Weak Government Accountability & Scrutiny
291 items
2 sources
Lack of clear departmental responsibility for budgeting tax reliefs and insufficient parliamentary scrutiny of government non-executives.
Cross-Source Insight
Weak Government Accountability & Scrutiny has been flagged across 2 independent accountability sources:
283 inquiry recs
8 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (283)
R3 — Prison service reform process
Recommendation: We have identified a series of failures in the management of the NIPS in 1997. What we learned about the current management of the NIPS in the course of the Inquiry, for example during the document recovery hearings, left us …
Gov response: Secretary of State Owen Paterson stated on 14 September 2010 that he would discuss all three recommendations with Justice Minister David Ford, as prisons had become a devolved matter. Justice Minister Ford established a Prison …
Accepted
BRIS-134 — Make public the trust validation standards and revalidation results.
Recommendation: The standards against which trusts are to be validated, and the results of the process of validation or revalidation, should be made public.
Unknown
BRIS-153 — Develop clear, high-quality national healthcare performance indicators comprehensible to the public
Recommendation: At national level, the indicators of performance should be comprehensible to the public as well as to healthcare professionals. They should be fewer and of high quality, rather than numerous but of questionable or variable quality.
Unknown
BRIS-155 — Ensure patients and public can access trust and consultant unit performance information
Recommendation: Patients and the public must be able to obtain information as to the relative performance of the trust and the services and consultant units within the trust.
Unknown
BRIS-156 — Require trust boards to publicly report compliance with national clinical standards
Recommendation: As part of their Annual Reports trust boards should be required to report on the extent of their compliance with the national clinical standards. These reports should be made public and be made available to CHI.
Unknown
BRIS-159 — Ensure transparent public involvement processes in NHS organisations, reported annually
Recommendation: The processes for involving patients and the public in organisations in the NHS must be transparent and open to scrutiny: the annual report of every organisation in the NHS should include a section setting out how the public has been …
Unknown
BRIS-162 — Routinely evaluate NHS public involvement mechanisms based on evidence of effectiveness
Recommendation: The mechanisms for the involvement of the public in the NHS should be routinely evaluated. These mechanisms should draw on the evidence of what works.
Unknown
BRIS-38 — Make DoH roles explicit: NHS headquarters and independent regulatory framework
Recommendation: The DoH’s roles in relation to the NHS must in future be made explicit. The DoH should have two roles. It should be the headquarters of the NHS. It should also establish an independent framework of regulation which will assure …
Unknown
BRIS-39 — Create two independent councils for healthcare quality and professional regulation
Recommendation: The framework of regulation must consist of two overarching organisations, independent of government, which bring together the various bodies which regulate healthcare. A Council for the Quality of Healthcare should be created to bring together those bodies which regulate healthcare …
Unknown
BRIS-40 — Ensure independent Councils report to DoH and Parliament with DoH oversight
Recommendation: The two Councils should be independent of government and report both to the DoH and to Parliament. There should be close collaboration between the two Councils. The DoH should establish and fund the Councils and set their strategic framework, and …
Unknown
BRIS-41 — Ensure all healthcare quality and professional competence bodies are independent of DoH
Recommendation: The various bodies whose purpose it is to assure the quality of care in the NHS (for example, CHI and NICE) and the competence of healthcare professionals (for example, the GMC and the Nursing and Midwifery Council) must themselves be …
Unknown
BRIS-42 — Regulatory bodies must be independent and reflect interests of patients and professionals
Recommendation: All the various bodies and organisations concerned with regulation, besides being independent of government, must involve and reflect the interests of patients, the public and healthcare professionals, as well as the NHS and government.
Unknown
BRIS-51 — Establish NHS Appointments Commission for non-executive director appointments
Recommendation: As recommended in ‘The NHS Plan’, there should be an NHS Appointments Commission responsible for the appointment of non-executive directors of NHS trusts, health authorities and primary care trusts.
Unknown
BRIS-72 — Prioritise establishing statutory Council for Regulation of Healthcare Professionals with broad membership
Recommendation: The Council for the Regulation of Healthcare Professionals should be established as a matter of priority. It should have a statutory basis. It should report to Parliament. It should have a broadly-based membership, consisting of representatives of the bodies which …
Unknown
BRIS-73 — Grant Council powers to enforce good regulation principles and consistent professional body behaviour
Recommendation: The Council for the Regulation of Healthcare Professionals should have formal powers to require bodies which regulate the separate groups of healthcare professionals to conform to principles of good regulation. It should act as a source of guidance and of …
Unknown
26 — Ensure Home Office staff presence and visibility in IRCs
Recommendation: The Home Office must ensure that its staff are regularly present and visible within each immigration removal centre.
Gov response: Detention Engagement Team expansion is underway, with further recruitment to increase Home Office staff presence in IRCs.
Accepted in Part
Delivered
HIDD-28 — Government to seek legislative effect for recommendation 27
Recommendation: Government shall seek to give legislative effect to recommendation 27.
Unknown
CR11 — Coastguard role in legislation
Recommendation: The role and functions of HM Coastguard should be set out in up-to-date legislation.
Response Pending
CR12 — Independent external oversight body
Recommendation: An independent external body should be given responsibility for the regular assessment of the effectiveness and efficiency of HM Coastguard. Consideration should be given to extending the remit of His Majesty's Inspectorate of Constabulary and Fire and Rescue Services as …
Response Pending
CR13 — Reconsider Border Force SAR function
Recommendation: The government should reconsider Mr Downer's recommendation in his independent review of Border Force that Border Force Maritime should not be providing an ongoing search and rescue function in the English Channel, with the result that HM Coastguard would assume …
Response Pending
CR14 — MoU between Coastguard and Border Force
Recommendation: For so long as the current arrangements in relation to search and rescue in the English Channel remain in place, the roles and responsibilities of HM Coastguard and Border Force should be set out in a memorandum of understanding.
Response Pending
CR18 — MAIB publication of implementation measures
Recommendation: The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details of implementation measures taken by those to whom a recommendation is addressed, or an explanation for not taking …
Response Pending
DM-16 — Duty to cooperate with independent scrutiny bodies
Recommendation: In the interest of transparency and public accountability, all public institutions should be under a duty to cooperate fully with independent scrutiny bodies created by Government, such as the Panel.
Gov response: The Home Office introduced a statutory duty of cooperation in February 2020 for serving police officers as part of wider integrity reforms. Police officers now have a responsibility to give appropriate cooperation during investigations, inquiries …
Accepted
Delivered
DM-18 — Realistic timelines for non-statutory inquiries
Recommendation: Prior to the establishment of any future non-statutory inquiries or panel, there should be an honest and full discussion between the relevant police force(s) and the sponsoring Government department, to enable a realistic, informed assessment of the nature and volume …
Gov response: It is right that full and proper consideration is given before establishing any form of public inquiry, and that ministers should consider when establishing a non-statutory inquiry or panel whether relevant information providers will cooperate …
Accepted
No update 2+ yrs
DM-19 — Timely access to material for panels
Recommendation: Arrangements must be made in future to ensure that any Panel has timely access to the material required to do its work. Organisations that promise to make 'exceptional and full disclosure' should be prepared to do so both within the …
Gov response: The Government's view is that in future, specific disclosure arrangements – including in respect of information security – should be agreed between inquiries and information providers at an early stage wherever possible. The Government agrees …
Accepted
No update 2+ yrs
ETI-12 — Record Keeping Requirements
Recommendation: For transparency, Scottish Ministers should maintain minutes documenting: discussions and decisions between Ministers and civil servants regarding publicly-funded project involvement; discussions with local authorities and contractors; and negotiations, including mediation discussions.
Gov response: The Scottish Government stated that 'robust and enhanced procedures regarding minute-taking and documentation management have also been embedded within the Government and the Civil Service.' Source: Transport Secretary Statement, 2 November 2023.
Accepted
Delivered
ETI-17 — Governance Structure
Recommendation: The governance structure for the delivery of a major project such as a light rail scheme should follow published guidance and ensure clarity regarding the respective roles of various bodies and individuals. The chairman of the company responsible for procurement …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
ETI-2 — Inquiry Independence
Recommendation: Scottish Ministers must not appoint any department, agency, or government organization as inquiry sponsor where it or its employees had involvement in the project under investigation.
Gov response: The Scottish Government stated that guidance similar to that suggested is already in development. Source: Transport Secretary Statement, 2 November 2023.
Accepted in Part
No update 2+ yrs
ETI-20 — Prohibition on Misleading Reports from ALEOs
Recommendation: The directors, employees and consultants of the company responsible for the procurement and delivery of the project as project managers, including an arm's-length external organisation (ALEO) wholly owned by the local authority that is the promoter and owner of the …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
ETI-21 — Duty of Officials to Councillors
Recommendation: Local authority officials should be mindful at all times of the distinction in roles between them and councillors, who are solely responsible for strategic decisions, and of their duty to provide accurate reports to councillors to enable them to take …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
ETI-22 — Civil Sanctions for Misleading Reports
Recommendation: Where a company, including an ALEO, knowingly submits a report or other information to local authority officials that is misleading by reason of the inclusion of false statements or the omission of relevant facts, or where such officials knowingly submit …
Gov response: The Scottish Government stated it is 'giving careful consideration' to recommendations about civil damages provisions and criminal statutory offences for misleading evidence. The Government noted that existing remedies may already exist under delictual liability and …
Response Unclear
ETI-23 — Criminal Sanctions for Misleading Information
Recommendation: In addition to civil liability from any sanction introduced in accordance with Recommendation 22, Scottish Ministers should consider whether there is need for a statutory criminal offence involving strict liability once it is established that information or reports were misleading …
Gov response: The Scottish Government stated it is 'giving careful consideration' to recommendations about civil damages provisions and criminal statutory offences for misleading evidence. The Government noted that existing remedies may already exist under delictual liability and …
Response Unclear
ETI-24 — Duty of Disclosure Legislation
Recommendation: Scottish Ministers should consider the need for legislation to impose a similar duty of disclosure to that owed by policyholders to their insurers upon a company, its directors, employees or consultants and upon a local authority and its officials towards …
Gov response: The Scottish Government stated it is 'giving careful consideration' to recommendations about provisions for misleading evidence. Source: Transport Secretary Statement, 2 November 2023.
Response Unclear
ETI-4 — Inquiry Cost Transparency
Recommendation: When reporting public inquiry costs, Scottish Ministers should disclose net costs to the public purse, excluding previously-incurred accommodation and staffing expenses, alongside total departmental account costs.
Gov response: The Scottish Government stated that guidance similar to that suggested is already in development. Source: Transport Secretary Statement, 2 November 2023.
Accepted in Part
No update 2+ yrs
FENN-120 — Resolve legal uncertainty regarding fire certification for underground stations.
Recommendation: The law on fire certification as it relates to underground stations is in a state of uncertainty. Steps should be taken to resolve the position.
Unknown
FENN-128 — Continue regular senior management safety meetings between LU, LFB, and RI.
Recommendation: The regular meetings at three levels of senior management between London Underground and the London Fire Brigade, and those between the Railway Inspectorate and the London Fire Brigade shall continue.
Unknown
FENN-129 — Bring Railway Inspectorate to full establishment to fulfil safety responsibilities.
Recommendation: The Railway Inspectorate must be brought up to establishment to carry out its responsibilities under section 3 of the Health and Safety at Work etc. Act 1974.
Unknown
FENN-130 — Railway Inspectorate to vigorously discharge duties concerning London Underground safety.
Recommendation: The Railway Inspectorate must be more vigorous in the discharge of its duties on London Underground.
Unknown
FENN-131 — Railway Inspectorate to review LU safety management and enlist external advice.
Recommendation: The Railway Inspectorate shall keep the management of safety by London Underground under review. It must enlist outside advice.
Unknown
FENN-132 — Invite CTCC observer to attend Railway Industry Advisory Committee meetings.
Recommendation: An observer from the Central Transport Consultative Committee, as the statutory body which represents the interests of the travelling public nationally, should be invited to attend meetings of the Railway Industry Advisory Committee.
Unknown
FENN-133 — Report all London Underground fires occurring outside traffic hours.
Recommendation: Fires which occur outside traffic hours on London Underground must be reported. The Department oS Transport should secure such reports until the 'Railways (Notice of Accidents) Order 1986' [SI 1986 No 21871 has been amended.
Unknown
FENN-134 — Include separate London Underground accident statistics in Railway Inspectorate annual reports.
Recommendation: Separate accident statistics for London Underground shall be shown in the Railway Inspectorate annual reports.
Unknown
FENN-135 — Review DoT Railway Construction and Operation Requirements for underground railways and stations.
Recommendation: The 'Department of Transport Railway Construction and Operation Requirements' in respect of underground railways and stations shall be reviewed, together with the letter dated 10 November 1958 to the railway undertakings entitled 'Submission of new works for approval by the …
Unknown
FENN-136 — Fire authority and RI to scrutinise new station designs for passenger safety.
Recommendation: The designs for new stations or significant alterations to stations shall be scrutinised by the fire authority and the Railway Inspectorate with special regard to passenger safety and fire precautions.
Unknown
FENN-137 — Hold twice-yearly safety meetings between Chief Inspecting Officer and LU directors.
Recommendation: There shall be twice-yearly meetings to discuss safety matters between the Chief Inspecting Officer of Railways, those of his staff responsible for enforcement on London Underground and the Engineering and Operations Directors and the Chief Safety Inspector of London Underground.
Unknown
FENN-138 — London Underground Board safety committee to meet Chief Inspecting Officer annually.
Recommendation: Each year the Board safety committee of London Underground shall meet the Chief Inspecting Officer of Railways.
Unknown
FENN-139 — Amend regulations for six-monthly competent person inspection of escalators and travolators.
Recommendation: 'The Offices Shops and Railway Premises (Hoists and Lifts) Regulations 1968' IS1 1968 No 8491 must be amended to require escalators and travolators in Underground stations to be inspected every six months by a competent person.
Unknown
FENN-140 — Railway Inspectorate to review fire precaution enforcement role
Recommendation: The Railway Inspectorate shall review its role in enforcing fire precautions under health and safety legislation in the light of this Investigation.
Unknown
FENN-141 — London Underground to review ticketing system proposals with safety bodies
Recommendation: London Underground shall review its proposals for the working of the Underground Ticketing System (UTS) at stations and take advice from the Railway Inspectorate and the London Fire Brigade.
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-145 — Boards to prioritise safety in London Underground resource allocation and investment decisions
Recommendation: Explicit consideration by the Boards of London Regional Transport and London Underground shall always be given to safety when decisions on resource allocation and investment are being made.
Unknown
FENN-146 — Reflect passenger numbers in London Underground investment appraisal criteria
Recommendation: The numbers of passengers using the system must be duly reflected in the criteria for investment appraisal in London Underground.
Unknown
FENN-147 — London Underground to fully utilise funds and assess safety of budget changes
Recommendation: Funds allocated to London Underground must be fully used, and particular attention paid to the safety implications of any changes to the budget.
Unknown
FENN-148 — London Underground to regularly inform public about safety and changes
Recommendation: London Underground shall regularly inform the travelling public about safety on the Underground and any proposed changes.
Unknown
FENN-149 — Introduce litter legislation and review smoking byelaw penalties on London Underground
Recommendation: Legislation against the dropping of litter on London Underground shall be introduced and a review undertaken of the byelaw prohibiting smoking and the penalties for the offence.
Unknown
FENN-156 — London Underground and LRT to report implementation progress to Secretary of State
Recommendation: London Underground and London Regional Transport shall make regular reports to the Secretary of State for Transport upon their progress with the implementation of those recommendations directed at them.
Unknown
FENN-157 — Include London Underground progress reports in relevant annual reports
Recommendation: Reports on the progress made by London Underground shall also be included in the annual reports of London Regional Transport, the London Regional Passengers' Committee and the Railway Inspectorate.
Unknown
FENN-46 — Continue annual LFB inspections, remedy defects, and publish reports publicly
Recommendation: The annual inspection by the London Fire Brigade of underground stations and tunnels shall continue, and unsatisfactory features must be remedied and reported on within six weeks. Copies of the reports shall be sent to the Chief Safety Inspector and …
Unknown
FENN-54 — Produce prompt reports and analysis of fire and smoke incidents
Recommendation: Reports of fires and smoke shall be produced promptly and an analysis made available for management and Board meetings, the Railway Inspectorate, the London Fire Brigade, and the London Regional Passengers' Committee.
Unknown
FENN-56 — Chief Safety Inspector to review, identify hazards, recommend policies, and audit safety
Recommendation: The Chief Safety Inspector shall review existing safety arrangements, identify hazards, recommend policies, objectives and systems to meet those hazards, and thereafter audit the effectiveness of the system. He should have direct access to the Chief Executive of London Underground …
Unknown
FENN-61 — Establish a London Underground Board safety committee with defined terms of reference
Recommendation: The Board of London Underground shall establish a safety committee and lay down its terms of reference.
Unknown
FENN-77 — Inform Passengers' Committee of accident inquiry conclusions affecting London Underground passengers
Recommendation: London Underground shall inform the London Regional Passengers' Committee, as the statutory body which represents the interests of passengers, of the conclusions and recommendations of internal inquiries into accidents which might affect passengers.
Unknown
FENN-78 — Appoint non-executive director with direct access for London Underground safety
Recommendation: A non-executive director with special responsibility for safety shall be appointed to the Board of London Underground. He shall have direct access to the Chairman of London Regional Transport.
Unknown
FENN-79 — Establish system for auditing London Underground operational safety with Board reports
Recommendation: London Regional Transport shall establish a system whereby the safety of operation of London Underground can be the subject of audit. The Board of London Regional Transport shall receive reports on such audit.
Unknown
P2-25 — Maintain public record of inquiry recommendations
Recommendation: That it be made a legal requirement for the government to maintain a publicly accessible record of recommendations made by select committees, coroners and public inquiries together with a description of the steps taken in response. If the government decides …
Gov response: The government accepts this recommendation in principle. We will establish a record on GOV.UK of all recommendations made by public inquiries since 2024, and will consider making this an enduring legal requirement. The government agrees …
Accepted in Part
Delivered
P2-3 — Consolidate fire safety functions under single department
Recommendation: That the government bring responsibility for the functions relating to fire safety currently exercised by MHCLG, the Home Office and the Department for Business and Trade into one department under a single Secretary of State. (113.8)
Gov response: The government accepts this recommendation. Fire safety related functions will move from the Home Office to MHCLG. The National Regulator for Construction Products in the Department for Business and Trade already reports to MHCLG's Secretary …
Accepted
Delivered
P2-4 — Appoint Chief Construction Adviser
Recommendation: That the Secretary of State appoint a Chief Construction Adviser with a sufficient budget and staff to provide advice on all matters affecting the construction industry, including: a) monitoring all aspects of the department's work relating to the Building Regulations …
Gov response: The government accepts this recommendation. We will appoint a Chief Construction Adviser to advise the Secretary of State, to monitor the department's work relating to the Building Regulations, statutory guidance and the construction industry more …
Accepted
In progress
SHEE-59 — Seriously consider the specific suggestion presented by the inquiry court
Recommendation: The court draws attention to this suggestion and expresses the hope that serious consideration will be given to it.
Unknown
SHEE-60 — Consider appointing independent counsel to public inquiry tribunals
Recommendation: In the course of considering all the related problems, further consideration should be given to the question of appointing counsel to the tribunal, and not on behalf of the Secretary of State, so that he can be seen to be …
Unknown
2 — Police records under Public Records Act 1958
Recommendation: We recommend that the preservation of police records be reviewed to ensure that all such documents are treated as public records, held on behalf of the public, subject to the Public Records Act 1958 and to transfer to the National …
Gov response: No formal government response published. The Hillsborough documents disclosed by the Panel were transferred to The National Archives, but a broader review of police records treatment under the Public Records Act 1958 has not been …
No Response
No update 2+ yrs
3 — Central government documents to National Archives
Recommendation: We recommend that relevant central government documents - particularly those of the Cabinet Office and No 10 - be transferred to the National Archives, thus enabling full public access to this material in the future.
Gov response: Implemented. Central government documents relating to Hillsborough that were disclosed to the Panel have been transferred to The National Archives. The Panel's report stated: "The Panel recommends that central government documents relating to Hillsborough which …
Accepted
Delivered
4 — Distributed Permanent Archive at Sheffield/Liverpool/Kew
Recommendation: We recommend that a Distributed Permanent Archive be established across the Central Library in Sheffield, the Liverpool Record Office and the National Archives, Kew, so that all original materials are preserved. Record office staff should liaise to rationalise the archiving …
Gov response: Implemented. A Distributed Permanent Archive was established as recommended. The Panel's report stated: "The Panel proposes a Distributed Permanent Archive of the original material at Sheffield Archives and Liverpool Record Office, with central government records …
Accepted
Delivered
5 — Private owners encouraged to deposit records
Recommendation: We recommend that, once a copy of all material has been placed on a Digital Archive, private owners - including the FA and SWFC - be encouraged to deposit original materials to an appropriate archive in the Distributed Permanent Archive. …
Gov response: No formal government response published. Private organisations including the FA and Sheffield Wednesday FC contributed documents to the Panel's disclosure process. The encouragement of further deposits of private records is ongoing but no formal mechanism …
No Response
No update 2+ yrs
6 — Editor-in-Chief for digital archive
Recommendation: We recommend the appointment of an Editor-in-Chief to oversee the presentation on the Digital Archive of documents relating to the disaster, and to the role of each of the organisations involved. The organisations concerned should fund this post and work …
Gov response: No formal government response published. There is no evidence that an Editor-in-Chief position was established for ongoing management of the Digital Archive. The original Panel website (hillsborough.independent.gov.uk) was archived by The National Archives as a …
No Response
7 — Protocol for adding/removing archive material
Recommendation: We recommend the development of a protocol which identifies the criteria according to which material not disclosed by the Panel may be added in the future, and material currently disclosed may be removed. Such decisions should be made by the …
Gov response: No formal government response published. Without the appointment of an Editor-in-Chief (Recommendation 6), no formal protocol for adding or removing archive material was developed. The archive exists as a static snapshot at The National Archives.
No Response
8 — Digital archive accessible with professional support
Recommendation: We recommend that the Digital Archive be permanently accessible at the Liverpool Record Office, the Central Library, Sheffield and other appropriate local venues, so that members of the public have access to the full archive at these sites, with professional …
Gov response: Implemented. The Digital Archive was made publicly accessible. On Disclosure Day (12 September 2012), the Panel launched a website containing 450,000 pages of material collated from 85 organisations. The archive website (hillsborough.independent.gov.uk) provided public access …
Accepted
Delivered
9 — Digital archive permanently archived at National Archives
Recommendation: We recommend that the Digital Archive be permanently archived at the National Archives at Kew (or its successor). Regardless of any developments in relation to the Digital Archive, this permanent copy should be held alongside the other archival materials.
Gov response: Implemented. The National Archives holds archived snapshots of the Hillsborough Independent Panel website dating from 2012 onward. The TNA catalogue (reference C14176659) confirms: "This series contains dated gathered versions (or 'snapshots') of the Hillsborough Independent …
Accepted
Delivered
49 — Catholic non-compliance framework
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a clear framework for dealing with cases of non-compliance with safeguarding policies and procedures. That framework should identify who is responsible for dealing with issues …
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the trustee bodies of all Catholic dioceses and religious orders were invited to subscribe to the Catholic Safeguarding Standards Agency. The Catholic Safeguarding …
Accepted
No update 2+ yrs
50 — Independent validation of Catholic audit programme
Recommendation: The Catholic Safeguarding Advisory Service should have the effectiveness of its audit programme regularly validated by an independent organisation which is external to the Church. These independent reports should be published.
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the Catholic Safeguarding Standards Agency (CSSA) Board is committed to the independent verification of its audit processes, and would undertake a formal process …
Accepted
No update 2+ yrs
60 — Independent school governance standards
Recommendation: The Department for Education and the Welsh Government should: amend the Independent School Standards to include the requirements that there is an effective system of governance, based on three principles of openness to external scrutiny, transparency and honesty within the …
Gov response: On 30 June 2022, the UK government stated that it agreed with the first two points of the recommendation in principle. It stated that it intended to consult on revised Independent School Standards in 2023 …
Accepted in Part
No update 2+ yrs
93 — Financial redress for former child migrants
Recommendation: The Chair and Panel have recommended that the UK government establishes a financial redress scheme for surviving former child migrants, providing for an equal award to every applicant. This is on the basis that they were all exposed to the …
Gov response: The Department for Health and Social Care announced details of the scheme on 31 January 2019 and the scheme was opened to applicants on 1 March 2019. Each eligible former British child migrant is entitled …
Accepted
Delivered
FR-19 — Tiered Redress Scheme
Recommendation: The Inquiry recommends that the UK government establishes a single redress scheme in England and Wales, taking into account devolved responsibilities. The detailed rules of, and funding for, this redress scheme should reflect the following core elements. Eligibility: Victims and …
Gov response: We accept the need to introduce a redress scheme to acknowledge the institutional failures that led to the suffering of victims and survivors. The detail of the scheme, including eligibility, types of redress available, the …
Accepted in Part
FR-2 — Child Protection Authorities
Recommendation: The Inquiry recommends that the UK government establishes a Child Protection Authority for England and the Welsh Government establishes a Child Protection Authority for Wales. Each Authority's purpose should be to: improve practice in child protection; provide advice and make …
Gov response: We accept the need for a stronger safeguarding system. We will ensure the relevant actions included within our reform programme, Stable Homes, Built on Love, fulfil this recommendation.
Accepted in Part
In progress
FR-3 — Cabinet-Level Minister for Children
Recommendation: The Inquiry recommends that the UK government creates a cabinet-level ministerial position for children. The Inquiry recommends that the Welsh Government ensures that there is cabinet-level ministerial responsibility for children.
Gov response: We accept the importance of placing the best interests of the child front and centre in policy and decision making at the highest level of Government. This role is already fulfilled through the work of …
Accepted
Delivered
P1-13 — Board review governance - assurance not reassurance
Recommendation: We have illustrated throughout this Report how Maidstone and Tunbridge Wells NHS Trust relied on reassurance rather than assurance in monitoring its processes. The Board must review its governance structures and function in light of this.
Gov response: Implemented. The Trust Board has reviewed its governance structures to ensure proper assurance mechanisms are in place rather than relying on reassurance. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 …
Accepted
Delivered
P1-14 — Board oversight of licensed mortuary activity
Recommendation: Maidstone and Tunbridge Wells NHS Trust Board must have greater oversight of licensed activity in the mortuary. It must ensure that the Designated Individual is actively involved in reporting to the Board and is supported in this.
Gov response: Implemented. The Board now has direct oversight of licensed mortuary activity. The Designated Individual reports regularly to the Board and is supported in this role. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial …
Accepted
Delivered
P1-15 — Treat HTA compliance as Trust statutory responsibility
Recommendation: Maidstone and Tunbridge Wells NHS Trust should treat compliance with Human Tissue Authority standards as a statutory responsibility for the Trust, notwithstanding the fact that the formal responsibility under the Human Tissue Act 2004 rests with the Designated Individual. The …
Gov response: Implemented. The Trust treats HTA compliance as a corporate statutory responsibility alongside the formal duties of the Designated Individual. Phase 2 recommendations address broader legislative reform. (Source: Trust assurance statement, February 2024; confirmed in Written …
Accepted
Delivered
P1-16 — Chief Nurse responsible for mortuary assurance
Recommendation: The Chief Nurse should be made explicitly responsible for assuring the Maidstone and Tunbridge Wells NHS Trust Board that mortuary management is delivered in such a way that it protects the security and dignity of the deceased.
Gov response: Implemented. The Chief Nurse has explicit responsibility for assuring the Board on mortuary management and protection of the deceased. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
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
P2-12 — DI attendance at governance forums
Recommendation: NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as well as reporting upwards when required.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-15 — Routine mortuary reporting to trust boards
Recommendation: All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include the presentation of a formal report, by the accountable executive director, to the trust board on a routine …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-16 — Trust boards assure recommendation implementation
Recommendation: Trust boards should assure themselves that the recommendations in this Report have been implemented.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-18 — Mortuaries treated as regulated activity in governance
Recommendation: Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent regard to other regulated activities within trust governance arrangements.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-53 — Local authority report implementation to committee
Recommendation: The implementation of these recommendations must be reported to the relevant statutory committee.
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
P2-75 — Government responsible for implementation monitoring
Recommendation: The government should take responsibility for the implementation of all the recommendations we make in this Report, regardless of the primary organisation they are directed at, and make arrangements to monitor the progress of their implementation.
Gov response: As part of the Government's commitment to responding to the Inquiry's recommendations, DHSC, as the Inquiry sponsor, established a Programme Board in July 2025 to work across Government and with other responsible organisations to scope …
Accepted
In progress
IBI-11a — Ministerial Power to Call Inquiries
Recommendation: That a minister should retain the power to call an inquiry as the minister sees fit, in accordance with the Inquiries Act 2005 – but where a minister does not choose to do so, then:
Gov response: UK Government It is clear that blood products and blood were contaminated, and despite a wealth of evidence, no action was taken to spell out the risks, and insufficient precautions were taken. It is also …
Accepted in Part
In progress
IBI-11b — Parliamentary Referral to PACAC
Recommendation: If there is sufficient support from within Parliament for there to be an inquiry, the question whether there should be one should be referred to the Public Administration and Constitutional Affairs Committee (PACAC) for it to consider the question.
Gov response: UK Government It is clear that blood products and blood were contaminated, and despite a wealth of evidence, no action was taken to spell out the risks, and insufficient precautions were taken. It is also …
Accepted in Part
In progress
IBI-11c — PACAC Recommendation Power
Recommendation: If it appears to PACAC that there is sufficient concern to justify a public inquiry, either because what happened and why has caused concern (as the committee sees it) or there are likely to be lessons learned which may prevent …
Gov response: UK Government It is clear that blood products and blood were contaminated, and despite a wealth of evidence, no action was taken to spell out the risks, and insufficient precautions were taken. It is also …
Accepted in Part
In progress
IBI-11d — Ministerial Reasons for Disagreement
Recommendation: If the minister disagrees with the recommendation, they must set out in detail and publish reasons for this disagreement which are sufficient to satisfy PACAC that the matter has been carefully and properly considered.
Gov response: UK Government It is clear that blood products and blood were contaminated, and despite a wealth of evidence, no action was taken to spell out the risks, and insufficient precautions were taken. It is also …
Accepted in Part
In progress
IBI-12a — Implementation Commitment Within 12 Months
Recommendation: Within the next 12 months, the Government should consider and either commit to implementing the recommendations which I make, or give sufficient reason, in sufficient detail for others to understand, why it is not considered appropriate to implement any one …
Gov response: The Government understands that the delay on the part of successive governments to take heed of the need for a public inquiry to be held into this matter has led to a fundamental loss of …
Accepted
Delivered
IBI-12b — Parliamentary Progress Report
Recommendation: During that period, and before the end of this year – the Government should report back to Parliament as to the progress made on considering and implementing the recommendations.
Gov response: The Government understands that the delay on the part of successive governments to take heed of the need for a public inquiry to be held into this matter has led to a fundamental loss of …
Accepted
Delivered
IBI-12c — No Delay to Second Interim Response
Recommendation: This timetable should not interfere with earlier consideration and response to the Recommendations of the Second Interim Report of the Inquiry.
Gov response: The Government understands that the delay on the part of successive governments to take heed of the need for a public inquiry to be held into this matter has led to a fundamental loss of …
Accepted
Delivered
IBI-12d — PACAC Oversight of Implementation
Recommendation: The Public Administration and Constitutional Affairs Committee (“PACAC”) should review both the progress towards responding to the Inquiry’s recommendations and, to the extent that they are accepted, implementing those recommendations.
Gov response: The Government accepts the principles behind recommendations 12d) and 12e), and notes that they are for Parliament to consider. Alongside the UK Government's response to the House of Lords Statutory Inquiries Committee report, the UK …
Accepted in Part
In progress
IBI-12e — PACAC Role for Future Inquiries
Recommendation: PACAC should accept the role in respect of any future statutory inquiry of reviewing the government’s timetable for consideration of recommendations, and of its progress towards implementation of that inquiry’s recommendations.
Gov response: The Government accepts the principles behind recommendations 12d) and 12e), and notes that they are for Parliament to consider. Alongside the UK Government's response to the House of Lords Statutory Inquiries Committee report, the UK …
Accepted in Part
In progress
IBI-5a — Civil Service Statutory Duty of Candour
Recommendation: The Government should reconsider whether, in the light of the facts revealed by this Inquiry, it is sufficient to continue to rely on the current non-statutory duties in the Civil Service and Ministerial Codes, coupled with those legal duties which …
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
In progress
IBI-5b — Monitoring Non-Statutory Duties
Recommendation: If, on review, the Government considers that it is sufficient to rely on the current non-statutory duties in the Civil Service Code, it should nonetheless introduce a statutory duty of accountability on senior civil servants for the candour and completeness …
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
In progress
IBI-5c — Ministerial Duty of Candour
Recommendation: The Government should consider the extent to which Ministers should be subject to a duty beyond their current duty to Parliament under the Ministerial Code.
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
In progress
IR2-14 — Arms Length Body Administration
Recommendation: I recommend that an Arms Length Body (ALB) should be set up to administer the compensation scheme, with guaranteed independence of judgement, chaired by a judge of High Court or Court of Session status as sole decision maker, transparent in …
Gov response: In line with recommendations 14 and 16 of the Second Interim Report, IBCA has been established to deliver the Infected Blood Compensation Scheme and financial compensation to victims of infected blood on a UK-wide basis. …
Accepted
Delivered
IR2-18 — Immediate Establishment of Scheme
Recommendation: I recommend that a compensation scheme should be set up now and it should begin work this year.
Gov response: Recommendation 18 of the Second Interim Report recommended that the Government set up the compensation scheme upon publication of the Second Interim Report in April 2023, and that it should begin work as soon as …
Accepted
Delivered
IHRD-2 — Criminal Liability for Candour Breach
Recommendation: Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.
Gov response: Under review as part of wider duty of candour and accountability framework development.
Accepted in Part
No update 2+ yrs
IHRD-33 — CEO Responsibility for Investigations
Recommendation: Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.
Gov response: Chief Executive accountability for SAI investigations established in governance frameworks.
Accepted
Delivered
IHRD-34 — Independent SAI Investigation
Recommendation: The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.
Gov response: Independent investigation arrangements strengthened but fully independent external unit not yet established.
Accepted in Part
No update 2+ yrs
IHRD-35 — Non-Cooperation as Disciplinary Offence
Recommendation: Failure to co-operate with investigation should be a disciplinary offence.
Gov response: Incorporated into Trust investigation procedures and employment policies.
Accepted
Delivered
IHRD-36 — Separation of Investigation and Litigation
Recommendation: Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.
Gov response: Separation of investigation and litigation roles implemented in Trust procedures.
Accepted
Delivered
IHRD-51 — Independence of Coroner Witness Statements
Recommendation: Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.
Gov response: Procedures updated to separate Trust involvement from Coroner witness statement management.
Accepted
Delivered
IHRD-53 — Legal Privilege Disclosure to Coroner
Recommendation: In the event of a Trust asserting entitlement to legal privilege in respect of an expert report or other document relevant to the proceedings of an inquest, it should inform the Coroner as to the existence and nature of the …
Gov response: Guidance issued on legal privilege assertions and disclosure obligations to Coroner.
Accepted
Delivered
IHRD-55 — Board Member Training on Patient Safety
Recommendation: Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.
Gov response: Training programmes implemented for Board members on scrutiny of patient safety performance.
Accepted
Delivered
IHRD-7 — Monitoring Candour Compliance
Recommendation: Trusts should monitor compliance and take disciplinary action against breach.
Gov response: Compliance monitoring mechanisms being developed as part of duty of candour framework.
Accepted
No update 2+ yrs
IHRD-70 — Board Meeting Minutes Preservation
Recommendation: Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.
Gov response: Board and committee meeting minutes preservation procedures strengthened.
Accepted
Delivered
IHRD-72 — Candour in Trust Communications
Recommendation: All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a nominated non-executive Director.
Gov response: Non-executive Director oversight of Trust communications implemented.
Accepted
No update 2+ yrs
IHRD-94 — Clinical Negligence Litigation Reform
Recommendation: The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical negligence litigation as it presently operates might be abolished or …
Gov response: Under consideration. No government committee established to date to examine clinical negligence litigation reform.
Accepted in Part
No update 2+ yrs
IHRD-95 — Legal Privilege Protocol
Recommendation: Given that the public is entitled to expect appropriate transparency from a publically funded service, the Department should bring forward protocol governing how and when legal privilege entitlement might properly be asserted by Trusts.
Gov response: Protocol development for legal privilege assertions by Trusts progressing.
Accepted
No update 2+ yrs
IHRD-96 — Healthcare Litigation Standards
Recommendation: The Department should provide clear standards to govern the management of healthcare litigation by Trusts and the work of Trust employees and legal advisors in this connection should be audited.
Gov response: Standards for healthcare litigation management under development.
Accepted
No update 2+ yrs
LADB-21 — Require audited organisations to disclose all material information to auditors
Recommendation: An organisation the activities of which are being audited should disclose all material and relevant information to the auditor in regard to the area of the activity which is being audited (para 9.46).
Unknown
LADB-32 — Integrate signal sighting committee recommendations into Railtrack's safety management system
Recommendation: It should form part of Railtrack’s safety management system that it is the responsibility of senior Zone operating and signal engineering management to decide whether the recommendations of a signal sighting committee under the Group Standard on SPADs are to …
Unknown
L1 — Independent Board Governance
Recommendation: An independent self regulatory body should be governed by an independent Board. In order to ensure the independence of the body, the Chair and members of the Board must be appointed in a genuinely open, transparent and independent way, without …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L18 — Investigation Powers
Recommendation: The Board, being an independent self-regulatory body, should have authority to examine issues on its own initiative and have sufficient powers to carry out investigations both into suspected serious or systemic breaches of the code and failures to comply with …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L19 — Financial Sanctions Power
Recommendation: The Board should have the power to impose appropriate and proportionate sanctions, (including financial sanctions up to 1% of turnover with a maximum of £1m), on any subscriber found to be responsible for serious or systemic breaches of the standards …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L2 — Chair Appointment Panel
Recommendation: The appointment of the Chair of the Board should be made by an appointment panel. The selection of that panel must itself be conducted in an appropriately independent way and must, itself, be independent of the industry and of Government.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L21 — Annual Report Requirements
Recommendation: The Board should publish an Annual Report identifying: (a) the body's subscribers, identifying any significant changes in subscriber numbers; (b) the number of complaints it has handled and the outcomes reached, both in aggregate for the all subscribers and individually …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L22 — Arbitration Service
Recommendation: The Board should provide an arbitral process in relation to civil legal claims against subscribers, drawing on independent legal experts of high reputation and ability on a cost-only basis to the subscribing member. The process should be fair, quick and …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L23 — Coverage of News Publishers
Recommendation: A new system of regulation should not be considered sufficiently effective if it does not cover all significant news publishers.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L24 — Open Membership Terms
Recommendation: The membership of a regulatory body should be open to all publishers on fair, reasonable and non-discriminatory terms, including making membership potentially available on different terms for different types of publisher.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L25 — ICO and Regulatory Membership
Recommendation: In any reconsideration of the powers of the Information Commissioner (or replacement body), power should be given to that body to determine that membership of a satisfactory regulatory body, which required appropriate governance and transparency standards from its members in …
Gov response: Section 40 of the Crime and Courts Act 2013, which would have created an incentive for publishers to join a recognised regulatory body, was enacted but never commenced. On 1 March 2018, the Secretary of …
Not Accepted
L26 — Arbitration and Costs
Recommendation: It should be open any subscriber to a recognised regulatory body to rely on the fact of such membership and on the opportunity it provides for the claimant to use a fair, fast and inexpensive arbitration service. It could request …
Gov response: Section 40 of the Crime and Courts Act 2013, which would have created an incentive for publishers to join a recognised regulatory body, was enacted but never commenced. On 1 March 2018, the Secretary of …
Not Accepted
L27 — Legislative Recognition Requirements
Recommendation: In order to meet the public concern that the organisation by the press of its regulation is by a body which is independent of the press, independent of Parliament and independent of the Government, that fulfils the legitimate requirements of …
Gov response: The government established a Royal Charter on Self-Regulation of the Press (granted 30 October 2013) and passed the Crime and Courts Act 2013 as its legislative response. This was an alternative to the statutory framework …
Accepted in Part
L28 — Recognition Body Role
Recommendation: The responsibility for recognition and certification of a regulator shall rest with a recognition body. In its capacity as the recognition body, it will not be involved in regulation of any subscriber.
Gov response: The government established a Royal Charter on Self-Regulation of the Press (granted 30 October 2013) and passed the Crime and Courts Act 2013 as its legislative response. This was an alternative to the statutory framework …
Accepted in Part
L29 — Recognition Requirements
Recommendation: The requirements for recognition should be those set out the recommendations set out above numbered 1 to 24 inclusive and more fully described in Part K, Chapter 7, Section 4 of the Report.
Gov response: The government established a Royal Charter on Self-Regulation of the Press (granted 30 October 2013) and passed the Crime and Courts Act 2013 as its legislative response. This was an alternative to the statutory framework …
Accepted in Part
L3 — Appointment Panel Composition
Recommendation: The appointment panel: (a) should be appointed in an independent, fair and open way; (b) should contain a substantial majority of members who are demonstrably independent of the press; (c) should include at least one person with a current understanding …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L30 — Periodic Review of Regulator
Recommendation: The operation of any certified body should be reviewed by the recognition body after two years and thereafter at three yearly intervals.
Gov response: The government established a Royal Charter on Self-Regulation of the Press (granted 30 October 2013) and passed the Crime and Courts Act 2013 as its legislative response. This was an alternative to the statutory framework …
Accepted in Part
L31 — Ofcom as Recognition Body
Recommendation: The role of recognition body, that is to say, to recognise and certify that any particular body satisfies (and, on review, continues to satisfy) the requirements set out in law should fall on Ofcom. A less attractive alternative (on the …
Gov response: The government established a Royal Charter on Self-Regulation of the Press (granted 30 October 2013) and passed the Crime and Courts Act 2013 as its legislative response. This was an alternative to the statutory framework …
Accepted in Part
L32 — Multiple Regulatory Bodies
Recommendation: It should be possible for the recognition body to recognise more than one regulatory body, should more than one seek recognition and meet the criteria, although this is not an outcome to be advocated and, should it be necessary for …
Gov response: The government established a Royal Charter on Self-Regulation of the Press (granted 30 October 2013) and passed the Crime and Courts Act 2013 as its legislative response. This was an alternative to the statutory framework …
Accepted in Part
L33 — Duty to Protect Press Freedom
Recommendation: In passing legislation to identify the legitimate requirements to be met by an independent regulator organised by the press, and to provide for a process of recognition and review of whether those requirements are and continue to be met, the …
Gov response: The government established a Royal Charter on Self-Regulation of the Press (granted 30 October 2013) and passed the Crime and Courts Act 2013 as its legislative response. This was an alternative to the statutory framework …
Accepted in Part
L34 — Compliance Reports and Senior Responsibility
Recommendation: In addition to Recommendation 10 above, a new regulatory body should consider requiring: (a) that newspapers publish compliance reports in their own pages to ensure that their readers have easy access to the information; and (b) as proposed by Lord …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L35 — Kite Mark for Trusted Journalism
Recommendation: A new regulatory body should consider establishing a kite mark for use by members to establish a recognised brand of trusted journalism.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L36 — Code Review with Public Consultation
Recommendation: A regulatory body should consider engaging in an early thorough review of the Code (on which the public should be engaged and consulted) with the aim of developing a clearer statement of the standards expected of editors and journalists.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L37 — Pre-litigation Complaints
Recommendation: A regulatory body should be prepared to allow a complaint to be brought prior to commencing legal proceedings if so advised. Challenges to that approach (and applications to stay) can be decided on the merits.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L39 — Ring-fenced Enforcement Fund
Recommendation: A new regulatory body should establish a ring-fenced enforcement fund, into which receipts from fines could be paid, for the purpose of funding investigations.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L4 — Board Appointment Independence
Recommendation: The appointment of the Board should also be an independent process, and the composition of the Board should include people with relevant expertise. The requirement for independence means that there should be no serving editors on the Board.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L41 — Strict Accountability for Published Material
Recommendation: A new regulatory body should make it clear that newspapers will be held strictly accountable, under their standards code, for any material that they publish, including photographs (however sourced).
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L42 — Public Interest Guidance
Recommendation: A regulatory body should provide guidance on the interpretation of the public interest that justifies what would otherwise constitute a breach of the Code. This must be framed in the context of the different provisions of the Code relating to …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L43 — Public Interest Record Keeping
Recommendation: A new regulatory body should consider being explicit that where a public interest justification is to be relied upon, a record should be available of the factors weighing against and in favour of publication, along with a record of the …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L44 — Advisory Service on Public Interest
Recommendation: A new regulatory body should consider whether it might provide an advisory service to editors in relation to consideration of the public interest in taking particular actions.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L45 — Source Transparency
Recommendation: A new regulatory body should consider encouraging the press to be as transparent as possible in relation to the sources used for stories, including providing any information that would help readers to assess the reliability of information from a source …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L5 — Board Member Composition
Recommendation: The members of the Board should be appointed by the same appointment panel that appoints the Chair, together with the Chair (once appointed), and should: (a) be appointed by a fair and open process; (b) comprise a majority of people …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L50 — Compensation for Distress
Recommendation: It should be made clear that the right to compensation for distress conferred by section 13 of the Data Protection Act 1998 is not restricted to cases of pecuniary loss, but should include compensation for pure distress.
Gov response: The Data Protection Act 2018 (Section 168) provides for compensation for distress without requiring pecuniary loss, implementing this recommendation. Source: https://www.legislation.gov.uk/ukpga/2018/12/section/168
Accepted
L57 — Reconstitute ICO as Commission
Recommendation: The opportunity should be taken to consider amending the Data Protection Act 1998 formally to reconstitute the Information Commissioner's Office as an Information Commission, led by a Board of Commissioners with suitable expertise drawn from the worlds of regulation, public …
Gov response: The Prime Minister stated on 29 November 2012: "I am instinctively concerned about this proposal. There is a real danger of this recommendation being used to curb freedom of the press. We need to consider …
Not Accepted
L6 — Funding Settlement
Recommendation: Funding for the system should be settled in agreement between the industry and the Board, taking into account the cost of fulfilling the obligations of the regulator and the commercial pressures on the industry. There should be an indicative budget …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L62 — ICO Annual Report on Press
Recommendation: The Information Commissioner's Office, in the Annual Report to Parliament which it is required to make by virtue of section 52(1) of the Act, should include regular updates on the effectiveness of the foregoing measures, and on the culture, practices …
Gov response: The Prime Minister did not specifically address ICO operational recommendations in his 29 November 2012 statement. The Data Protection Act 2018 (Section 124) required the ICO to produce a data protection and journalism code of …
Accepted in Part
L7 — Standards Code Responsibility
Recommendation: The standards code must ultimately be the responsibility of, and adopted by, the Board, advised by a Code Committee which may comprise both independent members of the Board and serving editors.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L76 — ACPO Media Contact Recording
Recommendation: It should be mandatory for ACPO rank officers to record all of their contact with the media, and for that record to be available publicly for transparency and audit purposes. This record need be no more than a very brief …
Gov response: The Prime Minister stated on 29 November 2012: "Lord Justice Leveson makes a number of recommendations that are designed to break the perception of an excessively cosy relationship between the press and the police and …
Accepted
L8 — Code Content Requirements
Recommendation: The code must take into account the importance of freedom of speech, the interests of the public (including the public interest in detecting or exposing crime or serous impropriety, protecting public health and safety and preventing the public from being …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L82 — Party Policy on Press Relations
Recommendation: As a first step, political leaders should reflect constructively on the merits of publishing on behalf of their party a statement setting out, for the public, an explanation of the approach they propose to take as a matter of party …
Gov response: The Prime Minister stated on 29 November 2012: "On the Government's behalf I can say that we accept that recommendation" regarding disclosure of interaction between politicians and the press. Ministerial transparency data on meetings with …
Accepted in Part
L83 — Disclosure of Media Contacts
Recommendation: Party Leaders, Ministers and Front Bench Opposition spokesmen should consider publishing: (a) the simple fact of long term relationships with media proprietors, newspaper editors or senior executives which might be thought to be relevant to their responsibilities and, (b) on …
Gov response: The Prime Minister stated on 29 November 2012: "On the Government's behalf I can say that we accept that recommendation" regarding disclosure of interaction between politicians and the press. Ministerial transparency data on meetings with …
Accepted
L84 — Immediate Transparency Need
Recommendation: The suggestions that I have made in the direction of greater transparency about meetings and contacts should be considered not just as a future project but as an immediate need, not least in relation to interactions relevant to any consideration …
Gov response: The Prime Minister stated on 29 November 2012: "On the Government's behalf I can say that we accept that recommendation" regarding disclosure of interaction between politicians and the press. Ministerial transparency data on meetings with …
Accepted
L85 — Plurality Focus on News
Recommendation: The particular public policy goals of ensuring that citizens are informed and preventing too much influence in any one pair of hands over the political process are most directly served by concentrating on plurality in news and current affairs. This …
Gov response: The government accepted recommendations on media plurality. Ofcom developed a measurement framework for media plurality in 2015, publishes regular Media Nations reports, and has a full menu of remedies available for plurality concerns. The Enterprise …
Accepted
L86 — Include Online in Plurality
Recommendation: Online publication should be included in any market assessment for consideration of plurality.
Gov response: The government accepted recommendations on media plurality. Ofcom developed a measurement framework for media plurality in 2015, publishes regular Media Nations reports, and has a full menu of remedies available for plurality concerns. The Enterprise …
Accepted
L87 — Plurality Measurement Framework
Recommendation: Ofcom and the Government should work, with the industry, on the measurement framework, in order to achieve as great a measure of consensus as is possible on the theory of how media plurality should be measured before the measuring system …
Gov response: The government accepted recommendations on media plurality. Ofcom developed a measurement framework for media plurality in 2015, publishes regular Media Nations reports, and has a full menu of remedies available for plurality concerns. The Enterprise …
Accepted
L88 — Plurality Thresholds Lower Than Competition
Recommendation: The levels of influence that would give rise to concerns in relation to plurality must be lower, and probably considerably lower, than the levels of concentration that would give rise to competition concerns.
Gov response: The government accepted recommendations on media plurality. Ofcom developed a measurement framework for media plurality in 2015, publishes regular Media Nations reports, and has a full menu of remedies available for plurality concerns. The Enterprise …
Accepted
L89 — Full Menu of Plurality Remedies
Recommendation: Ofcom has presented the Inquiry and the Government with a full menu of potential remedies, and it has not been argued or suggested that any of them are inappropriate in principle. Each of them might be appropriate in a given …
Gov response: The government accepted recommendations on media plurality. Ofcom developed a measurement framework for media plurality in 2015, publishes regular Media Nations reports, and has a full menu of remedies available for plurality concerns. The Enterprise …
Accepted
L9 — Internal Governance Processes
Recommendation: The Board should require, of those who subscribe, appropriate internal governance processes, transparency on what governance processes they have in place, and notice of any failures in compliance, together with details of steps taken to deal with failures in compliance.
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
L90 — Periodic Plurality Reviews
Recommendation: The Government should consider whether periodic plurality reviews or an extension to the public interest test within the markets regime in competition law is most likely to provide a timely warning of, and response to, plurality concerns that develop as …
Gov response: The government accepted recommendations on media plurality. Ofcom developed a measurement framework for media plurality in 2015, publishes regular Media Nations reports, and has a full menu of remedies available for plurality concerns. The Enterprise …
Accepted
L91 — Media Merger Referral Consultation
Recommendation: Before making a decision to refer a media merger to the competition authorities on public interest grounds, the Secretary of State should consult relevant parties as to the arguments for and against a referral, and should be required to make …
Gov response: The government accepted recommendations on media plurality. Ofcom developed a measurement framework for media plurality in 2015, publishes regular Media Nations reports, and has a full menu of remedies available for plurality concerns. The Enterprise …
Accepted
L92 — Secretary of State Media Merger Decisions
Recommendation: The Secretary of State should remain responsible for public interest decisions in relation to media mergers. The Secretary of State should be required either to accept the advice provided by the independent regulators, or to explain why that advice has …
Gov response: The government accepted recommendations on media plurality. Ofcom developed a measurement framework for media plurality in 2015, publishes regular Media Nations reports, and has a full menu of remedies available for plurality concerns. The Enterprise …
Accepted
LIT-1 — Closed Recommendation
Recommendation: One recommendation contained within the closed section of the report (classified).
Gov response: Home Secretary Statement to Parliament, 21 January 2016: The Home Secretary stated she could not reveal details of the classified recommendation but assured Members the Government would respond to the Inquiry Chair in due course.
Accepted
Delivered
LIT-2 — Asset Freezes on Suspects
Recommendation: Asset freezes should be implemented against the suspects Andrey Lugovoy and Dmitri Kovtun.
Gov response: Home Secretary Statement to Parliament, 21 January 2016: 'Treasury Ministers have today agreed to put in place asset freezes against the two individuals.' Asset freezes implemented against Lugovoy and Kovtun and remain in place.
Accepted
Delivered
LIT-3 — Maintain Arrest Warrants
Recommendation: Interpol notices and European Arrest Warrants should remain in place for the suspects.
Gov response: Home Secretary Statement to Parliament, 21 January 2016: 'Interpol notices and European Arrest Warrants are in place so that the main suspects...can be arrested if they travel abroad.' Metropolitan Police investigation remains open.
Accepted
Delivered
LIT-4 — Diplomatic Representations to Russia
Recommendation: Senior diplomatic representations should be made to Russia regarding its failure to cooperate with justice.
Gov response: Home Secretary Statement to Parliament, 21 January 2016: 'We are making senior representations to the Russian Government in Moscow.' The Russian Ambassador was summoned to express 'profound displeasure at Russia's failure to co-operate.' The Home …
Accepted
Delivered
LIT-5 — Review Further Legal Actions
Recommendation: The Director of Public Prosecutions should consider whether further action can be taken on extradition and asset freezing.
Gov response: Home Secretary Statement to Parliament, 21 January 2016: The Home Secretary wrote to the Director of Public Prosecutions 'asking her to consider whether any further action should be taken, both in terms of extradition and …
Accepted
Delivered
MAI-142 — Compel LRF attendance from Category 1 and 2 responders
Recommendation: The Home Office should consider empowering the leadership of local resilience forums to compel the attendance of a senior representative of its Category 1 and Category 2 responders at all local resilience forum meetings. Inspections by His Majesty's Inspectorate of …
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-48 — Statutory powers for witness attendance at inquiries
Recommendation: It is recommended that consideration be given to the creation of statutory powers under section 36 that can be used to prevent a material witness to an inquiry putting themselves beyond the reach of the existing powers to compel 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 Part
In progress
MAI-52 — Consider Commission for Countering Extremism report
Recommendation: In 2021, the Commission for Countering Extremism published a report entitled Operating with Impunity. Hateful Extremism: The Need for a Legal Framework. I recommend that the Home Office consider and respond to this document as a matter of urgency.
Gov response: Home Secretary Suella Braverman made a statement to Parliament on 6 March 2023 following publication of Volume 3 on 2 March 2023. She stated: 'We will carefully consider the report's findings and recommendations in full' …
Accepted
Delivered
MAI-56 — Address extradition difficulties for section 35 offences
Recommendation: It is recommended that the Home Office give consideration to addressing the difficulties in extradition in relation to an offence under section 35, given that the maximum sentence for such an offence is below the minimum qualifying threshold for extradition.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted in Part
In progress
MAI-57 — Amend section 21 for witness interview requirements
Recommendation: It is recommended that the Ministry of Justice give consideration to amending section 21 of the 2005 Act to include the express provision for requiring a potential witness to participate in an interview.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted in Part
In progress
MAI-58 — Amend section 36 for pre-emptive witness enforcement
Recommendation: It is recommended that the Ministry of Justice, possibly in conjunction with the Law Commission, give consideration to amending section 36 of the 2005 Act to make provision for issuing pre-emptive enforcement proceedings for witnesses in relation to whom there …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted in Part
In progress
MAI-61 — Independent inspection regime for LRFs
Recommendation: Local resilience forums have a vital role in the preparation for the response to any Major Incident. The Cabinet Office and the Home Office should consider implementing an independent inspection regime for local resilience forums.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-63 — Monitor LRF attendance and flag concerns
Recommendation: Local resilience forums should monitor attendance and participation at their meetings, and flag promptly any concerns about attendance by members to the leadership of the organisation concerned. The Home Office should ensure that this is being done by local resilience …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
CLAR-11.24 — Limit Department and MAIB dealings to proper investigatory functions
Recommendation: I recommend that in the future both the Department and the MAIB take steps to ensure that dealings between them are limited to those matters which necessarily arise in connection with the performance by the MAIB of its proper investigatory …
Unknown
CLAR-11.25 — Publish clear guidelines defining roles of MAIB and Department
Recommendation: In these circumstances I recommend that clear guidelines be laid down setting out precisely the role of the MAIB on the one hand and the role of the Department on the other. Such guidelines should be published so that the …
Unknown
CLAR-12.31 — Secretary of State to consider Alder Hey style inquiry for Marchioness
Recommendation: If, contrary to my recommendation, the appropriate Secretary of State orders a public inquiry into any of these matters, I recommend that he consider whether there might be a case for including it, not with an FI, but with an …
Unknown
CLAR-3.20 — Send consultees interim report section including Department's views
Recommendation: I recommend that the consultees now be sent a copy of that part of my interim report, perhaps with the views of the Department upon it.
Unknown
F176 — Openness with regulators
Recommendation: Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F177 — Openness in public statements
Recommendation: Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F182 — Statutory duty of openness and transparency
Recommendation: There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf of the organisation, where given in compliance with a statutory …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F183 — Criminal liability
Recommendation: It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an authorised or registered healthcare organisation: Knowingly to obstruct another in the performance of these statutory duties; To provide …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (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
F184 — Enforcement by the Care Quality Commission
Recommendation: Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and wilful deception. The Care Quality Commission should be supported by …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F33 — Interim measures
Recommendation: Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F34 — Interim measures
Recommendation: Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F54 — Care Quality Commission independence strategy and culture
Recommendation: Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission's statutory role.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F70 — Duty of utmost good faith
Recommendation: A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant information material to the application and to ensure that any information is complete and accurate. This duty should …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F71 — Role of Secretary of State
Recommendation: The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a service to patients which is, at the time of his consideration, safe, effective and compliant with all relevant …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F73 — Need for constructive working with other parts of the system
Recommendation: The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with the Department of Health and whether the appropriate degree of clarity of understanding of the scope of their …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F74 — Enhancement of role of governors
Recommendation: Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation to account to the public, and in particular in arranging for communication with the public served by the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F75 — Enhancement of role of governors
Recommendation: The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its obligations and to represent the public interest. They should produce …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F76 — Enhancement of role of governors
Recommendation: Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large – it is important that regular and constructive contact between governors and the public is maintained.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
44 — Establish framework for future investigations
Recommendation: This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were …
Gov response: 69. We accept this recommendation in principle. A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. The Service will also respond to the concerns that had been previously …
Accepted
WATE-(2) — Define Commissioner's duties: monitor rights, examine cases, publish reports
Recommendation: The duties of the Commissioner should include: (a) ensuring that children's rights are respected through the monitoring and oversight of the operation of complaints and whistleblowing procedures and the arrangements for children's advocacy; (b) examining the handling of individual cases …
Unknown
WATE-(44) — Urgently review legislation to establish stricter regulation for private residential schools
Recommendation: There should be an urgent review of the legislation governing the regulation of private residential schools to include particularly:71 (a) approvals and consents under section 347 of the Education Act 1996921 and for provisional registration of schools, (b) the Notice …
Unknown
WATE-(51) — Send local authority children's homes inspection reports to Chief Executives
Recommendation: Copies of the reports of inspections of local authorities' children's homes and services should be sent to the Chief Executives as well as the Directors of Social Services.
Unknown
WATE-(52) — Send private and voluntary care inspection reports to relevant placing authorities
Recommendation: Copies of reports of inspections of private and voluntary children's homes and of private residential schools should be sent to the Director of Social Services of any placing authority with a child at the school and of the authority in …
Unknown
WATE-(53) — Require agency to present annual report on work and constraints
Recommendation: The agency referred to in recommendation (47) should present an annual report on all aspects of its work, including any constraints upon that work and any shortfall in fulfilling its obligations.
Unknown
WATE-(71) — Invite Law Commission to review legal issues of inquiry report publication.
Recommendation: The Law Commission should be invited to consider the legal issues that arose in relation to the publication of the Jillings report and the associated problems, as explained in Chapter 32 of this report.
Unknown
WATE-(72) — Update and reissue guidance for local authorities on conducting public inquiries.
Recommendation: Subject to the preceding recommendation, guidance to local authorities on the setting up and conduct of inquiries and the dissemination of reports thereon should be up-dated and re-issued923.
Unknown
POH-1 — Respond to recommendations by 10 October 2025
Recommendation: HM Government and/or the Department and where appropriate the Post Office and Fujitsu shall provide written responses to my recommendations by 10 October 2025.
Gov response: Department for Business and Trade accepts this recommendation and has fulfilled it by publishing the government response on the date specified (10 October 2025).
Accepted
Delivered
POH-17 — Establish standing public body to administer future redress schemes
Recommendation: As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Gov response: Department for Business and Trade acknowledges this recommendation and sees clear advantages in establishing a standing public body for financial redress. However, the government recognises that establishing such an independent redress body requires careful consideration …
Response Unclear
In progress
POH-2 — Define and publish meaning of full and fair financial redress
Recommendation: The Minister and/or the Department in conjunction with the Post Office shall make a public announcement explaining what is meant by the phrase "full and fair financial redress". Such an explanation should indicate that claimants should be awarded sums which …
Gov response: Department for Business and Trade accepts the Inquiry's recommendation and has published a statement explaining what is meant by the phrase "full and fair financial redress". The statement indicates that claimants should be awarded sums …
Accepted
Delivered
POH-4 — Fund legal advice for HSS claimants before scheme choice
Recommendation: All claimants in HSS shall be entitled to obtain legal advice funded by the Department prior to choosing between accepting the Fixed Sum Offer or seeking financial redress which is assessed. The remuneration for such advice shall be in accordance …
Gov response: Department for Business and Trade broadly accepts this recommendation. Rather than providing upfront legal advice, DBT provides funding for legal advice at the appeal permission stage. Additionally, an information support service has been established which …
Accepted in Part
In progress
POH-IR1-1 — Allow Advisory Board to monitor individual compensation cases
Recommendation: The Horizon Compensation Advisory Board should not be prevented from monitoring individual cases in which compensation has been or is to be determined by paragraph 4 of its Terms of Reference.
Gov response: Department for Business and Trade accepts this recommendation in part. The Horizon Compensation Advisory Board shall consider whether "full and fair compensation is being paid out to applicants under the 3 schemes" and shall advise …
Accepted in Part
Delivered
POH-IR1-2 — Publish Advisory Board meeting reports within 21 days
Recommendation: The Horizon Compensation Advisory Board shall produce written reports in respect of each of their meetings in relation to each of the 3 schemes and publish the same within 21 days of the date of each meeting.
Gov response: Department for Business and Trade accepts this recommendation. Written reports are already being published and shall be issued within a week of each meeting unless the Board agrees otherwise.
Accepted
Delivered
POH-IR1-3 — Make monitoring full and fair compensation a core Board duty
Recommendation: It must be one of the core duties of the Horizon Compensation Advisory Board that it monitors whether compensation payments are full and fair.
Gov response: Department for Business and Trade accepts this recommendation in part. The Department endorses the Board's view that it "would not be possible or advisable for us to intervene in individual cases" but has confirmed that …
Accepted in Part
Delivered
POH-IR1-4 — Increase Advisory Board membership if needed for capacity
Recommendation: If the Horizon Compensation Advisory Board considers it necessary, the number of persons appointed to the Board should be increased so as to ensure that the Board has sufficient capacity to perform the functions set out above.
Gov response: Department for Business and Trade accepts this recommendation. The Department will keep under review the case for expanding the Board, in discussion with its current members, to ensure it has sufficient capacity to fulfil its …
Accepted
Delivered
POH-IR1-5 — Seek court directions for GLO compensation in bankruptcy cases
Recommendation: DBT shall take such steps as are necessary within 28 days of the publication of this report to seek appropriate directions under section 306 of the Insolvency Act 1986 in respect of the dispute between Moore UK and the Department …
Gov response: Department for Business and Trade accepts this recommendation. The Department instructed counsel to submit a court application and made an expedited request. One postmaster will be named as an interested party in the proceedings to …
Accepted
Delivered
POH-IR1-6 — Publish proposals for equal tax treatment of compensation payments
Recommendation: DBT shall publish within 28 days of the publication of this report its proposals for ensuring that applicants to all schemes are treated equally and fairly in respect of liability to Income Tax, Capital Gains Tax, and Inheritance Tax on …
Gov response: Department for Business and Trade accepts this recommendation. Payments under the GLO scheme and overturned convictions are exempt from Income Tax, National Insurance contributions, and Capital Gains Tax. HSS claimants receive top-up payments that are …
Accepted
Delivered
POH-IR1-7 — Amend Limitation Act to extend GLO deadline if needed
Recommendation: HM Government shall bring forward as soon as possible legislation amending section 11(3)(a) of the Limitation Act 1980 to allow payments of compensation under the GLO scheme to be made to applicants after midnight on 7 August 2024 if that …
Gov response: Department for Business and Trade accepts this recommendation in principle. The Department is determined to deliver the GLO scheme by August 2024 and will consider bringing forward legislation if the deadline appears to be at …
Accepted in Part
Delivered
POH-IR1-8 — Set agreed closing date for Horizon Shortfall Scheme applications
Recommendation: No applications for compensation to the Horizon Shortfall Scheme shall be entertained after such date as shall be agreed by the Minister, the Department for Business and Trade, the Post Office and the Horizon Compensation Advisory Board.
Gov response: Department for Business and Trade accepts this recommendation in part. The Department will discuss and agree a closing date with Post Office. The Advisory Board will be consulted before any closing date is notified to …
Accepted in Part
Delivered
RHI-25 — Ministerial Decision-Making
Recommendation: In light of their legal responsibility to direct and control the Department for which they are responsible, and their democratic accountability to the Northern Ireland Assembly, ministerial decisions should be taken by Ministers (in conjunction with other ministerial colleagues, where …
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
Delivered
RHI-26 — Meeting Records
Recommendation: Notes of significant meetings between officials and ministers, particularly those affecting decision-making and spending, must be taken and retained. The responsibility for ensuring this is done should be clearly identified and compliance should be ensured in practice.
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-27 — Private Office Record Keeping
Recommendation: Ministers' responses to submissions should be formally and timeously recorded and disseminated to officials by the Minister's Private Office. That responsibility should not be left to policy teams. One clear corollary is the need for a better system to carry …
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-28 — Record Keeping Culture and Audit
Recommendation: The culture and practice of record keeping and access to records within the Northern Ireland Civil Service needs to change so that staff responsible for a given area of work have easy access to the analysis and decisions underpinning the …
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-29 — Departmental Finance Functions
Recommendation: The finance function within a Department should exert the necessary authority and capability to fulfil the requirements of 'Managing Public Money Northern Ireland', namely to retain a firm grasp of the organisation's financial position and performance. The Inquiry recommends that …
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 re-establishment of DoF-led Finance Director meetings and the initiation of …
Accepted
Delivered
RHI-31 — Value for Money Priority
Recommendation: Any imperative to spend a budget within a given timeframe should not be allowed to take precedence over how that budget is used and the longer term benefits and overall value of such expenditure. Ministers, Special Advisers and the Northern …
Gov response: [Note: The NI Executive responded to recommendations 19-23, 29-33 together as a group under the 'Governance and Financial Controls' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full. It is important …
Accepted
Delivered
RHI-32a — Governance Systems Review
Recommendation: The checks and balances within a Department designed to catch problems early failed over many years in DETI to identify certain of the risks of the RHI or their materialisation. All Departments would benefit from reviewing how their governance systems …
Gov response: [Note: The NI Executive responded to recommendations 19-23, 29-33 together as a group under the 'Governance and Financial Controls' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full. It is important …
Accepted
No update 2+ yrs
RHI-32b — Civil Servants Raising Concerns
Recommendation: Civil servants should be encouraged not to feel in any way inhibited about disclosing possible or emerging problems, raising concerns, negative aspects or adverse criticisms of a project as necessary to ensure that decisions are properly informed.
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-38 — Assembly Committee Scrutiny
Recommendation: The Inquiry recommends that the Northern Ireland Assembly should strengthen the scrutiny role of Assembly Committees, reviewing whether the existing balance between legislative and scrutiny work is appropriate, and considering whether Committees should have greater research capacity and whether there …
Gov response: Responsibility of the NI Assembly. Chairpersons' Liaison Group published 'Report on Strengthening Committee Scrutiny' in March 2022. Work continuing post-February 2024 assembly resumption.
Accepted in Part
No update 2+ yrs
RHI-39 — Ministerial Familiarity with Legislation
Recommendation: Any Minister presenting the Assembly with legislation for approval should sufficiently read and familiarise themselves with that legislation and ensure an adequate evidence base is publicly available to demonstrate that the benefits justify any attendant costs.
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-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-40 — Declaration of Interests
Recommendation: Ministers, Special Advisers and officials in Northern Ireland government Departments should declare their interests annually in writing. When any conflict of interest arises during the course of government business each individual should understand that he/she has an obligation formally to …
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
Delivered
RHI-41 — Special Adviser Code of Conduct Revision
Recommendation: The Special Adviser Code of Conduct should be revised. How these changes are achieved will need to be a matter for the political representatives concerned in the construction of a system in which the public can have confidence. The Inquiry's …
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
Delivered
RHI-42 — Ministerial Code Revision
Recommendation: The Code of Conduct issued to Northern Ireland Ministers in 2007 (contained within the Northern Ireland Ministerial Code 2006) should be revised and brought up to date reflecting the findings of the RHI Inquiry and drawing on relevant best practice …
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-43 — Independent Compliance Assessment
Recommendation: In addition, the Northern Ireland Executive and Assembly ought, in the Inquiry's view, to give due consideration to an independent mechanism to assess compliance with codes of conduct in public life as they apply to Ministers and Special Advisers. Whatever …
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 …
Not Accepted
RHI-44 — NIAO Progress Assessment Role
Recommendation: The Inquiry recommends a role in future for the Northern Ireland Audit Office in assessing and validating the extent of progress in implementing the lessons learned from the NI RHI scheme and implementing those recommendations, including reporting on such progress …
Gov response: Responsibility of NIAO. This second report (October 2024) fulfills the recommendation; periodic reporting mechanism now established. First report published June 2022, second report October 2024.
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-6 — Special Adviser Role Clarity
Recommendation: (i) Under existing arrangements, Northern Ireland Ministers should be responsible for their Special Advisers. (ii) New or returning Ministers should be invited to convey to the relevant Permanent Secretary, and make transparent to the Department, how the Minister expects his …
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
Delivered
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
RONA-47 — Ensure Building Regulations and Codes of Practice are kept updated with new knowledge
Recommendation: The Ministry of Housing and Local Government should take urgent steps to ensure that the Building Regulations and Codes of Practice are kept up to date, and that they are revised as soon as new knowledge becomes available {paragraph 217}.
Unknown
MACP-6 — Reconsider Metropolitan Police Authority powers to align with other services, including appointments
Recommendation: That proposals as to the formation of the Metropolitan Police Authority be reconsidered, with a view to bringing its functions and powers fully into line with those which apply to other Police Services, including the power to appoint all Chief …
Unknown
MACP-9 — Apply Freedom of Information Act to all policing with "substantial harm" test
Recommendation: That a Freedom of Information Act should apply to all areas of policing, both operational and administrative, subject only to the "substantial harm" test for withholding disclosure.
Unknown
TAYL-F24 — Secretary of State to mandate specific safety conditions in Safety Certificates
Recommendation: The Secretary of State should exercise his powers under either section 6(2) or section 15(A) of the Safety of Sports Grounds Act 1975 so as to make mandatory in Safety Certificates those conditions specified in the original section 2(2) of …
Unknown
TAYL-F25 — Local authorities must follow Green Guide criteria for Safety Certificate assessments
Recommendation: In assessing these mandatory requirements in the Certificate for a particular ground, the local authority should follow the Green Guide criteria. Once that is done, the resultant figures and terms for that ground should be specified in the Safety Certificate …
Unknown
TAYL-F26 — Clarify absolute or flexible compliance for Green Guide provisions in Safety Certificates
Recommendation: Where a local authority incorporates any provision of the Green Guide into the Safety Certificate, othei than one within the scope of Recommendation 25 above, it should make clear whether that provision is to be complied with absolutely or with …
Unknown
TAYL-F27 — Immediately review all Safety Certificates with stakeholders and stadium inspection
Recommendation: There should be an immediate review of each Safety Certificate (if this has not already been don< following the Interim Report) by the responsible local authority, which should consult the club in respect oi which the Certificate is issued, the …
Unknown
TAYL-F28 — Local authorities must immediately issue Safety Certificates for designated sports grounds
Recommendation: Any local authority within whose area there exists a sports ground designated under the 1975 Act foi which no Safety Certificate has yet been issued should proceed forthwith to remedy the situation.
Unknown
TAYL-F29 — Local authorities must annually review and renew all Safety Certificates
Recommendation: Every Safety Certificate should be reviewed by the local authority at least once annually and eacl Certificate should require to be renewed annually.
Unknown
TAYL-F30 — Local authorities must review Safety Certificate arrangements and administrative structure
Recommendation: Each local authority should review its arrangements for issuing, monitoring, enforcing, reviewing, amending and renewing Safety Certificates (if this has not already been done following the Interin Report). Such review should require that there exists or is provided an accountable …
Unknown
TAYL-F31 — Local authorities should establish an Advisory Group for crowd safety oversight
Recommendation: To assist the local authority in exercising its functions, it should set up an Advisory Group (if this has not already been done) consisting of appropriate members of its own staff, representatives of the police, of the fire and ambulance …
Unknown
AS-1 — Document Retention and Storage Policy
Recommendation: Consideration should be given to the establishment of a policy by the Ministry of Defence to ensure that all documents or other material, including electronic material, are retrieved from theatre and elsewhere at the conclusion of an operation, catalogued and …
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-2 — Recording of Interrogation and Tactical Questioning
Recommendation: Digital video and audio recordings should be made of both interrogation and tactical questioning sessions. Such recordings should be retrieved from theatre, catalogued and stored in the same way and for the same period of time as the other documents/records …
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-4 — Shooting Incident Policy
Recommendation: A Shooting Incident Policy should be drafted which is achievable in practice in Theatre, which is compliant with Article 2 of the ECHR and which enables the ascertainment of the relevant facts leading up to, during and consequent upon the …
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
COVID-M2.1 — NI CMO Independence
Recommendation: The Department of Health (Northern Ireland) should reconstitute the role of the Chief Medical Officer for Northern Ireland as an independent advisory role. The Chief Medical Officer for Northern Ireland should not have managerial responsibilities within the Department of Health …
Gov response: No formal response published by this government.
Unknown
COVID-M2.11 — Leadership Succession Arrangements
Recommendation: The UK government and the devolved administrations should each establish formal arrangements for covering the roles of Prime Minister and First Minister (and in Northern Ireland, deputy First Minister) as applicable during a whole-system civil emergency, should the incumbent be …
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M2.12 — Central Emergency Taskforces
Recommendation: The response to a future whole-system civil emergency should be coordinated via central taskforces in each of the UK, Scotland, Wales and Northern Ireland, with responsibility for the commissioning and synthesis of advice, coordination of a single data picture and …
Gov response: No formal response published by this government.
Unknown
COVID-M2.13 — NI Executive Confidentiality Duty
Recommendation: The Executive Office should amend the Ministerial Code to impose a duty of confidentiality on ministers that prohibits the disclosure of the individual views of ministers expressed during meetings of the Northern Ireland Executive Committee.
Gov response: No formal response published by this government.
Unknown
COVID-M2.15 — Parliamentary Scrutiny of Emergency Powers
Recommendation: The UK government and devolved administrations should ensure that the draft affirmative procedure is the standard process for enacting substantial and wide-ranging powers in a civil emergency, such as a pandemic, under primary public health legislation. Any departure from this …
Gov response: No formal response published by this government.
Unknown
COVID-M2.16 — Civil Contingencies Act Review
Recommendation: The UK government should undertake a review of the Civil Contingencies Act 2004 to assess its potential role in managing future civil emergencies, including pandemics, and whether it could be employed as an interim emergency framework until more specific legislation …
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M2.18 — Devolved Nations COBR Attendance
Recommendation: The UK government should invite the devolved administrations, as a matter of standard practice, to nominate relevant ministers and officials to attend COBR meetings in the event of relevant whole-system civil emergencies that have the potential to have UK-wide effects.
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M2.19 — Four Nations Pandemic Structure
Recommendation: While intergovernmental relations should be facilitated through COBR in the initial months of any future pandemic, the UK government and devolved administrations should ensure that a specific four-nations structure, concerning pandemic response, is stood up at the same time as …
Gov response: No formal response published by this government.
Unknown
COVID-M2.2 — Devolved Nations SAGE Attendance
Recommendation: The Government Office for Science (GO-Science) should invite the governments of Scotland, Wales and Northern Ireland to nominate a small number of representatives to attend meetings of the Scientific Advisory Group for Emergencies (SAGE) from the outset of any future …
Gov response: No formal response published by this government.
Unknown
COVID-M2.4 — Publish Technical Advice During Emergencies
Recommendation: During a whole-system civil emergency, the UK government and devolved administrations should each routinely publish technical advice on scientific, economic and social matters at the earliest opportunity, as well as the minutes of expert advisory groups – except where there …
Gov response: No formal response published by this government.
Unknown
COVID-M2.5 — Advisory Group Terms of Appointment
Recommendation: The Government Office for Science (GO-Science), the Scottish Government, the Welsh Government and the Department of Health (Northern Ireland) should each develop standard terms of appointment for all participants in scientific advisory groups. These terms should include: clarity around the …
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M2.6 — Enact Socio-economic Duty
Recommendation: The UK government should bring into force in England section 1 of the Equality Act 2010, implementing the socio-economic duty. The Northern Ireland Assembly and Northern Ireland Executive should consider an equivalent provision within section 75 of the Northern Ireland …
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M2.9 — NI Emergency Powers Review
Recommendation: The Northern Ireland Executive and UK government (in consultation with the Irish government where necessary) should review the structures and delegated powers of government in Northern Ireland to consider: the empowerment of the First Minister and deputy First Minister jointly …
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
R47 — ICM reports to CEO
Recommendation: Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive or, at least, to an executive board member.
Gov response: Section 2.2 of the Scottish Government's response explicitly states that the Infection Control Manager (ICM) is accountable directly to the chief executive and the board. Furthermore, the Scottish Government has been working with partners since …
Accepted
R48 — ICM Board HAI reporting
Recommendation: Health Boards should ensure that the ICM is responsible for reporting to the Board on the state of HAI in the organisation.
Gov response: Section 2.2 of the Scottish Government's response specifies that the Infection Control Manager (ICM) is responsible for producing an annual report on the state of HAI, decontamination, and cleaning in the NHS board and releasing …
Accepted
R49 — National ICM role guidance
Recommendation: Scottish Government should re-issue national guidance on the role of the ICM, stipulating that the ICM must be responsible for the management of the infection prevention and control service.
Gov response: Section 2.2 of the Scottish Government's response indicates that the government has been working with partners since 2014/15 to ensure the stipulation that infection control managers have direct lines of communication and accountability to the …
Accepted
R55 — CDI reporting to CEO and Board
Recommendation: Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the Chief Executive and the Board.
Gov response: Section 2.1 of the Scottish Government's response highlights that national surveillance of C. diff infection is conducted, and a specific C. diff infection target is included in Local Delivery Plan Standards, requiring NHS boards to …
Accepted
R58 — Lay representation on IPC committee
Recommendation: Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy on public involvement.
Gov response: Section 2.1 of the Scottish Government's response outlines several initiatives to ensure patient and public involvement, including the National Health Service Reform (Scotland) Act 2004, which requires NHS boards to involve the public in service …
Accepted
LAMI-1 — Establish a ministerial Children and Families Board within government
Recommendation: With the support of the Prime Minister, a ministerial Children and Families Board should be established at the heart of government. The Board should be chaired by a minister of Cabinet rank and should have ministerial representation from government departments …
Unknown
LAMI-10 — Government inspectorates to assess quality and inter-agency effectiveness for child services
Recommendation: As part of their work, the government inspectorates should inspect both the quality of the services delivered, and also the effectiveness of the inter-agency arrangements for the provision of services to children and families.
Unknown
LAMI-101 — Home Office to actively maintain child protection investigation standards through inspections
Recommendation: The Home Office, through Her Majesty’s Inspectorate of Constabulary, must take a more active role in maintaining high standards of child protection investigation by means of its regular Basic Commands Unit and force inspections. In addition, a follow-up to the …
Unknown
LAMI-106 — Home Office to make child protection policing a ministerial priority
Recommendation: The Home Office must ensure that child protection policing is included in the list of ministerial priorities for the police.
Unknown
LAMI-11 — Government to review law on private foster carer registration
Recommendation: The Government should review the law regarding the registration of private foster carers.
Unknown
LAMI-2 — Incorporate Children's Commissioner responsibilities into National Agency Chief Executive role
Recommendation: The chief executive of a newly established National Agency for Children and Families will report to the ministerial Children and Families Board. The post of chief executive should incorporate the responsibilities of the post of a Children’s Commissioner for England.
Unknown
PFD Reports (8)
Oli Hoque
Concerns: The MHRA's inability to compel timely clinical data hinders robust safety investigations into potential vaccine adverse events, impacting public interest in drug safety.
Responded
Charles Stringer
Concerns: The council demonstrated a lack of reflection and action on pothole management, with insufficient information for inspectors, mechanistic risk assessments, poor communication, and slow repairs.
Overdue
Oliver Weston
Concerns: An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in "exceptional circumstances" led to arbitrary decisions.
Overdue
Michael Hoolickin
Concerns: No specific safety concerns or systemic failures were detailed beyond the general mention of "Serious Further Offence Reviews" needing to be conducted.
Responded
Thelma Joyce
Concerns: The report provided no specific details regarding the matters of concern, indicating a boilerplate introduction without further content.
Responded
Dean Elie
Concerns: The report highlights a need for consideration of further legislation to address a critical point, indicating a gap in existing legal frameworks relevant to preventing future deaths.
Responded
Kuldip Singh Dhillon
Concerns: Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and auditing of transport regulations by the Department of Transport.
Overdue
Michael Joseph Hirrell
Concerns: Npower failed to recognise a clearly vulnerable person, disconnecting their power despite staff concerns. Systemic failures in consumer protection and inadequate industry-wide changes risk future deaths.
Response: Ofgem proposes that the Safety Net wording be made more explicit regarding vulnerable domestic consumers with non-domestic supplies, including a commitment for suppliers to maintain an audit trail. Ofgem will …
Response: Energy UK reviewed its Safety Net policy for vulnerable domestic consumers with non-domestic supplies and has published an updated version. The amendment clarifies that such supplies will not be knowingly …
Response: Npower has permanently reviewed and updated its disconnection processes and guidance for domestic properties supplied via non-domestic lines, including clear guidance for identifying vulnerable occupants. All affected agencies and internal …
Responded