No open learning culture
Absence of a culture of openness, honesty, and learning from error within organisations, leading to failures in responding to concerns.
882 items
16 sources
19 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
83match
#30 - FCDO demonstrates a strong monitoring, evaluation, and learning culture and processes.
We have been glad to hear that there is a stronger evaluation culture in the FCDO than can be seen in many other Government departments, and that the FCDO’s monitoring, evaluation and learning (MEL) processes are strong in comparison to other international actors. There has been a clear continuity of MEL processes from DFID to the FCDO, with...
Matched on
terms: culture, learning
Committee recommendation
78match
#18 - Departments remain reluctant to share cyber incident information, hindering collective learning.
We asked the Cabinet Office what the impact was when departments did not share information about their cyber incidents. The Cabinet Office agreed that sharing data is essential to learn lessons, understand vulnerabilities, share best practice and work out what has gone wrong. The Cabinet Office reassured us that if departments find any vulnerabilities that could affect other...
Matched on
terms: culture, learning
Committee recommendation
74match
#20 - Government still faces challenges in robustly evaluating and sharing AI pilot learning.
We questioned DSIT on how it is evaluating and sharing learning from AI pilot activity across government to avoid reinventing the wheel and to support AI adoption at scale. It told us that it was taking a range of approaches including developing guidance and identifying good practice case studies, establishing communities of AI practitioners, and adopting an ‘open...
Matched on
terms: learning, open
Committee recommendation
73match
#4 - Address cultural issues allowing Home Office controls and processes to be overridden too easily.
We are concerned that the Home Office’s culture allowed it to override too easily the controls and processes in place to protect taxpayers’ money. The Home Office appears to have been operating in crisis mode for several years and now asserts that it is moving back to business- as-usual. It argues that its response to an “emergency” meant...
Matched on
terms: culture, learning
IOPC learning recommendation
72match
Recommendations - Metropolitan Police Service, August 2021
The IOPC recommends the MPS ensures that changes implemented to develop a culture of openness, transparency, improve cross-team working and collaboration between teams are embedded and a clear plan is in place to support continuous improvement in this area. An IOPC independent investigation found multiple instances of decisions not being recorded; perceived conflicts of interests not being recorded;...
Matched on
terms: culture, learning, open
Committee recommendation
69match
#25 - Home Office refuses to publish extensive lessons learned review from large site acquisitions.
When we questioned the Home Office about repeated mistakes in its acquisitions of large sites, it explained that it was learning from multiple projects at the same time. The Home Office informed us that its lessons learned review identified over 1,000 lessons. 82 When asked if it planned to publish the review, the Home Office stated that it...
Matched on
terms: 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
Committee recommendation
66match
#12 - Efficient waste retrieval demands constant iteration, strong performance culture, and sophisticated, transparent target setting.
We explored with the witnesses what Sellafield Ltd needs to do to reach the point where retrieving waste becomes an efficient, routine activity. As well as installing the right equipment, they emphasised the importance of “constant iteration” – addressing problems such as the availability of cranes as they arise and the importance of developing a site culture focussed...
Matched on
terms: culture
Committee recommendation
62match
#4 - Establish mechanism for AI pilot learning and scale successful products across government.
DSIT has no systematic mechanism for bringing together learning from pilots and there are few examples of successful at–scale adoption across government. At the time of the NAO report (March 2024), levels of AI use in government were low, but 70% of surveyed government bodies were piloting or planning AI tools. Examples of pilot activity include use of...
Matched on
terms: learning
PFD report
61match
Doreen Wood
Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. The practice also needs an internal investigation to ensure comprehensive learning among all GPs.
Matched on
terms: learning
PFD report
61match
Vasilis Ktorakis
The report identifies errors in care, including a delay in starting Syntocinon, inadequate recording of a management plan, an error of judgement in allowing passive descent, and a systemic issue in learning from incidents.
Matched on
terms: learning
PFD report
57match
Carol Ann Gibson
A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
Matched on
terms: culture
PFD report
57match
Lloyd Butler
A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.
Matched on
terms: culture
PFD report
57match
Tanya Page
Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.
Matched on
terms: learning
PFD report
57match
Wanda Stachurska
Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.
Matched on
terms: learning
PFD report
57match
Stephen Bird
Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.
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
Committee recommendation
57match
#5 - Transparency and accuracy lacking in SPS control models undermine trust and scrutiny.
There is a critical need for greater transparency and accuracy in the modelling and implementation of SPS controls. A failure to publish risk assessments and data informing inspection rates, limits scrutiny and undermines trust in the system. Addressing these issues through open publication and review of underlying models will support more effective, evidence-based policy and enforcement at the...
Matched on
terms: open
ICIBI recommendation
55match
An inspection of contingency asylum accommodation November 2023 – June 2024
Strengthen organisational learning in relation to asylum accommodation by producing a framework, with associated processes and guidelines, for capturing, evaluating and sharing learning (‘best practice’ and pitfalls) from ‘business as usual’ and from new projects, including the findings and recommendations from inspections and reviews. Accepted in full We fully agree that strengthening organisational learning is critical for our...
Matched on
terms: culture, learning
PFD report
53match
Stephanie Daniels
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.
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PFD report
53match
Martin McGlasson
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff were key concerns.
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PFD report
53match
Daniel Williams
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
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PFD report
53match
Jackson Chadd
Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.
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PFD report
53match
Anne Sandever
A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids despite renal failure, with no adequate hospital investigation following.
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Committee recommendation
53match
#24 - UK's extensive nutrition and food security research resources remain underutilised.
The UK has a tremendous array of research institutes and a strong history of contributing to the fields of nutrition and food security. There is more the Government could be doing to make use of these resources and to integrate learning into programming. (Conclusion, Paragraph 74)
Matched on
terms: learning
Committee recommendation
53match
#25 - Residents still lack sufficient information and transparency regarding their building's remediation progress
In 2020 the previous Committee noted that many residents were not being kept informed about the process of remediation and requested that MHCLG set out how it would improve transparency.42 We therefore asked whether government was now doing enough to help residents whose lives felt on hold while they waited to find out if their buildings needed remediation,...
Matched on
terms: open
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
IOPC learning recommendation
51match
Inappropriate photographs taken at crime scene – Metropolitan Police Service, June 2020
The IOPC recommends the Metropolitan Police Service reviews whether supervisors and senior management at Forest Gate Police Station are taking personal responsibility to identify and eliminate patterns of inappropriate behaviour, whilst simultaneously promoting a safe and open culture which makes clear to officers and staff that they are dutybound to challenge and report behaviour that does not align...
Matched on
terms: culture, open
PFD report
49match
Agostino Costa
Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.
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classifier match
PFD report
49match
Dana Baker
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
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PFD report
49match
Phyllis Kerry
There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment protocols.
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PFD report
49match
Thor Dalhaug
Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing distress.
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PFD report
49match
William Tolen
Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.
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classifier match
PFD report
49match
Angela Brealey
The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.
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PFD report
49match
Jonathan Lander
A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.
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classifier match
PFD report
49match
Amanda Coulthard
Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.
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classifier match
PFD report
49match
Michael Parke
Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.
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PFD report
49match
Michelle Lawrence
Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.
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Committee recommendation
49match
#13 - Adopt a 'leading from behind' approach to share MOD expertise with other departments.
The Ministry of Defence should proactively adopt a greater ‘leading from behind’ approach to sharing its leadership, organisational and wider expertise with other departments to bolster their intrinsic long-term resilience planning and preparedness. This should reduce their demands on the Ministry of Defence during any critical grey zone or conventional military crisis, thus allowing Defence to focus on...
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Committee recommendation
49match
#2 - Assess and report on improving accountability for family justice system by December 2025.
The family justice system is complex, but excessive fragmentation hinders transparency, leading to poor accountability for service improvement and overall performance. The family justice system involves many organisations across government and the independent judiciary. There is no single body accountable for overall system performance, including delivery of the statutory time limit of 26 weeks for most public law...
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classifier match
Committee recommendation
49match
#18 - Families of children with SEND lack trust in the system due to poor communication
Children and young people with SEND, and their families, have little trust and confidence in the SEND system, often shaped by adverse experiences. Inadequate communication and engagement from the Department with parents and carers and their organisations about future reforms, as well as media speculation, has further undermined parental trust in the Department for Education and in the...
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classifier match
NAO recommendation
48match
Investigation into student finance for study at franchised higher education providers
establish a common anti-fraud and corruption culture and risk tolerance by, for example, encouraging the reporting of fraud and corruption and embedding discussions in risk management forums
Matched on
terms: culture
CQC action
48match
St Clare's Hospice
The provider should review the culture within the hospice and identify positive processes to improve current concerns. Specifically in relation to bullying.
Matched on
terms: culture
HMICFRS recommendation
47match
FRS 2023-25 CoC Recommendations: Dorset and Wiltshire Fire and Rescue Service
Cause of concern: The service needs to do more to ensure that its staff routinely demonstrate behaviours in line with its values. We found strong evidence of behaviours that weren’t in line with service values. We were told about cultures among some teams where staff demonstrate unacceptable behaviour. And staff don’t always have the confidence to report these...
Matched on
terms: culture
HMICFRS recommendation
47match
FRS 2021-22 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: The service has shown a clear intent from the executive board to improve the culture of the service. However, more needs to be done throughout the organisation. We have found evidence of poor behaviours that are not in line with service values. Some staff didn’t have the confidence to report these issues. Recommendation: By 31...
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terms: culture
PFD report
45match
Muniza Mehrban
This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for suicide prevention measures at the location.
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classifier match