No open learning culture
Absence of a culture of openness, honesty, and learning from error within organisations, leading to failures in responding to concerns.
61 items
1 source
22 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
81match
AFA-2 - Organisational development and cultural reform
The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. Devising a Northern Ireland patient safety strategy would consolidate and clarify the various strands of work in progress....
Matched on
terms: culture, learning, open
Inquiry recommendation
69match
F57 - Care Quality Commission independence strategy and culture
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 the first inquiry, and open that evaluation for public scrutiny.
Matched on
terms: culture, open
Inquiry recommendation
66match
RHI-36 - Learning from Failures
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 proactive in explaining to staff what changes are needed and supporting staff to adapt their working practices. A...
Matched on
terms: learning
Inquiry recommendation
61match
AFA-5 - Serious Adverse Incidents
We recommend that: • The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in each Trust. This involves ongoing feedback and backing for Trusts in terms of making the best use of the new framework and training staff to understand it. Departmental...
Matched on
terms: learning
Inquiry recommendation
57match
LADB-17 - Develop a blame-free culture for safety information communication in industry
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).
Matched on
terms: culture
Inquiry recommendation
57match
BRIS-107 - Create open, non-punitive NHS environment for reporting sentinel events
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.
Matched on
terms: open
Inquiry recommendation
57match
MAI-26 - Review international practice on medics with firearms officers
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 in the UK or some further learning taken from them.
Matched on
terms: learning
Inquiry recommendation
53match
R34 - Debriefing policies for aggressive behaviour and restraint
All HSCTs should develop two clear operational debriefing policies. The first should apply to both staff and people with learning disabilities and autistic people who are involved in, or affected by, aggressive behaviour. A separate debriefing after any restraint or seclusion incident should also be developed. This should include both staff and people with learning disabilities and autistic...
Matched on
terms: learning
Inquiry recommendation
53match
F119 - Learning and information from complaints
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.
Matched on
terms: learning
Inquiry recommendation
53match
F118 - Learning and information from complaints
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, refuses to agree, or for some other reason publication of an upheld, clinically related complaint is not possible,...
Matched on
terms: learning
Inquiry recommendation
52match
AFA-1 - Patient focus and complaints
The Inquiry recommends that the Trust and Department work together to ensure there is: • A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and families are treated as partners in care. • Direct communication with patients as standard practice. • More effective handling of concerns and complaints, with an emphasis on early...
Matched on
terms: learning
Inquiry recommendation
45match
MAI-51 - Address Showsec failings identified in Volume 1
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.
Matched on
classifier match
Inquiry recommendation
45match
MAI-50 - Address Arena failings identified in Volume 1
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.
Matched on
classifier match
Inquiry recommendation
41match
26 - Ensure Home Office staff presence and visibility in IRCs
The Home Office must ensure that its staff are regularly present and visible within each immigration removal centre.
Matched on
classifier match
Inquiry recommendation
41match
MAI-155 - Obtain comprehensive accounts from commanders
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 debrief process following a Major Incident.
Matched on
classifier match
Inquiry recommendation
41match
MAI-128 - National systems to record lessons from exercises
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 is indicated.
Matched on
classifier match
Inquiry recommendation
41match
MAI-127 - Robust debrief systems for multi-agency exercises
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 lessons that need to be learned.
Matched on
classifier match
Inquiry recommendation
41match
MAI-94 - Review firearms officer Post Incident Procedures delays
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.
Matched on
classifier match
Inquiry recommendation
41match
MAI-62 - LRF oversight of lessons from exercises and incidents
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 events.
Matched on
classifier match
Inquiry recommendation
41match
MAI-18 - Address BTP systemic failings from Volume 1
BTP should address the systemic failings identified in Volume 1, so as to ensure that they are not repeated.
Matched on
classifier match
Inquiry recommendation
36match
R2 - Coroners to send post mortem reports to consultants
We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or not demanded under Rule 57 of the Coroner's Rules 1984 (para 4.2.9)
Matched on
classifier match
Inquiry recommendation
36match
R67 - Independent review of systemic abuse conditions
Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An independent review of enabling conditions should be conducted separately from case-specific or PSNI investigations. This review must be led by investigators with appropriate expertise in safety science to support rapid system-level changes. PHA, in conjunction with...
Matched on
classifier match
Inquiry recommendation
36match
P2-34 - London Fire Brigade to establish lessons learned process
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 any appropriate changes in practice or procedure are implemented speedily. (113.58)
Matched on
classifier match
Inquiry recommendation
36match
BRIS-112 - Conduct structured analysis of sentinel events considering organisational factors
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 given rise to the event.
Matched on
classifier match
Inquiry recommendation
32match
FENN-54 - Produce prompt reports and analysis of fire and smoke incidents
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.
Matched on
classifier match
Inquiry recommendation
32match
HIDD-92 - Promptly update Rule Book and Books of Instruction incorporating report observations
The Rule Book and Books of Instruction of a similar status shall be promptly updated and observations made in this Report taken into account.
Matched on
classifier match
Inquiry recommendation
32match
HIDD-39 - Urgently introduce independent monitoring and auditing for all safety-related work
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.
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classifier match
Inquiry recommendation
32match
HIDD-9 - Introduce national testing instruction with workforce explanation, monitoring, and auditing
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.
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classifier match
Inquiry recommendation
31match
LADB-33 - Review SPAD Group Standard to avoid presuming driver error as sole cause
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 factor (para 11.27).
Matched on
classifier match
Inquiry recommendation
31match
HIDD-38 - Urgently use outside consultants to review safety management and communication issues
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.
Matched on
classifier match
Inquiry recommendation
31match
F101 - National Patient Safety Agency functions
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 representatives from outside the organisation. Consideration could also be given to involvement from time to time of a...
Matched on
classifier match
Inquiry recommendation
31match
F1 - Implementing the recommendations
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 earliest practicable time its decision on the extent to which it accepts the recommendations and what it intends...
Matched on
classifier match
Inquiry recommendation
27match
LAMI-30 - Directors must ensure senior managers regularly inspect children's social services case files
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.
Matched on
classifier match
Inquiry recommendation
27match
FENN-56 - Chief Safety Inspector to review, identify hazards, recommend policies, and audit safety
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 and the power to call for any reports, logs and correspondence relating to safety.
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classifier match
Inquiry recommendation
27match
FENN-44 - Encourage trade union participation in all internal inquiries
Trade union participation in internal inquiries shall be encouraged.
Matched on
classifier match
Inquiry recommendation
27match
LADB-39 - Establish system for signaller briefing and information sharing after SPAD incidents
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 elsewhere (para 12.13).
Matched on
classifier match
Inquiry recommendation
27match
LADB-35 - Train SPAD investigators in human factors and root cause analysis
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 analysis of SPAD data should be specifically directed to eliciting the part played by human factors and assessing...
Matched on
classifier match
Inquiry recommendation
27match
HIDD-47 - Report 6-monthly to Railway Inspectorate on Automatic Train Protection implementation progress
BR shall report at 6 monthly intervals to the Railway Inspectorate on its progress in implementing ATP.
Matched on
classifier match
Inquiry recommendation
27match
HIDD-42 - Report 6-monthly to Railway Inspectorate on accident follow-up and recommendations
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.
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classifier match
Inquiry recommendation
27match
HIDD-8 - Require BR to provide and monitor full documentation for proper testing
BR shall ensure that full documentation is provided and later monitored in order that proper testing is carried out.
Matched on
classifier match
Inquiry recommendation
27match
R75 - Health Board review of IPC reports
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.
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classifier match
Inquiry recommendation
27match
R74 - Review of UK IPC reports
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 reviewed as soon as possible.
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classifier match
Inquiry recommendation
27match
R72 - Internal investigation independence
Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.
Matched on
classifier match
Inquiry recommendation
27match
AR-2 - Protocol for Post-Incident Debriefing
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 a police officer of an early debriefing as an obligation equal and complementary to any IPCC investigation. The...
Matched on
classifier match
Inquiry recommendation
27match
RHI-34 - Rapid Response Capacity
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, establishing a parallel investigatory team and/or developing a specialist capacity within the internal audit service that can be...
Matched on
classifier match
Inquiry recommendation
23match
FENN-72 - Institute and maintain cleaning and maintenance standards for London Underground
London Underground must institute and maintain a set of standards for cleaning and maintenance.
Matched on
classifier match
Inquiry recommendation
23match
FENN-71 - Implement job specifications and inspection for all maintenance and cleaning activities
Proper job specification and inspection arrangements shall be put in place for all maintenance and cleaning activities.
Matched on
classifier match
Inquiry recommendation
23match
FENN-59 - Establish a managed safety programme to implement inquiry recommendations
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.
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classifier match
Inquiry recommendation
23match
FENN-50 - Maintain formal health and safety monitoring system at all management levels
London Underground shall maintain a formal system for health and safety monitoring at all levels of management.
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classifier match
Inquiry recommendation
23match
FENN-43 - Ensure director-level consideration of internal accident inquiry recommendations
The recommendations of internal inquiries into accidents must be considered at director level.
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classifier match