The Inquiry recommends that:
• The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. Devising a Northern Ireland patient safety strategy would consolidate and clarify the various strands of work in progress.
• The Trust should continue and strengthen its organisational development work. This should be aligned to a clearly articulated commitment to a just, open and learning culture.
• To ensure that each staff member understands their role in patient safety and the meaning of an open and just culture, the Trust should develop a fully funded development programme for all staff, including clinical staff in training. The programme should address what specific leadership development is required for staff and specifically, how best to ensure alignment between professional groups. Medical staff benefit from bespoke development, as do nursing staff and operational staff but there is also benefit in training groups of staff together, especially in the context of advancing an understanding of shared aims, such as patient safety. This programme should ensure that all staff understand how this aligns with Trust processes, aims and objectives, and more widely with these same objectives at a regional level.
• Specific consideration should be given to what ongoing data would best support the oversight of work to prioritise safety, so that this can be openly measured and tracked. Regard should be had to suitable resources such as "A framework for safety measuring and monitoring".
• This programme should be supported and monitored by the Department with a view to using it as a model across Northern Ireland.