## CHECK-00 — Provider, jurisdiction and applicable requirements **When this matters:** All comparisons. Provider and jurisdiction determine which requirements apply. **Policy areas:** the service description, commissioning agreement, NHS placement agreement, regulatory scope, command responsibilities and applicable clinical governance arrangements. JSP 950 is listed as internal access only; a public extract does not establish the complete current policy. [S19](https://thirlwall-wiki.pages.dev/sources/index.md#s19) **Questions:** - Who legally provides the care? - Who employs or commands each staff group? - Who holds clinical authority? - Which patients and countries are covered? - Does Defence provide neonatal care, purchase it, supply staff, or only support families after care elsewhere? - Which external agencies can investigate or regulate this activity? - Which organisation is the Provider, and which appointments hold each level of Responsible Person responsibility? - Where are command intent, service dependencies, operating status and the assessment of safety and compliance recorded under DSA02 Article 1001? **Questions about legal scope:** - For activity in England, does the precise Schedule 2 paragraph 10 exception apply? - Which provider's registration covers any NHS-hosted or contracted activity? - Which host-nation and Defence requirements govern overseas delivery? - Which professional registration and scope apply to each role? - How do worker status and legal jurisdiction affect reporting protections? **What the evidence can show:** A service description, responsibility map and referral arrangements can establish scope. Statutory obligations, Defence regulatory requirements, professional duties, policy commitments and contractual requirements have different authority. A public applicability reference cannot determine how those requirements apply to a particular service or person. **Sources:** [Legal applicability reference](https://thirlwall-wiki.pages.dev/defence-comparison/index.md#legal-applicability-reference); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11); [S12](https://thirlwall-wiki.pages.dev/sources/index.md#s12); [S20](https://thirlwall-wiki.pages.dev/sources/index.md#s20); [S21](https://thirlwall-wiki.pages.dev/sources/index.md#s21); [S22](https://thirlwall-wiki.pages.dev/sources/index.md#s22); [S23](https://thirlwall-wiki.pages.dev/sources/index.md#s23); [S43](https://thirlwall-wiki.pages.dev/sources/index.md#s43). This check does not supply a legal determination.

## CHECK-01 — Neonatal monitoring and family access **When this matters:** Neonatal care provided, commissioned or supported through a relevant agreement. **Related recommendation:** [R1](https://thirlwall-wiki.pages.dev/recommendations/index.md#r1). **Policy areas:** neonatal service specifications, remote-viewing procedures, clinical technology approval, privacy assessment and family communication arrangements. **Questions:** - If cot cameras are relevant, who can view them and who responds to parental concerns? - How are access rights granted and removed? - What happens during an outage? - How are privacy, consent or other legal grounds, retention and operational security assessed? - Does the provider explain the limits of monitoring? **What the evidence can show:** Service specifications, access rules, concern-response arrangements and downtime provisions describe intended coverage. Evidence of their operation is separate. For purchased care, the contract and provider responsibilities determine the Defence interface. **Sources:** [S33](https://thirlwall-wiki.pages.dev/sources/index.md#s33)

## CHECK-02 — Insulin custody and laboratory escalation **When this matters:** Services storing insulin or commissioning relevant laboratory testing. **Related recommendation:** [R2](https://thirlwall-wiki.pages.dev/recommendations/index.md#r2). **Policy areas:** medicines-management procedures, insulin storage and access rules, laboratory contracts, critical-result procedures and out-of-hours arrangements. **Questions:** - Can an audit identify each person accessing stock, including temporary staff? - Who reviews exceptions? - Can a concerning insulin/C-peptide result reach a responsible clinician and senior clinical authority immediately? - Is receipt acknowledged and recorded? - Does the route continue if the first contact fails? - Who assesses safeguarding and external referral without waiting for a routine incident meeting? **What the evidence can show:** Access records, exception handling, laboratory notification arrangements and allocation of provider responsibilities concern distinct controls. Neonatal guidance has a specific clinical scope. CCTV and biometric proposals raise separate legal and information-governance questions. **Sources:** [S34](https://thirlwall-wiki.pages.dev/sources/index.md#s34); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11)

## CHECK-03 — Bereavement support and handover **When this matters:** Defence care or support for a bereaved family. **Related recommendation:** [R3](https://thirlwall-wiki.pages.dev/recommendations/index.md#r3). **Policy areas:** bereavement pathways, family liaison arrangements, commissioned neonatal services and clinical-to-welfare handover procedures. **Questions:** - Who contacts the family, arranges specialist support and checks that support was received? - Does this continue after transfer, discharge or an overseas move? - Can the family choose appropriate support? - Do staff have the skills and privacy needed for difficult conversations? **What the evidence can show:** Pathways, referral responsibilities, staff preparation and handover arrangements describe continuity of support. For purchased care, the hospital’s clinical obligations and Defence welfare responsibilities remain distinct. **Sources:** [S31](https://thirlwall-wiki.pages.dev/sources/index.md#s31)

## CHECK-04 — Safeguarding training and staff obligations **When this matters:** Defence healthcare, with distinct military, civilian and contractual arrangements. **Related recommendation:** [R4](https://thirlwall-wiki.pages.dev/recommendations/index.md#r4). **Policy areas:** current safeguarding policy, training standards, civilian employment terms, military instructions, contractor clauses and NHS placement agreements. **Questions:** - Does training explicitly cover possible deliberate harm by a colleague? - Are clinical and non-clinical leaders included? - What requires each staff group to report, act and cooperate? - Do agency, bank, contractor and visiting staff receive equivalent instructions? - Who checks that the duties are understood during induction and after transfer? **What the evidence can show:** Role-specific obligations, terms or instructions and training content establish written coverage. Training attendance alone does not establish recognition or escalation of a concern about a colleague. **Sources:** [S03](https://thirlwall-wiki.pages.dev/sources/index.md#s03); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11); [S16](https://thirlwall-wiki.pages.dev/sources/index.md#s16)

## CHECK-05 — Records and safety-data handovers **When this matters:** Clinical and safety information shared within Defence or with another provider. **Related recommendation:** [R5](https://thirlwall-wiki.pages.dev/recommendations/index.md#r5). **Policy areas:** clinical record standards, NHS interfaces, transfer protocols, data-sharing agreements and system clinical-safety documentation. **Questions:** - Can the receiving clinician obtain the relevant history, medicines, results and unresolved safety concerns? - What detects failed messages or mismatched identities? - Who reconciles duplicate records? - How are permissions and downtime handled? - Who holds clinical responsibility during a wait or transfer, and what review and escalation arrangements connect the services? - Can aggregate safety analysis join records without concealing missing data? **What the evidence can show:** Transfer requirements, identity matching, reconciliation records and responsibility for failed transfers address information continuity. Technical connectivity alone does not establish completeness or clinical receipt. **Sources:** [S35](https://thirlwall-wiki.pages.dev/sources/index.md#s35); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11)

## CHECK-06 — Mortality and harm escalation **When this matters:** Oversight of deaths and harm; the recommendation specifies child and baby deaths. **Related recommendation:** [R6](https://thirlwall-wiki.pages.dev/recommendations/index.md#r6). **Policy areas:** mortality-review policy, safety dashboards, governing committee terms, escalation thresholds and incident-notification procedures. **Questions:** - Who reviews unexpected deaths and patterns of harm? - Who can demand action between scheduled meetings? - Can staff escalate an individual concern independently of numerical thresholds? - Are denominators, changes in patient mix and missing information considered? - Who checks recurrence across sites or successive postings? - Who matches an incident to Article 1004's reporting category and makes each required notification immediately or without delay, as specified? - How are reporting failures handled, and how is receipt confirmed? **What the evidence can show:** Escalation routes, delegated authority, governing-body records and the treatment of missing data bear on oversight. Low-volume services present analytical limits. A numerical threshold and an individual safeguarding concern are different grounds for escalation. **Sources:** [S35](https://thirlwall-wiki.pages.dev/sources/index.md#s35); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11), Article 1004, pp.13–15

## CHECK-07 — Reporting ownership and cover **When this matters:** Services within the relevant neonatal reporting requirements. **Related recommendation:** [R7](https://thirlwall-wiki.pages.dev/recommendations/index.md#r7). **Policy areas:** national clinical-audit participation requirements, neonatal reporting agreements, local data-quality procedures and committee reporting schedules. **Questions:** - For an eligible neonatal service, who owns MBRRACE submission and review? - Is there trained cover? - Can the lead interpret alerts with clinicians? - Does the governing body receive both the finding and the action taken? - How are urgent alerts separated from routine reporting? **What the evidence can show:** Reporting scope, assigned responsibility, cover, data quality and urgent-alert arrangements describe coverage. An NHS host’s reporting responsibility and the Defence interface may differ. Data submission does not itself demonstrate clinical review. **Sources:** [S35](https://thirlwall-wiki.pages.dev/sources/index.md#s35)

## CHECK-08 — Unexpected infant and child deaths **When this matters:** Services treating children, subject to location-specific procedures. **Related recommendation:** [R8](https://thirlwall-wiki.pages.dev/recommendations/index.md#r8). **Policy areas:** local child-death procedures, emergency instructions, safeguarding referrals and agreements with police and death-investigation authorities. **Questions:** - Does the process include a baby who has never left hospital? - Which process applies in this jurisdiction? - Who makes each notification, preserves records and supports the family? - What happens outside normal hours? - How are NHS, overseas-provider and Defence responsibilities coordinated without delaying external referral? - For an England case, which child-death review partners cover the child's normal residence, and which local notification route applies? - Does the process distinguish notification under Working Together paragraph 447 from an information request under section 16N? - Who answers a section 16N request, supplies the specified information to the stated recipient, and preserves its permitted use? **What the evidence can show:** Location-specific procedures, notification responsibilities and external-agency arrangements establish the intended route. The place of death does not by itself determine whether an unexpected death requires safeguarding or external investigation. In England, section 16M review arrangements cover each death of a normally resident child, not only unexpected deaths. Defence care alone does not make Defence a statutory review partner. Section 16N creates a separate information duty when a request is made. The [external-duty reference](https://thirlwall-wiki.pages.dev/defence-comparison/index.md#death-notification-and-child-death-review-in-england) distinguishes these requirements from R8 and its [public implementation status](https://thirlwall-wiki.pages.dev/implementation/index.md). **Sources:** [S30](https://thirlwall-wiki.pages.dev/sources/index.md#s30); [S49](https://thirlwall-wiki.pages.dev/sources/index.md#s49), sections 16M–16N and 16Q; [S50](https://thirlwall-wiki.pages.dev/sources/index.md#s50), chapter 6, paragraphs 433, 439–440 and 447

## CHECK-09 — Suspected deliberate harm **When this matters:** Defence healthcare; employment, service-law and investigative routes depend on the setting. **Related recommendation:** [R9](https://thirlwall-wiki.pages.dev/recommendations/index.md#r9). **Policy areas:** suspected deliberate-harm instructions, safeguarding, incident management, restrictions on practice, HR procedures and civilian/service police referral arrangements. **Questions:** - Can a manager act on a good-faith concern without demanding proof? - Who can restrict patient contact immediately and obtain senior advice? - Who contacts safeguarding and the appropriate police? - Does a grievance or employment dispute delay patient protection? - Is any decision to take no action reasoned and recorded? - Can a concern bypass an implicated manager? - How does a patient or family complaint trigger safeguarding and incident reporting when it contains an allegation or evidence of abuse? - Who investigates the complaint and records necessary, proportionate action on any identified failure under Article 2006? **What the evidence can show:** Response instructions, authority to restrict patient contact, external referral routes and arrangements outside normal hours describe intended coverage. Communication, preservation of evidence and review of protective restrictions are related policy areas. Precautionary protection and a disciplinary finding are distinct. **Sources:** [S03](https://thirlwall-wiki.pages.dev/sources/index.md#s03); [S09](https://thirlwall-wiki.pages.dev/sources/index.md#s09); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11), Articles 1004 and 2004, pp.13–15 and 20–21

## CHECK-10 — Independent expert review **When this matters:** Services requiring independent specialist expertise. **Related recommendation:** [R10](https://thirlwall-wiki.pages.dev/recommendations/index.md#r10). **Policy areas:** external clinical-review arrangements, investigation commissioning rules, conflict-of-interest declarations and specialist support agreements. **Questions:** - Who can obtain independent expertise quickly? - How is independence checked in a small specialty? - Does the reviewer receive the complete concern and relevant records? - Who acts on uncertainty or disagreement? - Can specialist review proceed alongside necessary safeguarding, regulatory and police action? **What the evidence can show:** Commissioning arrangements, specialist expertise, terms of reference, funding and conflict declarations bear on access and independence. A proposed national panel is not evidence of an available service. **Sources:** [S03](https://thirlwall-wiki.pages.dev/sources/index.md#s03)

## CHECK-11 — Death scrutiny and records **When this matters:** Services treating relevant patients, subject to the applicable death-scrutiny arrangements. **Related recommendation:** [R11](https://thirlwall-wiki.pages.dev/recommendations/index.md#r11). **Policy areas:** death certification, medical-examiner liaison, coroner referral, record retention and child-death review instructions. **Questions:** - Who determines the applicable external route? - Are concerns about harm explicitly shared, including those from families? - Can the service promptly identify everyone involved in care? - For a neonatal safeguarding concern, can attending doctor and nurse contacts be recorded that day? - Who supplies records and follows up a request for clarification? - For an England case, does the doctor identify the regulation 3 notification circumstances and the coroner for the area where the body lies? - If prior notification is relied on, what supports the doctor's reasonable belief that a qualifying notification or referral was made? - Where the attending-practitioner route applies, who provides the certificate, relevant records and reviewed information to the medical examiner and answers enquiries? - How are the examiner's independence, opportunity for concerns to be raised, and any required coroner referral supported? **What the evidence can show:** Responsibility for records, timely access to attending staff details and external liaison bears on independent scrutiny. Clinical review, medical-examiner scrutiny and coroner referral are distinct processes; an internal investigation does not establish completion of an external requirement. The [England external-duty reference](https://thirlwall-wiki.pages.dev/defence-comparison/index.md#death-notification-and-child-death-review-in-england) identifies attending-practitioner and medical-examiner duties, their exceptions, and the separate route for certain coroner referrals. The Inquiry's proposed neonatal contact arrangements remain distinct from those existing duties. **Sources:** [S32](https://thirlwall-wiki.pages.dev/sources/index.md#s32); [S46](https://thirlwall-wiki.pages.dev/sources/index.md#s46), regulations 1–4; [S47](https://thirlwall-wiki.pages.dev/sources/index.md#s47), regulations 3, 6–10 and 15–20; [S48](https://thirlwall-wiki.pages.dev/sources/index.md#s48), regulations 6–7

## CHECK-12 — Specialist pathology access **When this matters:** Services dependent on paediatric or perinatal pathology. **Related recommendation:** [R12](https://thirlwall-wiki.pages.dev/recommendations/index.md#r12). **Policy areas:** pathology contracts, referral networks, transport arrangements and contingency plans for loss of specialist capacity. **Questions:** - Which service can provide paediatric or perinatal expertise where needed? - Who arranges an alternative when the usual provider cannot accept a case? - How are specimen integrity, authorisation and family communication maintained? - Are delays visible to the responsible clinical authority? **What the evidence can show:** Referral agreements, alternative providers, transport arrangements and capacity information bear on specialist access. Overseas arrangements may differ. The national staffing recommendation is not a Defence workforce target. The conflicting report dates remain unresolved. **Sources:** [S30](https://thirlwall-wiki.pages.dev/sources/index.md#s30); [S02](https://thirlwall-wiki.pages.dev/sources/index.md#s02), R12

## CHECK-13 — Manager suitability and candour **When this matters:** Clinical and non-clinical healthcare leadership, with role-specific duties. **Related recommendation:** [R13](https://thirlwall-wiki.pages.dev/recommendations/index.md#r13). **Policy areas:** appointment standards, suitability checks, conduct and performance procedures, references, posting handovers, candour policy and leadership training. **Questions — responsibilities and cover:** - Do clinical and non-clinical leaders have explicit patient-safety responsibilities? - Do Responsible Persons have current terms of reference and the ability, competence and capacity to perform the role? - Under Article 1003, how are changes of Responsible Person, a Responsible Person’s absence of 28 days or more, changed services and adverse assurance changes identified, recorded and managed? - Who receives unresolved safety risks when responsibility changes? **Questions — staff suitability and movement:** - How do staffing, supervision, appraisal and development arrangements cover temporary staff and staff with combined clinical and leadership duties? - How are unresolved capability or conduct concerns assessed before movement into another healthcare role? - What can lawfully be shared with the receiving organisation? - Who confirms fitness and any restrictions? - Who takes the action required by Article 2007 when suitability criteria cease to be met, including notification where the person is registered with a healthcare or social-care regulator? **Questions — candour:** - Which candour duties apply to the organisation and to each individual role? - Who assesses Article 2008's provider-specific incident definition and arranges notification, support, apology and written follow-up? **What the evidence can show:** Appointment criteria, suitability decisions, concern handovers and candour requirements bear on leadership accountability. Due process and lawful information sharing qualify movement between roles. Rank, seniority and professional registration are not equivalent to evidence of management suitability. **Sources:** [S04](https://thirlwall-wiki.pages.dev/sources/index.md#s04); [S05](https://thirlwall-wiki.pages.dev/sources/index.md#s05); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11)

## CHECK-14 — Inspection effectiveness **When this matters:** Defence medical assurance and any relevant commissioned inspection arrangements. **Related recommendation:** [R14](https://thirlwall-wiki.pages.dev/recommendations/index.md#r14). **Policy areas:** Defence medical assurance arrangements, CQC agreements where relevant, inspection methods, specialist competence requirements and action-closure rules. **Questions:** - Can inspectors observe routine care and test conflicting accounts? - Is expertise appropriate to the service? - Can staff and patients speak privately? - What permits unannounced access, including at secure sites? - How are clinical outcomes, complaints and incidents checked against written policies? - Does the inspection agreement distinguish CQC recommendations from DMSR corrective requirements and enforcement notices? - Who refers an unresolved finding to DMSR, and what current procedure governs that decision? **What the evidence can show:** Inspection scope, specialist competence, methods, findings and corrective-action evidence bear on assurance quality. A document check and evidence about care in practice answer different questions. CQC’s published Defence findings concern the inspected sample. The [dated inspection account](https://thirlwall-wiki.pages.dev/inspection-findings/index.md) separates first inspections, follow-ups and service-specific limits. **Sources:** [S06](https://thirlwall-wiki.pages.dev/sources/index.md#s06); [S14](https://thirlwall-wiki.pages.dev/sources/index.md#s14); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11), chapter 1 paragraphs 8(k)–10, p.6

## CHECK-15 — Oversight of assurance **When this matters:** Accountability for the quality and independence of medical assurance. **Related recommendation:** [R15](https://thirlwall-wiki.pages.dev/recommendations/index.md#r15). **Policy areas:** regulator and assurance accountability documents, governing committee responsibilities, quality-review arrangements and escalation mechanisms. **Questions:** - Who independently examines whether medical assurance identifies and reduces risk? - Who sees missed concerns, inspection delays and repeated findings? - Can the reviewer challenge both the provider and the assurance body? - What triggers a review of the inspection method itself? - How is the Accountable Person identified for enforcement, and what authority and resources does that person hold? - If the Accountable Person is also a Responsible Person, how are the distinct responsibilities recorded? **What the evidence can show:** Accountability arrangements, independent scrutiny, recorded challenge and responses to recurring findings bear on assurance quality. Access to information and freedom to escalate affect independence. The Inquiry’s CQC recommendation does not establish a new Defence oversight body. **Sources:** [S06](https://thirlwall-wiki.pages.dev/sources/index.md#s06); [S10](https://thirlwall-wiki.pages.dev/sources/index.md#s10); [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11), chapter 1 paragraphs 8(j–k)–10, pp.5–6

## CHECK-16 — Speaking up and response **When this matters:** Military personnel, civilian staff, contractors and NHS placements, with distinct routes and protections. **Related recommendation:** [R16](https://thirlwall-wiki.pages.dev/recommendations/index.md#r16). **Policy areas:** current raising-concerns policy, healthcare escalation guidance, civilian and service complaint routes, contractor arrangements and NHS placement instructions. **Questions:** - Can every staff group find a route outside its immediate management line? - What happens when a report is ignored or the recipient is implicated? - Who owns the patient-safety response? - How is the reporter kept informed and protected from detriment? - What independent route has actual authority for this person and issue? - When a staff concern also identifies a patient complaint or safety incident, who coordinates the separate response duties without losing the reporter's protection? - Which protection comes from policy, and which statutory protection applies to the person's status, jurisdiction and disclosure route? **What the evidence can show:** Routes, protections, response responsibilities, contacts and escalation arrangements depend on the staff group and issue. MOD extends PIDA principles to Service personnel as policy. Statutory eligibility remains a separate question, including the operative effect of ERA section 192 and its transitional provisions. The Inquiry’s proposed Ombudsman powers are not established Defence routes. **Sources:** [S08](https://thirlwall-wiki.pages.dev/sources/index.md#s08); [S15](https://thirlwall-wiki.pages.dev/sources/index.md#s15); [S23](https://thirlwall-wiki.pages.dev/sources/index.md#s23); [S43](https://thirlwall-wiki.pages.dev/sources/index.md#s43)

## CHECK-17 — Implementation and sustained effect **When this matters:** Implementation of relevant accepted recommendations and lessons. **Related recommendation:** [R17](https://thirlwall-wiki.pages.dev/recommendations/index.md#r17). **Policy areas:** lessons-management policy, recommendation register, accountable-owner arrangements, risk acceptance and independent closure criteria. **Questions:** - Who decides whether each recommendation applies? - What would demonstrate completion and improved safety? - Can an action close after issuing a document alone? - Who challenges rejected or overdue actions? - When is sustained effect tested, including after personnel change? - How are unresolved dependencies on funding, infrastructure or another organisation kept visible until the concern is resolved? - Which current DMSR procedure governs corrective requirements and enforcement notices, and who has authority to accept closure of each? - What evidence and independent check are required before closure? - How are a local completion statement, a CQC follow-up finding and any required regulator acceptance distinguished in the action record? **What the evidence can show:** An acceptance decision, an assigned responsibility, a completion statement and evidence of sustained effect are distinct records. Written policy coverage, implementation and effectiveness remain separate. An administrative completion date does not establish that the underlying concern has been resolved. **Sources:** [S07](https://thirlwall-wiki.pages.dev/sources/index.md#s07); [S17](https://thirlwall-wiki.pages.dev/sources/index.md#s17); [S14](https://thirlwall-wiki.pages.dev/sources/index.md#s14), Dental services: Infrastructure; [S11](https://thirlwall-wiki.pages.dev/sources/index.md#s11), chapter 1 paragraphs 8(k)–10, p.6, and Article 3002, p.29