Recommendation 18

Aside from the substantive reform of clinical negligence litigation that we have recommended, we also believe that the investigatory system should be reformed. After any tragedy involving medical error there should be a standardised process of investigation which focuses on the overriding priority to learn from mistakes and prevent tragedies being repeated. We recommend that, at a minimum, such investigations should: • last a maximum of six months, • be independently-led involving both families and the Trust in question, • include implementation of any safety recommendations that are made, • communicate lessons across the NHS.