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Written submissions from Counsel to the Inquiry

Tom Kark QC, Counsel to the Inquiry, provided the following written closing submissions to the Chairman on 9 December 2011.  These are the submissions of Counsel to the Inquiry and his team, and do not represent the views of the Chairman. 

Core participants were invited to submit factual corrections to Counsel to the Inquiry's closing submission, and the comments received are available here.

Written submissions from Counsel to the Inquiry

Front sheet and index


Summary of conclusions

Chapter 1 - patients and relatives of patients

Chapter 2 - patient support organisations

Chapter 3 - local general practitioners

Chapter 4 - patient and public involvement bodies

Chapter 5 - Local Authority overview and scrutiny committees

Chapter 6 - the coroner

Chapter 7 - local Members of Parliament

Chapter 8 - unions

Chapter 9 - the Trust

Chapter 10 - independent case note review

Chapter 11 - Primary Care Trusts

Chapter 12 - Strategic Health Authorities

Chapter 13 - peer review in the West Midlands

Chapter 14 - Monitor

Chapter 15 - Healthcare Commission

Chapter 16 - Care Quality Commission

Chapter 17 - Health and Safety Executive

Chapter 18 - Professional regulators and educators

Chapter 19 - Health Protection Agency

Chapter 20 - NHS Litigation Authority

Chapter 21 - National Patient Safety Agency

Chapter 22 - Dr Foster

Chapter 23 - NHS Information Centre

Chapter 24 - National Institute for Health and Clinical Excellence

Chapter 25 - Health Service Ombudsman

Chapter 26 - Department of Health