Question 28 in the Annex to our Terms of Reference asks: “Whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice? To what effect?”
In the light of Question 28, the Thirlwall Inquiry Legal Team has produced a Table in respect of the relevant inquiries and reviews which have been conducted in England and Wales over the last thirty years.
Recommendations from each inquiry have been set out in a comprehensive table, alongside details of whether or not those recommendations have been implemented. Evidence of the extent of implementation is based upon publicly available information that the Thirlwall Inquiry Legal Team has been able to identify. In February 2024 (and in response to the draft table) comments from the Department of Health and Social Care were obtained and have been included in an additional column.
Where we have identified evidence that a recommendation has been implemented, the relevant column has been colour-coded in green. Where a recommendation has been rejected, there is insufficient evidence of implementation, or steps have been taken but the implementation is not yet complete, the relevant column has been left blank.
Each section has a brief introduction to the issues investigated by the inquiry, and provides key information and dates. Where possible, links to published reports and other publicly available sources of information have also been included.
The Thirlwall Inquiry Legal Team has categorised and colour-coded recommendations relevant to four themes: (i) improving patient safety; (ii) improving NHS culture and governance; (iii) improving the ability to raise complaints and concerns; and (iv) regulation and oversight of NHS managers. A recommendation which does not fit one of these categories has not been colour-coded, but where a recommendation covers multiple categories, it has been colour-coded as such.
Appendix 1 sets out on a timeline the date of each report reviewed and the key date(s) when the recommendations made in each report were implemented.
Since the Thirlwall Inquiry Legal Team’s first draft of the Table produced in December 2023, four additional Inquiries have been reviewed and added in response to feedback from the Department of Health and Social Care and Sir Robert Francis.
This table will form part of the evidence adduced at the Thirlwall Inquiry oral hearings.