Each entry is one inquiry, investigation, policy review or national strategy. Open a review for the findings, the paraphrased recommendations, and the other reviews that share its themes.
OngoingStatutory inquiryOngoing
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
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
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
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
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
2025National strategyPublished
Department of Health and Social Care
The national plan published in July 2025, written after the Darzi investigation. It is organised around three shifts: hospital to community, analogue to digital, and sickness to prevention. It also promises more public information on quality, a national maternity and neonatal investigation, and a more data-led CQC.
Whole system
England
3 recommendations in this hub
2025Independent reviewPublished
Dr Penny Dash
Review of six organisations — CQC, HSSIB, the Patient Safety Commissioner, the National Guardian's Office, Healthwatch England, and the safety-learning role of NHS Resolution — and of the wider quality landscape. It found too much attention on structures, too little on outcomes, and so many recommendations from so many bodies that staff and patients could not tell what mattered. The government accepted all nine recommendations on 7 July 2025.
Whole system
England
9 recommendations in this hub
2025Statutory inquiryOngoing
Lord Brodie
Statutory inquiry into the planning, design, construction and maintenance of the Queen Elizabeth University Hospital campus in Glasgow and the Royal Hospital for Children and Young People in Edinburgh, and the effect on patients. An interim report on the Edinburgh hospital in March 2025 made 11 recommendations, which the Scottish Government accepted. The final report, largely about Glasgow, had not been published by October 2026. Lord Brodie said in June 2026 that it was still being written.
Infection and estates
Scotland
2 recommendations in this hub
2024Statutory inquiryOngoing
Baroness Hallett
The UK COVID-19 Inquiry is a statutory inquiry still in progress. Module 1, on resilience and preparedness, reported in July 2024. Later modules cover political decision-making, the health and care impact, and other parts of the response. This entry tracks the inquiry as a whole and summarises what Module 1 has already said.
Emergency preparedness
UK
2 recommendations in this hub
2024Independent reviewPublished
Dr Hilary Cass
Independent review of NHS gender identity services for children and young people. It found a weak evidence base, a service that had not kept up with a rapid rise in referrals, and a need for ordinary, holistic children's healthcare around gender-related distress.
Children
England
3 recommendations in this hub
2024Independent reviewPublished
Lord Darzi of Denham
Rapid investigation of the state of the NHS in England, published in September 2024. It diagnosed falling access, missed targets, a disengaged workforce, underinvestment in capital, and the unfinished business of social care. It was written to set the terms of a ten-year plan rather than to list new operational recommendations.
Whole system
England
2 recommendations in this hub
2024Independent reviewPublished
Dr Penny Dash
Review of whether CQC could do its job. An interim report in July 2024 and a final report in October 2024 found a regulator that had lost the confidence of providers and the public, with a failed IT transformation and unclear assessment.
Whole system
England
2 recommendations in this hub
2024Independent reviewPublished
Dr Henrietta Hughes
Report by the Patient Safety Commissioner on options for redress for people harmed by pelvic mesh and sodium valproate. It followed the Cumberlege recommendation for a redress agency, which had not been created.
Medicines and devices
England
2 recommendations in this hub
2024Statutory inquiryPublished
Sir Brian Langstaff
UK statutory inquiry into how people were infected with HIV and hepatitis by NHS blood and blood products, and into the response over subsequent decades. It found a systemic failure to put patient safety first, and a response that added to the harm.
Medicines and devices
UK
3 recommendations in this hub
2024Incident investigationPublished
Professor Oliver Shanley
Independent review after undercover filming of abuse at the Edenfield Centre and wider concerns about the trust. It described a closed culture, poor leadership and patients who were not safe.
Mental health
England
2 recommendations in this hub
2023Policy reviewPublished
Rt Hon Patricia Hewitt
Review of how integrated care systems were being overseen. It found too many national targets, too little autonomy, and prevention still losing out to acute pressure.
Whole system
England
2 recommendations in this hub
2023National strategyPublished
NHS England
The first long-term workforce plan for the NHS in England. It set out expansion of training, new roles, and retention, against demand modelled to the mid-2030s.
Workforce
England
2 recommendations in this hub
2022Independent reviewPublished
Dr Bill Kirkup
Independent investigation into maternity and neonatal care in East Kent. It found repeated failures over more than a decade. Kirkup deliberately did not add a long list of new recommendations. He set out four areas for action and argued that the problem was implementation of what was already known.
Maternity and neonatal
England
3 recommendations in this hub
2022Policy reviewPublished
Dr Claire Fuller
Stocktake of how primary care should work inside integrated care systems. It proposed neighbourhood teams for people with complex needs, and a simpler same-day access model for urgent but non-emergency problems.
Primary care
England
2 recommendations in this hub
2022Policy reviewPublished
Professor Ben Goldacre
Review of how NHS data should be used. It argued for trusted research environments, modern data platforms, and open methods, so that analysis can happen without shipping identifiable data around.
Digital and data
England
2 recommendations in this hub
2022Policy reviewPublished
General Sir Gordon Messenger and Dame Linda Pollard
Review of leadership across health and social care. It called for a single set of management standards, collaborative behaviour, and equality and diversity as a performance issue rather than a side programme.
Leadership
England
2 recommendations in this hub
2022Statutory inquiryPublished
Brett Lockhart KC
Statutory inquiry into neurology services in Belfast after the largest patient recall in Northern Ireland, concerning the practice of Dr Michael Watt. It examined complaints, governance and candour.
Acute care
Northern Ireland
2 recommendations in this hub
2022Independent reviewPublished
Donna Ockenden
Independent review of maternity services at Shrewsbury and Telford. An interim report in 2020 set immediate actions. The final report in March 2022 set 15 immediate and essential actions for maternity services in England, after reviewing failures across maternity and neonatal care.
Maternity and neonatal
England
4 recommendations in this hub
2020Independent reviewPublished
Baroness Cumberlege
Review of harm from hormone pregnancy tests, sodium valproate in pregnancy, and pelvic mesh. It found that patients, mostly women, were not listened to, and that the system was not set up to spot harm from a product once it was in use. The review made nine recommendations.
Medicines and devices
England
5 recommendations in this hub
2020Independent reviewPublished
Rt Revd Graham James
Inquiry into how surgeon Ian Paterson was able to perform inappropriate and unnecessary breast surgery in the NHS and the private sector for years. It found that colleagues, managers and insurers did not stop him, and that patients were not recalled properly.
Acute care
England
3 recommendations in this hub
2019Policy reviewPublished
Tom Kark KC
Review of the fit and proper persons test introduced after Francis. It found the test was not stopping directors with a record of failure from moving to another NHS job.
Leadership
England
2 recommendations in this hub
2019National strategyPublished
NHS England
The national plan for the decade from 2019: integrated care, out-of-hospital services, mental health, cancer, cardiovascular disease, maternity and a digital NHS. It assumed a funding settlement and a workforce to match.
Whole system
England
2 recommendations in this hub
2019National strategyPublished
NHS England and NHS Improvement
National strategy organised around insight, involvement and improvement. It set the direction for a new incident-reporting system and, later, the Patient Safety Incident Response Framework.
Whole system
England
2 recommendations in this hub
2019Independent reviewPublished
Professor Sir Mike Richards
Independent review of adult screening after a series of incidents in which people were not invited. It found ageing IT, split governance, and no single owner for making screening safe.
Whole system
England
2 recommendations in this hub
2019Policy reviewPublished
Dr Eric Topol
Review of how genomics, digital medicine and artificial intelligence would change NHS work, and what education needed to do about it. It was commissioned through Health Education England.
Digital and data
England
2 recommendations in this hub
2018Independent reviewPublished
Bishop James Jones
Independent panel report on the prescribing of opioids at Gosport War Memorial Hospital. It found that the lives of patients were shortened, and that families had raised concerns for years without being heard.
Medicines and devices
England
2 recommendations in this hub
2018Statutory inquiryPublished
Mr Justice O'Hara
Statutory inquiry into the deaths of children in Northern Ireland hospitals, including deaths associated with hyponatraemia and fluid management. It found failures of care, candour and how the system treated families afterwards.
Children
Northern Ireland
2 recommendations in this hub
2018Independent reviewPublished
Dr Bill Kirkup
Independent review of a community trust where a bullying culture and an aggressive cost-improvement programme harmed patients and staff. Concerns were known and not acted on.
Whole system
England
2 recommendations in this hub
2018Policy reviewPublished
Professor Sir Norman Williams
Rapid review of how gross negligence manslaughter is applied to healthcare, after concern that prosecutions and regulatory referrals were making clinicians afraid to be open.
Workforce
England
2 recommendations in this hub
2016National strategyPublished
Baroness Cumberlege
National maternity review that followed Morecambe Bay. It proposed personalised care, continuity of carer, safer teams, and better data, as a five-year forward view for maternity.
Maternity and neonatal
England
2 recommendations in this hub
2016Policy reviewPublished
Lord Carter of Coles
Review of unwarranted variation in how acute hospitals use staff, procurement, estates, pharmacy and pathology. It introduced the idea of a model hospital against which trusts could compare themselves.
Productivity
England
2 recommendations in this hub
2016Policy reviewPublished
Professor Robert Wachter
Review of how the NHS should digitise secondary care after earlier national IT programmes. It argued for clinical leadership, phased implementation, and interoperability rather than a single centrally built record.
Digital and data
England
2 recommendations in this hub
2015Independent reviewPublished
Sir Robert Francis KC
Independent review of how NHS staff raise concerns. It proposed principles for speaking up, a guardian in every trust, and a national office to support them.
Workforce
England
2 recommendations in this hub
2015Incident investigationPublished
Mazars
Review of how Southern Health investigated deaths of people with a learning disability or mental health problem. Most such deaths were not treated as needing a serious investigation.
Mental health
England
2 recommendations in this hub
2015Independent reviewPublished
Dr Bill Kirkup
Investigation into maternity and neonatal care at Furness General Hospital. It found dysfunctional relationships between midwives, obstetricians and paediatricians, and a failure to investigate deaths properly.
Maternity and neonatal
England
3 recommendations in this hub
2015Statutory inquiryPublished
The Rt Hon Lord Penrose
Scottish public inquiry into HIV and hepatitis infection from NHS blood and blood products. It was widely criticised by campaigners as not going far enough on fault and compensation.
Medicines and devices
Scotland
2 recommendations in this hub
2015Policy reviewPublished
Lord Rose
Review of leadership in NHS hospitals in England. It described a crowded centre, short-tenure chief executives, and too little systematic talent management.
Leadership
England
2 recommendations in this hub
2015Independent reviewPublished
Kate Lampard and Ed Marsden
Overview of the NHS investigations into access Jimmy Savile had to hospitals. It drew out common weaknesses in safeguarding, celebrity culture, volunteering, complaints and how unusual behaviour was excused.
Acute care
England
2 recommendations in this hub
2014Policy reviewPublished
Sir David Dalton
Review of how NHS organisations might combine: groups, chains, acquisitions and management franchises. It was a response to trusts that could not sustain quality on their own.
Whole system
England
2 recommendations in this hub
2014National strategyPublished
Simon Stevens
The national strategy that replaced a single blueprint with new models of care: more prevention, more care out of hospital, and organisations working together. It was a plan rather than an inquiry, and it set the frame for the decade that followed.
Whole system
England
2 recommendations in this hub
2013Independent reviewPublished
Professor Don Berwick
National advisory group on the safety of patients, convened after Francis. It argued that the NHS should become a learning system, and that criminal sanctions should be reserved for wilful neglect rather than honest error.
Whole system
England
3 recommendations in this hub
2013Policy reviewPublished
Baroness Cavendish
Review of the training and support of healthcare assistants in the NHS and social care, commissioned in the wake of Francis. It found a workforce doing intimate care with no common standard of preparation.
Workforce
England
2 recommendations in this hub
2013Policy reviewPublished
Rt Hon Ann Clwyd MP and Professor Tricia Hart
Review of how hospitals handle complaints, commissioned alongside the Francis response. It heard from patients who found the process exhausting, defensive and detached from learning.
Acute care
England
2 recommendations in this hub
2013Statutory inquiryPublished
Sir Robert Francis KC
Statutory public inquiry into the suffering of patients at Stafford Hospital. It described a culture that put the organisation's reputation and national targets ahead of patients, and a regulatory system that did not stop it. The inquiry made 290 recommendations.
Acute care
England
5 recommendations in this hub
2013Independent reviewPublished
Sir Bruce Keogh
Rapid review of 14 trusts identified from mortality data after Francis. Expert teams looked at leadership, safety, staffing and how each trust used data.
Acute care
England
2 recommendations in this hub
2012Independent reviewPublished
Department of Health
National review after the Panorama exposure of abuse at Winterbourne View, a private hospital for people with learning disabilities. It followed the serious case review and set out a programme to move people out of inappropriate inpatient units.
Mental health
England
2 recommendations in this hub
2011Policy reviewPublished
Professor Eileen Munro
Review of child protection after a decade of procedural reform. It argued that the system had become too focused on compliance and not enough on whether children were safer.
Children
England
2 recommendations in this hub
2010Policy reviewPublished
Professor Sir Michael Marmot
Review of the social determinants of health. It set out how health follows the social gradient, and proposed action from early years through work, income and healthy places. A ten-year reassessment in 2020 found inequalities had widened.
Inequalities
England
2 recommendations in this hub
2008Policy reviewPublished
Lord Darzi of Denham
The NHS Next Stage Review, led by a surgeon-minister. It argued that the next phase of reform should be organised around quality: safety, experience and effectiveness, with clinical leadership at the centre.
Whole system
England
2 recommendations in this hub
2005Independent reviewPublished
Nigel Pleming KC
Inquiry into how two psychiatrists in North Yorkshire were able to abuse patients over many years, and why complaints from patients, mostly women, were not believed.
Mental health
England
2 recommendations in this hub
2005Statutory inquiryPublished
Dame Janet Smith
Statutory inquiry into the murders committed by GP Harold Shipman and into how death certification, controlled drugs and professional oversight failed to stop him. The inquiry reported in stages, with the final report in 2005.
Primary care
England
3 recommendations in this hub
2003Statutory inquiryPublished
Lord Laming
Public inquiry into the murder of Victoria Climbié and the failure of health, police and social services to protect her. Information sat in separate organisations and was not acted on.
Children
England
2 recommendations in this hub
2001Independent reviewPublished
Michael Redfern KC
Inquiry into the removal, retention and disposal of human tissue at Alder Hey and related practice elsewhere. Families had not agreed to what happened to their children's organs.
Children
England
2 recommendations in this hub
2001Statutory inquiryPublished
Professor Sir Ian Kennedy
Public inquiry into the care of children undergoing heart surgery in Bristol between 1984 and 1995. It found a service with poor outcomes that families and some clinicians could not get the organisation to face.
Children
England
3 recommendations in this hub
1994Independent reviewPublished
Sir Cecil Clothier
Independent inquiry, chaired by Sir Cecil Clothier and published in February 1994, into the murders and attacks committed by enrolled nurse Beverly Allitt on a children's ward at Grantham and Kesteven General Hospital. The report was published in print by HMSO. It made recommendations on staff references, occupational health screening, paediatric pathology and the reporting of unexpected events.
Children
England
3 recommendations in this hub
