Safeguarding

82 Annex A Terms of reference of the inquiries
The Inquiry is asked:
• To identify the procedures in place during the period 1971-2000 within the local health services
to enable members of the public and other health service users to raise concerns or complaints
concerning the actions and conduct of health service professionals in their professional
capacity.
• To document and establish the nature of and chronology of the concerns or complaints raised
concerning the appointment, practice and conduct of Dr Clifford Ayling, a former GP from Kent,
during this period.
• To investigate the actions which were taken for the purpose of (a) considering the concerns and
complaints that were raised; (b) providing remedial action in relation to them; and (c) ensuring
that the opportunities for any similar future misconduct were removed.
• To investigate cultural or other organisational factors within the local health services, which
impeded or prevented appropriate investigation and action.
• To assess and draw conclusions as to the effectiveness of the policies and procedures in
place.
• To make recommendations, informed by this case, as to improvements which should be made
to the policies and procedures which are now in place within the health service (taking into
account the changes in procedure since the events in question).
• To provide a full report on these matters to the Secretary of State for Health for publication
by him.