Learning from NHS Inquiries: Comparing the Recommendations of the Ely, Bristol and Mid Staffordshire Inquiries

If one of the key reasons for an inquiry is to learn lessons and prevent similar events from reoccurring, recommendations must be implementable and implemented, but it is clear that lessons have not been learned and recommendations not implemented. This paper compares the 'implementability' of recommendations from the three inquiries of Ely, Bristol and Mid Staffordshire to stress the importance of learning lessons. It examines two broad issues of 'who?' and 'what?'. First, some 80 per cent of the Ely recommendations were aimed at the institution, while 72 per cent of the Bristol and Mid Staffordshire recommendations were aimed at the system. Moreover, about 7 per cent of Ely's forty-four recommendations have a clearly identified agent, compared to 15 per cent at Bristol and 41 per cent at Mid Staffordshire. Second, the policy tool of 'sermons' accounts for some 89 per cent of Ely recommendations, compared to 66 per cent at Bristol and 63 per cent at Mid Staffordshire. However, the earlier sermons did not appear to prevent the events at Mid Staffordshire occurring. Pulling these issues together, it can be suggested that, given the large number of potentially responsible agencies, recommendations should be 'active' with a clearly identified agent and that a clear policy tool or mechanism should be identified rather than rely on a vague tendency to sermonise.