No open learning culture
Absence of a culture of openness, honesty, and learning from error within organisations, leading to failures in responding to concerns.
107 items
1 source
30 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
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
60match
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
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
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
45match
RHI-32b - Civil Servants Raising Concerns
Civil servants should be encouraged not to feel in any way inhibited about disclosing possible or emerging problems, raising concerns, negative aspects or adverse criticisms of a project as necessary to ensure that decisions are properly informed.
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classifier match
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.
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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.
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classifier match
Inquiry recommendation
41match
85 - Responses to the S&SD paper on accident investigation
Responses to the S&SD paper “The Future of Accident Investigation in the Railway Industry” should be taken into consideration in applying the foregoing Recommendations (para 15.29).
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classifier match
Inquiry recommendation
41match
76 - HMRI to decide what data passes to rail companies
HMRI should decide, irrespective of any ongoing criminal investigation, what data or information is to be passed on to rail companies for rapid action (para 15.24).
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classifier match
Inquiry recommendation
41match
75 - Standing contracts for railway experts
Standing contracts for the provision of consulting services by recognised railway experts should be amended to make provision for HMRI to require any appropriate individual to provide expert services for the immediate accident investigation, including the services of any appropriate laboratory or testing house (para 15.23).
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classifier match
Inquiry recommendation
41match
74 - A single definitive technical investigation
HMRI should ensure that a single, thorough and definitive technical investigation is carried out, to include the recording of all appropriate factual data, the collection of physical evidence from the scene of the accident and decisions as to handing the site back to the rail companies (paras 2.19, 7.3, 15.24).
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classifier match
Inquiry recommendation
41match
73 - HMRI to control technical investigation of serious accidents
The technical investigation of serious rail accidents should be controlled by HMRI save in exceptional cases of suspected crime which is unconnected with the running of the railway (para 15.23).
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classifier match
Inquiry recommendation
41match
72 - Consultation on Group Standards
Consultation procedures and times involved in revision of Group Standards or the introduction of new Group Standards, should be reviewed by the Inquiry to be held into safety procedures (para 16.8).
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classifier match
Inquiry recommendation
41match
57 - Resolve inter-company research and development issues
Steps should be taken to put in place means to resolve inter-company issues relating to research and development at all levels. Specifically, the following issues must be addressed (paras 15.13, 16.21).
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classifier match
Inquiry recommendation
41match
55 - Data recorders on all trains
All trains should be fitted with data recorders. All data recorders should record speed, time/location, brake application and AWS cancellation, and should be simple and speedy to download (para 14.23).
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classifier match
Inquiry recommendation
41match
9 - Review of drivers' working hours
Current Rules governing drivers’ permitted daily and weekly working hours should be reviewed in the light of current research into human behaviour (para 5.9).
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classifier match
Inquiry recommendation
41match
6 - Encourage drivers to report faults
Drivers should be encouraged to report all actual or suspected faults, whether through formal fault reporting procedures or through CIRAS (paras 14.26, 16.4).
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classifier match
Inquiry recommendation
41match
3 - Simulators for driver training
Simulators should be introduced for driver training and for the observance of driver behaviour (para 16.3).
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classifier match
Inquiry recommendation
41match
2 - Evidence from CIRAS and on-train data recorders
Evidence should include that to be provided by CIRAS and from On-Train Data Recorders used to monitor driver behaviour. ASLEF in particular should give their full support to such an initiative (paras 14.23, 14.25, 15.15, 16.3).
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classifier match
Inquiry recommendation
41match
1 - Co-operate on research into driver behaviour
All parties in the rail industry should co-operate in the collection of evidence to support reliable research into human behaviour studies relating to driver performance. Railtrack should co-ordinate this work and TOCs incorporate the results into training programmes (paras 1.25, 7.16, 16.2).
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classifier match
Inquiry recommendation
41match
21 - Resolve doubt in favour of disclosure
Where there is any doubt as to whether a matter is of a substantial nature, if it relates to patient care the doubt shall always be resolved in favour of disclosure.
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classifier match
Inquiry recommendation
41match
FP86 - Recommendation 86
COPFS should task identified staff with maintaining up-to-date knowledge of cases, at least in anglophone jurisdictions, in which fingerprint evidence has been disputed, and with liaising with an identified contact in SPSA in relation to any implications that the findings of such courts may have for fingerprint evidence in Scotland.
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classifier match
Inquiry recommendation
41match
FP85 - Recommendation 85
The SPSA should task identified staff with: (i) maintaining up-to-date knowledge of cases, at least in anglophone jurisdictions, in which fingerprint evidence has been disputed; and (ii) monitoring cases in which courts, inquiries or other investigating bodies have made significant criticism of existing fingerprint practice and of considering whether those criticisms should be taken into account in developing...
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classifier match
Inquiry recommendation
41match
FP69 - Recommendation 69
The SPSA should consider whether their procedures require to be revised in the light of the findings of an investigation of an erroneous fingerprint identification or exclusion.
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classifier match
Inquiry recommendation
41match
FP67 - Recommendation 67
The SPSA should investigate all ‘erroneous’ fingerprint identifications or exclusions.
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classifier match
Inquiry recommendation
41match
FP4 - Recommendation 4
Differences of opinion between examiners should not be referred to as disputes.
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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.
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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.
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classifier match
Inquiry recommendation
41match
MAI-128 - National systems to record lessons from exercises
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 a result, where change is indicated.
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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.
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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.
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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.
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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.
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classifier match
Inquiry recommendation
40match
16 - Parliamentary and Health Service Ombudsman
The functions of the National Guardian’s Office should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman’s powers must be increased to include: a. investigating complaints that whistleblowing in the NHS has not been dealt with adequately b. assisting whistleblowers by referring their concerns to the relevant NHS bodies and overseeing the response.
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classifier match
Inquiry recommendation
36match
19 - Report tip slides and fires
The Mines (Notification of Dangerous Occurrences) Order, 1959, should be amended so as to include tip slides and fires among the matters required to be reported forthwith to Her Majesty's Inspectorate of Mines and Quarries (Paragraph 295).
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classifier match
Inquiry recommendation
36match
23 - Databases to highlight trends in reported faults
Databases should be programmed to determine and highlight statistically significant trends in faults reported and to display such information to managers and maintenance staff (para 16.9).
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classifier match
Inquiry recommendation
36match
22 - Fault databases to log repeat faults
Fault data bases (including RAVERS) should ensure that repeat faults are logged and that a 28 day history of defects is available to managers and maintenance staff (para 16.9).
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classifier match
Inquiry recommendation
36match
40 - Public relations and press liaison
The out-dated aura of seclusion at Whittingham should be dispelled by positive public relations activity. A member of the administrative staff, with suitable qualities, should be given a special responsibility for liaison with the press so as to cultivate constructive public interest in the life of the hospital.
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classifier match
Inquiry recommendation
36match
20 - Duty to disclose substantial matters
The duty of utmost good faith shall require either party to disclose to the other any substantial matter relating to the performance of the individual or department, whether clinical or academic.
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classifier match
Inquiry recommendation
36match
39 - Database of leaks, spills and ignitions
The regulatory body should be responsible for maintaining a database with regard to hydrocarbon leaks, spills and ignitions in the industry and for the benefit of the industry. The regulatory body should:- (i) discuss and agree with the industry the method of collection and use of the data, (ii) regularly assess the data to determine the existence of...
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classifier match
Inquiry recommendation
36match
30 - Protection of safety representatives
Safety representatives should be protected against victimisation by a provision similar to Sec 58(i)(b) of the Employment Protection (Consolidation) Act 1978 (para 21.86).
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classifier match
Inquiry recommendation
36match
28 - Workforce involvement part of the SMS
The operator’s procedures included in line management of operations which are aimed at involving the workforce in safety should form part of its SMS (para 21.56).
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classifier match
Inquiry recommendation
36match
27 - Workforce involvement in safety
The regulatory body, operators and contractors should support and encourage the involvement of the offshore workforce in safety. In particular, first line supervisors should involve their workforce teams in everyday safety (para 18.48).
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classifier match
Inquiry recommendation
36match
63 - Basic training on dealing with prisoners
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, two of the key attributes required of the prison officer should be stressed. They are the ability to...
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classifier match
Inquiry recommendation
36match
48 - Governors acting on external report comments
Governors should ensure that any relevant comments or recommendations in external reports about their establishments which have implications for the safety of prisoners be brought to the attention of the workforce.
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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)
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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...
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