Clinical negligence harms learning
Clinical negligence litigation hindering patient safety learning by focusing on blame rather than system-wide analysis.
63 items
1 source
8 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
98match
BRIS-119 - Abolish clinical negligence system, establish expert group for alternative patient compensation.
In order to remove the disincentive to open reporting and the discussion of sentinel events represented by the clinical negligence system, this system should be abolished. It should be replaced by an alternative system for compensating those patients who suffer harm arising out of treatment from the NHS. An expert group should be established to advise on the...
Matched on
terms: clinical, harm, negligence
Inquiry recommendation
93match
BRIS-37 - Urgently review compensation system for medical harm, replacing clinical negligence
There should be an urgent review of the system for providing compensation to those who suffer harm arising out of medical care. The review should be concerned with the introduction of an administrative system for responding promptly to patients’ needs in place of the current system of clinical negligence and should take account of other administrative systems for...
Matched on
terms: clinical, harm, negligence
Inquiry recommendation
90match
IHRD-94 - Clinical Negligence Litigation Reform
The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical negligence litigation as it presently operates might be abolished or reformed and/or whether appropriate alternatives can be recommended.
Matched on
terms: clinical, negligence
Inquiry recommendation
78match
IHRD-40 - SAI Learning Informing Clinical Audit
Learning and trends identified in SAI investigations should inform programmes of clinical audit.
Matched on
terms: clinical, learning
Inquiry recommendation
57match
LAMI-83 - Systematically and rigorously investigate and manage cases of deliberate harm to children.
The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.
Matched on
terms: harm
Inquiry recommendation
57match
F181 - Enforcement of the duty Statutory duties of candour in relation to harm to patients
A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform that patient or other duly authorised person as soon as is practicable of that fact and thereafter to...
Matched on
terms: harm
Inquiry recommendation
56match
F44 - Use of information about compliance by regulator from: Media
Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be derived has been successfully implemented.
Matched on
terms: harm, learning
Inquiry recommendation
48match
F95 - Information sharing
As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed over risk reports, consideration should also be given to allowing the Care Quality Commission access to these reports.
Matched on
classifier match
Inquiry recommendation
48match
IHRD-66 - Time for SAI Learning
Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
Matched on
terms: learning
Inquiry recommendation
48match
IHRD-57 - Clinical Training for Guidelines
Specific clinical training should always accompany the implementation of important clinical guidelines.
Matched on
terms: clinical
Inquiry recommendation
44match
F115 - Investigations
Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward incident; Subject matter involving clinically related issues is not capable of resolution without an expert clinical opinion; A complaint raises substantive issues of professional misconduct or the performance...
Matched on
terms: clinical
Inquiry recommendation
43match
IHRD-68 - Using Investigations for Training
Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.
Matched on
terms: clinical
Inquiry recommendation
40match
F96 - Information sharing
The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of its standards assessments and of the reliance which can be placed on them.
Matched on
classifier match
Inquiry recommendation
40match
F94 - Evidence-based assessment
As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider development of a relatively simple database containing the same information.
Matched on
classifier match
Inquiry recommendation
40match
F93 - NHS Litigation Authority Improvement of risk management
The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that effective risk assessments take place when changes to the numbers or skills of staff are under consideration. It...
Matched on
classifier match
Inquiry recommendation
40match
F92 - NHS Litigation Authority Improvement of risk management
The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.
Matched on
classifier match
Inquiry recommendation
40match
F91 - NHS Litigation Authority Improvement of risk management
The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority scheme, to have and to comply with risk management standards at least as rigorous as those required by the NHS Litigation Authority.
Matched on
classifier match
Inquiry recommendation
39match
IR2-8 - Tariff-Based Compensation Framework
I recommend that the Government should approve a scheme setting out a framework of tariff based compensation for eligible infected and affected persons, at rates which broadly take account of but are not limited by current practice in courts and tribunals across the UK and sums payable in other UK compensation schemes, and allowing an assessed basis for...
Matched on
terms: clinical
Inquiry recommendation
36match
IBI-A-7b - Wider Definition of Unethical Research
When considering the evidence IBCA applies the wider definition of research explained in the Infected Blood Inquiry Additional Report chapter on Unethical Research.
Matched on
classifier match
Inquiry recommendation
32match
IBI-A-7c - Unethical Research Award Amount Review
The Minister consider whether the £10,000 (£15,000 for Treloar's pupils) should in justice be increased and further decides what sum he considers accords most closely with the general public's sense of justice and fairness in respect of an individual being subject of research without informed consent.
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classifier match
Inquiry recommendation
32match
IHRD-48 - Mortality Meeting Recording and Audit
The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
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classifier match
Inquiry recommendation
32match
IHRD-39 - Investigation Team Reconvening
Investigation teams should reconvene after an agreed period to assess both investigation and response.
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classifier match
Inquiry recommendation
32match
IHRD-38 - Multi-Disciplinary Peer Review
Investigations should be subject to multi-disciplinary peer review.
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classifier match
Inquiry recommendation
31match
R38 - Medical record keeping
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
Matched on
classifier match
Inquiry recommendation
31match
IHRD-49 - Multi-Trust Mortality Meeting Engagement
Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant organisations should, in so far as is practicable, engage with the meeting.
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classifier match
Inquiry recommendation
31match
FP53 - Note-taking general practice
Note-taking as to the detail found on analysis and the process of comparison, though not mandatory, should become the general practice for all fingerprint comparison work.
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classifier match
Inquiry recommendation
31match
FP5 - Basis of conclusions
Experts should list all variables considered and state whether the conclusion has been reached through training and personal experience or on any other basis such as statistical analysis.
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classifier match
Inquiry recommendation
31match
FP1 - Fingerprint evidence as opinion
Fingerprint evidence should be recognised as opinion evidence, not fact, and those involved in the criminal justice system need to assess it as such on its merits.
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classifier match
Inquiry recommendation
31match
F229 - Revalidation
It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional protection to the public. It is essential that the Nursing and Midwifery Council has the resources and the...
Matched on
classifier match
Inquiry recommendation
31match
F227 - Nursing and Midwifery Council Investigation of systemic concerns
The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide to seek the cooperation of the Care Quality Commission, but as an independent regulator it must be empowered...
Matched on
classifier match
Inquiry recommendation
31match
F226 - Nursing and Midwifery Council Investigation of systemic concerns
To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic concerns as well as individual ones. It must be enabled to work closely with the systems regulators and to share their information and analyses on the working of...
Matched on
classifier match
Inquiry recommendation
31match
F224 - Information sharing
Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue guidance for use by employers of doctors to the same effect.
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classifier match
Inquiry recommendation
31match
F222 - General Medical Council Systemic investigation where needed
The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be made to it, enabling a more proactive approach to monitoring fitness to practise.
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classifier match
Inquiry recommendation
27match
IHRD-67 - Informing Teaching Authorities
Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.
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classifier match
Inquiry recommendation
27match
IHRD-65 - SAI Investigator Training
Training in SAI investigation methods and procedures should be provided to those employed to investigate.
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classifier match
Inquiry recommendation
27match
IR2-9 - Status of Awards and Legal Rights
I recommend that, with reference to the status of awards: a) eligible infected and affected persons should not be required to accept the offer of an award in full and final settlement of any right to pursue legal actions related to the infection; b) any accepted scheme award should be set off against any entitlement to damages for...
Matched on
classifier match
Inquiry recommendation
27match
IR2-6 - Categories of Loss and Award Heads
I recommend that the appropriate award in any case should be composed under the following categories of loss, applicable to both eligible infected and affected persons: a) an Injury Impact Award for past and future physical and mental injury, emotional distress and injury to feelings caused by the infection and treatments for it, or (whilst not being personally...
Matched on
classifier match
Inquiry recommendation
27match
IR2-4 - Affected Persons Categories
I recommend that the following relevant affected persons should be admitted to the scheme: a) spouses, civil partners and long term cohabitees (for at least one year in the case of the latter) of living or deceased eligible infected persons; b) children of an eligible living or deceased infected person; c) parents of an eligible living or deceased...
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classifier match
Inquiry recommendation
27match
IR2-3 - Standard of Proof and Automatic Eligibility
As above, save that (a) the last bullet point should read: "eligibility is accepted if the information available points towards eligibility and the opposite cannot be shown to be more likely" and (b) eligibility should be automatic for individuals already accepted under an existing support scheme.
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classifier match
Inquiry recommendation
27match
FP16-18 - Academic study requirement
Expert opinion should be informed by proper academic study of the subject.
Matched on
classifier match
Inquiry recommendation
27match
FP66 - Unable to exclude findings
Before a finding of 'unable to exclude' is led in evidence, careful consideration will require to be given to (a) the types of mark for which such a finding is meaningful and (b) the proper interpretation of the finding.
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classifier match
Inquiry recommendation
27match
FP60 - Disclosure of opinion basis - recording
Experts should record and properly disclose all of the basis of their opinion to enable a court to understand it and the defence to assess it.
Matched on
classifier match
Inquiry recommendation
27match
FP-COMPLEX - Complex marks examination
Processes should be developed to ensure that complex marks such as those in question are treated differently, by examination by three suitably qualified examiners who reach their conclusion independently, make notes at each stage, and record reasons for their conclusions.
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classifier match
Inquiry recommendation
27match
FP9 - Features demonstrable to lay persons
Features on which examiners rely should be demonstrable to a lay person with normal eye sight as observable in the mark.
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classifier match
Inquiry recommendation
27match
FP3 - Discontinue certainty claims
Examiners should discontinue reporting conclusions on identification or exclusion with a claim to 100% certainty or on any other basis suggesting that fingerprint evidence is infallible.
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classifier match
Inquiry recommendation
27match
F232 - Employment liaison officers
The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this is impractical, a support network of senior nurse leaders will have to be engaged in filling this gap.
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classifier match
Inquiry recommendation
27match
F231 - Coordination with internal procedures
It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be possible, through cooperation, to allow both to proceed in parallel. This may require a review of employment disciplinary procedures, to make it clear that the employer is entitled...
Matched on
classifier match
Inquiry recommendation
27match
F225 - Peer reviews
The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic way, in order to be advised whether there are individual concerns. Such reviews could be jointly commissioned with the Care Quality Commission in appropriate cases.
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classifier match
Inquiry recommendation
27match
IBI-1 - Compensation Scheme
My principal recommendation remains that a compensation scheme should be set up now
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classifier match
Inquiry recommendation
27match
IBI-A-9a - Bereaved Partner Support Scheme
The IBSS cut-off date of 31 March 2025 be reviewed, that the scheme should as soon as possible reinstate support payments to partners bereaved after 31 March 2025 until such time as they receive compensation and that they should have a continuation of those payments as an option in their compensation package.
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