Clinical negligence harms learning
Clinical negligence litigation hindering patient safety learning by focusing on blame rather than system-wide analysis.
63 items
1 source
9 inquiries
Source spread
Where this theme appears
Clinical negligence harms learning has been flagged across 1 independent accountability source:
63 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (63) — showing 50 strongest matches
10 — Panel of experts
Recommendation: Serious consideration should be given by DHSC to the setting up of a panel of independent experts from all specialties to be called upon in situations where there are emerging concerns about an individual and harm to a patient or …
Gov response: No formal government response published. The Secretary of State for Health and Social Care's oral statement of 15 September 2026, made on the day the Inquiry's report was published, names neither this recommendation nor its …
Unknown
BRIS-119 — Abolish clinical negligence system, establish expert group for alternative patient compensation.
Recommendation: 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 …
Unknown
IHRD-94 — Clinical Negligence Litigation Reform
Recommendation: 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 …
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-40 — SAI Learning Informing Clinical Audit
Recommendation: Learning and trends identified in SAI investigations should inform programmes of clinical audit.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F96 — Information sharing
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The NHS Litigation Authority has included a comprehensible explanation of the limitations of the standards and assessments process on its website. Following the publication of the NHS Litigation Authority’s Industry Review in January 2012, …
Accepted
F95 — Information sharing
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. In response to the Caldicott Review, Information: To Share or Not to Share (2013), the Department of Health stated that health and care professionals must make decisions about how information is shared and used …
Accepted
F94 — Evidence-based assessment
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The NHS Litigation Authority has launched a new extranet which provides members with detailed information about their claims so they can easily identify areas where they need to focus on reducing claims. The information …
Accepted
F93 — NHS Litigation Authority Improvement of risk management
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. As in the response to recommendation 91, the NHS Litigation Authority will move away from assessments against a set of risk management standards to a new outcome focused approach. The new approach …
Accepted in part
F92 — NHS Litigation Authority Improvement of risk management
Recommendation: The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. From 1 April 2013, the NHS Litigation Authority introduced a revised pricing methodology for the Clinical Negligence Scheme for Trusts. The new approach means that organisations with a good claims record will see the …
Accepted
F91 — NHS Litigation Authority Improvement of risk management
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. We agree that the effectiveness of any national scheme of this kind to promote the improvement of risk management and any associated benefits for patient safety will be dependent on it continuing …
Accepted in part
IBI-A-7c — Unethical Research Award Amount Review
Recommendation: 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 …
Words of: Cabinet Office, Infected Blood Inquiry Additional Report: Government Response, 21 July 2025
Gov response: The issue of unethical research is one of the most shocking areas of this scandal. In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at how the …
Response Unclear
In progress
IBI-A-7b — Wider Definition of Unethical Research
Recommendation: When considering the evidence IBCA applies the wider definition of research explained in the Infected Blood Inquiry Additional Report chapter on Unethical Research.
Words of: Cabinet Office, Infected Blood Inquiry Additional Report: Government Response, 21 July 2025
Gov response: The issue of unethical research is one of the most shocking areas of this scandal. In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at how the …
Accepted in part
In progress
LAMI-83 — Systematically and rigorously investigate and manage cases of deliberate harm to children.
Recommendation: 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.
Unknown
IHRD-48 — Mortality Meeting Recording and Audit
Recommendation: The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-39 — Investigation Team Reconvening
Recommendation: Investigation teams should reconvene after an agreed period to assess both investigation and response.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-38 — Multi-Disciplinary Peer Review
Recommendation: Investigations should be subject to multi-disciplinary peer review.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F181 — Enforcement of the duty Statutory duties of candour in relation to harm to patients
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. As set out in recommendation 174, the Government will introduce an explicit duty of candour as a Care Quality Commission registration requirement. The duty would apply to health and adult social care …
Accepted in part
F115 — Investigations
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in part. Investigation of any complaints should be proportionate to the needs of the individual case. This follows the fundamental principle that complaints cases should be handled according to the needs of that individual …
Accepted in part
F44 — Use of information about compliance by regulator from: Media
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in part. The Care Quality Commission’s new approach to inspection includes a published set of ‘Intelligent Monitoring’ indicators for monitoring quality in providers: for the first time indicators in relation to acute trusts were …
Accepted in part
BRIS-37 — Urgently review compensation system for medical harm, replacing clinical negligence
Recommendation: 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 …
Unknown
R38 — Medical record keeping
Recommendation: 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, and that they are routinely audited by senior medical staff.
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
IHRD-68 — Using Investigations for Training
Recommendation: Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-67 — Informing Teaching Authorities
Recommendation: Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-66 — Time for SAI Learning
Recommendation: Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-65 — SAI Investigator Training
Recommendation: Training in SAI investigation methods and procedures should be provided to those employed to investigate.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-57 — Clinical Training for Guidelines
Recommendation: Specific clinical training should always accompany the implementation of important clinical guidelines.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-49 — Multi-Trust Mortality Meeting Engagement
Recommendation: 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 …
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IR2-9 — Status of Awards and Legal Rights
Recommendation: 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 …
Words of: The UK Government, in the Government response to the Infected Blood Inquiry (CP 1224), 17 December 2024
Gov response: In line with recommendations 9 and 10 of the Second Interim Report, acceptance of an award does not require applicants to waive their right to pursue litigation. In defined circumstances, if an infected person's condition …
Accepted
IR2-8 — Tariff-Based Compensation Framework
Recommendation: 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 …
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: In line with recommendation 8 of the Second Interim Report, the Scheme will use a tariff-based framework to calculate the amount of compensation payable to those eligible. In practice, this means that compensation will be …
Accepted
IR2-6 — Categories of Loss and Award Heads
Recommendation: 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 …
Words of: The UK Government, in the Government response to the Infected Blood Inquiry (CP 1224), 17 December 2024
Gov response: With respect to recommendation 6 of the Second Interim Report, the Government has accepted the Inquiry's recommended categories of award, and has therefore designed the Scheme to award compensation to include the following: Injury Impact …
Accepted
IR2-4 — Affected Persons Categories
Recommendation: 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; …
Words of: The UK Government, in the Government response to the Infected Blood Inquiry (CP 1224), 17 December 2024
Gov response: With respect to recommendation 4 of the Second Interim Report, for those who have been affected by this scandal, affected persons will be eligible where their case is linked to that of an eligible infected …
Accepted
IR2-3 — Standard of Proof and Automatic Eligibility
Recommendation: 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 …
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: The Government acknowledges the further distress and trauma that can be caused to those applying for compensation, and so the Scheme has been designed to minimise the burden on applicants whilst protecting against fraud. People …
Accepted
FP16 — Academic study requirement
Recommendation: An emphasis needs to be placed on the importance not only of learning and practising the methodology of fingerprint work, but also of engaging with members of the academic community working in the field.
Words of: Kenny MacAskill, Justice Secretary, in a Scottish Government news release, 14 December 2011
Gov response: We should all recognise that there have been significant advances in the delivery of Scotland's forensic services since the McKie case, and I am confident that the recommendations from this Inquiry will further enhance these …
Accepted
FP66 — Unable to exclude findings
Recommendation: 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. An …
Words of: Kenny MacAskill, Justice Secretary, in a Scottish Government news release, 14 December 2011
Gov response: We should all recognise that there have been significant advances in the delivery of Scotland's forensic services since the McKie case, and I am confident that the recommendations from this Inquiry will further enhance these …
Noted
FP53 — Note-taking general practice
Recommendation: Subject to any requirement under ISO 17025 and recommendations 50 and 51, 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.
Words of: Kenny MacAskill, Justice Secretary, in a Scottish Government news release, 14 December 2011
Gov response: We should all recognise that there have been significant advances in the delivery of Scotland's forensic services since the McKie case, and I am confident that the recommendations from this Inquiry will further enhance these …
Accepted
FP42 — Complex marks examination
Recommendation: The SPSA should develop a process to ensure that complex marks such as Y7 and QI2 Ross are treated differently. Such a process should include the following principal elements: (i) Examination should be by three suitably qualified examiners. (ii) Notes …
Words of: Kenny MacAskill, Justice Secretary, in a Scottish Government news release, 14 December 2011
Gov response: We should all recognise that there have been significant advances in the delivery of Scotland's forensic services since the McKie case, and I am confident that the recommendations from this Inquiry will further enhance these …
Accepted
No update 2+ yrs
FP9 — Features demonstrable to lay persons
Recommendation: Features on which examiners rely should be demonstrable to a lay person with normal eye sight as observable in the mark.
Words of: Kenny MacAskill, Justice Secretary, in a Scottish Government news release, 14 December 2011
Gov response: We should all recognise that there have been significant advances in the delivery of Scotland's forensic services since the McKie case, and I am confident that the recommendations from this Inquiry will further enhance these …
Accepted
FP5 — Basis of conclusions
Recommendation: In order to allow the court to assess the strength of their evidence, fingerprint examiners should highlight the variables relevant to their assessment and how they have formed their conclusions in the light of those variables. The conclusion should state …
Words of: Kenny MacAskill, Justice Secretary, in a Scottish Government news release, 14 December 2011
Gov response: We should all recognise that there have been significant advances in the delivery of Scotland's forensic services since the McKie case, and I am confident that the recommendations from this Inquiry will further enhance these …
Accepted
FP3 — Discontinue certainty claims
Recommendation: 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.
Words of: Kenny MacAskill, Justice Secretary, in a Scottish Government news release, 14 December 2011
Gov response: We should all recognise that there have been significant advances in the delivery of Scotland's forensic services since the McKie case, and I am confident that the recommendations from this Inquiry will further enhance these …
Accepted
FP1 — Fingerprint evidence as opinion
Recommendation: 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.
Words of: Kenny MacAskill, Justice Secretary, in a Scottish Government news release, 14 December 2011
Gov response: We should all recognise that there have been significant advances in the delivery of Scotland's forensic services since the McKie case, and I am confident that the recommendations from this Inquiry will further enhance these …
Noted
F232 — Employment liaison officers
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Nursing and Midwifery Council have started planning the introduction of new regional advisors who will perform a function similar to the General Medical Council’s employer liaison advisers of providing support and guidance locally …
Accepted
F231 — Coordination with internal procedures
Recommendation: 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. …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Nursing and Midwifery Council have made clear their view that their procedures should not obstruct internal disciplinary action, and that it would not expect the making of an interim order by the Nursing …
Accepted
In progress
F229 — Revalidation
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Nursing and Midwifery Council has committed to introducing a proportionate and effective model of revalidation, which is affordable and value for money, to enhance public protection. Subject to public consultation, the proposed model …
Accepted
F227 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. The Nursing and Midwifery Council are taking a different approach to achieving this recommendation. The Nursing and Midwifery Council is committed to working closely with the Care Quality Commission and with other …
Accepted in part
F226 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in part. The Nursing and Midwifery Council have made it clear that they are determined to work closely with other regulators, including the Care Quality Commission to share information and analyses, and that it …
Accepted in part
F225 — Peer reviews
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The General Medical Council has made it clear that it is determined to work with others to explore the development of appropriate forms of joint ownership of generic issues, so that unacceptable patient care …
Accepted
In progress
F224 — Information sharing
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The General Medical Council has made it clear that the exchange of information with Royal Colleges should be further systematised, and that it will take forward action to ensure that this takes place. The …
Accepted
F222 — General Medical Council Systemic investigation where needed
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The General Medical Council has made it clear that it recognises the need to contribute to the identification and in some cases the investigation of generic concerns, building on its progress in recent years …
Accepted
In progress
IBI-1 — Compensation Scheme
Recommendation: My principal recommendation remains that a compensation scheme should be set up now
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: This recommendation is accepted in full. The Inquiry was unequivocal that those who have suffered as a result of this scandal must be compensated for the harm that has been inflicted upon them. The UK …
Accepted
In progress
IBI-A-9a — Bereaved Partner Support Scheme
Recommendation: 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 …
Words of: Cabinet Office, Infected Blood Inquiry Additional Report: Government Response, 21 July 2025
Gov response: In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at the 31 March 2025 'cut-off' date for bereaved partners to join an Infected Blood Support Scheme. The …
Accepted