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
Source spread
Where this theme appears
No open learning culture has been flagged across 1 independent accountability source:
61 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (61) — showing 50 strongest matches
AFA-5 — Serious Adverse Incidents
Recommendation: 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 …
Response Pending
AFA-2 — Organisational development and cultural reform
Recommendation: 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. …
Response Pending
R34 — Debriefing policies for aggressive behaviour and restraint
Recommendation: 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 …
Response Pending
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
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
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-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
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
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
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
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
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
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-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
AFA-1 — Patient focus and complaints
Recommendation: 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 …
Response Pending
R2 — Coroners to send post mortem reports to consultants
Recommendation: 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 …
Unknown
R67 — Independent review of systemic abuse conditions
Recommendation: 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 …
Response Pending
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
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
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
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
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
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
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-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
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
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
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
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
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-44 — Encourage trade union participation in all internal inquiries
Recommendation: Trade union participation in internal inquiries shall be encouraged.
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
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-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
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-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-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-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
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
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
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
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
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
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
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
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
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-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-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-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