Repeated ask
Regulation and oversight
34 of 60 reviews in this catalogue come back to it. The next most common threads are data and early warning, leadership and boards, listening to patients and families.
Finance focused. Digitally enabled. People centred.
Where health and care reviews agree
Inquiries, incident investigations and national strategies keep asking the NHS for the same things. This hub gathers the public record, review by review, and shows the recommendations they share.
60
Reviews
4
Still open
166
Recommendations
25
Shared themes
Implementation
Writing it down is the easy part
135 of 166 paraphrased recommendations are still in progress, only partly done, not implemented, or waiting for a response. East Kent said this plainly in 2022. The 2026 reports say it again.
Why a hub
A clearing house, in public
Dr Penny Dash's 2025 review said the volume of recommendations had become a problem, and asked for one place to collect, prioritise and track them. This is an open Seagry reading of the landmark public record, not a subscription product.
Themes that cross reviews
Count of reviews in this hub that touch each theme.
- Regulation and oversight34
39 recommendations
- Data and early warning30
25 recommendations
- Leadership and boards29
24 recommendations
- Listening to patients and families28
18 recommendations
- Learning from harm20
23 recommendations
- Culture and conduct19
12 recommendations
- Safe staffing17
17 recommendations
- Candour16
12 recommendations
- Integration and neighbourhood care14
14 recommendations
- Digital and information13
17 recommendations
What we can say about delivery
A Seagry judgement of the public record, not an official implementation audit.
- Awaiting response32
- In progress17
- Partly done81
- Accepted24
- Not implemented5
- Not publicly clear6
- Superseded1
Themes that travel together
- Leadership and boards with Regulation and oversight · 21 reviews
- Listening to patients and families with Regulation and oversight · 20 reviews
- Regulation and oversight with Data and early warning · 20 reviews
- Leadership and boards with Data and early warning · 19 reviews
- Listening to patients and families with Data and early warning · 14 reviews
- Culture and conduct with Regulation and oversight · 14 reviews
When the record was published
Ongoing inquiries are placed in the year of their latest report, where one exists.
1990s
2000–04
2005–09
2010–14
2015–19
2020–24
2025–26
Latest in the catalogue
Full listOngoingStatutory inquiryOngoing
Lampard Inquiry
Baroness Kate Lampard
Statutory inquiry into more than 2,000 deaths of people who were under the care of NHS mental health services in Essex between 2000 and the end of 2023, focused on Essex Partnership University NHS Foundation Trust, North East London NHS Foundation Trust, and their predecessor organisations. It is the first public inquiry specifically into mental health deaths. In January 2026 the timetable slipped: closing statements are expected in summer 2027 and the final report in mid-2028. In October 2026 the inquiry held hearings on observation technology and resuscitation, and the chair said she would make interim recommendations if she found an urgent risk.
Mental health
England
1 recommendation in this hub
2026Independent reviewPublished
Amos maternity investigation
Baroness Valerie Amos
Rapid independent investigation ordered after the 10 Year Health Plan commitment and meetings with bereaved families. Baroness Amos was appointed in August 2025. The investigation looked at 12 trusts and at the national maternity system, and published final reports and recommendations on 30 June 2026. One expert adviser, Dr Bill Kirkup, stood down on 22 June 2026 because he could not agree the wording of the conclusions on normal-birth ideology.
Maternity and neonatal
England
4 recommendations in this hub
2026Incident investigationOngoing
HSSIB advice and guidance
Health Services Safety Investigations Body
Interim HSSIB investigation, published on 18 August 2026, into patient safety risks in advice-and-guidance services. These services let a GP seek specialist advice instead of, or before, referring a patient. Use has grown as a way of managing waiting lists. HSSIB found examples of good care and examples of delayed or missed diagnosis, including cancer, where local pathways forced advice and guidance or declined referrals despite ongoing concern.
Primary care
England
2 recommendations in this hub
2026Independent reviewPublished
Ockenden, Nottingham
Donna Ockenden
Independent maternity review led by Donna Ockenden, commissioned in 2022 and published on 24 June 2026. It looked at care from 2012 to 2025. More than 2,500 families and more than 800 staff contributed. The review identified potentially avoidable harm, failures of staffing, a failure to listen to parents, and a failure to investigate and learn. It made local actions and 18 immediate and essential actions for maternity services in England.
Maternity and neonatal
England
6 recommendations in this hub
2026Statutory inquiryPublished
Thirlwall Inquiry
Lady Justice Thirlwall
Statutory inquiry into events on the neonatal unit at the Countess of Chester Hospital between 2015 and 2018, after the convictions of Lucy Letby. Hearings ran from September 2024 to March 2025. The report was published on 15 September 2026 and made 17 recommendations. It examined the unit, the executives, the regulators, and why concerns raised by clinicians were not acted on. It also reviewed whether earlier inquiry recommendations had been implemented.
Children
England
18 recommendations in this hub