Resilience Unit should consider ensuring that there is further training of HART personnel so that at least one member on every HART deployment has the ability to deliver the …
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-108 — Regular Major Incident training for ambulance commanders
Recommendation: The Department of Health and Social Care and the National Ambulance Resilience Unit should ensure that all ambulance commanders receive regular Major Incident training. The training should include training on HART capabilities, on all the command roles and where they …
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-119 — Integrate air ambulances into Major Incident response
Recommendation: The Department of Health and Social Care, the NHS, the National Ambulance Resilience Unit, ambulance service trusts, Air Ambulances UK, Counter Terrorism Policing Headquarters and JESIP should consider what staff training and resources would be required to integrate air ambulance …
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-12 — Train BTP Inspectors as Bronze Commanders
Recommendation: British Transport Police should ensure that all its Inspectors are trained to undertake the Bronze Commander role in the event of a Major Incident
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-122 — Maintain radio communications during Major Incidents
Recommendation: The emergency services should prepare, train and exercise for how they will maintain effective radio communications between emergency responders on the ground, commanders and control rooms, during the response to a Major Incident.
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-124 — First responder training for all police officers
Recommendation: The Home Office and College of Policing should ensure that all newly recruited and existing police officers and all frontline police staff, such as Police Community Support Officers, are trained in first responder interventions.
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-125 — Silver Commander training for designated officers
Recommendation: The Home Office and College of Policing should ensure that any police officer whose position carries with it the expectation that they will assume a Tactical/Silver Commander role in the event of a spontaneous Major Incident (e.g. Night Silver in …
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-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-13 — Train BTP Sergeants in Bronze Commander role
Recommendation: British Transport Police should ensure that all its Sergeants are trained in what is required of a Bronze Commander in the event of a Major Incident. This will help to make sure that the first Sergeant on scene can undertake …
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-131 — Force Duty Officer comprehensive training course
Recommendation: The Home Office, College of Policing and Counter Terrorism Policing Headquarters should ensure that all police officers to be appointed to the role of Force Duty Officer or Force Incident Manager attend a comprehensive training course dedicated to Operation Plato …
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-133 — High fidelity training for emergency responders
Recommendation: The Home Office, Counter Terrorism Policing Headquarters, the College of Policing, the Fire Service College and the National Ambulance Resilience Unit should consider introducing the use of regular 'high fidelity training' to give emergency responders better experience of the stress, …
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-136 — Awareness of specialist capabilities across services
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and all local resilience forums should take steps to ensure, whether through multi-agency training …
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-147 — Employer requirement to train in first aid
Recommendation: The Home Office should consider the introduction of a requirement into law, for example through regulations issued under the Health and Safety at Work etc. Act 1974, that employers train all employees, or certain categories of employees, in first responder …
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-153 — Use recording equipment during exercises
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that, in the course of exercises, such equipment is used by those who would use it in the circumstances of a …
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-154 — Training on use of recording equipment
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that training is given to all who are issued with such equipment, on the circumstances in which it should be used …
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-160 — Train all firefighters in first responder interventions
Recommendation: The National Fire Chiefs Council and the Fire Service College should establish a scheme for ensuring that all firefighters are trained in first responder interventions.
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-163 — SIA encourage trauma care training for non-licensed staff
Recommendation: The Security Industry Authority should take steps to encourage the security industry generally to ensure that even those members of staff who do not require a licence from the Security Industry Authority develop skills in basic trauma care.
Gov response: The Security Industry Authority (SIA) published a formal statement on 17 June 2021 in response to Volume 1 of the Manchester Arena Inquiry. The SIA committed to collaborating with the private security industry, law enforcement, …
Accepted
In progress
MAI-164 — SIA first responder training for all licensees
Recommendation: The Security Industry Authority should take urgent steps to devise a training scheme in first responder interventions that educates all of those licensed by it, both existing licensees and new licence applicants. The Security Industry Authority may find it helpful …
Gov response: The Security Industry Authority (SIA) published a formal statement on 17 June 2021 in response to Volume 1 of the Manchester Arena Inquiry. The SIA committed to collaborating with the private security industry, law enforcement, …
Accepted
In progress
MAI-165 — Ten Second Triage training for frontline staff
Recommendation: The team led by Philip Cowburn has devised a tool that is designed for use by a wide range of emergency responders in a mass casualty situation. It is known as Ten Second Triage. The National Ambulance Resilience Unit, the …
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-21 — Firearms officer training on Operation Plato
Recommendation: Counter Terrorism Policing Headquarters and the College of Policing should ensure that all firearms officers, including firearms commanders, receive adequate training in Operation Plato, including in what such a declaration means and the demands it will place upon them. This …
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-22 — Unarmed officer training on Operation Plato
Recommendation: Counter Terrorism Policing Headquarters and the College of Policing should ensure that all unarmed frontline police officers receive training in what Operation Plato is and what will be expected of them following such a declaration. The training should include the …
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-29 — Adequate first responder training time for police
Recommendation: Each police service must ensure that adequate time is allocated to the training of all police officers and frontline police staff in first responder interventions.
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-3 — Cross-border ambulance training and exercising
Recommendation: All ambulance service trusts should undertake training and exercising with neighbouring ambulance service trusts to ensure that cross-border support is efficient and effective.
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-30 — Nationally accredited Force Duty Officer training
Recommendation: Given the broad command responsibilities that the Force Duty Officer or Force Incident Manager will have in the early stages of the response to a Major Incident, the Home Office and the College of Policing should develop nationally accredited training …
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-31 — Joint GMFRS/NWFC incident log review procedures
Recommendation: Greater Manchester Fire and Rescue Service and North West Fire Control should conduct a joint review of the circumstances in which it is appropriate for Greater Manchester Fire and Rescue Service personnel to check the North West Fire Control incident …
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-32 — Train GMFRS commanders in operational discretion
Recommendation: Greater Manchester Fire and Rescue Service should ensure that its commanders are adequately trained in the use of operational discretion.
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-5 — Major Incident training for North West Fire Control staff
Recommendation: All North West Fire Control staff should be trained on the best practices for responding to a Major Incident, as identified through its participation in exercises. North West Fire Control should ensure that learning is kept under review.
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-64 — Create centralised NaCTSO training library
Recommendation: NaCTSO should create a centralised library of training materials.
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-69 — Train NWAS commanders in operational discretion
Recommendation: North West Ambulance Service should ensure that its commanders are adequately trained in the use of operational discretion.
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-79 — Train NWAS commanders on command relief procedures
Recommendation: North West Ambulance Service should train its Operational Commanders on the appropriate practice for relieving another of command and being relieved of command.
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-90 — Firearms officers trained in Care Under Fire
Recommendation: The College of Policing and Counter Terrorism Policing Headquarters should ensure that all firearms officers are trained to understand that, while their primary role in an Operation Plato situation is to neutralise any armed terrorist, their role also involves providing …
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-95 — Improve police training record systems
Recommendation: The College of Policing should consider whether the current process for maintaining and storing training records for all police officers can be improved. That should include assessing the following: a. the introduction of electronic training records in a standard form …
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-97 — Control room trauma care guidance for 999 callers
Recommendation: The College of Policing, the Fire Service College and National Fire Chiefs Council should consider devising training packages for operators within control rooms, to enable them to give guidance on basic trauma care to 999 callers.
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
F108 — Support for other agencies
Recommendation: Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers' infection control arrangements.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F11 — Fundamental standards of behaviour
Recommendation: Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their employees comply with these requirements. Staff members affected by professional …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F148 — Training
Recommendation: The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F149 — Expert assistance
Recommendation: Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
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
F160 — Training and training establishments as a source of safety information
Recommendation: Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences in relation to raising concerns.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 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
F170 — Health Education England
Recommendation: Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F171 — Deans
Recommendation: All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F172 — Proficiency in the English language
Recommendation: The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required for a registered medical practitioner to assume professional responsibility for …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F185 — Focus on culture of caring
Recommendation: There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures the delivery of proper standards of nursing requires: Selection 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
F186 — Practical hands-on training and experience
Recommendation: Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F187 — Practical hands-on training and experience
Recommendation: There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision of a registered nurse. Such experience should include direct 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
F189 — Consistent training
Recommendation: The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 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
F190 — National standards
Recommendation: There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of compassionate 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 in Part
F193 — Standards for appraisal and support
Recommendation: Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which responsible officers would be obliged to comply. They could be required to report to the Nursing and Midwifery …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 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
F194 — Standards for appraisal and support
Recommendation: As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of nursing practice and its implementation. Alongside developmental requirements, this should contain documented …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 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
F195 — Nurse leadership
Recommendation: Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. They should know about the care plans relating to every …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 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
F196 — Nurse leadership
Recommendation: The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient care and, in particular, to the priority to be accorded to dignity and respect, and their acquisition 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
F197 — Nurse leadership
Recommendation: Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all NHS healthcare provider organisations that should be required under commissioning …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 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
F211 — Training standards for healthcare support workers
Recommendation: There should be a common set of national standards for the education and training of healthcare support workers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F212 — Training standards for healthcare support workers
Recommendation: The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation with all relevant stakeholders, including the Department of Health, other …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (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
F214 — Shared training
Recommendation: A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and leadership to potential senior staff; promote healthcare leadership and management as a profession; administer an accreditation scheme to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F220 — Accreditation
Recommendation: A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, at least initally, the objective should be to require all leadership posts to be filled by persons who …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
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
F77 — Enhancement of role of governors
Recommendation: Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and challenge deficiencies in the quality of the foundation trust's services.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F81 — Accountability of providers' directors
Recommendation: Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F86 — Requirement of training of directors
Recommendation: A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
10 — Establish partner Trust buddying arrangement
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should seek to forge links with a partner Trust, so that both can benefit from opportunities for learning, mentoring, secondment, staff development and sharing approaches to problems. This arrangement is promoted …
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
16 — Clarify manager quality responsibilities
Recommendation: As part of the governance systems work, we consider that the University Hospitals of Morecambe Bay NHS Foundation Trust should ensure that middle managers, senior managers and non-executives have the requisite clarity over roles and responsibilities in relation to quality, …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
2 — Review clinical staff competencies
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the skills, knowledge, competencies and professional duties of care of all obstetric, paediatric, midwifery and neonatal nursing staff, and other staff caring for critically ill patients in anaesthetics and …
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
22 — Recognise educational opportunities in smaller units
Recommendation: We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and exploited. We recommend that a review be carried out of …
Gov response: 19. We accept this recommendation in principle. Work already underway by Health Education England addresses this recommendation. Health Education England is committed to supporting efforts to improve the quality of patient care by ensuring that …
Accepted
28 — National standards for clinical leads
Recommendation: Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads of service, medical directors, nurse directors. Trusts should provide evidence …
Gov response: 57. We accept these recommendations in principle. 13 http://www.gmc-uk.org/guidance/good_medical_practice/respond_to_risks.asp 14 http://www.nmc.org.uk/standards/code/read-the-code-online/ 58. Following the tragedies at Mid Staffordshire NHS Foundation Trust and University Hospitals of Morecambe Bay NHS Foundation Trust there has been a renewed …
Accepted
29 — Standards for manager quality responsibilities
Recommendation: Clear national standards should be drawn up setting out the responsibilities for clinical quality of other managers, including executive directors, middle managers and non-executives. All Trusts should provide evidence to the Care Quality Commission, as part of their processes, of …
Gov response: 57. We accept these recommendations in principle. 13 http://www.gmc-uk.org/guidance/good_medical_practice/respond_to_risks.asp 14 http://www.nmc.org.uk/standards/code/read-the-code-online/ 58. Following the tragedies at Mid Staffordshire NHS Foundation Trust and University Hospitals of Morecambe Bay NHS Foundation Trust there has been a renewed …
Accepted
3 — Deliver staff training and development plans
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up plans to deliver the training and development of staff identified as a result of the review of maternity, neonatal and other staff, and should identify opportunities to broaden …
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
4 — Establish continuing professional development requirements
Recommendation: Following completion of additional training or experience where necessary, the University Hospitals of Morecambe Bay NHS Foundation Trust should identify requirements for continuing professional development of staff and link this explicitly with professional requirements including revalidation. This should be completed …
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
5 — Promote effective multidisciplinary team-working
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and develop measures that will promote effective multidisciplinary team-working, in particular between paediatricians, obstetricians, midwives and neonatal staff. These measures should include, but not be limited to, joint training …
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
WATE-(23) — Periodically audit Social Services staff recruitment and management vigilance
Recommendation: Social Services Departments should be reminded periodically that they must exercise vigilance in the recruitment and management of their staff in strict accordance with the detailed recommendations of the Warner committee917; and compliance with them by individual local authorities should …
Unknown
WATE-(25) — Provide appropriate and timely induction training for new residential child care staff
Recommendation: Social Services Departments should ensure that appropriate and timely induction training is provided for all newly recruited residential child care staff.
Unknown
WATE-(26) — Implement Utting's recommendations for children's home staff training expeditiously
Recommendation: The Tribunal endorses all five of the most recent recommendations of Sir William Utting in "People Like Us"918 in relation to the content and provision of training for staff in children's homes and the care units of residential special schools …
Unknown
WATE-(27) — Require senior children's home staff to be qualified social workers or train
Recommendation: It should be a requirement that senior staff of children's homes (including private and voluntary homes) must be qualified social workers or, if that is not practicable before appointment, that it should be a condition of their appointment that they …
Unknown
WATE-(28) — Promote and validate training in safe restraint methods for child care staff
Recommendation: Central government should take the initiative to promote and validate training in safe methods of restraint with a view to making such training readily available for residential child care staff and foster parents.
Unknown
WATE-(29) — Make specialist post-qualifying child care training widely available for senior staff
Recommendation: Suitable specialist training in child care at post-qualifying level should be made widely available and, in particular, to the senior residential care staff of children's homes and to field social workers.
Unknown
WATE-(30) — Conduct national review of pay and career for residential child care staff
Recommendation: There should be a national review of the pay, status and career development of residential child care staff and field social workers to ensure as far as possible that there is a sufficient supply of candidates for such posts of …
Unknown
WATE-(35) — Ensure foster carers receive continuing support and access to specialist services
Recommendation: Foster carers should receive continuing support and have access as necessary to specialist services. In this context we endorse the recommendations of Sir William Utting in relation to training in "People Like Us"919.
Unknown
WATE-(57) — Local authorities in Wales review senior management training and development
Recommendation: Local authorities in Wales should review their current arrangements for management training and development for senior managers, including social services managers, giving particular attention to the development of skills in strategic planning, policy implementation and performance appraisal.
Unknown
WATE-(68) — Consider national training and management development for senior local authority managers
Recommendation: Consideration should be given at national level to the need for, and provision of, training and management development for senior managers in local authorities in Wales, including the availability of such facilities for social services managers922.
Unknown
POPP-A.1 — Integrate evacuation procedures into police training and pre-match briefings.
Recommendation: Evacuation procedures should be a matter of police training and form part of the briefing by police officers before a football match.
Unknown
POPP-A.10 — Train stewards in fire safety, firefighting, and assisting police with evacuation.
Recommendation: Stewards in all grounds should not only be trained in fire precautions and fire fighting (see Recommendation 7 above) but should also be trained in how best to help the police in evacuation.
Unknown
POPP-A.12 — Amend Green Guide for comprehensive steward training and instruction on emergencies.
Recommendation: The Green Guide should be amended to contain a specific provision, in relation to stewards, (i) that they should be trained and instructed to deal with any emergency relating to fire or evacuation (see also Recommendations 7 and 10); (ii) …
Unknown
POPP-A.7 — Require fire fighting training for all sports ground stewards
Recommendation: Stewards at all sports grounds should be trained in fire fighting.
Unknown
POH-12 — Amend GLOS to allow claimants oral submissions at panel hearings
Recommendation: The scheme documents governing GLOS should be amended so that a right is conferred upon claimants (exercisable by the claimants themselves or their recognised legal representatives) to make oral submissions in support of their claim at the hearing convened by …
Gov response: Department for Business and Trade accepts this recommendation. GLOS claimants already had the right to make oral submissions for up to one hour at independent panel hearings prior to the panel making a binding determination. …
Accepted
Delivered
POH-15 — Set deadline for HSS claims with guidance on late applications
Recommendation: No claims for financial redress under HSS shall be entertained after midnight 27 November 2025.
Gov response: Department for Business and Trade broadly accepts this recommendation. HSS closes to new claims on 31 January 2026. Post Office is sending reminder letters to outstanding claimants. DBT will publish guidance on exceptional cases that …
Accepted in Part
Delivered
POH-18 — Devise redress process for affected family members
Recommendation: The Department shall devise a process for providing financial redress to close family members of those most adversely affected by Horizon. Such family members shall qualify for such redress only if they themselves, have suffered serious adverse consequences by reason …
Gov response: Department for Business and Trade accepts this recommendation. Some close family members of postmasters suffered serious adverse consequences because of the Horizon scandal. DBT is committed to establishing a redress scheme for close family members …
Accepted
In progress
RHI-1 — Policy Skills Assessment
Recommendation: A new policy at its earliest stage should be subject to a rigorous process to determine whether the Northern Ireland devolved administration has (or is prepared to assign) the necessary skills and resources to deliver the policy safely and competently. …
Gov response: [Note: The NI Executive responded to recommendations 1-4 together as a group under the 'Policy Development' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full. Some elements are addressed in existing …
Accepted
No update 2+ yrs
RHI-10 — External Consultants Guidance
Recommendation: The Northern Ireland Civil Service should consider what changes are needed to its guidance and practices on the use of external consultants arising from the experience of RHI. Specific recommendations include: (a) that better assessments are needed at the outset …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
No update 2+ yrs
RHI-11 — Project Management Disciplines
Recommendation: Best practice project and risk management disciplines should be the default practice within the Northern Ireland Civil Service when developing novel and complex policies and managing their implementation. These disciplines can be widely applied and should not be confined only …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
RHI-12 — Invest NI and SIB Collaboration
Recommendation: The leaders of the Northern Ireland Civil Service should work with Invest Northern Ireland and the Strategic Investment Board to consider how both organisations can better contribute their expertise to the work of mainstream Departments, particularly in relation to good …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
RHI-17 — Professional Development
Recommendation: The Northern Ireland Civil Service should take steps to draw on best practice from other jurisdictions to provide more support for professions within the civil service. The Inquiry specifically recommends: (a) the establishment of a project management profession with a …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
RHI-24 — Staff Move Sequencing
Recommendation: Senior managers in the Civil Service must take responsibility for guiding and, where necessary, sequencing the timing of staff moves so that continuity of business is secured. This includes allowing sufficient time for transferring staff to hand over, and discuss …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
No update 2+ yrs
RHI-3 — Policy Skills Training
Recommendation: As far as practicable, Northern Ireland Civil Service teams working on policies, particularly new and untested initiatives, should be trained and supported so that they have the skills to do the job, not least the ability to model the policy, …
Gov response: [Note: The NI Executive responded to recommendations 1-4 together as a group under the 'Policy Development' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full. Some elements are addressed in existing …
Accepted
Delivered
RHI-30 — Budget Holder Financial Training
Recommendation: Civil servants who are responsible for holding and monitoring a budget should have to demonstrate core requirements in financial literacy and an understanding of how public spending operates, including what is expected of them according to the core guidance contained …
Gov response: [Note: The NI Executive responded to recommendations 19-23, 29-33 together as a group under the 'Governance and Financial Controls' theme.] Accepted in full. Addressed through the delivery of an online package of Public Expenditure training …
Accepted
Delivered
RHI-36 — Learning from Failures
Recommendation: The Northern Ireland Civil Service should develop a better process to learn from past failures, one that goes beyond the traditional method of revising and circulating internal guidance. Leaders within the Senior Civil Service must be more systematic, persistent and …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
RHI-4 — Quality of Ministerial Advice
Recommendation: A lesson from the RHI experience is that action is needed to raise and sustain the quality of advice to Ministers and the clarity with which it is expressed. Options must be properly evaluated and, at the point of formal …
Gov response: [Note: The NI Executive responded to recommendations 1-4 together as a group under the 'Policy Development' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full. Some elements are addressed in existing …
Accepted
Delivered
RHI-5 — Ministerial Training and Support
Recommendation: One role of Ministers in a democratic system is to decide on policies and they can only do so effectively if they are prepared, in appropriate cases, to question and challenge material put to them in submissions and regulatory impact …
Gov response: [Note: The NI Executive responded to recommendations 5-7, 25, 37, 39-43 together as a group under the 'Ministers and Special Advisers' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full, with …
Accepted
No update 2+ yrs
RHI-7 — Special Adviser Induction
Recommendation: There should be a clearly defined induction process for new Special Advisers, shared by the appointing Minister and the relevant Permanent Secretary, in the course of which the structure and work of the relevant Department, the terms of the Special …
Gov response: [Note: The NI Executive responded to recommendations 5-7, 25, 37, 39-43 together as a group under the 'Ministers and Special Advisers' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full, with …
Accepted
No update 2+ yrs
RHI-9 — Commercial Awareness
Recommendation: Commercial and business awareness amongst policy officials, particularly those working in roles relating to the economy of Northern Ireland, must be improved. It is important that the leadership of the Northern Ireland Civil Service also devise and provide clear guidance …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
No update 2+ yrs
SHI-11 — Training for IPC professionals engineers and clinicians
Recommendation: I would recommend that IPC professionals should receive some basic training on the recommendations made by the NHS's own guidance for engineering systems, insofar as they are made in the interests of patient safety and care, before they are recruited …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: NHS Scotland Assure is developing a framework of training and lessons learned that will be accessible …
Accepted
In progress
SHI-8 — IPC role specifications and staffing levels
Recommendation: I accordingly recommend that priority be given to protecting scarce IPC resources. With that objective in view, what is expected of consideration and advice from individual disciplines at various stages of a project should be made clear. Job and role …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: The Scottish Government has published role descriptors for IPC staff and is engaging closely with NHS …
Accepted
In progress
MACP-31 — Ensure training and use of victim/witness liaison officers for racist incidents.
Recommendation: That Police Services ensure the provision of training and the availability of victim/witness liaison officers, and ensure their use in appropriate areas particularly in the field of racist incidents and crimes, where the need for a sensitive approach to young …
Unknown
MACP-45 — Review and revise First Aid training for all public contact police officers
Recommendation: That First Aid training for all "public contact" police officers (including senior officers) should at once be reviewed and revised to ensure that they have basic skills to apply First Aid. Officers must be taught to "think first aid", and …
Unknown
MACP-46 — Implement First Aid training and testing to recognised standards in all Police Services
Recommendation: That training in First Aid including refresher training should include testing to recognised and published standards in every Police Service.
Unknown
MACP-47 — Police Services annually review and test public contact officers' First Aid training
Recommendation: That Police Services should annually review First Aid training, and ensure that "public contact" officers are trained and tested to recognised and published standards.
Unknown
MACP-48 — Review and revise police racism awareness training for consistent cultural diversity strategy
Recommendation: That there should be an immediate review and revision of racism awareness training within Police Services to ensure:- a. that there exists a consistent strategy to deliver appropriate training within all Police Services, based upon the value of our cultural …
Unknown
MACP-49 — Train all police officers and staff in racism awareness and cultural diversity
Recommendation: That all police officers, including CID and civilian staff, should be trained in racism awareness and valuing cultural diversity.
Unknown
MACP-50 — Conduct local police racism awareness training involving minority ethnic communities
Recommendation: That police training and practical experience in the field of racism awareness and valuing cultural diversity should regularly be conducted at local level. And that it should be recognised that local minority ethnic communities should be involved in such training …
Unknown
MACP-51 — Promote joint police training with other organisations off police premises
Recommendation: That consideration be given by Police Services to promoting joint training with members of other organisations or professions otherwise than on police premises.
Unknown
MACP-52 — Home Office and Police Services publish racism awareness training standards and objectives
Recommendation: That the Home Office together with Police Services should publish recognised standards of training aims and objectives in the field of racism awareness and valuing cultural diversity.
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-54 — Review racism awareness training in local government and criminal justice agencies
Recommendation: That consideration be given to a review of the provision of training in racism awareness and valuing cultural diversity in local Government and other agencies including other sections of the Criminal Justice system.
Unknown
TAYL-F16 — Provide comprehensive training for police and stewards on crowd density and distress
Recommendation: All police officers and stewards with duties in relation to the standing areas and especially those with duties under Recommendation 12 above, should be fully briefed and trained with regard to the recognition of crowd densities, to the recognition of …
Unknown
TAYL-F42 — Recruit, retain, and fully train competent, fit, and active stewards
Recommendation: Clubs should recruit and retain sufficient competent stewards. They should be fit, active and robust, and preferably between the ages of 18 and 55. Clubs should ensure that stewards are fully trained, aware of their duties under Annex B of …
Unknown
TAYL-F52 — Provide specific training course for senior police commanders on football match strategy
Recommendation: Consideration should be given to the provision of a specific training course for senior officers presently acting as Police Commanders and those in line to do so. Such a course should include training in the basic strategy of policing football …
Unknown
TAYL-I6 — Provide mandatory training for police and stewards on crowd density recognition
Recommendation: All police officers and stewards with duties in relation to the terraced areas and especially those with duties under Recommendation 5 above, should be fully briefed and trained with regard to the recognition of crowd densities, to the recognition of …
Unknown
AS-3 — Training Material Dating and Archiving
Recommendation: All training material should be dated, appropriately retained and archived in such a way that it can easily be established when the training material was composed, when it came into force and the period during which it remained in force.
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AS-8 — Interpreter Availability
Recommendation: There should be an appropriate review of all current, relevant policy and procedures to ensure that a sufficient number of suitably trained interpreters are readily available and on hand during all aspects of prisoner detainee handling, including all forms of …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AG-2 — HMICFRS Thematic Inspection of Armed Policing
Recommendation: Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) should conduct a thematic inspection or inspections concerning: (i) the selection and training of officers authorised to use weapons requiring special authorisation; (ii) the selection and training of officers …
Gov response: HMICFRS response to the Anthony Grainger Inquiry. 13. HMICFRS have now had the opportunity to consider recommendation 2 of the Anthony Grainger Inquiry. 14. HMICFRS note that the Inquiry Chair, His Honour Judge Teague, was …
Accepted
Delivered
AG-6 — MASTS Documentation and Training Clarity
Recommendation: All documents and training relating to Mobile Armed Support to Surveillance (MASTS) should: clearly differentiate between MASTS as an operational method of supporting surveillance (and delivering a standard range of tactical options), and the additional tactical options of 'intervention' and …
Gov response: 28. This recommendation is complex and has required a review of Authorised Professional Practice (APP), the National Police Firearms Training Curriculum (NPFTC) and associated policy and doctrine. NPCC have decided to take responsibility, given the …
Accepted
No update 2+ yrs
AG-9 — Maximum Continuous Duty Period for AFOs
Recommendation: The National Police Chiefs' Council (NPCC) and the College of Policing should jointly decide, in the light of independent expert advice, whether there should be a maximum period of time during which authorised firearms officers (AFOs) are permitted to remain …
Gov response: 37. Following discussions with NPCC and the College of Policing, the Government understands that current guidance does not specify a time limit and that there would be significant operational implications of doing so. There are, …
Accepted
No update 2+ yrs
COVID-M1.1 — Simplify Emergency Preparedness Structures
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each simplify and reduce the number of structures with responsibility for preparing for and building resilience to whole-system civil emergencies. The core structures should be: a single Cabinet-level or …
Gov response: No formal response published by this government.
Accepted
Delivered
COVID-M1.10 — Independent Statutory Resilience Body
Recommendation: The UK government should, in consultation with the devolved administrations, create a statutory independent body for whole-system civil emergency preparedness and resilience. The new body should be given responsibility for: providing independent, strategic advice to the UK government and devolved …
Gov response: Since the pandemic, significant strategic and material changes have been made to the way in which the UK and devolved governments handle crises. Considerable progress has been made against the longer-term programme to build a …
Response Unclear
In progress
COVID-M1.2 — Cabinet Office Leadership for Emergencies
Recommendation: The UK government should: abolish the lead government department model for whole-system civil emergency preparedness and resilience; and require the Cabinet Office to lead on preparing for and building resilience to whole-system civil emergencies across UK government departments, including monitoring …
Gov response: The government agrees with the need for a greater Cabinet Office role for whole-system civil emergencies. This is in addition to the Lead Government Department model which retains an essential role in preparedness and resilience. …
Accepted in Part
In progress
COVID-M1.4 — UK-wide Civil Emergency Strategy
Recommendation: The UK government and devolved administrations should together introduce a UK-wide whole-system civil emergency strategy (which includes pandemics) to prevent each emergency and also to reduce, control and mitigate its effects. The strategy should: be adaptable; include sections dedicated to …
Gov response: No formal response published by this government.
Accepted in Part
In progress
COVID-M1.5 — Pandemic Data Systems and Research
Recommendation: The UK government, working with the devolved administrations, should establish mechanisms for the timely collection, analysis, secure sharing and use of reliable data for informing emergency responses, in advance of future pandemics. Data systems should be tested in pandemic exercises. …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.8 — Triennial Parliamentary Resilience Reports
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each produce and publish reports to their respective legislatures at least every three years on whole-system civil emergency preparedness and resilience. The reports should include as a minimum: the …
Gov response: No formal response published by this government.
Accepted in Part
In progress
COVID-M1.9 — External Red Teams for Resilience
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each introduce the use of red teams in the Civil Service to scrutinise and challenge the principles, evidence, policies and advice relating to preparedness for and resilience to whole-system …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M2.3 — UK-wide Expert Register
Recommendation: The Government Office for Science (GO-Science) should develop and maintain a register of experts across the four nations of the UK who would be willing to participate in scientific advisory groups, covering a broad range of potential civil emergencies.
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M3.10 — Healthcare Worker Support
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place plans to deliver effective support for healthcare workers at scale from the outset of a pandemic. Plans should …
Gov response: No formal response published by this government.
Unknown
COVID-M3.3 — Fit-Testing Preparedness
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review the availability of qualified fit testers and take steps to increase the number of fit testers accordingly. Availability …
Gov response: No formal response published by this government.
Unknown
COVID-M3.5 — Scale Up Urgent and Emergency Care
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for surge capacity in urgent and emergency care during a pandemic. Plans must ensure that there is sufficient workforce …
Gov response: No formal response published by this government.
Unknown
R23 — TVN training and qualification
Recommendation: Health Boards should ensure that a nurse appointed as Tissue Viability Nurse (TVN) is appropriately trained and possesses, or is working towards, a recognised specialist post-registration qualification.
Gov response: Section 4.3 of the Scottish Government's response indicates that accredited education programmes for specialist and advanced practice roles, including for Tissue Viability Nurses, are available through universities and funded by NHS boards. The government provided …
Accepted
R42 — Mandatory IPC training
Recommendation: Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention control training that includes CDI on appointment.
Gov response: Section 4.3 of the Scottish Government's response states that the HAI Taskforce delivery plan promoted a strategy to ensure all healthcare workers receive appropriate education and training related to HAI. The Cleanliness Champions Programme, which …
Accepted
R43 — IPC staff regular training
Recommendation: Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control of which a record should be kept.
Gov response: Section 4.3 of the Scottish Government's response notes that the HAI Taskforce delivery plan included an education framework for specialists working in infection prevention and control. For nurses, accredited education programmes for specialist and advanced …
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
R54 — Surveillance system training
Recommendation: Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to use and respond to the data available.
Gov response: Section 4.3 of the Scottish Government's response outlines national education and training initiatives, including a strategy from the HAI Taskforce to ensure all healthcare workers receive appropriate education and training related to HAI. This is …
Accepted
R60 — Cleanliness Champions implementation
Recommendation: Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as Cleanliness Champions Programme, are implemented without undue delay.
Gov response: Section 4.3 of the Scottish Government's response confirms that the Cleanliness Champions Programme was introduced in September 2003, with over 18,000 NHS Scotland staff having completed it. The program aims to prepare staff to promote …
Accepted
R67 — Link Nurse training
Recommendation: Health Boards should ensure that, where a local Link Nurse system is in place as part of the IPS system, the Link Nurses have specific training for that role.
Gov response: Section 4.3 of the Scottish Government's response describes the HAI Taskforce's support for education, which includes a strategy to ensure all healthcare workers receive appropriate education and training related to HAI. It also promotes an …
Accepted
LAMI-100 — Train child protection officers to confidently challenge other professionals' views
Recommendation: Training for child protection officers must equip them with the confidence to question the views of professionals in other agencies, including doctors, no matter how eminent those professionals appear to be.
Unknown
LAMI-102 — Home Office to implement national child protection officer training curriculum
Recommendation: The Home Office, through Centrex and the Association of Chief Police Officers, must devise and implement a national training curriculum for child protection officers as recommended in 1999 by Her Majesty’s Inspectorate of Constabulary in its thematic inspection report, Child …
Unknown
LAMI-103 — Chief constables to ensure trained detective officers in child protection teams
Recommendation: Chief constables must ensure that officers working on child protection teams are sufficiently well trained in criminal investigation, and that there is always a substantial core of fully trained detective officers on each team to deal with the most serious …
Unknown
LAMI-105 — Chief constables to integrate and adequately resource child protection teams
Recommendation: Chief constables must ensure that child protection teams are fully integrated into the structure of their forces and not disadvantaged in terms of accommodation, equipment or resources.
Unknown
LAMI-107 — Require police authorities to prioritise child protection investigations in policing plans
Recommendation: Chief constables and police authorities must give child protection investigations a high priority in their policing plans, thereby ensuring consistently high standards of service by well-resourced, well-managed and well-motivated teams.
Unknown
LAMI-108 — Add child protection policing training to strategic command course syllabus
Recommendation: The Home Office, through Centrex, must add specific training relating to child protection policing to the syllabus for the strategic command course. This will ensure that all future chief officers in the police service have adequate knowledge and understanding of …
Unknown
LAMI-13 — Amalgamate child welfare guidance documents into one simplified common language framework
Recommendation: The Department of Health should amalgamate the current Working Together and the National Assessment Framework documents into one simplified document. The document should tackle the following six aspects in a clear and practical way: • It must establish a ‘common …
Unknown
LAMI-14 — Require training bodies to include inter-agency joint working in national programmes
Recommendation: The National Agency for Children and Families should require each of the training bodies covering the services provided by doctors, nurses, teachers, police officers, officers working in housing departments, and social workers to demonstrate that effective joint working between each …
Unknown
LAMI-15 — Require local boards to provide and evaluate inter-agency training for staff
Recommendation: The newly created local Management Boards for Services to Children and Families should be required to ensure training on an inter-agency basis is provided. The effectiveness of this should be evaluated by the government inspectorates. Staff working in the relevant …
Unknown
LAMI-18 — Mandate interpreter use for non-English speaking children in welfare communications
Recommendation: When communication with a child is necessary for the purposes of safeguarding and promoting that child’s welfare, and the first language of that child is not English, an interpreter must be used. In cases where the use of an interpreter …
Unknown
LAMI-19 — Require duty managers to track child referrals, actions, responsibilities, and deadlines
Recommendation: Managers of duty teams must devise and operate a system which enables them immediately to establish how many children have been referred to their team, what action is required to be taken for each child, who is responsible for taking …
Unknown
LAMI-20 — Ensure social services intake staff are experienced and appropriately trained
Recommendation: Directors of social services must ensure that staff in their children and families’ intake teams are experienced in working with children and families, and that they have received appropriate training.
Unknown
LAMI-21 — Require written confirmation of child welfare referrals to social services within 48 hours
Recommendation: When a professional makes a referral to social services concerning the well-being of a child, the fact of that referral must be confirmed in writing by the referrer within 48 hours.
Unknown
LAMI-22 — Assess and record suitability of temporary child accommodation; report unsuitability to senior officer
Recommendation: If social services place a child in temporary accommodation, an assessment must be made of the suitability of that accommodation and the results of that assessment must be recorded on the child’s case file. If the accommodation is unsuitable, this …
Unknown
LAMI-25 — Require manager approval for child assessments and plans after seeing child and carer
Recommendation: All social services assessments of children and families, and any action plans drawn up as a result, must be approved in writing by a manager. Before giving such approval, the manager must ensure that the child and the child’s carer …
Unknown
LAMI-26 — Prohibit closing vulnerable child cases until child seen and welfare plan agreed
Recommendation: Directors of social services must ensure that no case involving a vulnerable child is closed until the child and the child’s carer have been seen and spoken to, and a plan for the ongoing promotion and safeguarding of the child’s …
Unknown
LAMI-31 — Ensure all staff working with children receive comprehensive vocational and ongoing training
Recommendation: Directors of social services must ensure that all staff who work with children have received appropriate vocational training, receive a thorough induction in local procedures and are obliged to participate in regular continuing training so as to ensure that their …
Unknown
LAMI-37 — Train social workers to confidently challenge other professionals' opinions on child needs
Recommendation: The training of social workers must equip them with the confidence to question the opinion of professionals in other agencies when conducting their own assessment of the needs of the child.
Unknown
LAMI-43 — Mandate training for Section 47 inquiries and audit staff for compliance
Recommendation: No social worker shall undertake section 47 inquiries unless he or she has been trained to do so. Directors of social services must undertake an audit of staff currently carrying out section 47 inquiries to identify gaps in training and …
Unknown
LAMI-84 — Revalidate doctors and paediatricians in deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: All designated and named doctors in child protection and all consultant paediatricians must be revalidated in the diagnosis and treatment of deliberate harm and in the multi-disciplinary aspects of a child protection investigation.
Unknown
LAMI-85 — Develop continuing education models for deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: The Department of Health should invite the Royal College of Paediatrics and Child Health to develop models of continuing education in the diagnosis and treatment of the deliberate harm of children, and in the multi-disciplinary aspects of a child protection …
Unknown
LAMI-87 — Ensure GPs receive regular training in deliberate harm recognition and child protection investigations.
Recommendation: The Department of Health should seek to ensure that all GPs receive training in the recognition of deliberate harm to children, and in the multi-disciplinary aspects of a child protection investigation, as part of their initial vocational training in general …
Unknown
LAMI-88 — Examine feasibility of deliberate harm training for all primary healthcare staff.
Recommendation: The Department of Health should examine the feasibility of introducing training in the recognition of deliberate harm to children as part of the professional education of all general practice staff and for all those working in primary healthcare services for …
Unknown
LAMI-89 — GPs must ensure staff know local child protection agency contact procedures.
Recommendation: All GPs must devise and maintain procedures to ensure that they, and all members of their practice staff, are aware of whom to contact in the local health agencies, social services and the police in the event of child protection …
Unknown
LAMI-90 — Ensure child protection training for liaison staff and audit policy compliance.
Recommendation: Liaison between hospitals and community health services plays an important part in protecting children from deliberate harm. The Department of Health must ensure that those working in such liaison roles receive child protection training. Compliance with child protection policies and …
Unknown
PFD Reports (1027) — showing 100 most recent
Rajwinder Singh
Concerns: HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Pending
Josh Tarrant (1)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Gareth Chumber-Kelly
Concerns: Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.
Pending
Josh Tarrant (2)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Josh Tarrant (3)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Elise Sebastian
Concerns: Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
Pending
Bonita Cleary
Concerns: A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Pending
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
Haaris Bhatti
Concerns: Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.
Response: FOLD nightclub has reviewed and revised its welfare escalation procedures to ensure earlier ambulance calls for seriously unwell guests. They have also introduced enhanced monitoring, updated public awareness communications, and …
Responded
Pippa Gillibrand
Concerns: A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data collection.
Pending
Lucy Thornton
Concerns: Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.
Pending
Matilda Pomfret-Thomas
Concerns: A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for midwives and patient care.
Response: NICE acknowledges the report but clarifies that the registration, regulation, and training of doulas are not its responsibility and are better addressed by other professional bodies like the NMC and …
Response: Developing Doulas, in a voluntary submission, disputes the coroner's suggestion that a doula's presence negatively impacted midwifery services. They explain the doula's actions aligned with a non-clinical support role and …
Response: The Department of Health and Social Care acknowledges concerns about unregulated doulas but states there is no legal requirement for their training or registration. It notes existing NMC guidance and …
Response: The NMC outlines its existing standards for midwives and highlights a video resource developed with Doula UK to clarify distinct roles, addressing the need for guidance. It states that doula …
Responded
Jean Waldron
Concerns: An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for carers.
Response: Ignite Health and Homecare Services has reinforced guidance to all staff, issued formal reminders on escalation procedures for clinical concerns, and reviewed existing supervision and audit processes to ensure adherence …
Responded
Dorothy Macdonald
Concerns: Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately refer to specialist falls teams.
Response: Springcare has revised falls risk assessment documentation, introduced new falls training for existing and new staff, and begun auditing assessments. Westwood Hall has also implemented a new policy to refer …
Responded
Sundeep Ghuman
Concerns: Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training and operational failure.
Response: HMP Belmarsh has withdrawn its S1 system and both Belmarsh and HMP High Down are now fully compliant with national CSRA policy. Naloxone is now available across residential units with …
Overdue
Izzah Ali
Concerns: Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of professional curiosity and adherence to guidance.
Response: The Trust has updated ED and paediatric documentation and made 'What is in the bottle?' a standard inquiry across services to improve clarity on infant feeding. They have also enhanced …
Response: Minor Injuries Unit staff have been instructed to specifically inquire about the contents of bottles if nutrition is a concern. Staff have also been reminded to weigh children on each …
Response: Cornwall Council has secured funding to rewrite its 'Essential Guide to feeding and caring for your baby' and the digital version has already been updated with translated versions. They plan …
Responded
Katherine Wright
Concerns: Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate safety concerns during searches.
Response: Thames Valley Police has reviewed and updated its Missing Persons Operational Guidance to include a new section on premises searches, covering search extent, equipment, hazards, and escalation protocols. This new …
Responded
June Findlay
Concerns: Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did not identify these consistent failures.
Response: Frimley Health NHS Foundation Trust has implemented a new Nutritional & Hydration Audit tool, developed and launched a new care planning tool with supporting guidance, and produced a training programme …
Responded
Evelyn Rae Le Masurier-O’Sullivan
Concerns: Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and escalation.
Overdue
Celia Phillips
Concerns: Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented need.
Response: Inspire You Care Ltd has updated all service user care plans to include repositioning instructions and information from other professionals, and trained staff to understand and follow these plans. Refresher …
Responded
Benedict Blythe
Concerns: Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing and retaining crucial scene evidence.
Response: The Royal College of Pathologists notes that existing autopsy guidelines for suspected acute anaphylaxis (2018) provide specific guidance on sampling blood and stomach contents. They will query the inclusion of …
Response: Cambridgeshire Constabulary has established full liaison with Scenes of Crime Officers (SOCOs) for forensic sample preservation in child death investigations. They have also amended and re-issued internal procedural guidance, incorporated …
Responded
Connor Nelson
Concerns: Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust process for its investigation and referral.
Response: Sherwood Forest Hospitals NHS Foundation Trust has conducted cardiac arrest simulation sessions and provided defibrillation training for EAU medical staff, introducing new mandatory annual BLS/ALS training. They also developed and …
Responded
Andrew McCleary
Concerns: Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the detainee adequately.
Response: Bedfordshire Police has enhanced existing mandatory Mental Capacity Act (MCA) training for frontline officers and ensures Restrictive Physical Intervention training covers risks and de-escalation. They have also introduced and embedded …
Responded
Ronald Perry
Concerns: Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.
Response: The Lakes Care Centre has appointed a new manager, completed 7 weeks of induction training for all Senior Carers, and improved the use of their Digital Care Record system for …
Responded
Aaron Taylor
Concerns: Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, with staff unaware of required frequency.
Response: HMPPS ensures all new officers receive training on suicide and self-harm prevention, including ACCT processes. HMP Garth has issued staff notices and a Governor's order in October and November 2025 …
Responded
Vivian Nolan
Concerns: Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
Response: The British Society of Gastroenterology clarifies that current UK guidance emphasizes individualised patient consent, balancing risks and benefits for colonoscopy, including for those over 80. They dispute the suggestion of …
Responded
Jennifer Cahill and Agnes Cahill
Concerns: There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and inadequate midwife training.
Response: NHS England is developing national home birth guidance for consultation by Q2 2026 and will work with UKMIDSS to improve national data collection. An updated Neonatal Life Support (NLS) course …
Response: NICE clarifies that home birth is covered in its existing intrapartum care guideline (NG235) and midwifery staffing guideline (NG4). They commit to reviewing their guidance to define high and low-risk …
Response: The RCOG notes the concerns and refers to existing NICE guidelines (2025) on intrapartum care and place of birth, and points to NHS England/DHSC or RCM/NMC as best positioned to …
Response: The RCM notes the concerns, refers to existing NICE guidelines and RCM/NMC position statements, and states they will continue to advocate for clearer guidelines, training funding, and safe staffing through …
Response: The NMC plans to engage with the Royal College of Midwives and NHS England to explore developing a national framework for home births and will consider strengthening their Code regarding …
Response: The Association of Ambulance Chief Executives has amended the JRCALC Postpartum Haemorrhage guideline to clarify the reconsideration of other bleeding causes if a firm uterus persists. They confirmed existing guidance …
Responded
Maureen Christy
Concerns: There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.
Response: Blackpool Teaching Hospitals plans to roll out a digital solution called ‘Alertive’ from Q4 2025/2026 to improve the dissemination of critical messages and ensure staff acknowledgment of policies, with scoping …
Responded
Gloria Simon (2)
Concerns: Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP declined and failed to consistently take, record, and act on basic patient observations.
Response: Riversdale Care Home has updated its 'Request for Care Form' to correctly identify as a 'Care Home'. They have also revised their policy to send letters to out-of-district GPs for …
Responded
Gunaratnam Kannan
Concerns: There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act assessments, causing confusion over referral responsibilities.
Response: EMAS has embedded supporting tools like non-conveyance checklists and MCA prompts into their patient record system. They are actively working with system partners to establish robust referral pathways with local …
Response: Nottinghamshire Healthcare has delivered bespoke training and developed/shared two flow charts for staff on Mental Capacity Act assessments. They have also established a multi-agency group to improve joint working on …
Response: The RCGP states its curriculum already requires GPs to understand mental health legislation, including the Mental Capacity and Mental Health Acts, and that the curriculum was recently reviewed. They express …
Responded
Shannon Lee
Concerns: There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
Response: The Trust states its Level 2 intermittent observation policy is unambiguous and clearly specifies 15-minute intervals with no reference to 30 minutes. It describes existing electronic observation (eObs) system functionality …
Responded
Louisa Walker (1)
Concerns: There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Responded
Louisa Walker (2)
Concerns: A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient safety.
Response: Following the inquest, the Trust has ensured all obstetric doctors (ST1 and above, Consultants) and Band 7 delivery suite and maternity clinical coordinator midwives have been trained in managing Impacted …
Responded
Stephen Neville
Concerns: Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes for these critical observations were also found to be severely inadequate.
Response: The Trust has updated its Observation Policy and a new training module, rolled out to all clinical staff by December 2025, with a new observation proforma also being implemented. It …
Responded
Alexander Lewis
Concerns: Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer crew for safety.
Response: The Department of Transport states there are no specific statutory regulations for the minimum distance single yellow lines must be from a junction, clarifying that it is for the local …
Response: The Minister highlights amendments to the Road Traffic Act 1988 via the Police, Crime, Sentencing and Courts Act 2022, ensuring high and consistent standards for police driver training and risk …
Response: South Wales Police disputes the coroner's concerns, asserting that its current single-crewed operational model and national training standards are designed to ensure public safety and officer competence. It states officers …
Responded
Rashida Sultana
Concerns: Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk assessments for Speech and Language Therapy referrals for dysphagia.
Response: The organisation has approved and implemented an updated 'Emergency Medical Response Policy including Management of Resuscitation' in March 2025, which outlines systems, processes, and structures for safe and effective care …
Responded
Steven Davidson
Concerns: Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during prisoner health assessments, indicating training deficiencies.
Response: HCRG has amended its training provision to include mandatory structured SystmOne training for all new staff during induction and refresher training for existing staff. They are also embedding this training …
Responded
Marc Davies
Concerns: Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.
Response: Monmouthshire County Council and MJ Events have implemented a new three-tier training program for all Safe Guards, covering first aid, safeguarding, drug and alcohol awareness, naloxone administration, mental health awareness, …
Overdue
John Rust
Concerns: Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all current and future clinical staff receive essential training on critical equipment.
Response: The response text is truncated; therefore, no actions taken or planned regarding mandatory training for CSF drainage systems can be identified.
Responded
Alexander McCormack
Concerns: Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in risk assessment and investigation.
Response: Northamptonshire Police are in the process of creating new training presentations for all ranks, including updated training for transferring Inspectors on COMPACT file handling. The Detective Superintendent will ensure future …
Responded
David Jones
Concerns: The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on atypical presentations.
Response: Nottingham University Hospitals NHS Trust has launched an Acute Aortic Dissection Improvement project, which will be undertaken by a newly formed Acute Aortic Dissection Improvement Group. This group will involve …
Responded
Paula Doreen
Concerns: National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new systems risk losing safety nets.
Response: NHS England explains that the Cerner system's duplicate checking functionality was available but likely not enabled and defers to the Royal College of Physicians for national ACVPU assessment training. NHS …
Response: The MHRA outlines existing Human Medicines Regulations 2012 regarding the labelling and warnings for paracetamol medicines and its role in monitoring medicine safety. The MHRA has liaised with NHS England, …
Response: The Royal Pharmaceutical Society (RPS) notes the concerns, clarifying its non-regulatory role and stating that most electronic prescribing systems have duplication alerts, though these often require national oversight to improve. …
Response: Lewisham and Greenwich NHS Trust's electronic prescribing system includes 'hard stop' alerts for concurrent paracetamol prescriptions and dose range checking, with oral dose range checking slated for an update. The …
Response: Oracle Health disputes any defect or fault in its Millennium software regarding concurrent paracetamol prescriptions, stating the functionality exists but is an optional, client-configurable setting. Oracle Health affirms its system …
Responded
Abigail Jelley
Concerns: Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for vulnerable mothers.
Response: The Trust has established multidisciplinary team (MDT) huddle meetings, weekly MDT reviews, and provided senior clinical leadership to support staff. They are also rolling out a redesigned training programme for …
Responded
Adrienne Studholme
Concerns: Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, posed significant risks.
Response: The Trust has clarified that seizure activity is escalated regardless of who witnesses it, communicating this to clinical teams. They have also reminded ED and surgical clinicians to ensure urgent …
Responded
Derek Crowther
Concerns: Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, risking future deaths.
Response: The Trust has launched a new Mandatory Training Policy and a monitoring dashboard to ensure staff complete required Intermediate Life Support training. They have also established a project group to …
Responded
Pauline Stirling
Concerns: Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to poor patient safety and persistent record-keeping failures.
Response: Malhotra Group has implemented an electronic care recording system (Nourish) which now includes specific fields for positional tilts and enhanced wound management oversight. They have also updated their Position Change …
Overdue
Air India Boeing 787
Concerns: Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to severe health risks.
Overdue
Edward Funnell
Concerns: Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading to unaddressed issues.
Responded
Kore Padgett
Concerns: There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, preventing informed patient decisions.
Responded
Gabriella Jaiyesimi
Concerns: Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving actions, or effectively communicate crucial information to emergency services.
Responded
Daisy McCoy
Concerns: Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, and poor escalation protocols, compounded by consultant oversight.
Responded
Brian Ringrose
Concerns: Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model or challenge inappropriate techniques, contributing to the death.
Responded
Margaret Medlicott
Concerns: A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge this decision and were inadequately trained in risk assessments and care plan creation.
Responded
Joan Whitworth
Concerns: There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff were unaware of resident dietary restrictions, posing risks to resident safety.
Responded
Samantha Young
Concerns: A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.
Responded
Michael Pugh
Concerns: Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
Responded
Madeline Reding
Concerns: Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do Not Resuscitate orders, led to critical care gaps.
Responded
Patryk Gladysz
Concerns: Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and healthcare staff, and insufficient training on risks for foreign nationals and first aid.
Overdue
Myles Scriven
Concerns: The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies and training having no impact on care and staff failing to act on crucial information.
Overdue
Gavin Wheale
Concerns: The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with concealed items.
Responded
Gemma Poterajko
Concerns: The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely cardiac surgical team support during procedures.
Responded
Sean Fitzgerald
Concerns: Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and fatal consequences.
Overdue
George Emmett
Concerns: An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
Overdue
Liliwen Thomas
Concerns: Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.
Responded
Sarah Lewis
Concerns: Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Responded
David Gifford
Concerns: Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.
Responded
Patrick Coffey
Concerns: Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or pressure damage, are not repositioned as required.
Responded
Joshua Allcock
Concerns: Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time test provided misleading reassurance regarding dehydration in children.
Overdue
Jordanne Roberts
Concerns: A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive essential training on reviewing full reports.
Responded
Muhammad Qasim
Concerns: Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic collision report.
Responded
Karl Dunstan
Concerns: Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated the scan.
Responded
Louise Crane
Concerns: Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.
Responded
REDACTED
Concerns: Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were also limited to telephone.
Responded
Finlay Roberts
Concerns: There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.
Responded
Vera Fortey
Concerns: Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Responded
Margaret Douglas
Concerns: The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding of patient requirements.
Overdue
Terence Colby
Concerns: A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and posing a risk to future patients.
Responded
Kathleen Gregory
Concerns: A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
Responded
Edward Cassin
Concerns: There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering patient care.
Responded
Valerie Hill
Concerns: The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.
Responded
Carol Taylor
Concerns: No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing a particular risk to vulnerable elderly patients.
Responded
Oscar Keenan
Concerns: Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays in obtaining early clinical assessment.
Responded
Simon Hockenhull
Concerns: Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.
Responded
Maureen Powell
Concerns: Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to a patient's deterioration.
Responded
Esme Atkinson
Concerns: Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing of cardiac anomaly scans contribute to delayed diagnosis.
Responded
Edward Wilson
Concerns: Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood pressure.
Responded
Colin Brooks
Concerns: Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues during cardiopulmonary bypass procedures.
Responded
Lewis Johnson
Concerns: The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time required for pursuit authorization decisions.
Responded
Etta-Lili Stockwell-Parry
Concerns: The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.
Responded
Emmy Russo
Concerns: Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of escalating concerns for labouring mothers and CTG traces.
Responded
Lorraine Parker
Concerns: A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical judgment alone risks overlooking critical objective indicators.
Responded
Ivy Dixon
Concerns: Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating inadequate training and integrity issues.
Responded
Christopher McDonald
Concerns: Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action planning.
Responded
Mr YZ
Concerns: Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical information despite the user's distress.
Responded
Hailey Thompson
Concerns: A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record of the handling.
Responded
Loraine Cheesman
Concerns: There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and Executive Dysfunction, hindering effective intervention and requiring revised protocols.
Responded
Peter Konitzer
Concerns: HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide a comprehensive guide on safety obligations for charitable and voluntary organizations.
Responded
Claire Driver
Concerns: Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff training on substance misuse and mental health.
Responded
Thomas Glover
Concerns: NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance for higher-risk para-oesophageal cases and hindering appropriate patient care.
Responded
William Grieve
Concerns: Critical suicide risk assessments were flawed because different healthcare teams used incompatible electronic systems, preventing access to complete patient notes. Unaddressed staff training needs pose ongoing risks.
Overdue