Thirlwall Inquiry: Search the Evidence

…l Tuesday, 10 December 2024 (10.00 am) LADY JUSTICE THIRLWALL: Ms Langdale. MS LANGDALE: My Lady, may I call Sir Robert Behrens, please. LADY JUSTICE THIRLWALL: Sir Robert, please come forward. SIR ROBERT BEHRENS (sworn) Questions by MS LANGDALE LADY JUSTICE THIRLWALL: Thank you, do sit down. MS LANGDALE: Sir Robert, you provided the Inqu…

…the organisation rather than the individual? A. Yes, that's correct. Q. The Inquiry has heard evidence from Sir Robert Behrens, and I think you have been directed to a section of t regulates the organisation rather than the individual? A. Yes, that's correct. Q. The Inquiry has heard evidence from Sir Robert Behrens, and I think you have…

…those tasked with implementation to account326. 322 [Herniman/ wk14/ day2/ p147/ln 17 - p149/ ln 18] 323 See Sir Robert Behren’s oral evidence to the Inquiry [Behrens/ wk13/ day1/ p40/ ln7-24]. 324 A notable example of this is the recommendation for a medical examiner system. This was made by three inquiries – the Shipman Inquiry, the Mid…

…ing barring. This should focus upon deliberate of reckless but not inadvertent behaviour. Apart from 318 See Sir Robert Francis KC’s oral evidence to the Inquiry [Francis KC/ wk4/ day1/ p73/ ln1-24, p151/ ln 21 – p152/ ln20]. 319 See Sir Robert Behren and Professor Smith’s oral evidence to the Inquiry [Behrens/ wk13/ day1/ p39/ ln15-24] a…

…mmission an independent review of the collective landscape of patient safety oversight bodies.”110 102. Both Sir Robert Francis KC and Professor Dixon-Woods have queried whether the complexity of the system itself is a hinderance to effective oversight. Professor Dixon- Woods said: “The institutional complexity is pretty extreme. Some of…

…n evidence that the system of regulation and oversight itself has structural flaws which limit its efficacy. Sir Robert Francis KC described the NHS as “less of a system than a series of entities, similar to planets which orbit round each other without necessarily connecting or communicating, at least not consistently.”109 101. In his wri…

…o in-patient neonatal deaths, and such deaths are not excluded simply because the neonate has never been 305 Sir Robert Behrens CBE told the Inquiry that the duty of candour does not work and is in urgent need of review and replacement with a stronger version of the principle underpinned by legislation, which contains consequences for org…

ment of Sir Robert Behrens INQ0014599_0024, paragraph 87; referencing report: INQ0014545_0009. 111 Professor Mary Dixon-Woods, week 3 day 4, 18:9-22. 112 William Vineall, week 15, day 3, 167:13-19. play a distinct and valuable role, including NHSE, the various Royal Colleges, the CQC, and professional regulators such as the GMC and NMC.11…

…the organisation rather than the individual? A. Yes, that's correct. Q. The Inquiry has heard evidence from Sir Robert Behrens, and I think you have been directed to a section of t

…irector of our 250 NHS Trusts in England and you have to think that Medical 191 lwall Inquiry 9 January 2025 Sir Robert Behrens, of course the former Ombudsman. He said: "The fact that Inquiries many years apart find the same failings is met with dismay but not always outrage or even surprise. There is almost an acceptance that this is ho…

…am going to ask you to comment on the second piece of evidence, thank you, you have responded in relation to Sir Robert Behrens' evidence. Sir Gordon Messenger gave evidence this week and it was related specifically to an induction document and training for senior managers but he made this observation generally about directives or materia…