No open learning culture
322 items
2 sources
Absence of a culture of openness, honesty, and learning from error within organisations, leading to failures in responding to concerns.
Cross-Source Insight
No open learning culture has been flagged across 2 independent accountability sources:
55 inquiry recs
267 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (55)
BRIS-107 — Create open, non-punitive NHS environment for reporting sentinel events
Recommendation: Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.
Unknown
BRIS-112 — Conduct structured analysis of sentinel events considering organisational factors
Recommendation: All sentinel events should be subject to a form of structured analysis in the trust where they occur, which takes into account not only the conduct of individuals, but also the wider contributing factors within the organisation which may have …
Unknown
BRIS-27 — Provide patients with performance information for trusts, specialties, and consultant units
Recommendation: Patients should be referred to information relating to the performance of the trust, of the specialty and of the consultant unit (a consultant and the team of doctors who work under his or her supervision). (See further the Recommendations on …
Unknown
26 — Ensure Home Office staff presence and visibility in IRCs
Recommendation: The Home Office must ensure that its staff are regularly present and visible within each immigration removal centre.
Gov response: Detention Engagement Team expansion is underway, with further recruitment to increase Home Office staff presence in IRCs.
Accepted in Part
Delivered
HIDD-38 — Urgently use outside consultants to review safety management and communication issues
Recommendation: The Court endorses the use of outside consultants to review safety management issues within BR and recommends that the consultants proceed with their programme with the greatest urgency looking particularly at problems of communication up and down the organisation.
Unknown
HIDD-39 — Urgently introduce independent monitoring and auditing for all safety-related work
Recommendation: BR shall introduce monitoring and independent auditing systems in all safety-related aspects of work, in particular the S&T Departments, with the greatest urgency, in advance of Total Quality Management as an aid to good management.
Unknown
HIDD-42 — Report 6-monthly to Railway Inspectorate on accident follow-up and recommendations
Recommendation: BR shall report at 6 monthly intervals to the Railway Inspectorate on its follow-up to the Clapham Junction accident and implementation of its own and this Report's recommendations.
Unknown
HIDD-47 — Report 6-monthly to Railway Inspectorate on Automatic Train Protection implementation progress
Recommendation: BR shall report at 6 monthly intervals to the Railway Inspectorate on its progress in implementing ATP.
Unknown
HIDD-8 — Require BR to provide and monitor full documentation for proper testing
Recommendation: BR shall ensure that full documentation is provided and later monitored in order that proper testing is carried out.
Unknown
HIDD-9 — Introduce national testing instruction with workforce explanation, monitoring, and auditing
Recommendation: BR shall introduce a national testing instruction with all speed. Such introduction shall be accompanied by a full explanation to the workforce, including workshops or seminars as necessary. Implementation must be monitored and audited.
Unknown
HIDD-92 — Promptly update Rule Book and Books of Instruction incorporating report observations
Recommendation: The Rule Book and Books of Instruction of a similar status shall be promptly updated and observations made in this Report taken into account.
Unknown
CR4 — Training on normalcy bias
Recommendation: HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one being the need to avoid normalcy bias, in particular, assumptions about exaggeration in calls from small boats.
Response Pending
FENN-43 — Ensure director-level consideration of internal accident inquiry recommendations
Recommendation: The recommendations of internal inquiries into accidents must be considered at director level.
Unknown
FENN-44 — Encourage trade union participation in all internal inquiries
Recommendation: Trade union participation in internal inquiries shall be encouraged.
Unknown
FENN-50 — Maintain formal health and safety monitoring system at all management levels
Recommendation: London Underground shall maintain a formal system for health and safety monitoring at all levels of management.
Unknown
FENN-54 — Produce prompt reports and analysis of fire and smoke incidents
Recommendation: Reports of fires and smoke shall be produced promptly and an analysis made available for management and Board meetings, the Railway Inspectorate, the London Fire Brigade, and the London Regional Passengers' Committee.
Unknown
FENN-56 — Chief Safety Inspector to review, identify hazards, recommend policies, and audit safety
Recommendation: The Chief Safety Inspector shall review existing safety arrangements, identify hazards, recommend policies, objectives and systems to meet those hazards, and thereafter audit the effectiveness of the system. He should have direct access to the Chief Executive of London Underground …
Unknown
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
FENN-71 — Implement job specifications and inspection for all maintenance and cleaning activities
Recommendation: Proper job specification and inspection arrangements shall be put in place for all maintenance and cleaning activities.
Unknown
FENN-72 — Institute and maintain cleaning and maintenance standards for London Underground
Recommendation: London Underground must institute and maintain a set of standards for cleaning and maintenance.
Unknown
P2-34 — London Fire Brigade to establish lessons learned process
Recommendation: That the London Fire Brigade establish effective standing arrangements for collecting, considering and effectively implementing lessons learned from previous incidents, inquests and investigations. Those arrangements should be as simple as possible, flexible and of a kind that will ensure that …
Gov response: London Fire Brigade accepts all the recommendations relevant to them, including this one aimed directly at them. London Fire Brigade is committed to ensuring lessons from incidents are learned from and good practice is shared …
Accepted
In progress
HIA-1 — Public Apology
Recommendation: We recommend that the Northern Ireland Executive and those who were responsible for each of the institutions investigated by the Inquiry where we found systemic failings should make a public apology. The apology should be a wholehearted and unconditional recognition …
Gov response: No formal government response published.
Accepted
Delivered
92 — Apologies to former child migrants
Recommendation: The Chair and Panel have recommended that institutions involved in the child migration programmes who have not apologised for their role should give such apologies as soon as possible. Apologies should not only be made through public statements but specifically …
Gov response: An apology by the Sisters of Nazareth was repeated during the Child migration programmes investigation (p126). Between January 2020 and July 2020, Action for Children, Barnardo's, Catholic Church in England and Wales, Church of England, …
Accepted
Delivered
14 — Board apologies
Recommendation: We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability.
Gov response: Accepted. Duty of Candour regulations require healthcare providers to be open when things go wrong. NHS Resolution promotes early apology and has clarified that sincere apologies do not constitute admission of liability. Professional Standards Authority …
Accepted
No update 2+ yrs
IHRD-81 — Board Awareness of SAI Reports
Recommendation: Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.
Gov response: Procedures established for ensuring Board members receive all SAI-related reports.
Accepted
Delivered
IHRD-82 — Policy on Learning from SAI Deaths
Recommendation: Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.
Gov response: Trusts have published policies on responding to and learning from SAI-related deaths.
Accepted
Delivered
IHRD-83 — SAI Deaths in Annual Reports
Recommendation: Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.
Gov response: SAI-related death reporting incorporated into Trust annual reports.
Accepted
No update 2+ yrs
LADB-17 — Develop a blame-free culture for safety information communication in industry
Recommendation: The development of a culture within the industry in which information is communicated without fear of recrimination, and blame is attached only where this is justified, is commended (para 9.60).
Unknown
LADB-33 — Review SPAD Group Standard to avoid presuming driver error as sole cause
Recommendation: The Group Standard on SPADs and its associated documentation should be reviewed to ensure that there is no presumption that driver error is the sole or principal cause, or that any part played by the infrastructure is only a contributory …
Unknown
LADB-35 — Train SPAD investigators in human factors and root cause analysis
Recommendation: Persons who investigate, and make recommendations as a consequence of, SPADs should be trained in the identification of human factors and in root cause analysis. Their competence in these areas should be formally recorded, and renewed by refresher courses. The …
Unknown
LADB-39 — Establish system for signaller briefing and information sharing after SPAD incidents
Recommendation: Railtrack should institute a system whereby all signallers in the signal box (or centre) are briefed by their line manager following a SPAD in their area, and there is appropriate dissemination of information which may be of assistance to signallers …
Unknown
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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-128 — National systems to record lessons from exercises
Recommendation: The Ministry of Housing, Communities and Local Government 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 a result, where change …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-50 — Address Arena failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made at the Arena to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-51 — Address Showsec failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made by Showsec to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-94 — Review firearms officer Post Incident Procedures delays
Recommendation: The College of Policing should assess whether delays in the provision of written accounts by some firearms officers involved in the response to the Attack were due to Post Incident Procedures. If so, those procedures should be reviewed.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
F1 — Implementing the recommendations
Recommendation: It is recommended that: All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this report and decide how to apply them to their own work; Each such organisation should announce at the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F101 — National Patient Safety Agency functions
Recommendation: While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it should be possible to organise for mutual peer review inspections or the inclusion in Patient Environment Action Team …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F118 — Learning and information from complaints
Recommendation: Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F119 — Learning and information from complaints
Recommendation: Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F57 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
12 — Review incident investigation structures
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
RHI-34 — Rapid Response Capacity
Recommendation: The Northern Ireland Civil Service should have regard to best practice elsewhere about how to respond effectively when serious problems emerge, such as those that did so with the non-domestic NI RHI in the summer of 2015, by, for example, …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
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 …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
Delivered
SHI-4 — Standard form for derogations from guidance
Recommendation: The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use throughout the NHS in Scotland would be beneficial. This would ensure that derogations are captured and recorded in …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
No update 2+ yrs
SHI-9 — Documentation of technical adviser advice
Recommendation: I accordingly recommend that a similar procedure should be considered when technical advisers (particularly engineers) are providing specific technical advice in relation to a project such as the RHCYP and DCN. There should be a clear record of the advice …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
No update 2+ yrs
AR-2 — Protocol for Post-Incident Debriefing
Recommendation: At an early date there should be liaison between the IPCC, the MPS and ACPO (and, more significantly, lawyers acting for each) with a view to establishing a protocol for the future conduct in the event of a shooting by …
Gov response: No formal government response published. MPS provided updates on 12 August 2014 confirming work on post-incident debriefing protocols.
Accepted
Delivered
R72 — Internal investigation independence
Recommendation: Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.
Gov response: Section 3.2 notes that the report addresses issues in NHS boards relating to internal investigations (recommendation 72). While the "Our current position" section discusses feedback, complaints, and the introduction of a statutory duty of candour …
Accepted
R74 — Review of UK IPC reports
Recommendation: Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports published in the UK and in other relevant jurisdictions on infection prevention and control and patient safety are …
Gov response: Section 2.1 notes the report's call for the Scottish Government to ensure timely review and implementation of relevant measures from existing inquiry reports, including those from other jurisdictions, as a matter of standard practice (recommendation …
Accepted
R75 — Health Board review of IPC reports
Recommendation: Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or otherwise) should be put in place.
Gov response: Section 2.1 highlights the report's recommendation for NHS boards to review existing inquiry reports from the UK and other jurisdictions to learn lessons and implement necessary measures (recommendation 75). While the response details how NHS …
Accepted
LAMI-30 — Directors must ensure senior managers regularly inspect children's social services case files
Recommendation: Directors of social services must ensure that senior managers inspect, at least once every three months, a random selection of case files and supervision notes.
Unknown
PFD Reports (267) — showing 100 most recent
Linda Fury
Concerns: The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds also prevent private disclosure of family concerns regarding risk.
Overdue
Evie Muir
Concerns: Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed for associated risks.
Response: Mid and South Essex NHS Foundation Trust plans to undertake a quality improvement programme to enhance learning from deaths and improve sharing across teams. The Rheumatology team will invite Cardiology …
Responded
Mark Foster
Concerns: The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Response: The surgery has appointed a new practice manager and GP partner for governance, implemented a new governance structure, and revised its Significant Event Policy. All staff are now instructed to …
Responded
David Jones
Concerns: The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on atypical presentations.
Response: Nottingham University Hospitals NHS Trust has launched an Acute Aortic Dissection Improvement project, which will be undertaken by a newly formed Acute Aortic Dissection Improvement Group. This group will involve …
Responded
Mohan Hothi
Concerns: The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
Overdue
Matthew Goldsmith
Concerns: Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality assurance at the Trust.
Response: The Trust has implemented an action plan by reconfiguring its radiology IT system for mandatory internal peer review, establishing a Radiology Quality and Safety Team, and rolling out a formal …
Responded
Richard Hunt
Concerns: Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of central oversight for wing office fault reporting.
Overdue
Mohammad Asghar
Concerns: The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines and an inability to learn from adverse events.
Overdue
Tony Jackson
Concerns: A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for investigation, hindering learning and remediation of sub-optimal practice.
Responded
Mary Fitzpatrick
Concerns: An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm in an elderly patient.
Responded
Masood Hamid
Concerns: There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and future prevention.
Responded
John Bell
Concerns: Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a necessary renal procedure. Subsequently, no formal investigation or learning review occurred for eight months.
Responded
Azroy Dawes-Clarke
Concerns: There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion regarding command primacy and effective response strategies during acute medical emergencies in prison.
Responded
David Ejimofor
Concerns: The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that new deterrence measures are working, poses an ongoing risk.
Responded
Charlotte Werner
Concerns: A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that it is not a mental health service.
Overdue
Lewis Johnson
Concerns: The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest by lacking objective evidence crucial for future learning and policy development.
Responded
David Bateman
Concerns: Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied since the incident.
Responded
Wayne Brown
Concerns: The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.
Responded
Kenneth Foster
Concerns: The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a significant incident, risking future deaths from unaddressed sub-optimal practice.
Responded
Lorraine Parker
Concerns: The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about a specific surgeon also remain unaddressed.
Responded
Ivy Dixon
Concerns: Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating inadequate training and integrity issues.
Responded
June Thompson
Concerns: Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for processing medical reports from other hospitals.
Responded
Linda Farmer
Concerns: The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a detailed inquiry, leaving systemic issues unaddressed and risking future patient harm.
Responded
William Hewes
Concerns: A patient experienced significant delays receiving critical treatment despite immediate recognition of their life-threatening condition. The hospital's subsequent learning from this event has not been shared nationally.
Responded
Derek Cole
Concerns: The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust system for learning from significant events, delaying critical internal reviews.
Responded
Ida Lock
Concerns: The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure to learn from past incidents, unreliable data, and inadequate reporting of serious harms.
Responded
Reginald Smith
Concerns: A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded by the loss of the defective jig preventing proper investigation.
Responded
Aarav Chopra
Concerns: Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented electronic records also led to missed patient risk factors.
Responded
David Tighe
Concerns: The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, and unrecorded family concerns.
Responded
Sheila Nicholls
Concerns: The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by untrained staff.
Responded
Victor Knowles
Concerns: The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed opportunities or improve care for residents.
Overdue
David Lodge
Concerns: The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and appropriately escalate high NEWS2 scores, coupled with a lack of internal incident review.
Responded
Andrew Lewis
Concerns: Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, with national concerns about oversight and unaddressed PFD reports.
Responded
James Alderman
Concerns: There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for breastfeeding, putting infants at risk of suffocation.
Responded
Karen Day
Concerns: The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems for internal investigation of patient safety incidents.
Responded
Rachael Ryan
Concerns: The absence of a clear protocol for deep tissue biopsy and failure to hold a multi-disciplinary meeting led to significant delays in diagnosis and appropriate antibiotic treatment.
Responded
Aviva Otte, Oscar Barker and Yousef Al-Kharboush
Concerns: A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from being shared with regulatory bodies, other trusts, or the wider industry.
Responded
Kumaran Chetty
Concerns: The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled drug abuse and initiate medication reviews.
Responded
Alison Binyon
Concerns: Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's failure to conduct an internal review risks inadequate learning and future deaths.
Responded
Lacey Brookman
Concerns: Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound and inadequate medical training in considering this diagnosis for abdominal pain.
Responded
Janet Brown Townend
Concerns: The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.
Responded
Phyllis Tromans
Concerns: A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. The subsequent investigation failed to identify the root causes of these critical care gaps.
Responded
Susan Shipley
Concerns: An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a fall and hip fracture. This indicates systemic failures in patient assessment and incident learning.
Responded
Chloe Every
Concerns: The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.
Responded
Joan Knight
Concerns: The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.
Responded
Robert Taylor
Concerns: Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure or actions to prevent recurrence.
Responded
Geoffrey Cheney
Concerns: An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.
Responded
Janet Seddon
Concerns: A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.
Responded
Sally Mills
Concerns: There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being fully embedded or known.
Responded
Kingsley Imafidon
Concerns: Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, including pre-biopsy assessment and post-operative monitoring.
Responded
James Southern
Concerns: Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with patients.
Responded
Gordon Long
Concerns: The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of improvements from an agreed action plan was demonstrated.
Overdue
Terence Clark
Concerns: Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately scrutinise this, compromising proper inquiry into the death.
Responded
Wendy Afford
Concerns: Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack of management oversight, and insufficient staff training on skin integrity.
Overdue
Elise Walsh
Concerns: A significant patient complaint form, containing a "note of intent," was not read or included in investigations, and the family was unaware of it, indicating critical failures in handling patient information.
Responded
Alan Fallows
Concerns: Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and missed opportunities to investigate patient safety incidents effectively.
Responded
Juliette Sewell
Concerns: Key actions from a Structured Judgement Review, including patient record reviews and caseload stratification, remain outstanding with no firm completion date, posing a risk of future deaths.
Responded
Craig Steadman
Concerns: Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing recommendations from being fully acted upon.
Pending
Philips Evans
Concerns: The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to recurring patient safety risks.
Responded
Paul Roberts
Concerns: The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient safety.
Responded
Nancy Rogers
Concerns: The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or protocols for recognising and managing aortic dissection presentations.
Responded
Nicola Forster
Concerns: A culture of institutional defensiveness and poor management persists within the Metropolitan Police Service, with junior officers fearing speaking out and senior management failing to address concerns independently.
Responded
Thomas Gibson
Concerns: The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between specialisms. There's no clear guidance for clinicians or senior review of incongruous test results.
Overdue
Graham Faulkner
Concerns: The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and hindering the ability to establish facts and implement preventative measures.
Responded
Mohammed Akramuzzaman
Concerns: Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. There was also a lack of follow-up checks and no demonstrable learning or procedural changes post-incident.
Responded
Elvon Morton
Concerns: Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance failed to identify and review a serious incident, compromising patient safety.
Responded
Mohammed Azizi
Concerns: Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
Responded
Charlie Millers
Concerns: A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in ineffective reviews, lost learning, and no consistent oversight for rectifying systemic issues.
Responded
Olayemi Kehinde
Concerns: Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure to conduct a proper governance investigation into the incident.
Responded
Paul Templeton
Concerns: The Trust seriously failed to recognize a patient's prolonged refusal to eat or drink as an active suicide attempt and an elevated suicide risk, indicating a systemic failure in risk assessment.
Responded
Ellen Woolnough
Concerns: Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, with many identified safety measures remaining prospective or unimplemented by the Trust.
Responded
Alexander Lyalushko
Concerns: The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, and exclude family input, indicating a lack of thorough investigation and learning.
Responded
Neil Edwards
Concerns: The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.
Responded
Iain Hughes
Concerns: Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can lead to unnecessary delays and increased risk.
Responded
Nesta Jones
Concerns: Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked adequate systems for urgent complaints and failed to conduct a full, timely investigation into the death.
Responded
Chloe Tapp
Concerns: An overwhelmed, understaffed neurology department caused delayed referrals, inadequate consultations, medication errors, and unanswered patient queries. This created unsafe backlogs and sub-optimal care, persisting years after the death.
Responded
Benjamin Leonard
Concerns: The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.
Responded
Larry Spriggs
Concerns: Systemic failures include a lack of demonstrated cultural change in patient care, inadequate risk assessment and management, poor information sharing, and insufficient management of intermittent observations.
Responded
Morgan-Rose Hart
Concerns: The Trust's investigation was incomplete and delayed, failing to address critical issues like inadequate staff observations and security breaches on a locked mental health ward. A dispute over permitted items and failure to escalate risk were also concerns.
Responded
Linda Banks
Concerns: Identified systemic failures in mental health services were not effectively addressed. Significant delays in Serious Incident Investigations (9 months) compromise evidence quality, hindering prompt learning and improvement in patient safety.
Responded
Vivienne Greener
Concerns: A lack of out-of-hours emergency endoscopy and insufficient Emergency Department staff contribute to ineffective triage and ambulance offloading delays. Unclear clinical protocols and inadequate sharing of investigation learning also pose risks.
Responded
John Taylor
Concerns: Paramedics failed to adequately check an unlocked door, leading to a 30-minute delay awaiting police entry, an issue not addressed in the internal investigation. Alternative transport options were also not considered.
Responded
Olivia Russell
Concerns: GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due to varied approaches and time limitations. A significant event meeting regarding the death was also delayed for over two years.
Overdue
Ruth Perry
Concerns: Ofsted's inspection system lacks transparency, negatively impacts school leader welfare, and has insufficient training for managing distress or clear channels for raising concerns. Local authority support also lacks formal policy.
Responded
William Gray
Concerns: Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.
Responded
Ian Jacka
Concerns: A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of a prior hypoxic brain injury, leading to an ill-timed operation.
Responded
Sarah Chappell
Concerns: Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.
Responded
Kyra Aslam
Concerns: A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.
Responded
Hazel Pearson
Concerns: Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a serious risk.
Responded
Kevin O’Hara
Concerns: Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk assessment follow-ups, results in missed opportunities to identify and address safety issues.
Responded
Gareth Etchells-Height
Concerns: Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led to fragmented care and a lack of understanding of the patient's condition.
Responded
Gerard Goodwin
Concerns: A vulnerable adult's safeguarding concerns were disregarded at triage, and a recommended care assessment was overridden. Systemic failures in referral processing and case management risk vulnerable individuals being overlooked.
Responded
Francis Barnes
Concerns: The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an unreliable statement, and was uncooperative in evidence sharing, hindering learning from the death.
Responded
Jennifer Campbell
Concerns: A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.
Responded
Iris Fordham
Concerns: Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing patient records, suggests a systemic culture of indifference within the Trust.
Responded
Brian Moreton
Concerns: Radiologists lack direct access to patient medical notes, relying on inadequate summary documents, and there is a pervasive issue of poor and misleading communication between clinicians and departments impacting patient care.
Responded
Ian Darwin
Concerns: Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past assurances and national guidelines for 60-day completion.
Responded
Marie Zarins
Concerns: Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving prescribed anti-depressants or sleeping tablets due to incorrect medication understanding and poor record review.
Responded
Phoenix Chapman
Concerns: A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, particularly between obstetricians and midwives, hindered effective care.
Responded
Mohammed Hussain
Concerns: Systemic failures in monitoring clozapine levels, communicating critical results, and implementing medication changes posed significant risks. Unaddressed previous PFD reports indicate a failure to learn and improve patient safety.
Responded