Major project lessons learned
Repeated failure to effectively apply lessons learned from past major projects, leading to recurring mistakes in cost and schedule management.
54 items
1 source
20 inquiries
Source spread
Where this theme appears
Major project lessons learned has been flagged across 1 independent accountability source:
54 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
Browse by source
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 (54) — showing 50 strongest matches
17 — Implementation of recommendations
Recommendation: A new responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office. Funding for appropriate additional staffing should be made available so that it may begin its work …
Words of: Yvette Cooper, Secretary of State for Health and Social Care, oral statement to the House of Commons, 15 September 2026 (text as published on GOV.UK)
Gov response: Finally, Lady Justice Thirlwall highlights problems with past inquiry recommendations not being implemented. So, my department is setting up a recommendation hub to properly track our implementation progress internally, not just for this inquiry, but …
Response Unclear
RHI-44 — NIAO Progress Assessment Role
Recommendation: The recommendations for change made here, to the extent they are adopted, will take time to implement; they may indeed not even be sufficient to address the range of shortcomings revealed by the Inquiry. The Inquiry therefore recommends a role …
Words of: Northern Ireland Audit Office, report by the Comptroller and Auditor General, Northern Ireland Non-Domestic Renewable Heat Incentive Scheme: progressing implementation of the Public Inquiry recommendations, 22 March 2022 (paras 1.24 to 1.25)
Gov response: As a mechanism for avoiding a similar outcome in this case, the C&AG was asked to monitor and, as necessary, pursue the effective implementation of this Inquiry’s recommendations and report its findings to the Northern …
Noted
POH-16 — Clarify whether HCRS and OCS assessment processes differ
Recommendation: The Department shall make a public announcement in which (a) it clarifies whether there will be any differences in the process for assessing financial redress, between the merged HCRS and OCS, and the process currently operating in OCS and if …
Words of: Department for Business and Trade, Government response to the Post Office Horizon IT Inquiry report (volume 1), 9 October 2025
Gov response: DBT confirms that the HCRS will apply the same principles as the previous OC scheme, ensuring no OC claimant is disadvantaged by the transfer to HCRS. DBT has published further guidance on GOV.UK about the …
Accepted
MAI-155 — Obtain comprehensive accounts from commanders
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should take steps to ensure that all emergency services understand the importance of promptly obtaining comprehensive accounts from commanders as part of the …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
MAI-128 — National systems to record lessons from exercises
Recommendation: The Home Office and the Department for Levelling Up, Housing and Communities should ensure that there exist robust national and local systems to identify and record the lessons learned from all multi-agency exercises and ensure that change is implemented as …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
MAI-127 — Robust debrief systems for multi-agency exercises
Recommendation: The Home Office and the Department for Levelling Up, Housing and Communities should ensure that there exist robust national and local systems and sufficient resources to make sure that the debrief process following multi-agency exercises is effective to capture the …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
MAI-62 — LRF oversight of lessons from exercises and incidents
Recommendation: Local resilience forums should establish procedures to ensure that they oversee the process of identifying the lessons to be learned from major exercises, or serious incidents, in their areas, and that they are responsible for overseeing the debriefing of those …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
MAI-26 — Review international practice on medics with firearms officers
Recommendation: Counter Terrorism Policing Headquarters should review the experience of other jurisdictions that embed medics with police firearms officers, such as Recherche, Assistance, Intervention, Dissuasion (RAID) in France, to understand how their systems operate and whether they ought to be replicated …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
MAI-18 — Address BTP systemic failings from Volume 1
Recommendation: BTP should address the systemic failings identified in Volume 1, so as to ensure that they are not repeated.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
RHI-36 — Learning from Failures
Recommendation: The Northern Ireland Civil Service should develop a better process to learn from past failures, one that goes beyond the traditional method of revising and circulating internal guidance. Leaders within the Senior Civil Service must be more systematic, persistent and …
Words of: Northern Ireland Executive, Executive Response to the RHI Inquiry Report Recommendations and Action Plan, Annex A, 7 October 2021
Gov response: These recommendations can be accepted in full. They have been partially addressed through: • the revision of the NICS Code of Ethics; • the GIAFIS review of whistleblowing; • the Leadership Development training for senior …
Accepted
No update 2+ yrs
5 — Require proper cell sharing risk assessments
Recommendation: The Home Office must ensure that adequate risk assessment for cell sharing is carried out by contractors in relation to every detained person. This must be done at the outset of detention and then repeated at reasonable intervals (at least …
Words of: Home Office, Government response to the public inquiry into Brook House Immigration Removal Centre (CP 1041), March 2024
Gov response: 6.3.1. A new staffing model has been developed to deliver a considerably healthier ratio of custodial staff per detained individual to nearly double what it was in 2017. The new model represents an increase in …
Accepted, fully or in part (not specified)
No update 2+ yrs
25 — Less detailed questions in future investigations
Recommendation: In the meantime, we suggest that in any future FI the questions attached to the Notice of Investigation might be less detailed than they were here.
Unknown
63 — Basic training on dealing with prisoners
Recommendation: That part of the basic training course for new prison officers which focuses on the development of their inter-personal skills should be reviewed in the light of this report and the lessons to be learned from Zahid’s murder. In particular, …
Unknown
FLIX-209 (iii) — Extend steam boiler modification regulations to hazardous material pressure systems
Recommendation: That existing regulations relating to modifications of steam boilers which do not apply to pressure systems containing hazardous materials should be extended so as to apply to such systems. In framing such regulations consideration will no doubt be given to …
Unknown
FLIX-209 (ii) — Inspect and test modified hazardous pressure systems by competent persons
Recommendation: That all pressure systems containing hazardous materials should be subject to inspection and test by a person recognised by the appropriate authority as competent after any significant modification has been carried out and before the system is again brought into …
Unknown
FLIX-209 (i) — Ensure plant modifications meet original design, construction, testing standards
Recommendation: That any modifications should be designed, constructed, tested and maintained to the same standards as the original plant.
Unknown
SHI-10 — Uniform policy for obtaining technical advice
Recommendation: This issue was highlighted in the Grant Thornton report where similar recommendations are made to what is set out above. NHSL has taken steps to address the issue. However, it is not clear from the available evidence that any such …
Words of: Neil Gray, Cabinet Secretary for Health and Social Care, in a letter to Clare Haughey MSP, Convener of the Health, Social Care and Sport Committee, 17 September 2025
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
No update 2+ yrs
SHI-7 — Independent validation of hospital construction
Recommendation: It is clearly desirable that a health board has the assurance prior to the handover of a new or refurbished healthcare facility that the facility's specialised ventilation systems have been independently validated by an Authorising Engineer as fit for purpose …
Words of: Neil Gray, Cabinet Secretary for Health and Social Care, in a letter to Clare Haughey MSP, Convener of the Health, Social Care and Sport Committee, 17 September 2025
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
No update 2+ yrs
SHI-6 — Information on common construction errors
Recommendation: NHS Assure should consider, in consultation with relevant stakeholders, whether and how to provide health boards with more detailed information about common errors and issues experienced by other health boards than is currently provided.
Words of: Neil Gray, Cabinet Secretary for Health and Social Care, in a letter to Clare Haughey MSP, Convener of the Health, Social Care and Sport Committee, 17 September 2025
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
No update 2+ yrs
SHI-5 — Streamlining NHS construction quality procedures
Recommendation: A range of procedures now exists to help ensure health board projects meet appropriate standards. One is the NHS Scotland Design Assessment Process ("NDAP"). There is also a Sustainable Design and Construction Procedure ("SDAC"). In addition, there is the NHS …
Words of: Neil Gray, Cabinet Secretary for Health and Social Care, in a letter to Clare Haughey MSP, Convener of the Health, Social Care and Sport Committee, 17 September 2025
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
No update 2+ yrs
BAHA-46 — Lessons Learned Process
Recommendation: The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed back far more quickly both to the operational theatre and …
Words of: Liam Fox, Secretary of State for Defence, statement to the House of Commons, 8 September 2011 (HC Deb vol 532 col 571), as published by the Ministry of Defence
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
FENN-59 — Establish a managed safety programme to implement inquiry recommendations
Recommendation: London Underground must establish a managed safety programme under the control of the Director and Company Secretary initially to implement the recommendations in this Report. In time it should be extended to cover other activities.
Unknown
HIDD-46 — Fully implement Automatic Train Protection within five years, prioritising busy lines
Recommendation: The Court welcomes BR's commitment to introduce Automatic Train Protection on a large percentage of its network, but is concerned at the timetable proposed. After the specific type of ATP system has been selected, ATP shall be fully implemented within …
Unknown
HIDD-41 — Utilise on-train data recorder information for systematic safety monitoring procedures
Recommendation: BR shall consider the use of information from on-train data recorders as part of a systematic safety monitoring procedure.
Unknown
HIDD-36 — Continue implementing Total Quality Management Initiative and BS5750 quality systems
Recommendation: BR shall continue to press ahead with its Total Quality Management Initiative and the application of British Standard BS5750: Quality systems.
Unknown
FLIX-224 — Urgently investigate crack propagation and corrosion protection for clad steel vessels
Recommendation: The question of crack propagation and detection in internally clad mild steel vessels and their protection from corrosion on the outside should be investigated as a matter of urgency.
Unknown
FLIX-223 — Review regulations for licensing and storage of highly flammable liquids
Recommendation: We have pointed out in Paragraph 194 (c) above that the present situation is unsatisfactory. We recommend review of the existing regulations.
Unknown
FLIX-221 — Devise scheme for HSE to advise planning authorities on plant safety
Recommendation: A scheme for co-ordination between the planning authorities and the Health and Safety Executive should be devised so that the planning authorities may be advised on the safety problems involved in any proposed plant before planning permission is granted.
Unknown
FLIX-216 — Install fire and explosion-proof recording devices for vital plant information
Recommendation: It is recommended that consideration be given to installing devices or systems for recording vital plant information in a form which would survive the effects of fire or explosion. An example of such a device is the “black-box” used in …
Unknown
FLIX-214 — Inform industry about rapid creep cavitation fractures in stainless steel
Recommendation: Creep cavitation fractures in stainless steel have been known for some time but previously it had not been generally known that these could, under appropriate conditions of stress and temperature be produced in a relatively short time. Such a fracture …
Unknown
FLIX-213 — Alert industry to risks of zinc-coated components in chemical plants
Recommendation: Since many chemical plants contain zinc coated components, eg galvanised wire and walkways, it is important that the attention of industry should be drawn to these matters.
Unknown
FLIX-212 — Alert industry to nitrate stress corrosion risk from contaminated cooling water
Recommendation: The cracked Reactor R2525 initiated the sequence of events which led to disaster. Examination of the crack by expert metallurgists showed that the crack had been caused by nitrate stress corrosion. This corrosion was created because nitrate treated cooling water …
Unknown
CR18 — MAIB publication of implementation measures
Recommendation: The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details of implementation measures taken by those to whom a recommendation is addressed, or an explanation for not taking …
Words of: Department for Transport, Cranston Inquiry Report: Interim Response (CP 1635), July 2026
Gov response: The Marine Accident and Investigation Branch (MAIB) and Department for Transport (DfT) agree that implementing this recommendation will be beneficial in improving visibility and transparency on the actions that have been taken in response to …
Accepted
In progress
ETI-19 — Collaborative Delivery
Recommendation: At all stages of the project there should be a collaborative approach to delivering it. This should include the co-location of representatives from each organisation relevant to the particular stage reached and having an interest in its completion to enable …
Words of: Andrew Kerr, Chief Executive, City of Edinburgh Council, report "Response to the Edinburgh Tram Inquiry" to the Council, 14 December 2023 (item 7.1)
Gov response: The Inquiry Report describes some of the damaging behaviours adopted during project delivery by various parties. The advantage of co locating representatives having an interest in project completion is understood and indeed was successfully adopted …
Accepted
ETI-18 — Interviews of Key Personnel in Readiness Reviews
Recommendation: As part of their investigations, representatives of OGC undertaking an independent “readiness review” of a publicly funded project and representatives of any person, including representatives of any public body such as Audit Scotland, undertaking a review of the progress of …
Words of: Andrew Kerr, Chief Executive, City of Edinburgh Council, report "Response to the Edinburgh Tram Inquiry" to the Council, 14 December 2023 (item 7.1)
Gov response: While this Recommendation is for third parties who may undertake a readiness review or audit of a publicly funded project in future, it is recommended that the Council agrees to support any such review or …
Noted
F126 — Preserving corporate memory
Recommendation: The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This code should cover both transitions between commissioners, for example as …
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. NHS organisations have gained significant learning from the transition to the reformed NHS system in 2013. NHS England will continue to work with commissioners to build on this, so that information handed over in …
Accepted
In progress
44 — Establish framework for future investigations
Recommendation: This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: 69. We accept this recommendation in principle. A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. The Service will also respond to the concerns that had been previously …
Accepted in part
In progress
37 — Protocol for organisational change transitions
Recommendation: Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting out how such processes will be managed in future. This …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: 100. We accept this recommendation. We agree that these are important concepts, and indeed a number of protocols were drawn up and widely communicated in managing changes to the health system in 2012. The Department …
Accepted
BAHA-20 — Doctrine Usability Review
Recommendation: The MoD should ensure that Development Concepts and Doctrine Centre (DCDC) reviews whether its protocols for layout and pagination of joint doctrine really serve the end user.
Words of: Liam Fox, Secretary of State for Defence, statement to the House of Commons, 8 September 2011 (HC Deb vol 532 col 571), as published by the Ministry of Defence
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
FENN-58 — Provide separate funds for scientific adviser's research and development
Recommendation: The scientific adviser of London Underground shall be provided with separate funds for research and development.
Unknown
LADB-6 — Improve Railtrack procedures for implementing and monitoring accepted recommendations with clear accountability
Recommendation: Railtrack procedures, and the actions of management to enforce them, should be directed to ensuring that: (i) a recommendation which is accepted is implemented according to a defined timescale; (ii) the person to whom a recommendation is allocated for implementation …
Unknown
LADB-5 — Require holistic safety and risk assessment for all track or signalling changes
Recommendation: Where a material change to track or signalling or both is proposed, there should be an express consideration of all relevant safety issues by an analysis of the material factors, if necessary by means of a risk assessment. This should …
Unknown
CLAR-2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the …
Unknown
CLAR-1 — Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
Recommendation: The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the …
Unknown
CLAR-13.53.2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the …
Unknown
CLAR-13.53.1 — Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
Recommendation: The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the …
Unknown
HIDD-54 — Complete research programme into structural integrity of rolling stock by April 1991
Recommendation: BR shall carry out its stated programme of research into the structural integrity of its rolling stock within its planned timescale of completion by April 1991.
Unknown
HIDD-43 — Prioritise installation of driver-signalman radio communication on all traction units
Recommendation: BR shall implement as a priority its programme to install a system of radio communication between driver and signalman on all traction units. The introduction of this system shall be in addition to signal-post telephones and not automatically entail their …
Unknown
HIDD-40 — Prioritise introduction of on-train data recorders for incident investigation assistance
Recommendation: BR shall give a higher priority to the introduction of on-train data recorders to assist investigation of any future incident.
Unknown
P2-58 — Reconsider LGA Guide paragraph 79.11 advice
Recommendation: We also recommend that the advice contained in paragraph 79.11 of the LGA Guide be reconsidered. (113.83)
Words of: HM Government, Grenfell Tower Inquiry Phase 2 Report: Government response (CP 1248), presented to Parliament by the Deputy Prime Minister and Secretary of State for Housing, Communities and Local Government, 26 February 2025
Gov response: The government accepts this recommendation. The advice contained in paragraph 79.11 of the LGA Guide was redacted in 2021. The Home Office intends to publish new guidance on the issues covered in paragraph 79.11 in …
Accepted