Regulation and oversight

Create a specialist approach to regulating maternity and neonatal services, with clinicians involved, rather than a generic inspection model.

NHS England, DHSC and CQC

NHS England and the Department of Health and Social Care should rapidly evaluate advice-and-guidance processes. Patient Safety Learning read this as something to finish before further expansion.

NHS England and DHSC

Create a panel of independent clinical experts who can be sent quickly when harm by an individual is suspected.

DHSC

Give medical examiners a clear neonatal checklist, and review whether their funding is adequate in 2027.

National Medical Examiner and DHSC

Bar unfit managers from September 2027, review that scheme in 2030, and aim for full statutory regulation by 2032. Senior moves should not be used to hide conduct or capability problems.

DHSC and NHS England

Inspect hospital departments without notice, with practising specialists on the team, and test whether patients are safe rather than whether a policy exists.

CQC

Have the Health and Social Care Committee examine CQC's performance regularly.

Parliament

Ask the National Audit Office to audit whether statutory inquiry recommendations are implemented, starting by September 2027.

Government and the National Audit Office

Publish quality information, including league tables, so people can see how services compare.

NHS England

Keep rebuilding CQC as the principal quality regulator, with sector-specific assessment and a harder look at boards.

CQC

Keep HSSIB as a specialist investigation function, hosted inside CQC, with its independence from providers protected.

DHSC

Put accountability for the quality of care back onto commissioners and providers.

ICBs and providers

Rebuild CQC's assessment approach and its technology, with clinical expertise back in inspection.

CQC and DHSC

Reduce the number of national targets and judge systems on outcomes, including prevention.

Government and NHS England

Stop commissioning new recommendation lists as a substitute for implementing the old ones.

Government and NHS England

Appoint a Patient Safety Commissioner.

Government

Reform the MHRA so that it looks harder for harm after a product is in use, with patients in the work.

MHRA

Make multidisciplinary team discussion a real check on individual practice, including in the private sector.

NHS and independent providers

Close the indemnity gap so private patients are not left without a route to compensation.

Government

Give a body the power to disbar directors who are not fit.

Government

Give staff an external route when the trust itself is the problem.

NHS England

Improve the quality of expert advice to coroners and prosecutors in healthcare cases.

Government

Put a Freedom to Speak Up guardian in every NHS organisation, with a national office to support the role.

NHS and government

Refer professional failures to the relevant regulators.

Trusts and regulators

Simplify the instructions the centre sends to trusts so leaders can lead.

Department of Health and NHS England

Apply safeguarding rules to volunteers, celebrities and anyone else with access to patients.

NHS trusts

Be clearer about delegation and the boundary between registered and support roles.

Employers and regulators

Improve advocacy and the speed of the Parliamentary and Health Service Ombudsman route.

Government

Set fundamental standards of care and make serious failure enforceable.

Government and CQC

Put trusts with worrying mortality onto an urgent support and improvement footing.

NHS England and regulators

Strengthen inspection of learning-disability inpatient units, including unannounced visits.

Care Quality Commission

Put quality accounts, clinical dashboards and NICE quality standards into routine use.

NHS

Take complaints of sexual misconduct by clinicians seriously and investigate them independently of the team.

NHS employers and regulators

Improve information sharing when a clinician moves, so concerns are not left behind.

Employers

Reform death certification so that deaths are scrutinised by someone independent of the doctor.

Government

Revalidate doctors so that a licence to practise is not held for life without check.

Professional regulators

Require explicit consent for the retention and use of tissue after death.

Government

Publish comparable outcomes and act when a service is an outlier.

NHS and regulators

Regulate the quality of the service, not only the conduct of individual professionals.

Government