Chapter 31. Implementation of recommendations of inquiries

The first detailed work carried out by this Inquiry was a review of all recommendations made in all inquiries into the NHS in the last 30 years. It was published in May 2024, and updated in April 2025 to incorporate further comments from DHSC and NHS England in respect of 19 of the 33 inquiries listed, and three further inquiries.¹ The review is structured so as to lead the reader to the source material on every topic and I do not repeat either the source material (reports, recommendations and responses from government) or the commentary, all of which are self-explanatory. The review, although focused and concise, runs to 818 pages. Recommendations have been divided into four types, reflecting the four predominant themes of this Inquiry: patient safety, improving culture and governance, improving the ability to raise complaints and concerns, and regulation and oversight of managers.
The review shows that, whilst some significant changes have been introduced in response to Inquiry recommendations over the last 30 years, most have not been implemented. In very short summary: many of the recommendations made by Dame Janet Smith DBE in the Shipman Inquiry have been implemented. This required years of determined effort by many people in DHSC backed by political will. The last remaining change to be implemented, the introduction of medical examiners, occurred 20 years after the government proposed the medical examiner system in response to Dame Janet’s recommendation that there should be a medical coroner system (which was not accepted). Her wide-ranging recommendations about changing the way coroners were arranged and operated were implemented much earlier, beginning with the passing of the Coroners’ and Justice Act in 2009. I deal with the history of the introduction of medical examiners at Chapter 32.
In respect of most other reports, some of the recommendations have been implemented. Some have been implemented in part. Most have not been implemented, either because government did not accept them, as they are entitled to do, or for other reasons. The reasons for not implementing are set out in the review in so far as the Inquiry was able to establish them. I should add that, as explained in the review, which has been scrutinised and responded to by DHSC and NHS England, it is not always clear whether something has been implemented. Where that is the case, it is reasonable to infer that, whatever has been done, if anything, has not been effective in addressing the issue to which the recommendation was directed.
In September 2024, the House of Lords Statutory Inquiries Committee (to whom the Inquiry provided the findings of our initial review) published its review of public inquiries that had taken place since the Inquiries Act 2005 came into force: Public Inquiries: Enhancing public trust. It was not restricted to inquiries into the NHS. The committee recognised the partial successes achieved by public inquiries but pointed out that recommendations, whilst accepted by government, were often not subsequently implemented. The committee described this as “inexcusable”. The committee wrote that this “risks the recurrence of a disaster and undermines the whole purpose of holding an inquiry in the first place”.² I agree. By way of example, the committee said that they had been told that, had the recommendations from the public inquiry into deaths at the Bristol Royal Infirmary in 2001 been implemented, patient deaths investigated by the Mid Staffordshire inquiry in 2013 “may have been less likely to occur”. The committee concluded that the 2005 Act and the wider governance structure of public inquiries “must be improved”.³
I accept that the government has a choice about whether to accept recommendations but where the same failings are being identified in different places, repeatedly, effective action must be taken – by implementing recommendations or otherwise. It is inexcusable to ignore such failings. Even where recommendations are accepted, there is no mechanism to track progress or enforce implementation.
On the day before closing submissions were made by all Core Participants in this Inquiry, the government announced the abolition of NHS England. During closing submissions on 17 March 2025, I asked DHSC and NHS England for details of who would be responsible for implementing recommendations from this Inquiry. I was told that responsibility would lie with DHSC. I pressed for further details. On 20 May 2026, I received a response in which DHSC and NHS England confirmed that the Inquiry’s recommendations will be considered by DHSC “in the usual established way”, and it is usual to constitute a programme board to coordinate the government’s response. In addition, the National Maternity and Neonatal Taskforce will “address recent developments … including recommendations” from this Inquiry. DHSC and NHS England were unable to provide detail on how this will work in practice. This is very disappointing. Given the track record of DHSC and its predecessors to date, knowing that things will be done in the usual way is not reassuring. There are no specifics about how things will work in practice. The reference to the National Maternity and Neonatal Taskforce is important, not least because there is no neonatal expertise in the taskforce membership. This was raised by the Inquiry on 8 May 2026. In answer to a question from the Inquiry, DHSC indicated that BAPM would provide a suitable representative on the taskforce. DHSC and NHS England again were not able to set out how neonatal-specific issues will be addressed in practice. I note that Baroness Amos has also produced her report and recommendations for maternity and neonatal services, and a Maternity and Neonatal Commissioner will be appointed.⁴

Reasons recommendations are not implemented

I heard evidence on a number of topics from Dr Rosie Benneyworth, Interim Chief Executive at the Health Services Safety Investigation Body (HSSIB). At the request of DHSC, she conducted a review of safety and risk in the NHS. Her report reviews recommendations made by national organisations but I accept her view that it is equally applicable to recommendations made by inquiries and local investigations.⁵
The nature of the findings is evident from the title of the report: ‘Recommendations but No Action: Improving the effectiveness of quality and safety recommendations in healthcare’.⁶ The report concluded that “the sheer number [of recommendations] being made and the variance in their quality means that they can be a burden to an already pressured healthcare system which is expected to digest, prioritise, pay for and implement actions in relation to them”.⁷ This echoed the evidence of Professor Dixon-Woods⁸ and Dr Penny Dash (lead for two independent reviews).⁹ Dr Benneyworth’s report observed that “failure to implement actions following recommendations can impact public confidence in the healthcare system and compound harm to patients”.¹⁰ The reasons for the failure, in addition to the sheer numbers, were given as follows:
1. The noise created by the significant volume of recommendations being made to the healthcare system means that providers struggle to prioritise and implement recommendations. This echoes Professor Dixon-Woods’ reference to “priority thickets”.¹¹
2. Some recommendations duplicate or contradict others. The development of a searchable repository, which includes recommendations made across the healthcare system, may help to reduce this.
3. There is currently a lack of visibility of ongoing work across arm’s-length bodies that would enable collaborative working on related workstreams.
4. Few recommendations require a formal response from the recipient organisation and there is a lack of monitoring of the actions planned or taken to address the recommendations.
Dr Benneyworth added that some recommendations are not evidence based and do not provide a clear path to implementation. Some recommendations are too prescriptive and do not account for the fact that, when individual providers are implementing the recommendations, they also need to take into consideration their local needs.¹²
She concluded: “I think it’s about visibility, I think it’s about being clear about how these are going to be tracked and monitored and it’s about mechanisms for escalation when things aren’t happening.”¹³
Sir Robert Francis made the point in his evidence that the volume of structural change within the NHS over years makes it extremely difficult to follow through the implementation of Inquiry recommendations.¹⁴ Mr Vineall, a highly experienced and long-serving director at DHSC, had considered the Inquiry’s review before providing his evidence, written and oral, to this Inquiry. His assessment was more positive than mine.¹⁵ I acknowledge that, in recent years, there have been significant changes within the NHS as a result of inquiries: medical examiners and the introduction of the fit and proper person test for board members and senior executives. But, whatever the perspective, there is a lot that has not been done, as has been recognised in a number of reports.
Sometimes recommendations are implemented, but the change is not maintained and so progress is not made. It is instructive to look in this context at the report of the public inquiry into events at Bristol Royal Infirmary cardiology department between 1984 and 1995. Sir Ian Kennedy, the Chair, presented his excellent report to Parliament in 2001.¹⁶ The response of the government in 2002 was detailed and positive.¹⁷ It acknowledged that the NHS needed fundamental reform. A new plan for the NHS, of which Sir Ian approved, was already in place.¹⁸ Of particular relevance to the Bristol inquiry was that the then government acknowledged that children’s services had not been accorded appropriate priority. It instituted changes within the NHS and across government departments to improve the health of children. This plan was put into operation and met with some success, not least in lifting children out of poverty.
It is, however, inescapable that now, over 20 years later, paediatrics is once again considered to be at the back of the queue in terms of resources in hospitals. Dr Kingdon referred in her evidence to a “significant problem” of “lack of resource”, noting that the lack of workforce in paediatrics was a particular issue.¹⁹ The National Clinical Director role for neonatology was introduced only in 2024. Although welcome, it is part time and underfunded.
More urgently, from the standpoint of those working in neonatology, the current government’s 10 Year Health Plan for England, whilst encouraging in many respects, has not, yet, identified where additional nurses and doctors are to come from for children’s wards (including neonatal units). I recognise that poor maternity care is in many places a huge and very long-standing problem, which must be dealt with – but fixing that must not lead to babies and children being overlooked. Sir Stephen Powis was asked about the provision for further staff for neonatal units. His response was that it was recognised that staffing of neonatal units has been an issue and that this was a focus of neonatal delivery plans, and progress had been made in increasing staffing in neonatal units. However, he accepted that, in terms of the 2023 NHS Workforce Plan, there was no specific commitment in terms of any sub-specialty of medicine, save for a commitment to increase GPs. Whilst he said this was the next step of the plan, he was unable to give any commitment as to timings.²⁰ This must be addressed urgently. I note the new 10 Year NHS Workforce Plan, due in Spring 2026, is still awaited.
As well as reorganisations and structural change, as identified by Sir Robert Francis, and the sheer number of recommendations, there are at least two other important reasons for not implementing recommendations that have been accepted. The first is lack of political will. There is a broadly held view that an inquiry serves its primary purpose when it is set up by taking the heat out of a difficult political situation. By the time it reports, there has often been at least one change of government, probably more than one change of Secretary of State, priorities have changed and, once the story of what happened has been told, the media and the public gaze generally move elsewhere and recommendations are quietly forgotten.
Both Sir Rob Behrens CBE (Parliamentary and Health Service Ombudsman from April 2017 to March 2024) and Sir Robert Francis pointed to a further reason, namely the absence of effective oversight or enforcement.²¹ This chimes with the findings of Dr Benneyworth’s group in respect of recommendations and guidance from within the NHS.

Establishment of a public inquiries committee?

The House of Lords Statutory Inquiries Committee’s report from September 2024, Public Inquiries: Enhancing public trust, recommended that the House of Commons Liaison Committee facilitate the formation of a joint committee of Parliament to ensure that inquiry recommendations are followed up and implemented.²² The committee would oversee public inquiries, monitor the publication of government responses to inquiry recommendations and hold the government to account for implementing accepted recommendations. The government responded in April 2025 that this recommendation would be a matter for Parliament.²³ However, it committed to providing Parliament with a further update on its intentions regarding potential “wider reforms” to the policy and operational frameworks governing public inquiries.²⁴ Whilst reform of the system of public inquiries is not within my Terms of Reference, the question of implementation of recommendations is. I see the force of the Committee’s recommendation. My only question (and this is surely something that could be worked on) would be whether such a committee would have the time, resources and flexibility to carry out its functions effectively. Provided those issues were addressed this could and should work.
The Committee also recommended, and the government indicated it would support, better resourcing for the Cabinet Office Inquiries Unit. This would allow greater sharing of good practice and learning from the experience of those who have been and are involved in public inquiries. It ought to remove the need for every chair of a public inquiry to reinvent the wheel. It should not, of course, cut across the Chair’s independence.²⁵

Independence of the monitoring and enforcement body

The Cabinet Office Inquiries Unit launched their Inquiry dashboards in July 2025, as a record of public inquiry recommendations made since 2024. The dashboards track the government’s commitments in response to these recommendations, and update on implementation.²⁶ So far only six inquiries, not covering all modules and report phases, have been included. Keeping the dashboards up to date relies on government departments providing progress reports to the Cabinet Office. The dashboards do not provide further information on the implementation of ‘in progress’ recommendations. The Cabinet Office Inquiries Unit, however well resourced, is not the right body to monitor (with a view to enforcement) inquiry recommendations because it is independent neither of government nor of the civil service. A joint committee of Parliament would be both.

National Quality Board?

DHSC and NHS England’s plans for a “revitalised” National Quality Board are set out in the 10 Year Health Plan.²⁷ I have been informed since the hearings that this board will be responsible for a repository of recommendations and act as a “clearing-house function to prioritise existing and new recommendations”. The board was to be refreshed “from September 2025” but there has been no further public update about that. I am told the “recommendations hub” will provide enhanced oversight and accountability for recommendations from multiple sources and provide an efficient system for prioritising, implementing and evaluating recommendations at the national level. There is no clear information on how prioritisation decisions will be made and by whom. I understand the hub will be implemented in a phased approach, with rollout starting in 2027. This does not lead me to expect great speed or urgency, nor is it clear where, if at all, this will work with the dashboards produced by the Cabinet Office Inquiries Unit. Finally, I am not persuaded that this board will be adequately resourced for the size of the task. It is not independent of government or the Civil Service and I am not at all confident of its practical effect.

National Audit Office

There is an alternative option which could be introduced more quickly. Sir Rob Behrens advised that the National Audit Office would be the ideal body to carry out this task.²⁸ I agree with him. The National Audit Office has a wide range of skills, expertise and experience. They audit programmes across the public sector and they report to Parliament. Importantly, they are independent of Government and of the Civil Service. They are held in high regard and are trusted.
I do not doubt that the National Audit Office would prefer not to add to their programme of work, but adding responsibility for monitoring the implementation of recommendations of the reports of statutory inquiries into NHS bodies, together with appropriate additional staffing, would transform the approach to recommendations and the effectiveness of public inquiries (even without any further changes as envisaged by the House of Lords Statutory Inquiries Committee). I am confident of this because the National Audit Office, and the House of Commons Public Accounts Committee through which it reports, have continued political clout.
I return to the question of recommendations in Chapter 45.