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
Source spread
Where this theme appears
No open learning culture has been flagged across 1 independent accountability source:
107 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 (107) — showing 50 strongest matches
85 — Responses to the S&SD paper on accident investigation
Recommendation: 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).
Unknown
76 — HMRI to decide what data passes to rail companies
Recommendation: 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).
Unknown
75 — Standing contracts for railway experts
Recommendation: 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 …
Unknown
74 — A single definitive technical investigation
Recommendation: 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 …
Unknown
73 — HMRI to control technical investigation of serious accidents
Recommendation: 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).
Unknown
72 — Consultation on Group Standards
Recommendation: 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).
Unknown
57 — Resolve inter-company research and development issues
Recommendation: 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).
Unknown
55 — Data recorders on all trains
Recommendation: 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).
Unknown
9 — Review of drivers' working hours
Recommendation: 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).
Unknown
6 — Encourage drivers to report faults
Recommendation: 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).
Unknown
3 — Simulators for driver training
Recommendation: Simulators should be introduced for driver training and for the observance of driver behaviour (para 16.3).
Unknown
2 — Evidence from CIRAS and on-train data recorders
Recommendation: 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).
Unknown
1 — Co-operate on research into driver behaviour
Recommendation: 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, …
Unknown
21 — Resolve doubt in favour of disclosure
Recommendation: 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.
Unknown
FP86 — Recommendation 86
Recommendation: 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 …
No response yet
FP85 — Recommendation 85
Recommendation: 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 …
No response yet
FP69 — Recommendation 69
Recommendation: 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.
No response yet
FP67 — Recommendation 67
Recommendation: The SPSA should investigate all ‘erroneous’ fingerprint identifications or exclusions.
No response yet
FP4 — Recommendation 4
Recommendation: Differences of opinion between examiners should not be referred to as disputes.
No response yet
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 …
Words of: Mike Nesbitt, Health Minister, in a Department of Health (Northern Ireland) news release, 24 June 2026
Gov response: will undertake a detailed and urgent review of the findings and recommendations
Response Unclear
In progress
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. …
Words of: Dr Stephen Austin, Southern Trust Medical Director, in a Southern Health and Social Care Trust news release, 24 June 2026
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
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 …
No response yet
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 …
Words of: Northern Ireland Executive, Executive Response to the RHI Inquiry Report Recommendations and Action Plan, Annex A, 7 October 2021
Gov response: These recommendations can be accepted in full. They have been partially addressed through: • the revision of the NICS Code of Ethics; • the GIAFIS review of whistleblowing; • the Leadership Development training for senior …
Accepted
No update 2+ yrs
RHI-32b — Civil Servants Raising Concerns
Recommendation: 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.
Words of: Northern Ireland Executive, Executive Response to the RHI Inquiry Report Recommendations and Action Plan, Annex A, 7 October 2021
Gov response: These recommendations can be accepted in full. They have been partially addressed through: • the revision of the NICS Code of Ethics; • the GIAFIS review of whistleblowing; • the Leadership Development training for senior …
Accepted
No update 2+ yrs
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.
Words of: Home Office, Government response to the public inquiry into Brook House Immigration Removal Centre (CP 1041), March 2024
Gov response: 6.8.3. The DET teams are being expanded, with further recruitment underway to support the Home Office’s commitment to improving the access of detained individuals to Home Office staff. DET staff are regularly present and visible …
Accepted, fully or in part (not specified)
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
MAI-128 — National systems to record lessons from exercises
Recommendation: 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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
19 — Report tip slides and fires
Recommendation: 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).
Unknown
23 — Databases to highlight trends in reported faults
Recommendation: 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).
Unknown
22 — Fault databases to log repeat faults
Recommendation: 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).
Unknown
40 — Public relations and press liaison
Recommendation: 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 …
Unknown
20 — Duty to disclose substantial matters
Recommendation: 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.
Unknown
39 — Database of leaks, spills and ignitions
Recommendation: 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 …
Unknown
30 — Protection of safety representatives
Recommendation: 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).
Unknown
28 — Workforce involvement part of the SMS
Recommendation: 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).
Unknown
27 — Workforce involvement in safety
Recommendation: 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).
Unknown
63 — Basic training on dealing with prisoners
Recommendation: 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, …
Unknown
48 — Governors acting on external report comments
Recommendation: 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.
Unknown
16 — Parliamentary and Health Service Ombudsman
Recommendation: 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 …
Gov response: No formal government response published. The Secretary of State for Health and Social Care's oral statement of 15 September 2026, made on the day the Inquiry's report was published, names neither this recommendation nor the …
Unknown
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 …
Words of: Dr Stephen Austin, Southern Trust Medical Director, in a Southern Health and Social Care Trust news release, 24 June 2026
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
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 …
Words of: Virginia Bottomley, Secretary of State for Health, reporting the Home Secretary's acceptance, in a statement to the House of Commons, 11 February 1994
Gov response: The report makes 12 detailed recommendations to tighten procedures to safeguard children in hospital. I have instructed immediate action to be taken on the 11 that are my responsibility. The Home Secretary has accepted the …
Accepted in part
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 …
No response yet
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