Major project lessons learned
Repeated failure to effectively apply lessons learned from past major projects, leading to recurring mistakes in cost and schedule management.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
54 inquiry recs
62 PFD reports
676 committee recs
1 HSSIB rec
6 CQC actions
7 ICIBI recs
1 PPO rec
393 NAO recs
32 IMB recs
15 IMB reports
2 detention investigation recs
107 DHR recs
1 LGO/SPSO decision
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(54)— showing 50 strongest matches
17 — Implementation of recommendations
Recommendation: A new responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office. Funding for appropriate additional staffing should be made available so that it may begin its work …
Gov response: Finally, Lady Justice Thirlwall highlights problems with past inquiry recommendations not being implemented. So, my department is setting up a recommendation hub to properly track our implementation progress internally, not just for this inquiry, but …
Response Unclear
RHI-44 — NIAO Progress Assessment Role
Recommendation: The recommendations for change made here, to the extent they are adopted, will take time to implement; they may indeed not even be sufficient to address the range of shortcomings revealed by the Inquiry. The Inquiry therefore recommends a role …
Gov response: As a mechanism for avoiding a similar outcome in this case, the C&AG was asked to monitor and, as necessary, pursue the effective implementation of this Inquiry’s recommendations and report its findings to the Northern …
Noted
POH-16 — Clarify whether HCRS and OCS assessment processes differ
Recommendation: The Department shall make a public announcement in which (a) it clarifies whether there will be any differences in the process for assessing financial redress, between the merged HCRS and OCS, and the process currently operating in OCS and if …
Gov response: DBT confirms that the HCRS will apply the same principles as the previous OC scheme, ensuring no OC claimant is disadvantaged by the transfer to HCRS. DBT has published further guidance on GOV.UK about the …
Accepted
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: Accepted in full
Accepted
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 …
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 …
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 …
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 …
Gov response: Accepted in full
Accepted
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: Accepted in full
Accepted
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: 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
5 — Require proper cell sharing risk assessments
Recommendation: The Home Office must ensure that adequate risk assessment for cell sharing is carried out by contractors in relation to every detained person. This must be done at the outset of detention and then repeated at reasonable intervals (at least …
Gov response: 6.3.1. A new staffing model has been developed to deliver a considerably healthier ratio of custodial staff per detained individual to nearly double what it was in 2017. The new model represents an increase in …
Accepted, fully or in part (not specified)
25 — Less detailed questions in future investigations
Recommendation: In the meantime, we suggest that in any future FI the questions attached to the Notice of Investigation might be less detailed than they were here.
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
FLIX-209 (iii) — Extend steam boiler modification regulations to hazardous material pressure systems
Recommendation: That existing regulations relating to modifications of steam boilers which do not apply to pressure systems containing hazardous materials should be extended so as to apply to such systems. In framing such regulations consideration will no doubt be given to …
Unknown
FLIX-209 (ii) — Inspect and test modified hazardous pressure systems by competent persons
Recommendation: That all pressure systems containing hazardous materials should be subject to inspection and test by a person recognised by the appropriate authority as competent after any significant modification has been carried out and before the system is again brought into …
Unknown
FLIX-209 (i) — Ensure plant modifications meet original design, construction, testing standards
Recommendation: That any modifications should be designed, constructed, tested and maintained to the same standards as the original plant.
Unknown
SHI-10 — Uniform policy for obtaining technical advice
Recommendation: This issue was highlighted in the Grant Thornton report where similar recommendations are made to what is set out above. NHSL has taken steps to address the issue. However, it is not clear from the available evidence that any such …
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
SHI-7 — Independent validation of hospital construction
Recommendation: It is clearly desirable that a health board has the assurance prior to the handover of a new or refurbished healthcare facility that the facility's specialised ventilation systems have been independently validated by an Authorising Engineer as fit for purpose …
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
SHI-6 — Information on common construction errors
Recommendation: NHS Assure should consider, in consultation with relevant stakeholders, whether and how to provide health boards with more detailed information about common errors and issues experienced by other health boards than is currently provided.
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
SHI-5 — Streamlining NHS construction quality procedures
Recommendation: A range of procedures now exists to help ensure health board projects meet appropriate standards. One is the NHS Scotland Design Assessment Process ("NDAP"). There is also a Sustainable Design and Construction Procedure ("SDAC"). In addition, there is the NHS …
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
BAHA-46 — Lessons Learned Process
Recommendation: The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed back far more quickly both to the operational theatre and …
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
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
HIDD-46 — Fully implement Automatic Train Protection within five years, prioritising busy lines
Recommendation: The Court welcomes BR's commitment to introduce Automatic Train Protection on a large percentage of its network, but is concerned at the timetable proposed. After the specific type of ATP system has been selected, ATP shall be fully implemented within …
Unknown
HIDD-41 — Utilise on-train data recorder information for systematic safety monitoring procedures
Recommendation: BR shall consider the use of information from on-train data recorders as part of a systematic safety monitoring procedure.
Unknown
HIDD-36 — Continue implementing Total Quality Management Initiative and BS5750 quality systems
Recommendation: BR shall continue to press ahead with its Total Quality Management Initiative and the application of British Standard BS5750: Quality systems.
Unknown
FLIX-224 — Urgently investigate crack propagation and corrosion protection for clad steel vessels
Recommendation: The question of crack propagation and detection in internally clad mild steel vessels and their protection from corrosion on the outside should be investigated as a matter of urgency.
Unknown
FLIX-223 — Review regulations for licensing and storage of highly flammable liquids
Recommendation: We have pointed out in Paragraph 194 (c) above that the present situation is unsatisfactory. We recommend review of the existing regulations.
Unknown
FLIX-221 — Devise scheme for HSE to advise planning authorities on plant safety
Recommendation: A scheme for co-ordination between the planning authorities and the Health and Safety Executive should be devised so that the planning authorities may be advised on the safety problems involved in any proposed plant before planning permission is granted.
Unknown
FLIX-216 — Install fire and explosion-proof recording devices for vital plant information
Recommendation: It is recommended that consideration be given to installing devices or systems for recording vital plant information in a form which would survive the effects of fire or explosion. An example of such a device is the “black-box” used in …
Unknown
FLIX-214 — Inform industry about rapid creep cavitation fractures in stainless steel
Recommendation: Creep cavitation fractures in stainless steel have been known for some time but previously it had not been generally known that these could, under appropriate conditions of stress and temperature be produced in a relatively short time. Such a fracture …
Unknown
FLIX-213 — Alert industry to risks of zinc-coated components in chemical plants
Recommendation: Since many chemical plants contain zinc coated components, eg galvanised wire and walkways, it is important that the attention of industry should be drawn to these matters.
Unknown
FLIX-212 — Alert industry to nitrate stress corrosion risk from contaminated cooling water
Recommendation: The cracked Reactor R2525 initiated the sequence of events which led to disaster. Examination of the crack by expert metallurgists showed that the crack had been caused by nitrate stress corrosion. This corrosion was created because nitrate treated cooling water …
Unknown
CR18 — MAIB publication of implementation measures
Recommendation: The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details of implementation measures taken by those to whom a recommendation is addressed, or an explanation for not taking …
Gov response: The Marine Accident and Investigation Branch (MAIB) and Department for Transport (DfT) agree that implementing this recommendation will be beneficial in improving visibility and transparency on the actions that have been taken in response to …
Accepted
ETI-19 — Collaborative Delivery
Recommendation: At all stages of the project there should be a collaborative approach to delivering it. This should include the co-location of representatives from each organisation relevant to the particular stage reached and having an interest in its completion to enable …
Gov response: The Inquiry Report describes some of the damaging behaviours adopted during project delivery by various parties. The advantage of co locating representatives having an interest in project completion is understood and indeed was successfully adopted …
Accepted
ETI-18 — Interviews of Key Personnel in Readiness Reviews
Recommendation: As part of their investigations, representatives of OGC undertaking an independent “readiness review” of a publicly funded project and representatives of any person, including representatives of any public body such as Audit Scotland, undertaking a review of the progress of …
Gov response: While this Recommendation is for third parties who may undertake a readiness review or audit of a publicly funded project in future, it is recommended that the Council agrees to support any such review or …
Noted
F126 — Preserving corporate memory
Recommendation: The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This code should cover both transitions between commissioners, for example as …
Gov response: Accepted. NHS organisations have gained significant learning from the transition to the reformed NHS system in 2013. NHS England will continue to work with commissioners to build on this, so that information handed over in …
Accepted
44 — Establish framework for future investigations
Recommendation: This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were …
Gov response: 69. We accept this recommendation in principle. A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. The Service will also respond to the concerns that had been previously …
Accepted in part
37 — Protocol for organisational change transitions
Recommendation: Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting out how such processes will be managed in future. This …
Gov response: 100. We accept this recommendation. We agree that these are important concepts, and indeed a number of protocols were drawn up and widely communicated in managing changes to the health system in 2012. The Department …
Accepted
BAHA-20 — Doctrine Usability Review
Recommendation: The MoD should ensure that Development Concepts and Doctrine Centre (DCDC) reviews whether its protocols for layout and pagination of joint doctrine really serve the end user.
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
FENN-58 — Provide separate funds for scientific adviser's research and development
Recommendation: The scientific adviser of London Underground shall be provided with separate funds for research and development.
Unknown
LADB-6 — Improve Railtrack procedures for implementing and monitoring accepted recommendations with clear accountability
Recommendation: Railtrack procedures, and the actions of management to enforce them, should be directed to ensuring that: (i) a recommendation which is accepted is implemented according to a defined timescale; (ii) the person to whom a recommendation is allocated for implementation …
Unknown
LADB-5 — Require holistic safety and risk assessment for all track or signalling changes
Recommendation: Where a material change to track or signalling or both is proposed, there should be an express consideration of all relevant safety issues by an analysis of the material factors, if necessary by means of a risk assessment. This should …
Unknown
CLAR-2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the …
Unknown
CLAR-1 — Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
Recommendation: The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the …
Unknown
CLAR-13.53.2 — Secretary of State to direct formal investigation includes search and rescue operation
Recommendation: Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the …
Unknown
CLAR-13.53.1 — Secretary of State to initiate formal investigation into Marchioness and Bowbelle collision
Recommendation: The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the …
Unknown
HIDD-54 — Complete research programme into structural integrity of rolling stock by April 1991
Recommendation: BR shall carry out its stated programme of research into the structural integrity of its rolling stock within its planned timescale of completion by April 1991.
Unknown
HIDD-43 — Prioritise installation of driver-signalman radio communication on all traction units
Recommendation: BR shall implement as a priority its programme to install a system of radio communication between driver and signalman on all traction units. The introduction of this system shall be in addition to signal-post telephones and not automatically entail their …
Unknown
HIDD-40 — Prioritise introduction of on-train data recorders for incident investigation assistance
Recommendation: BR shall give a higher priority to the introduction of on-train data recorders to assist investigation of any future incident.
Unknown
P2-58 — Reconsider LGA Guide paragraph 79.11 advice
Recommendation: That the advice contained in paragraph 79.11 of the LGA Guide be reconsidered. (113.83)
Gov response: The government accepts this recommendation. The advice contained in paragraph 79.11 of the LGA Guide was redacted in 2021. The Home Office intends to publish new guidance on the issues covered in paragraph 79.11 in …
Accepted
Prevention of Future Deaths reports(62)— showing 50 strongest matches
Dean Griffiths
Concerns: The coroner raised concerns about time pressures on the Range Conducting Officer to complete exercises, noting that the Exercise Director must ensure sufficient time is allocated for final assurance checks.
Overdue
Sean Cunningham
Concerns: The coroner noted a continuing significant risk of strap misrouting impacting the safe operation of ejection seats, for which no design solution has been found. Concerns were also raised about the manufacturer's system for the urgent dissemination of safety-critical information to all end users.
Overdue
Esther Jones
Concerns: The coroner identified substantial delays in completing Serious Incident Reviews (SIRs) and sharing them with the coroner and family. This could hinder the timely dissemination of lessons learned and delay the coroner's own investigations, potentially limiting the effectiveness of PFD reports.
Overdue
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
Concerns: The report notes the absence of national governance, a lead, and disease-specific benchmarking for autologous stem cell transplant. Unreleased international trial results prevent clinicians from knowing normal recovery times, potentially affecting optimal care for children.
Response (NHS England): • NHS England will issue a Specialised Services Circular to commissioning teams and providers, restating requirements for transplant providers. • NHS England will review service specifications for paediatric bone marrow … (AI summary)
Responded
Huseyin Erdogan
Concerns: The coroner noted a lack of evidence that steps outlined in two action plans, created in response to Mr. Erdogan's death, had been completed by the stated deadlines prior to the inquest. This delay in implementation raises concerns about preventing future deaths.
Overdue
Michael Pollard
Concerns: An outdated on-call rota used by the hospital switchboard caused delays in contacting the correct consultant for an emergency endoscopy. The coroner identifies a need for an up-to-date, centrally managed rota accessible to all relevant staff.
Response (University Hospitals of Leicester NHS Trust): • The Interim Medical Director wrote to all doctors reminding them of their obligations to inform switchboard of any amendments to the on-call rota. • The Director of Estates and … (AI summary)
Responded
Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac
Concerns: The coroner identified numerous front suspension failures in UK-modified Ridgeback vehicles due to increased weight and requested a review of the entire suspension system. Concerns were also raised regarding height restrictions for vehicle drivers and commanders.
Response (Ministry of Defence): • The Ministry of Defence is conducting a review of the whole vehicle suspension system, including data analysis to determine the best maintenance schedule. • An investigation into alternative bolts … (AI summary)
Responded
Richard Laco
Concerns: Planning documents for a specific construction task did not recognise a different methodology and lacked critical instructions for the procedure. Additionally, some site witnesses with pivotal roles did not demonstrate a clear understanding of the processes or basic terminology.
Response (Richard Laco Response2): • Following the incident, the lifting method was revised to incorporate an additional lifting frame, chains instead of slings, and a second winch for tilting. • Future lifting operations will … (AI summary)
Response (Richard Laco): • Laing O'Rourke suspended all lift plans and initiated a full review of method statements and lifting plans across all packages. • The company issued a Safety Alert requiring all … (AI summary)
Responded
Peter Barnes
Concerns: The coroner identified a lack of specific policy and in-depth consultation regarding tall buildings impacting London Heliport flight paths. Further concerns included the non-implementation of a 2014 safety recommendation for the CAA to assess new obstacles before planning permission.
Response (Peterwood): • The London Heliport has continued correspondence with the CAA and DfT to progress consideration of official safeguarding. • The London Heliport has provided information to the CAA regarding existing … (AI summary)
Response (Peterwood): • The Civil Aviation Authority (CAA) is conducting a review of the safety of onshore helicopter operations in the UK, including London airspace and H4, scheduled for completion by 30 … (AI summary)
Overdue
Darren Wakefield
Concerns: The coroner highlighted an issue requiring national dissemination and requested confirmation that previous IPCC recommendations for police forces had been followed.
Response (Department for Transport): • The Department for Transport undertook a review of legislation concerning derelict vessels in harbours. • The review concluded that the existing primary legislation and common law duties provide a … (AI summary)
Responded
Joseph Sarkozi
Concerns: The coroner noted fire officers concluded dust on light fittings caused smoke and a burning smell without positive evidence, recommending national dissemination of learning on this risk.
Response (Avon Fire PFD): • The incident scenario will be included in training packages for operational crews, commencing this April. • Information will be shared via the "Fire Alert" system and distributed to the … (AI summary)
Overdue
Jakovas Fofonovas
Concerns: Safety recommendations from a British Transport Police report, aimed at creating a safer environment at the bridge and restricting public access to the railway, had not been implemented by the time of the inquest.
Response (Network Rail): • The original footbridge was demolished and replaced with a new structure, which includes railings at industry standard height and an encased span over the railway. • Acoustic fencing, 3m … (AI summary)
Responded
Steven Murphy
Concerns: The coroner noted that South West Trains had not responded to a British Transport Police report recommending safety measures for a footbridge at Liss Station, which were intended to reduce the risk of persons climbing over the parapet.
Overdue
Nathan Charman
Concerns: The winter maintenance policy and decision-making process did not account for extreme local or "microclimatic" road conditions. There has been no formal review or learning sharing following the incident.
Response (Durham County Council): • The Winter Maintenance Operational Plan was amended to align gritting route 28 with the Low Pennines weather forecasting domain. • The Winter Maintenance Operational Plan was amended to confirm … (AI summary)
Responded
Gerome Reyes
Concerns: The coroner raises concerns about the lack of confirmation that door limit switches have been installed on the MV Moonray's goods lift, and that Marine Safety Advisory No. 20-13 has been implemented for similar lifts on other ships.
Overdue
Melanie Lowe
Concerns: The coroner noted the trust's action plan was very basic, lacked specific detail, and had an absence of supporting evidence, requiring a more rigorous plan.
Responded
Gordon Penistan
Concerns: The coroner noted that adult services in other local authorities could benefit from lessons learned from shortcomings identified and addressed by Hampshire County Council following this death.
Response (ADASS): • ADASS circulated a briefing to all 153 local authorities with adult social care responsibilities. • The briefing was distributed via the ADASS news bulletin on 31 October. • The … (AI summary)
Responded
Dorothy Breislin
Concerns: Concerns were raised regarding the significant delay in providing the Incident Review Report and the family's assertion that they never received an apology. Additionally, it was noted that none of the proposed action plan items have been implemented since the incident date.
Response (Response United Lincolnshire Hospitals NHS Trust): • The Trust is implementing a new Serious Incident (SI) process, which incorporates training across the Trust on undertaking SI investigations. • An Interim Director of Governance is leading the … (AI summary)
Responded
Neville Welton
Concerns: The coroner identified delays by the Health Board in concluding its investigation and formulating an Action Plan for Mr Welton's death, with agreed implementation timescales not met. Concerns were also raised about the Health Board's general timeframes for Serious Incident Reviews and subsequent Action Plans.
Response: • The Health Board is revising its model for serious incident investigations to support divisions and ensure action plans are developed earlier in the process, with formal commencement in September … (AI summary)
Overdue
Alexia Walenkaki
Concerns: The coroner noted equipment failure due to inappropriate materials and a lack of accountability for annual inspections, particularly regarding unclear staff handovers. Concerns remain about potential recurrence of these organizational issues.
Overdue
Evie Wright
Concerns: The coroner noted a significant delay in constructing a safety-enhancing footbridge near a level crossing, despite planning permission existing since 1991, with new plans now requiring a fresh application.
Response (Persimmon Homes): • Persimmon Homes attended two meetings with North Somerset District Council. • Persimmon Homes agreed to attend a further meeting with North Somerset District Council and Network Rail. • Persimmon … (AI summary)
Response (North Somerset Council): • The council confirmed it had met with Persimmon Homes to discuss progressing a response to the report. • The council stated it would seek Network Rail's comments on further … (AI summary)
Responded
Clive Jones
Concerns: The coroner noted recommendations for an independent review of UK Search and Rescue operational capability and Her Majesty's Network Coastguard. Additionally, a thorough review of Search and Rescue information technology systems was advised to ensure network reliability.
Response (Department for Transport): • The Maritime and Coastguard Agency confirmed that a thorough review of Search and Rescue information technology systems had been completed, resulting in greater reliability and resilience. • An independent … (AI summary)
Responded
Lucia Stear
Concerns: The coroner raised concerns that other public authorities may not proactively address safety issues without a fatal incident, requesting national learning following a tragic avoidable death.
Response (Local Government Association): • The LGA included an item in its weekly email bulletin to local authority chief executives. • The LGA will set up an online event by December 2019 to discuss … (AI summary)
Response (Ministry of Housing Communities Local Government): • The department allocated £9.7 million to all local authorities across England for remedial work and renovation of existing parks. • The department noted that Core Spending Power for local … (AI summary)
Responded
Jean Waghorn
Concerns: The coroner identified concerns regarding unnecessary and inappropriate patient transfers between hospitals, noting that the Trust's transfer policy was effectively ignored. Additionally, previous Regulation 28 reports concerning the transfer policy had not led to changes, and new assessment tools were not used.
Overdue
Joshua Hoole
Concerns: The coroner notes a persistent failure to address previously raised safety concerns, specifically regarding commanders' awareness and training on heat illness prevention guidance (JSP539). The report highlights that JSP539 is complex, inconsistent with other guidance, and lacks clarity for new fitness tests, alongside an absence of a system for sharing individual risk factor information.
Response (Ministry of Defence): • The Ministry of Defence acknowledged that lessons had not been learned from past tragedies and stated that awareness of Joint Service Publication 539 (JSP 539) among commanders had improved. … (AI summary)
Responded
Malyun Karama
Concerns: The Royal Free Hospital has not shared national learning about the increased risk of uterine rupture in multi-gravida mothers. Additionally, the lack of computers in the delivery suite hindered midwives from contemporaneous observation recording.
Response (Royal Free London NHS Foundation Trust): • The Trust shared learning regarding the increased risk of rupture in multigravida women with a national maternity risk/governance managers email distribution forum and the Maternity Clinical Network – NHS … (AI summary)
Responded
Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook
Concerns: The coroner identified the absence of a national database for gas appliances, noting that a lack of mandatory recording hinders communication between parties and makes tracing potentially dangerous items difficult and time-consuming.
Response (MP BEIS): • The Office for Product Safety and Standards (OPSS) has established a national Product Safety Database. • OPSS has commissioned research to encourage greater registration of products to facilitate corrective … (AI summary)
Overdue
Lee Marsden
Concerns: The coroner identified a delay in activating motorway warning signals and noted communication issues between Highways England and the North West Motorway Police Group. No internal review of the accident circumstances was undertaken by Highways England.
Response (National Highways): • An internal review of the Regional Operations Centre's handling of the incident was carried out. • Highways England and the North West Motorway Police Group agreed to use clearer … (AI summary)
Response (North West Motorway Police Group): • A briefing note was circulated to North West Motorway Police Group staff on 25 May 2021, advising the use of plain language when identifying police or emergency services employees … (AI summary)
Responded
Vilmantas Venskutonis
Concerns: The coroner requested confirmation of the full implementation of a December 2019 action plan, including implementation dates for all nine points. They also sought reasons for any partial implementation of the plan.
Overdue
Christine Gould
Concerns: The coroner noted that investigations into railway deaths should keep an open mind regarding potential access routes, as a failure to do so risks missing opportunities for mitigating measures to prevent future fatalities.
Response (Network Rail): • Network Rail is renewing and upgrading 1.48km of fencing between Cherry Hinton and Teversham level crossings, with some sections completed and others scheduled for completion. • Guidance has been … (AI summary)
Response (British Transport Police): • The British Transport Police (BTP) created a single Fatality Investigation Team in April 2020 to standardise the management of non-suspicious fatalities. • The BTP Disruption Team commenced a programme … (AI summary)
Responded
Kyle Hurst
Concerns: The coroner identified delays in adopting a proposed N-Acetylcysteine administration protocol and in implementing diagnostic results procedures by a stated deadline. The report raises concerns about the Health Board's timely implementation of changes.
Response (BCUHB): • The Health Board stated it would take an executive decision to approve the SNAP protocol by 31 January 2022, with immediate implementation. • A new Procedure for the Communication … (AI summary)
Responded
Susan Merton
Concerns: The Health Board did not review an Action Plan as scheduled, which is a recurring issue where the Board fails to complete its own actions within set timeframes. The coroner noted that this lack of follow-through with recommendations puts lives at risk.
Response (BCUHB): • The Health Board implemented a new serious incident process in April 2021, requiring all investigation reports to be submitted for scrutiny and approval at an Incident Learning Panel. • … (AI summary)
Overdue
Jonathan Bayliss
Concerns: A final decision is pending on whether to incorporate an artificial stall warning capability in the Hawk Mk 1 aircraft, which may stall without pre-stall buffet. The current simulator training also does not accurately reflect the aerodynamic model of an RAF aerobatic aircraft with a smoke pod fitted.
Response (Ministry of Defence): • The Royal Air Force will fit a combined Artificial Stall Warning System and Angle of Attack gauge to remaining Hawk T Mk1 aircraft. • Pilot training will continue to … (AI summary)
Responded
Gregory Barber
Concerns: The coroner notes that Network Rail has not responded to the British Transport Police's recommendation to curtail access to railway tracks at a specific location, indicating the identified weakness remains unaddressed.
Response (Network Rail): • Network Rail committed to procuring and installing 8 metres of 2.4m palisade fencing behind the wall. • Network Rail committed to installing specially fabricated palisade fencing to close gaps … (AI summary)
Responded
Glendys Roberts
Concerns: The coroner noted slow progress in reviewing and acting on intra-hospital transfers, particularly regarding the vascular pathway for emergency admissions. There are also concerns about the slow development and lack of enforcement of a pan-Local Health Board ambulance handover plan to improve resource availability.
Response (Betsi Cadwaladr University Health Board): • The Health Board has implemented changes to the vascular pathway, including a protocol for Ambulance Critical Care Team transfers and a revised clinical protocol for patient conveyance. • An … (AI summary)
Response (Welsh Ambulance Service NHS Trust): • The Trust has engaged with Betsi Cadwaladr University (BCU) Health Board and the National Collaborative Commissioning Unit (NCCU) to develop an action plan for intra-hospital transfers. • A bypass … (AI summary)
Responded
John Abrahams
Concerns: The coroner noted a significant delay in implementing recommendations from an expert working group regarding Isotretinoin prescribing for patients under 18, despite ongoing reports of psychiatric adverse events.
Response (Medicines and Healthcare Products Regulatory Agency): • The Commission on Human Medicines (CHM) convened the Isotretinoin Expert Working Group (IEWG) to evaluate data on psychiatric adverse reactions and sexual dysfunction, and the IEWG presented its findings … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Isotretinoin Expert Working Group's report was published on 26 April 2023. • A Drug Safety Update Bulletin was issued to healthcare professionals, detailing new safety measures for isotretinoin. … (AI summary)
Response (Department of Health and Social Care): • The Isotretinoin Implementation Working Group has met three times, with the third meeting occurring on 12 May 2023. • The Group is drafting a report for the Commission for … (AI summary)
Responded
Raniya Khan
Concerns: The coroner noted that undertakings previously given by the trust regarding placenta retention processes, including storing placentas for 48 hours and implementing a new Standard Operating Procedure (SOP) with staff training, had not been completed.
Response (Royal Berkshire NHS Foundation Trust): • The Trust implemented a process for storing all placentas for 48 hours for histological examination, detailed in Standard Operating Procedure MATSOP064, which became fully operational on 13th February 2023. … (AI summary)
Responded
Ben Harrison
Concerns: The coroner noted concerns that the Health Board's action plan following the death was not quickly addressed, with outstanding actions two years later. This delay indicates a lack of strategic direction for investigations and learning.
Overdue
Thomas Jayamaha
Concerns: The coroner identified delays in the Autism Strategy work, insufficient progress in complex case management, and expressed a lack of reassurance regarding actions from the Serious Incident Investigation process.
Response (Nottinghamshire Healthcare NHS Foundation Trust): • The Trust and the Integrated Care Board have produced an action plan outlining the implementation of key components of the autism strategy. • A clinician-led triage assessment process and … (AI summary)
Responded
Jodie McCann
Concerns: The coroner identified gaps in comprehensive airway strategies for anticipated difficult airways, including a lack of structured planning, universal use of NAP4 algorithms, and robust daily equipment checks. Additionally, the Mortality Review policy was not followed, delaying serious incident review and Trust learning.
Response (University Hospitals of Derby and Burton NHS Foundation Trust): • The Trust stated it had taken robust actions as a result of learning from the case. • The Trust stated it had planned future work regarding its mortality governance … (AI summary)
Responded
Nancy Price
Concerns: The Health Board's internal investigations are significantly delayed, with actions often unrealistic or not completed by their due dates, hindering timely identification of learning needs and training implementation.
Response (Betsi Cadwaladr University Health Board): • The health board is re-evaluating its incident process and will develop a new procedure document by the end of August 2023. • A new Organisational Learning Forum has been … (AI summary)
Responded
Christine Cumbers
Concerns: The Practice did not implement learnings identified in its Significant Event Analysis, despite noting shortcomings in their practice. As of the inquest date, no plans or timescales for implementation were available.
Response (Ranworth Medical Group): • The practice addressed the identified consultation concern with the individual clinician through refresher training and reflection. • Learning from the consultation concern was disseminated anonymously at a practice meeting … (AI summary)
Responded
Leah Barber
Concerns: Bradford Council lacked a single point of overview or a system for coordinating its various departments' involvement with the deceased child, both before and after her death. This absence made it difficult for the Council to identify and learn lessons from the case.
Response (City of Bradford Metropolitan District Council): • The council confirmed it has strengthened processes to ensure organisational oversight when multiple teams are involved with a child who dies. • It implemented a risk register for serious … (AI summary)
Responded
Paula Lenihan
Concerns: The coroner noted ongoing issues at Birmingham & Solihull Mental Health NHS Foundation Trust with risk assessments not being properly completed or updated, raising concerns about insufficient recording of risk. A task and finish group addressing this is in its early stages, and there is no evidence the issues have been resolved.
Response (Birmingham and Solihull Mental Health): • The Trust has provided dedicated time for staff to update risk assessment documentation. • A project group has been established to review the risk assessment process and medical outpatient … (AI summary)
Responded
Sarah Holmes
Concerns: The coroner noted substantial and repeated delays in the completion of a serious incident investigation by the Trust, significantly exceeding the NHS framework's 60-working-day timescale. These delays impede the timely identification of system weaknesses to prevent future deaths.
Response (Independent Office for Police Conduct): • The Independent Office for Police Conduct (IOPC) outlined its established role in the police complaints system, including identifying learning opportunities and issuing organisational learning recommendations. • The IOPC reported … (AI summary)
Response (Department for Work and Pensions): • The Department for Work and Pensions established a Customer Experience Advanced Support Team in January 2021 to provide specialist support for vulnerable customers. • The department introduced additional steps … (AI summary)
Response (Tees Esk and Wear Valleys): • The Trust re-shared safety planning information and a presentation video with staff, and conducted reflective practice sessions and team discussions on safety planning and confidentiality. • Carer awareness training … (AI summary)
Response (Durham Constabulary): • Organisational learning following the incident has been reflected upon to mitigate future risks. • The force implemented an interim escalation policy with Tees, Esk and Wear Valleys NHS Foundation … (AI summary)
Response (Police): • Durham Constabulary has implemented an interim escalation policy for welfare checks, including training for Force Incident Managers, Critical Incident Managers, and Force Silver Commanders. • A Force Project Team … (AI summary)
Responded
Michael Pender, Jan Klempar and Paul Mullen
Concerns: The coroner raised concerns that seasonal lifeguards were ineligible for furlough, leading to staff shortages, and that the RNLI received no advance notice of lockdown relaxation, making it impossible to provide lifeguards when beaches reopened. Difficulties in sourcing PPE were also noted.
Response (Cabinet Office): • Concerns regarding lifeguard furlough eligibility were shared with HM Treasury and HMRC, and concerns regarding PPE supply were passed to the Department of Health and Social Care. • The … (AI summary)
Responded
Thomas Loxton
Concerns: Administrative errors causing distress through post-death letters revealed insufficient collaborative working on death notification between trusts. Both trusts also had outstanding Root Cause Analysis recommendations with delayed completion dates.
Response (Dudley Integrated Health and Care NHS Trust): • Dudley Integrated Health and Care NHS Trust implemented an enhanced process for notifying patient deaths, including routinely contacting Black Country Healthcare NHS Foundation Trust (BCH) upon an unexpected death. … (AI summary)
Response (Black Country Healthcare): • The Trust provided an updated action plan detailing the completion status of learning objectives from its investigation. • Black Country Healthcare stated it has implemented an enhanced process for … (AI summary)
Responded
Anne Rowland
Concerns: The coroner raises concerns about ongoing infrastructure risks at East Surrey Hospital that could delay hip fracture operations. The hospital's use of a 48-hour surgery metric, rather than the NICE guideline timeframe, may place patients at risk of complications and early death.
Response (Surrey and Sussex Healthcare): • The orthopaedic department expanded its consultant team and the Trust opened two new wards in October 2023, providing increased elective surgical capacity and ring-fenced beds for hip fracture patients. … (AI summary)
Responded
Nancy Rogers
Concerns: The coroner noted a lack of learning or teaching by the hospital following similar deaths from the same cause, specifically aortic dissection, after patients were discharged from the emergency department.
Response (Morecambe Bay NHSFT): • The Trust created and displayed an A4 poster in Emergency Department clinical areas and triage, with a QR code linking to a video on aortic dissection. • Awareness raising … (AI summary)
Responded
Joseph Parker
Concerns: The coroner raises concerns about the lack of widespread endorsement and dissemination of PUMA guidelines, which state capnography is the mainstay for confirming tracheal tube placement. It is also noted that unrecognised oesophageal intubation is no longer a 'Never Event' by NHS England, despite prior PFD reports on this issue leading to no changes.
Response (NHS England): • NHS England stated it would clarify the future direction for the Never Events Framework as part of its current review. • A decision will be made on next steps … (AI summary)
Response (Association of Anaesthetists RCOA and Faculty of Intensive Care Medicine Joint Respons): • The organisations confirmed their agreement that capnography is the gold standard for tracheal tube placement and stated this message has been and will continue to be emphasised in communications … (AI summary)
Response (Royal College of Emergency Medicine): • The Royal College of Emergency Medicine (RCEM) stated its full support for the use of capnography in resuscitation areas and for transport monitors. • The RCEM noted that its … (AI summary)
Responded
Select committee recommendations(676)— showing 50 strongest matches
#83 —
Recommendation: However, much evidence argued that innovative construction methods, including MMC, digital design and standardisation, has potential to improve delivery and productivity onsite. 139 Simon Rawlinson, Vice Chair of the Construction Industry Council, told us that MMC has been broadly successful …
#76 —
Recommendation: During our inquiry we heard that the new towns programme presents an opportunity to embed innovative methods of construction and project delivery into development. 123 As large Government-backed projects, the new towns could prove the effectiveness of new products or …
#169 —
Recommendation: Kim Thornden-Edwards told us that the national contracts came in âat paceâ in 2021, when the end of the Community Rehabilitation Companies led to the unification of the Probation Service (see Box 4), with 110 contracts being live at the …
Response attribution not verified
#133 —
Recommendation: Best practice was also identified in âproperly embedded multi-agency workingâ and âthe range of local services that youth offending services have a connection toâ. 251 Kim Thornden-Edwards explained that âyouth offending services are very networked into services for young peopleâ …
Response attribution not verified
#130 —
Recommendation: In our search for best practices in the delivery of non-custodial sentences, it was suggested that âYouth Justice Services seem to be doing much betterâ than the adult Probation Service. 243 The Minister for Prisons and Probation, Damian Hinds MP, …
Response attribution not verified
#129 —
Recommendation: Over the course of our inquiry, we were told about a range of best practices in the delivery of probation services across England and Wales. In this chapter, we consider how they could be scaled up. We look at the …
Response attribution not verified
#125 —
Recommendation: These pilots should be properly monitored and evaluated to determine whether any of them should be made more widely available. A plan for evaluation is essential to the launch of any new pilots. Best practices should be shared and scaled …
Response attribution not verified
#111 —
Recommendation: We heard that âthere is a plethora of pilot schemes all over the placeâ, some of which are designed to create such incentives. 209 Dr Abramovaite explained that, sometimes, police forces âdo not know themselves what they are runningâ because …
Response attribution not verified
#66 —
Recommendation: Despite all the advantages of community orders, their use has been declining in recent years. Various explanations were brought forward. The negative impact of the Transforming Rehabilitation reforms persistsâsentencers lost confidence in the ability of Community Rehabilitation Companies (CRCs, to …
Response attribution not verified
#20 —
Recommendation: These pilots should be properly monitored and evaluated to determine whether any of them should be made more widely available. A plan for evaluation is essential to the launch of any new pilots . Best practices should be shared and …
Response attribution not verified
#37 —
Recommendation: Recent post-war reconstruction efforts in Europe, notably in the Western Balkans, have a mixed record in terms of achieving their longer-term objectives. The UK, the EU and other participants in the reconstruction of Ukraine should reflect on what lessons can …
Response attribution not verified
#16 —
Recommendation: Although the Cold War-era Coordinating Committee for Multilateral Export Controls cannot simply be replicated in current circumstances, it established a precedent for an efficient and effective cooperation mechanism that operated successfully for almost 45 years. We ask the Government to …
Response attribution not verified
#15 —
Recommendation: Looking beyond the current crisis to the longer-term, we consider that the objective should be to ensure that lessons learned from this intensive phase of international cooperation on sanctions are retained and applied in other contexts, including where there may …
Response attribution not verified
#76 —
Recommendation: In setting a timetable for the implementation of a measure, the Government must take full account of the steps taxpayers need to take to prepare for the change and the support HMRC needs to provide for this. Regulations and guidance …
Response attribution not verified
#28 —
Recommendation: We are doubtful that final guidance of the quality needed to support businesses as they adjust to the merged scheme can be put in place by 1 April 2024. Without final detailed guidance, well in advance of the start date, …
Response attribution not verified
#25 —
Recommendation: We recommend that the start date for the new scheme be delayed until a company’s first accounting period to start on or after 1 April 2025.
Response attribution not verified
#24 —
Recommendation: We remain concerned that, even with the latest possible start date under the revised timetable, businesses will not have enough time to prepare for the new scheme.
Response attribution not verified
#25 —
Recommendation: We asked the Department what lessons it had learned from the intervention. The Department told us it has a centre of expertise on economic shocks, which has developed frameworks and “playbooks” to use in emerging situations. The centre gathers evidence …
#15 —
Recommendation: The trade unions told us they would like the Department to learn lessons from the transition currently taking place in Tata Steel’s Port Talbot steelworks, which have switched off their blast furnaces while converting to electric arc furnaces. They said …
#40 —
Recommendation: Anti-SLAPP legislation is unlikely to be supported by everyone in the legal profession. Some concerns are valid, others less so. The Ministry of Justice must learn lessons from the experience of developing the Strategic Litigation Against Public Participation Bill introduced …
Response attribution not verified
#8 —
Recommendation: The Government should establish a new Future News innovation catalyst scheme. The objective should be to facilitate technology-driven business transformation to help participants improve their long-term financial sustainability. While the Government should provide the funding, the scheme should be delivered …
Response attribution not verified
#20 —
Recommendation: We asked about the Bank’s decision to adapt the programme governance arrangements as it moved from planning into delivery, which the Bank explained was driven by “learning by doing”.42 Initial programme oversight was through the NED-led RTGS Renewal Committee (RRC), …
Response attribution not verified
#8 —
Recommendation: It is important that the Bank implements the recommendations in the C&AG’s Report to maximise potential benefits from the new RTGS. However, wider government has an opportunity to learn from the Bank’s successful implementation of this programme, and we therefore …
Response attribution not verified
#17 —
Recommendation: We asked the departments whether they agree that there needs to be more co-design with victims on future schemes as early as possible. The Cabinet Office told us that co-design is essential for compensation schemes, because it believes it is …
#14 —
Recommendation: We asked the Cabinet Office whether there should be a permanent body within government that is learning lessons from what went wrong with earlier schemes. Cabinet Office told us that it is the natural place for such learning, considering it …
#13 —
Recommendation: Sir Alan Bates told us of the importance of establishing an organisation that learns lessons from those involved with compensation schemes, including for example victims and lawyers.29 Shaila Pal, Director of the King’s Legal Clinic at King’s College London and …
#12 —
Recommendation: We asked the Departments how they had learned lessons from what went wrong with earlier compensation schemes. DBT told us that it learnt lessons as it continued to administer the Horizon IT compensation schemes and applied the learning from earlier …
#11 —
Recommendation: Officials from compensation schemes across government attend eight- weekly meetings of a cross-Whitehall network to share updates on schemes, learning and best practice. The NAO’s report found that these meetings are helpful opportunities for Departments to raise questions on operational …
#10 —
Recommendation: We asked the Cabinet Office why there is still no permanent central body to oversee and advise how compensation schemes are administered. The Cabinet Office acknowledged the merits of a single body independently administering schemes in a consistent way but …
#2 —
Recommendation: Government compensation schemes are expected to provide people who have experienced harm, either directly or indirectly, from the actions or inaction of public bodies with the compensation or financial redress they are rightly entitled to. The NAO’s report examined the …
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took oral evidence from several public bodies administering compensation schemes – the Cabinet Office, the Home Office, the Ministry of Defence (MoD), the Department of Business & …
#2 —
Recommendation: Until the transition to the Transformed Labour Force Survey, the Labour Force Survey remains the primary measure of UK employment and considerable efforts have been taken to improve its robustness. We are pleased to see that response rates have returned …
#1 —
Recommendation: The transition from the Labour Force Survey to the Transformed Labour Force Survey has not been handled well enough and the result has been significant reputational damage to the ONS. Project management for the Transformed Labour Force Survey was poor. …
#9 —
Recommendation: The government should, in response to this report, publish the lessons it has learned from the Afghan data-breach injunction and set out clear principles governing when it or any other public body may exceptionally seek an injunction preventing disclosure of …
Response status not verified
#2 —
Recommendation: In responding to this report, the government should publish a single action plan covering lessons from the breach and the resettlement response, with each action assigned a named owner, timetable for completion, intended outcome and means of reporting progress. After …
Response status not verified
#24 —
Recommendation: We also asked how the Department intends to ensure that lessons are learned and applied early in the life of the NHDF. The Department told us that it is designing its evaluation with clear review points so that it can …
Response status not verified
#23 —
Recommendation: We asked the Department what evaluation arrangements were in place for the NHDF and when these would be available. The Department told us that it is finalising the business case for the NHDF now and that further work is still …
Response status not verified
#22 —
Recommendation: Evaluations of the legacy unlocking land programmes helped shape the design of the NHDF.54 However, the NHDF will launch before the outcomes of these programmes have been fully evaluated. The Department will need to put in place evaluation that provides …
Response status not verified
#5 —
Recommendation: The Department failed to put in place external evaluation at the launch of the NHDF, risking gaps in early data collection and limiting opportunities for timely improvements. Despite launching the NHDF in March 2026 the Department has given itself another …
Response status not verified
#12 —
Recommendation: The investments announced during the State Visit were correlated to the Technology Prosperity Deal, not caused by it. Investors were clear that their decisions rested on the UK’s fundamentals: strong underlying demand for AI infrastructure, the UK’s strong rule of …
Response status not verified
#9 —
Recommendation: One year on, the Economic Prosperity Deal has delivered mixed results. Sector specific tariff mitigations in aerospace, automotive, beef, lumber and timber, pharmaceuticals and whisky show that negotiated outcomes are achievable even in a challenging US trade policy environment. However, …
Response status not verified
#13 —
Recommendation: However, a Department-wide review by the Government Internal Audit Agency (GIAA) in January 2026 found that programme and project teams across the Department were not consistently applying lessons they had identified.25 We asked the Department how it was responding to …
Response status not verified
#12 —
Recommendation: The NAO found the Department had established appropriate steps to identify lessons from other major programmes, but that it needed to go further to embed these in Northern Powerhouse Rail.23 In oral evidence, the Department was clear on the importance …
Response status not verified
#6 —
Recommendation: We are not convinced that the Department has embedded all lessons from past failures into its management of the programme. We recognise that the Department has adapted its approach to Northern Powerhouse Rail in response to lessons from High Speed …
Response attribution not verified
#5 —
Recommendation: In response to our report, we ask that DWP provide an update on programme mobilisation, including the agreement of delivery plans and what steps it took to reduce delays, and set out what lessons it has learned that could be …
Response status not verified
#3 —
Recommendation: We welcome the programme’s devolved design and recognise the government’s view that it appropriately balances national oversight with local flexibility. We are reassured that extensive performance monitoring is part of CtW, and that there is also a comprehensive evaluation programme …
Response status not verified
#13 —
Recommendation: We also examined lessons learned from recent accommodation initiatives. The NAO’s 2024 investigation into the acquisition of the Northeye site identified significant weaknesses in due diligence, 17 C&AG’s Report, paras 2.8, 2.11-2.16 18 Q 5 19 Qq 17, 137 20 …
Response status not verified
#2 —
Recommendation: The Home Office has yet to demonstrate that it has learned from previous attempts to reform the asylum system, putting it at continued risk of repeating past failures. Recent reform efforts give us little confidence that the Home Office has …
Response attribution not verified
#9 —
Recommendation: We welcome work being done to increase in-country collaboration, and believe that in-country leadership of projects should be enhanced, not diminished. The new Department has the opportunity to build on examples of excellent in-country work completed by both the FCO …
Response attribution not verified
#5 —
Recommendation: To integrate the Departments successfully, the new PUS must have the skills and experience necessary to effectively oversee both diplomatic and development projects. Above all else, they must have exceptional knowledge and experience of change management and major project delivery …
Response attribution not verified
CQC inspection actions(6)
North Devon District Hospital
The service should aim to ensure recommendations made from Ockenden 2020 and 2022 are considered and changes made are made so within a timely manner.
Should Do
Scarborough Hospital
The trust must ensure that structured case reviews are focussed on the implementation of recommended actions and the actions are monitored, completed, and recorded.
Must Do
The York Hospital
The trust must ensure that structured case reviews are focussed on the implementation of recommended actions and the actions are monitored, completed, and recorded.
Must Do
Berwick Infirmary
The trust should ensure that quality improvement projects are sustainable and quantify the impact upon the trust.
Should Do
Taplow Manor
The service must ensure that they complete the actions of the action plan following the issue of the letter of intent and embed the improvements to the service.
Must Do
Pinhoe View
The provider must ensure they complete the actions contained in their improvement plans.
Must Do
ICIBI immigration recommendations(7)
A further inspection of the EU Settlement Scheme (July 2020 – March …
Recommendation 2 Making best use of management information (MI) and ‘lessons learned’ and ‘improvements made’ stories, expand and regularly update its messaging regarding the length of time an application will …
An inspection of visit visa operations December 2022 to January 2023
Cease the use of routing, decision-making and enrichment practices, including unassured information sources such as ‘Enrichment OneNotes’, that are not compliant with policy. Managers should provide decision makers with solutions …
An inspection of visit visa operations December 2022 to January 2023
Conduct a review to ensure that the CARS tool reflects the full range of known immigration risks to the UK and that a mechanism exists to incorporate new and emerging …
An inspection of visit visa operations December 2022 to January 2023
Review the ‘interim’ status of the Complexity Application Routing Solution (CARS) and declare the Home Office’s long-term intentions
An inspection of the Border Force intelligence functions at the Humber ports …
Continue to review the tools and technology used by intelligence officers and frontline staff to maximise the benefits of intelligence and targeting opportunities by:ensuring they enable staff to undertake their …
An inspection of the Border Force intelligence functions at the Humber ports …
Review the communications strategy for the MINERVA programme to ensure that the end state of MINERVA and how it will be delivered is clearly defined and communicated to staff.
An inspection of the Border Force intelligence functions at the Humber ports …
Review the tasking process at the Operational Intelligence Tasking and Co-ordination Group (Ops ITCG) to improve its effectiveness, including:provision of a clear escalation mechanism to the Intelligence Tasking and Co-ordinating …
PPO death in custody recommendations(1)
NAO audit recommendations(393)— showing 50 strongest matches
Increasing the capacity of the prison estate to meet demand
MoJ should improve its case for bolstering the resilience of the estate by evaluating: lessons learned from delivering the prison expansion portfolio; and
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
The Cabinet Office should routinely gather and disseminate lessons learned from organisational changes across government. It should engage with all departments who have undergone MoG changes to obtain lessons learned and use this to review, update and publish its guidance …
Accepted
The government’s resources and waste reforms for England
Defra should carry out a lessons-learned exercise in advance of the formal evaluation of the reforms to determine practical steps that could be taken to help avoid the challenges it has faced recurring in its future resources and waste work. …
Accepted
Supporting investment into the UK
DIT should draw out lessons from the first two years of the OFI, to inform DIT?s transformation programme and its approach to managing investors. This should also help inform further development of the OFI.
Accepted
Supporting local economic growth
• capture and apply lessons learned at key points in the design and delivery of new local growth funds.
Accepted
The challenges in implementing digital change
c) disseminate and apply lessons learned from the successes and failures of the past and seek to understand why digital strategies have made poor progress.
Accepted
Crossrail – a progress update
The Department and TfL should examine the types of benefits realised by the Crossrail programme and Elizabeth line, and those benefits expected but not achieved, and take account of their learnings in the business cases and benefits strategies for other …
Accepted
Improving the performance of major equipment contracts
The Department is developing a programme of important reforms, some of which are at a relatively early stage. To support this agenda and to complement the recommendations in our recent report on the Department’s 2020–2030 Equipment Plan, we recommend that: …
Partially accepted
Carrier Strike – Preparing for deployment
e) conduct in-depth lessons-learned exercises on the Carrier Enabled Power Projection projects. The Department should ensure that it assesses the factors that lead projects to succeed or fail, including the root causes, and disseminate the lessons so that they are …
Accepted
Completing Crossrail
For the Department’s other current and future major programmes: d) We note that the Department has completed a lessons learned exercise and we would encourage it to also apply the lessons to other major projects including High Speed 2.
Accepted
NHSE's management of elective care transformation programmes
The national level oversight board should play an active role in ensuring that lessons are learned on and between the transformation programmes. Practical steps may include reviews, workshops or problem-solving sessions to allow everyone involved to share their perspectives and …
Accepted
Lessons learned: Governance and decision-making on mega-projects
For mega-projects, HM Treasury and NISTA should strengthen the project gateway and business case approval processes to ensure that government has assurance about the affordability, value for money and feasibility of the project before it is given final approval to …
Accepted
Lessons learned: Governance and decision-making on mega-projects
the roles and responsibilities of those who may not be directly involved in governance but are part of the broader government decision-making landscape, such as HM Treasury, cross-government or departmental programme boards, mission and leads, and NISTA, are clear and …
Accepted
Lessons learned: Governance and decision-making on mega-projects
Any alternative governance approach should also ensure that: ? roles and responsibilities are clear across those charged with governance and those involved with decision-making; this is particularly critical where decisions and accountabilities stretch across a system or set of organisations;
Accepted
Lessons learned: Governance and decision-making on mega-projects
HM Treasury and NISTA should consider using alternative governance approaches for the projects it determines are mega-projects to ensure those who have the authority to make decisions are accountable for the impact of those decisions on the project. This could …
Accepted
Government's general grant schemes
To achieve greater, proportionate monitoring and evaluation of grant schemes, the Grants Management Function should: (h) work with departments and the Evaluation Task Force to explore different approaches to identifying, sharing and using lessons learned, to inform and improve the …
Accepted
Progress on the Buckingham Palace Reservicing programme
Identify the lessons it has learnt and discuss these with the Infrastructure and Projects Authority (IPA) and HM Treasury to decide a set of lessons for major projects, particularly for heritage projects and those taking place in a live environment. …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
The Cabinet Office should ensure there is proper consideration of the costs and benefits of major MoG changes and provide longer-term support and guidance to departments facing significant organisational change. Once the decision has been taken to implement a MoG …
Partially accepted
Rail reform: the rail transformation programme
Over the next year, DfT should develop its understanding of how it can successfully deliver rail reform, including any potential pilots it could undertake, so that it is well placed to advise ministers early in the next Parliament. This work …
Accepted
Levelling up funding to local government
DLUHC should develop its plans to disseminate learning and insight from its evaluations in a timely way and engage with local authorities to maximise understanding of what works prior to waiting for final evaluation reports.
Accepted
Levelling up funding to local government
DLUHC should further use the learning from the process and impact evaluation to build an evidence base of what works to stimulate local economies.
Accepted
Levelling up funding to local government
Given the delays to projects across the Levelling Up Fund and Towns Fund, DLUHC should set out what further action it is going to take if projects cannot be completed within the existing funding deadlines. This could include resetting expectations …
Accepted
Resilience to flooding
h in the next 12 months, develop a plan of work to investigate the reasons for the increased inaccuracy and uncertainty in its business case forecasts and, based on the findings, put in place remedial actions
Accepted
Support for innovation to deliver net zero
DSIT, working with DESNZ, should by October 2023 identify the lessons learned from the development of the cross-government Net Zero Research and Innovation Framework. These lessons should be documented and actively considered in future to aid consistent and effective support …
Accepted
High Speed Two: Euston
DfT and HS2 Ltd should apply the lessons from Euston to the HS2 Manchester stations and other parts of Phase 2b of the HS2 programme. These should include: ? ensuring that a robust estimate is used to set the budget …
Accepted
High Speed Two: Euston
As part of planning an affordable and deliverable station, DfT and HS2 Ltd should learn lessons from how other projects have approached a reset, including those we set out in our report on resetting major programmes. This will include having …
Accepted
Investigation into the UNBOXED festival
identify lessons for the future about the importance of agreeing clear objectives and then setting performance targets early enough in any similar future programme?s lifecycle
Accepted
Investigation into the UNBOXED festival
identify lessons for the future from the experience of how projects have performed against their targets, including on cost and attendance, and the split between physical and digital/broadcast audiences;
Partially accepted
Government Shared Services
k) Departments working together as clusters should each complete a ?lessons identified? assessment to demonstrate how they have taken on board lessons from previous strategies and share these with the Cabinet Office.
Accepted
Supporting local economic growth
Given the challenges of carrying out high-quality evaluation, the Department should also: • carry out a prioritisation exercise to identify and fill the most important gaps in its evidence; and
Accepted
Supporting local economic growth
The Department should set out and publish its plans to formally evaluate the Levelling Up Fund and the UK Shared Prosperity Fund in line with the Magenta Book’s emphasis on the importance of planning an evaluation early. It should ensure …
Accepted
The decommissioning of the AGR nuclear power stations
The Department and HM Treasury should draw upon the lessons from the AGR arrangements when informing strategies for funding the decommissioning of new nuclear stations. This should include consideration of how the taxpayer’s position can be protected for the longer …
Accepted
BBC savings and reform
• undertake more consistent identification and dissemination of lessons arising from its delivery of savings measures;
Accepted
Progress with trade negotiations
DIT should ensure it learns lessons from the progress it has made on multiple negotiations so far. It should ensure that feedback, learning and sector knowledge from across departments and devolved administrations is recorded and shared, and used to inform …
Accepted
Improving Single Living Accommodation
The Department (and specifically, DIO) should work with the Commands to introduce, as soon as possible, a booking system that is easy to use and reduces costs. It must ensure lessons have been learned from its previous experiences and from …
Accepted
Progress report: Terminating the Magnox contract
d) ensure that its subsidiaries have the capacity to test, challenge and validate supplier information in a timely way, maintaining assurance as a primary activity in the management and oversight of the work at all times.
Accepted
Progress report: Terminating the Magnox contract
c) ensure that its subsidiaries have the capability to design and manage complex contracts; and
Accepted
Progress report: Terminating the Magnox contract
With input from the Government Commercial Function, the NDA should: b) explore with its subsidiaries what contractual levers can be included in future contracts to support the timely and effective management of underperformance;
Accepted
Progress report: Terminating the Magnox contract
With specific reference to the Magnox contract the NDA should: a) expedite its work to review the standard of quality assurance processes for asbestos and consider whether it should recoup fees from CFP.
Accepted
NHSE's management of elective care transformation programmes
Having brought oversight of the outpatients transformation into the wider elective recovery programme, NHSE should: ? make a full assessment of the lessons learned to date. NHSE should set out how these lessons will be incorporated in its plans for …
Accepted
Lessons learned: Governance and decision-making on mega-projects
HM Treasury and NISTA should develop how they categorise major projects according to their risk and strategic importance. In particular, they should define a category for ?mega-projects? that may require a different approach to governance and specify the criteria for …
Accepted
Dangerous cladding: the government’s remediation portfolio
MHCLG should share any relevant learning with the Public Sector Fraud Authority and the Cabinet Office Complex Grants Advice Panel. It should also report the results of such an exercise in its annual report and explain how it is using …
Accepted
Dangerous cladding: the government’s remediation portfolio
MHCLG should assess the feasibility of conducting a measurement exercise to estimate the extent of undetected fraud and error across its remediation portfolio. A measurement exercise would help it to understand the scale of the problem and whether further investigations …
Partially accepted
Progress on the Buckingham Palace Reservicing programme
The IPA and HM Treasury should share the lessons with government?s project delivery and project assurance and review communities. This could mean, for example, that the IPA adds the lessons to the government?s project delivery hub, includes examples on its …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should formally review what was de-prioritised from the Transformation Portfolio when creating the Integration Portfolio, to ensure that nothing has been missed, and build it into future activity. FCDO should: ? ensure that the lessons learned, and feedback from …
Accepted
Rail reform: the rail transformation programme
If DfT aims to deliver reform at speed in the future, it should fully assess the benefits of this approach and the risks to implementation and ensure there are contingencies in place. In making decisions about whether to proceed at …
Accepted
Investigation into the East West Rail project (Oxford – Cambridge)
To maintain an affordable programme of work, DfT and EWR Co should reflect on learning from other recent rail projects and assure themselves that they have adequate controls and governance in place to monitor and manage costs.
Accepted
The BBC’s implementation of Across the UK
e set out a revised communications and engagement strategy. Building on its learning from phase one, the BBC should set out plans for sustaining culture change from ATUK. As it moves into phases two and three, it needs to collect …
Accepted
The BBC’s implementation of Across the UK
c set out a benefits management strategy and plans for measuring changes in audience portrayal and economic growth without further delay. The plan should set out the baseline against which benefits will be measured, how benefits measured relate back to …
Accepted
The BBC’s implementation of Across the UK
Building on the work the BBC has underway as it moves into phase two of ATUK, it should: a review changes it has made to ATUK since March 2021, including the underlying data it is using to track these, to …
Accepted
IMB annual reports(15)
East Sutton Park (2021)
HMP East Sutton Park is an open prison for women, commended by the Board for being a safe and well-run establishment during a period affected by the Covid-19 pandemic. Key strengths include strong healthcare provision, effective resettlement preparation with good accommodation and employment outcomes, and valuable educational programmes. Challenges persist with ensuring prisoners are transferred with sufficient time to serve, effectively utilizing the IEP scheme for disruptive behaviour, and managing weekend medication administration.
PRISON
Key concerns
Channings Wood (2021)
HMP Channings Wood maintained a largely settled environment during a challenging year of Covid-19 restrictions, with notable reductions in self-harm, assaults, and substance misuse. The prison adapted its healthcare and education provisions effectively, earning commendations from Ofsted and HM Inspectorate of Probation for education and resettlement services respectively. However, significant concerns persist regarding staffing shortages impacting key worker schemes and offender management, the backlog in offending behaviour programmes, and ongoing issues with property transfers and resettlement accommodation.
PRISON
Key concerns
Ford (2021)
HMP Ford experienced a challenging year marked by Covid-19 restrictions, which the prison successfully managed, limiting outbreaks and reducing violence. Significant accommodation changes occurred with the condemnation of B wing and the introduction of new pods, which, despite initial issues, led to a reduced but more modern estate. The Board commended the prison's efforts in restoring and increasing external employment opportunities for prisoners post-restrictions, contributing positively to resettlement goals.
PRISON
Key concerns
Fosse Way (2024)
HMP Fosse Way opened in May 2023 as a category C prison and quickly reached its operational capacity of 1715 prisoners by February 2024. The IMB's first annual report highlights significant building design flaws, including inadequate facilities and security concerns, alongside staffing shortages and regime limitations. Despite successful integration of vulnerable prisoners, the rapid population increase led to a rise in self-harm and violent incidents, coupled with insufficient purposeful activity and education provision.
PRISON
Key concerns
Rochester (2025)
Rochester experienced an exceptionally challenging year marked by leadership instability and an HMIP Urgent Notification highlighting long-standing failures. While safety metrics showed improvement and staff interactions with prisoners were generally positive, the prison grappled with dilapidated infrastructure, persistent property issues, and staffing shortages impacting the regime. Major cohort changes were implemented too quickly, creating significant logistical demands.
PRISON
Key concerns
Hatfield (2022)
HMP/YOI Hatfield, a Category D resettlement prison, was found to be a safe environment with no recorded self-harm, staff assaults, or prisoner assaults during the reporting year. The prison demonstrated excellence in work and education provision, achieving high employment rates on release, and healthcare was well-managed. However, significant concerns persist regarding the poor and unhygienic condition of ablution facilities across both sites and the lack of funding for their essential refurbishment.
PRISON
Key concerns
Feltham (2022)
HMP/YOI Feltham reported a population of 348 young people and young adults at the end of the reporting year. While physical health and general well-being are met, the prison struggles with serious long-term mental health issues. Safety remains a significant concern, with a notable increase in violence and use of force incidents post-Covid, alongside challenges related to staffing, disrepair of the estate, and the regime's adaptation to larger groups. The IMB identified several key concerns, including inadequate time out of cell, insufficient support for looked after children, and issues with prison fabric and gang culture.
PRISON
Key concerns
Ford (2022)
HMP Ford is largely deemed a safe environment with fair and humane treatment, effective healthcare, and strong resettlement efforts. However, significant concerns remain regarding unsuitable prisoner arrivals, chronic understaffing in Probation, and a deteriorating prison estate, including outdated accommodation and delays in new builds. The Board also highlights issues with procurement, the lack of consistency in property rules nationally, and challenges in catering and post-release accommodation.
PRISON
Key concerns
Highpoint (2022)
HMP Highpoint, a Category C training and resettlement prison with an operational capacity of 1,270, experienced a decrease in self-harm but a 28% increase in violent incidents during the reporting year. Persistent concerns include significant maintenance backlogs by GFSL, ongoing issues with lost prisoner property, and restricted library access. Despite these challenges, healthcare provision maintained a 'green' rating, and the key worker scheme continued its development.
PRISON
Key concerns
Holme House (2022)
HMP Holme House demonstrated significant improvements in 2022, effectively recovering from Covid-19 disruptions and enhancing safety, healthcare, and resettlement services. While the prison maintained a safe and humane environment, key challenges included slow estate maintenance, deterioration in food quality, and the disproportionate impact of a growing young adult population on violence and self-harm. The IMB also highlighted issues with contractual transparency and the provision of adequate programs for vulnerable prisoners, making several recommendations to address these concerns.
PRISON
Key concerns
Featherstone (2022)
HMP Featherstone experienced a challenging year, marked by significant staffing issues that disrupted the regime and various services, including healthcare and purposeful activity. The prison's aging infrastructure is a major concern, along with the inadequate management of mentally ill prisoners in segregation. While violence reduced and overall safety improved, issues with staff culture, property management, and inconsistent use of body-worn cameras persist.
PRISON
Key concerns
Channings Wood (2024)
HMP Channings Wood has navigated a challenging year following the closure of HMP Dartmoor, resulting in significant population changes and regime disruptions. While staff resilience and a downward trend in self-harm and assaults are positive, the prison faces persistent issues with property loss, inadequate infrastructure maintenance, and delays in access to purposeful activity. Concerns also remain regarding the care of an expanding ageing population and the plight of IPP prisoners.
PRISON
Key concerns
Ford (2024)
HMP Ford, a Category D open prison, generally provides a safe and humane environment, with commendable improvements in induction processes, security measures, and a strong focus on rehabilitation through education and employment. However, the Board remains concerned about the failing building infrastructure, including critical boiler issues, inadequate phone provision, and persistent delays from probation services impacting prisoner progression and resettlement. The ongoing delay in the prison expansion project and budget cuts to vocational training are also significant concerns.
PRISON
Key concerns
Downview (2025)
HMP/YOI Downview, a women's closed prison and YOI, reported an average population of 319 against an operational capacity of 356. Key concerns include significant delays in mental health transfers for acutely unwell prisoners, persistently low rates of Release on Temporary Licence, and extremely high levels of property loss during inter-prison transfers. While staffing levels were generally healthy, the Board noted inconsistencies in staff effectiveness and operational oversight, alongside ongoing impacts of population pressure on safety and regime delivery.
PRISON
Key concerns
Erlestoke (2022)
The report covers HMP Erlestoke from April 2021 to March 2022, a period significantly impacted by Covid-19 restrictions that limited out-of-cell time. Despite challenges like staff shortages and high turnover, the Board found prisoners to be relatively safe, though violence increased and self-harm remained high. Key concerns include delays in transfers, inadequate mental health provision, and the slow pace of infrastructure improvements.
PRISON
Key concerns
IMB individual recommendations(32)
Cookham Wood (2024)
The Board recommends that there should be close scrutiny of the decisions taken in this restructure and re-roling of a YOI to determine lessons learned and how those lessons are being disseminated.
Other
Implemented
Thorn Cross (2025)
A new building was almost complete when it had to be demolished because there were so many faults with it. What lessons have been learnt to prevent this happening again? (7.3.4)
HMPPS
Implemented
Hewell Grange (2020)
The closure process adopted at Hewell Grange should be utilised as a case study for senior management development.
HMPPS
Lowdham Grange (2024)
Have lessons been learned from the transfer of prison management from one private provider to another at HMP Lowdham Grange, and is action being taken to avoid the significant negative impact on prisoners and staff occurring at any future transfer between private prison operators?
Ministry of Justice
In Progress
Fosse Way (2024)
The Board is seriously concerned about prison build shortcomings, which have been identified in the report. What will the Minister do to avoid the same errors being repeated in future builds (one of which we believe is due to open near York in the coming year)?
HMPPS
Accepted
Fosse Way (2024)
The Board is seriously concerned about prison build shortcomings, which have been identified in the report. What will the Minister do to avoid the same errors being repeated in future builds (one of which we believe is due to open near York in the coming year)?
Ministry of Justice
Accepted
Eastwood Park (2020)
In her reply to our previous annual report, the minister stated that the new offender management unit (activities centre) building remained a priority project, and that (subject to caveats) work on it was likely to start by the first quarter of 2021. Is this still the expectation?
Ministry of Justice
In Progress
Dartmoor (2020)
How will the Prison Service ensure that prisoners are not disadvantaged by the lack of investment in Dartmoor in the lead-up to the proposed closure in 2023?
HMPPS
Dartmoor (2020)
The planned closure of HMP Dartmoor in 2023 is having a significant impact on prisoners’ experience and staff morale. When will the minister provide clarity on the closure plans for the prison, so that detailed plans can be made for the future of all stakeholders?
Ministry of Justice
Noted
Belmarsh (2020)
Will the minister direct HMPPS to allocate funding for this works programme and to ensure that it takes place in 2020/21 (see section 5.1)?
Ministry of Justice
Partially Accepted
The Mount (2021)
The MoJ’s statisticians should take this as an opportunity to assess the effectiveness of these programmes in stopping re-offending.
Ministry of Justice
In Progress
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that the Home Office identify the learning that arises from both of these projects and builds that learning into future design, commissioning and oversight procedures and practices.
Home Office
North East Midlands, Yorkshire & Humber STHF (2024)
We recommend that the Home Office and Contractor undertake a review of learning from the floor works project. The review should incorporate the many concerns identified in this report, including a breach of STHF rules, The content and results of that review should be shared with the Board.
Other
Bedford (2024)
The long delay and design issues associated with the relocation of the CSU suggest some basic flaws in understanding how prisons work and a lack of consultation with local managers. When will the Prison Service address this issue?
HMPPS
In Progress
Werrington (2025)
How are interventions programmes evaluated and what evidence is there of their success?
HMPPS
Warren Hill (2025)
Further follow-up work is developed so that the effectiveness of the Warren Hill regime can be assessed against the recall rates.
Governor / Director
Hewell (2025)
What measures will the Prison Service take to ensure that funded pilot schemes, such as the HMP Hewell Here-to-Help peer mentorship programme, include metrics and criteria for success, as well as a contingency plan for scaling up if successful?
HMPPS
Implemented
Featherstone (2020)
Despite expenditure on a refurbishment programme, much of the residential accommodation, such as windows, heating and showers, is below the standard expected in the 21st century. While there has been some improvement in the operation of the maintenance contract, prison managers are often frustrated by the lack of progress, which is outside of their remit. How will the minister support …
Ministry of Justice
Erlestoke (2020)
GFSL continues to disappoint (see paragraphs 7.2 to 7.6). Will the Minister consider ways in which radical changes can be made to ensure a responsive and well-managed system for repairs and improvement?
Ministry of Justice
In Progress
Aylesbury (2020)
Share a clear set of nationally agreed priority improvements in young prisoner employment and vocational training, to ensure a much improved use of resources over a two- to five-year period. Back this effort with collection and analysis of appropriate data.
Ministry of Justice
In Progress
Thorn Cross (2021)
The number of places in the open estate nationally has fallen, which means there are a number of prisoners who are unable to benefit from the rehabilitative culture they offer and so aid a reduction in reoffending.
Ministry of Justice
In Progress
Swinfen Hall (2021)
Will the Minister assure the Board that there will be an improvement in contract monitoring and adequate supervision of works carried out in the prison estate?
Ministry of Justice
In Progress
Dartmoor (2021)
Continue to track the recommendations from last year’s IMB annual report, which have been in abeyance because of the Covid-19 regime.
Governor / Director
Bristol (2021)
It would also be useful to share details of how various initiatives are aligned to key areas for improvement, so we can better monitor and report on developments.
Governor / Director
Thorn Cross (2022)
To learn from the experiences of the recent introduction of extra accommodation, resulting in better planning and implementation of any future new accommodation (5.1.1).
Governor / Director
Portland (2022)
Will the minister address the serious shortcomings in the management processes within HMPPS particularly with reference to poorly planned reforms introduced to the service?
Ministry of Justice
Oakwood (2022)
The Board is concerned that after three years this framework has not yet been published (see section 5.8).
Ministry of Justice
Implemented
Feltham (2020)
What do you and your team consider to be the principal lessons learned over the lockdown period? How will the prison use these lessons to improve the lived experience for all young people and young adults held in custody at Feltham?
Governor / Director
Deerbolt (2020)
At Deerbolt, as throughout the prison estate, the COVID-19 lockdown has meant less violence and a better situation for some vulnerable prisoners, while most interventions intended to rehabilitate prisoners have been lost. Does the minister agree that lessons can be learned from this? Is any planning going on, to devise regimes and activities that can capture the benefits of lockdown, …
Ministry of Justice
In Progress
Warren Hill (2021)
The Board is pleased that the long-awaited upgrade in telephone and information technology data lines have been undertaken and that plans are well advanced for the installation of in-cell telephony at Warren Hill. However, the Board notes with regret that the opportunity was not being taken to install in-cell laptops at the same time (see section 7.4.3).
HMPPS
Bristol (2022)
The Board wishes to receive more regular updates on performance indicators and progress reports on various initiatives. Can this be provided more often?
Governor / Director
Dartmoor (2022)
With the appointment of the new head of business assurance, will the Governor continue to track and report on the implementation of the recommendations from the IMB, HMIP and other report recommendations?
Governor / Director
Health investigations(50)
Independent investigation: Liaquat Ali, Bury (1999) — Rec 1.i
In the development of the Action Plan that will follow the report, the Trust should draw together the recommendations of the other three incidents that occurred in 1999, to make absolutely certain that all lessons are learned.
north_west
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 36
When commissioning inquiries DHSSPS and Boards should ensure that inquiry panels have early access to research and similar inquiries of which DHSSPS and/or Boards are aware. This would avoid duplication of effort and support the learning objectives of inquiries.
northern_ireland
Independent investigation: Gerry Fairall, Kilburn, London (2006) — Rec 8
We recommend that the lessons learned from this investigation should be disseminated to all staff and put together into an action plan for implementation.
london
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 2.1.1.1
The new Research Director should be asked to review the Wendy Fisher report, ’Initiating Research’ and the 2012 report, ’External Performance Review of the Systems and Processes in the R&D Division’ together with the progress on the action planning for both with a view to engaging a wide range of …
Christie NHS Foundation Trust
north_west
*Mental health homicide investigation legacy report into the care and … — Rec 6
The Trust should undertake a review to examine the efficacy of the processes in place for the learning and sharing of lessons learned to establish their efficacy
south_east
A post-publication assurance review in relation to the implementation of … — Rec A7
The EIP team should utilise this report within a learning event in order to ensure that the lessons learnt are discussed and integrated into the Care Coordination process. To be discussed within Trust wide EIP away day and the strategy group. Individual team members should have the opportunity to reflect …
north_east_yorkshire
Independent investigation into the care and treatment of Mr B — Rec 15
The Trust must manage clinical and organisational commitments appropriately to ensure that they do not cause delays in investigation of serious incidents and implementation of learning.
Mr B who committed a homicide in 2012. Mr B was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr B — Rec 14
The Trust must identify all stakeholders required to be present on the Board Level Inquiry panel at the point that investigations are commissioned, in order to reduce delays in implementing lessons learned.
Mr B who committed a homicide in 2012. Mr B was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
An independent review into the independent sector provider One to … — Rec 5
Mainstreaming of a new service should be at a prudent pace to allow full consideration of issues and risks raised as well as re-evaluation at milestone points.
north_west
An independent review into the independent sector provider One to … — Rec 3
Pilot evaluation should consider the impact on the wider system and include system-wide engagement and deliberation with all stakeholders involved. The potential risks of the cultural barriers involved in bringing the independent sector into an established NHS infrastructure should be assessed.
north_west
An independent review into the independent sector provider One to … — Rec 2
A comprehensive pilot evaluation should be undertaken as a fundamental step in the commissioning process, at a pace which allows all stakeholders to contribute to feedback. This should set out the learning and challenges experienced, potential risks and implications for future commissioning, and should allow recalibration of options and retesting …
north_west
Independent investigation: Karen Leonard, Middlesbrough (2009) — Rec 10
The recommendations of this independent review should be endorsed and in addition the panel recommends:- (a) An action plan is developed and shared with key stakeholders both internal and external to implement the recommendations of this report and; (b) The Board of Tees, Esk and Wear Valley NHS Foundation Trust …
north_east_yorkshire
Independent investigation: Lisa Sullivan, Walton on the Naze (2005) — Rec 10
The Strategic Health Authority should ensure that Independent Investigations following a homicide are conducted promptly. The SHA should ensure where there is also a Serious Case Review being conducted by the Local Safeguarding Children Board, that there is good liaison and joint planning between these reviews, particularly at the stage …
east_of_england
Independent investigation: Leonie McGlashan, Wood Green (1995) — Rec 12
The East London and The City Health Authority should establish an interagency group to examine the conclusions and recommendations of this report and to establish clear implementation plans, with a clear timetable, involving the prison, probation, health and social services.
london
Independent investigation: Jordan Cooper, Washington (2011) — Rec 8
NTW should undertake an evaluation of the impact of the changes that were introduced as a direct result of the SI’s recommendations.
north_east_yorkshire
Independent investigation: Jonathan Palgrave, Preston (2018) — Rec 3
The Trust must revise and refresh the action plans for these investigations to assess progress and whether actions are still appropriate to meet the original recommendations. Action owners should also be revised and refreshed and revised timelines for delivery of their actions agreed with approval from the CCG and the …
north_west
Independent investigation: Janet Hossein, East London (2007) — Rec Recommendation 6
The analysis of the Trust‟s own investigation did not reveal information consistent with an effective investigation process, or one that evidenced knowledge and competency in information analysis or root cause analysis. Consequently, it is important that East London Foundation Trust: Identify lead investigators for its serious untoward incident investigations …
london
Independent investigation: Janet Hossein, East London (2007) — Rec Recommendation 5
Although it was clear to the Independent Investigation Team that East London Foundation Trust has taken action on the recommendations it made following its own internal investigation into the care and treatment of Mr SU, whose care and treatment is subject to this independent investigation, the Trust was not able …
london
Independent investigation: Hamidi HamidullahKhizer Hayat, Tulse Hill (2006) — Rec Recommendation Numbe
The Trust acknowledges the far reaching nature of the independent investigation and the opportunity that this provides for organization-wide learning. The Trust should arrange learning feedback sessions to enable the findings of this investigation to be raised with a wide audience and to help ensure that lessons are learnt.
london
Independent investigation: Frank Empson, Harlow (2006) — Rec R4
NHS East of England should share issues arising from these investigations to ensure best practice in SUI policy development and the appropriate learning of lessons arising from such investigations. One way in which this could be achieved would be to hold a workshop for key senior managers from mental health …
east_of_england
Independent investigation: George Acres, Rochford (2018) — Rec 3
EPUT must ensure that internal investigation reports meet the timeliness standards expected by the NHS England Serious Incident Framework, and that recommendations are outcome focused.
east_of_england
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 3.4.2.1
That either the full Board or a limited-lif e sub-committee, with a majority of non-executive directors reviews the reports that have been received about R&I including ’External Performance Review of the Systems and Processes in the R&D Division’f rom 2012; the Wendy Fisher report; the report of the Non-Executive Director …
Christie NHS Foundation Trust
north_west
Independent review of mental health treatment and care provided in … — Rec 3
We recommend that the Action Plan that was developed by Dorset Healthcare in relation to the DHR recommendations should be revisited in the light of this report. The purpose would be to set out clearly the ways in which the impact of changes in the service will be measured.
south_west
An independent investigation into the care and treatment of a … — Rec 3
The NHS Dorset Clinical Commissioning Group must ensure that: • provider action plans properly address recommendations in the associated serious incident reports; • provider action plans are appropriately monitored, and that evidence is assessed to provide assurance that the required actions are in place; • when actions are not completed …
Mr P in Dorset NHS England has published an independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust
south_west
A post-publication assurance review in relation to the implementation of … — Rec B3
The Trust should assure itself within three months of receipt of the final report that it can evidence the implementation and completion of each recommendation, all of which were signed off at the South Locality Quality Standards Group meeting in September 2019.
north_east_yorkshire
A post-publication assurance review in relation to the implementation of … — Rec B2
The Trust should ensure that SI action plan evidence is rigorously tested and recorded in advance of action plan sign off.
north_east_yorkshire
Independent Quality Assurance Review – Norfolk and Suffolk NHS Foundation … — Rec 6
Public Health Suffolk should undertake an assurance audit of the implementation of the action plan from this independent investigation.
Norfolk and Suffolk NHS Foundation Trust
east_of_england
Independent external quality assurance review following the independent investigation into … — Rec 24
There should be a local ‘lessons learned’ day, as soon as practicable, for each organisation to share with others an update on the progress made on the implementation of their action plans, seek clarification and share experiences. We also recommend that the outcome of the ‘lessons learned day’ is a …
midlands
Accepted
Independent investigation: Janet Frost, Meadowfielsd – County Hospital Durham (1999) — Rec 8.3
Social services should make more use of case review meetings.
north_east_yorkshire
Independent investigation: Jane Edwards, Hanwood, Shrewsbury (2010) — Rec 3
The trust should develop a system for monitoring investigation teams to ensure there are adequate resources to conduct the work identified in the Incident, Near Miss and Serious Incident Policy.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 56
After a year has elapsed from the implementation of these recommendations, a review should be undertaken to assess their impact and to give an opportunity to consider any necessary reinforcements of their objectives.
midlands
Independent investigation: Gordon Stalker, Brighton (2010) — Rec 3.12
In discussion with the trust we have identified a number of key themes arising from this investigation. We recommend that these themes should be part of a short independent review but carried out in partnership with the trust. The objective of the review would be to identify how effectively the …
south_east
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 34
The Trust should draw up an Action Plan in the light of these Recommendations
london
Independent investigation: Catherine Ogram, Aldershot (2002) — Rec 4.48
The SHB Trust’s Scrutiny Panel should, at the earliest opportunity, highlight each agreed action not yet addressed or partially completed. The Panel should formally agree a timetable, responsible organisation and responsible officer for each “non-completed” action to be implemented with a target date for completion. Any difficulties in meeting agreed …
south_east
Independent investigation: Jean Robertson, Sittingbourne (2015) — Rec 13
NHS England (South) should consider overseeing all recommendations made for NHS England by any independent reports.
south_east
Independent investigation: Bianca ‘Kay’ Shepherd, Uxbridge (2015) — Rec 4
The CCG should undertake an audit of Serious Incidents within the past 12 months with a view to confirming that action plans were monitored and tested.
london
Independent investigation: Bianca ‘Kay’ Shepherd, Uxbridge (2015) — Rec 3
The CCG should assure itself within the next three months that it has robust systems and processes in place to monitor and test individual SI action plans. This should include finalising its SOP for the ‘internal management of Serious Incidents utilising “Datix”’
london
Independent investigation: Abida Bi, Bradford (2010) — Rec 3
Although the Trust’s internal investigation report demonstrated a sincere commitment to the conduct of an effective investigation, there are a number of elements that the Trust needs to improve to ensure that future investigations: Maintain objectivity; Deliver good practice standards in investigative interviewing techniques; Demonstrate a good …
north_east_yorkshire
Independent investigation: Abida Bi, Bradford (2010) — Rec 1
BDCT commissioned its own review of the CMHT under which Mr S was managed. The report of this review was published in March 2012. The Independent Team recommends that BDCT provides its commissioners with a detailed breakdown of its considerations of the recommendations made in this report and any actions …
north_east_yorkshire
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 2.4.6.5
The Trust’s Audit Committee may wish to commission a study of the procurement processes in relation to the relationship with Roche and corporate partners in order that the Trust can develop SOPs for future ventures.
Christie NHS Foundation Trust
north_west
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 2.4.6.3
Any plans to enter into commercial partnerships in future should be supported by clearly articulated programme management arrangements including a lead director, assigned responsibilities, timescales, risk management arrangements and escalation points. This should incorporate a communications plan f or engagement with key stakeholders and reporting to the Board of Directors …
Christie NHS Foundation Trust
north_west
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 2.4.6.1
That the Board of Directors considers the f ull report ’Independent Assessment of the Progression of Real-World Evidence/Big Data Partnership Opportunities at The Christie 2018-2020’, Professor Andrew Hughes and the Non-Executive Director’s ’Freedom to Speak Up – a Review June 2, 2020’ to draw out the key learning points for …
Christie NHS Foundation Trust
north_west
*Independent investigation into the care of Mr A: March 2013 — Rec 1
CPFT to prepare a detailed action plan, incorporating a timetable and measurable deliverables, in relation to the Bradley Report to ensure that the recommendations of the Bradley Report have been incorporated into MHIRT practices and procedures with a view to improving the provision of services to offenders with dual mental …
Cambridge and Peterborough NHS Foundation Trust
east_of_england
An independent mental health homicide investigation into the care and … — Rec 14
At Sancus Solutions’ six-month quality assurance review, AWP and Cygnet Health Care must demonstrate that they have a quality assurance process in place that monitors and evaluates the impact of changes that have been made as a result of recommendations from their serious incident investigations.
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent investigation into the care and treatment of a … — Rec 10
The Trust should strengthen its process in relation to how it assures itself that the actions from Serious Incidents have been fully operationalised and embedded.
south_east
An assessment of a mental health trust’s internal investigation of … — Rec R10
The Trust should ensure that the impact of external factors, such as the Covid-19 pandemic, on service delivery and effective risk management is thoroughly examined in future investigations, to maximise learning and inform resilience planning.
north_east_yorkshire
Independent investigation into the care and treatment of patient Y: … — Rec 9
The Trust should review the systems in place to sign off action plans from serious incidents, and ensure that there is an assurance process to evidence implementation and embedded practice changes.
South Essex Partnership University NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of Patient R: … — Rec 10
The Trust should test for effectiveness their implementation of the internal investigation’s recommendations, and ensure that the new model of care is operating fully and effectively by conducting some qualitative audits of the whole care pathway including for someone with personality disorder.
5 Boroughs Partnership NHS Foundation Trust
north_west
Independent investigation into the care and treatment of P in … — Rec 24
There should be a local ‘lessons learned’ day, as soon as practicable, for each organisation to share with others an update on the progress made on the implementation of their action plans, seek clarification and share experiences. We also recommend that the outcome of the ‘lessons learned day’ is a …
midlands
Accepted
A Joint Domestic Homicide Review and independent mental health homicide … — Rec 13
The Northumberland Multi Agency Risk Assessment Conference protocol must be reviewed to incorporate learning from this review.
Joint Domestic Homicide Review and independent mental health homicide investigation in April 2019 in Northumberland. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Detention investigations(2)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 18
IND pulls together the lessons on design from the Yarl’s Wood experience (size, long corridors, siting of the control room, construction materials etc) and ensures that they underpin the production of any future footprints or alternative designs submitted by contractors.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 12
• Contractors be required to draw up and implement action plans following any serious incident. The plans should incorporate all lessons learned and, where those lessons are generic, should be applied across all the contractor’s centres; • IND monitors implementation within agreed timescales; • IND ensures that contractors prepare contingency …
Immigration Detention
Independent reviews(50)
Cunliffe Water Commission — Rec 85
Recommendation 85: Water companies should work with Water UK to disseminate innovation learnings across the water industry in England and Wales.
Other
Corry Defra Regulation Review — Rec 3
Establish a Defra Infrastructure Board to accelerate the delivery of significant projects by providing early and strategic perspectives on priorities and outcomes. This should include a rolling, forward-looking pipeline of Nationally Significant Infrastructure Projects and other wider complex projects where relevant; in-depth lessons learned from previous projects; working closely with …
Other
Jones: Patronising Disposition Review — Rec 22
The bereaved families' experience of the various public inquiries which have taken place into Hillsborough points to a number of points of learning. In particular: The Hillsborough Independent Panel demonstrates that formal inquiries under the Inquiries Act 2005 are not the only option available to government when it is considering …
Policing & Security
Carter Legal Aid Review — Rec 4.27
Following the introduction of the first community legal advice networks in 2006, options for networks should be tested out in different areas by the Legal Services Commission to identify which approach works best in each of a variety of different circumstances.
Justice & Legal
Carter Legal Aid Review — Rec 4.12
DCA and the Legal Services Commission should review the effectiveness of the October 2005 changes to the advocacy graduated fee cracks and guilties scheme in the Crown Court, and any changes proposed to this scheme, on the timing of cracked cases. This should report in January 2007 and be considered …
Justice & Legal
Carter Legal Aid Review — Rec 3.6
It is recommended that the Legal Services Commission should carefully evaluate the impact of the transition in the first wave of community legal advice centres from 2007, so lessons can be learnt for later waves from 2008 09 onwards.
Justice & Legal
Levene Defence Reform Report — Rec 7
Key recommendation 7. Some military capabilities have to be integrated on a ‘joint’ basis in order to effectively enable operations. Such enabling capabilities need more effective proponency within Defence. To that end, a Joint Forces Command should be created to manage and deliver specific joint capabilities and to take the …
Other
Pitt Floods Review — Rec 92
Local Resilience Forums should evaluate and share lessons from both the response and recovery phases to inform their planning for future emergencies.
Other
Tooke MMC Inquiry — Rec 7
The introduction of necessary changes stemming from this report should i) involve all relevant stakeholders especially professional representatives, ii) abide by best principles of project and change management and include trialling where appropriate and feasible, iii) be subject to rigorous monitoring and evaluation.
Health & Social Care
Heseltine Growth Review — Rec 71
As part of their growth commitments, departments should set out plans for sector-based supply chain programmes, learning from the experiences of the Advanced Manufacturing Supply Chain Initiative.
Other
Goldacre Review — Rec TRE 53
An overview of prior investments All new funding via national funders such as UKRI of TREs and related resources should begin with an appropriately detailed open inventory of all prior investment in this space over the past decade, with the positive intention to learn helpful lessons around optimal delivery. This …
Health & Social Care
Goldacre Review — Rec TRE 48
There should be follow-up on all TRE projects resourced This should be regarded as a positive opportunity to share outputs, methods, code, insights and technical documentation for others to review, re use, or improve; and a chance to share barriers encountered for others. It is to be expected that some …
Health & Social Care
Goldacre Review — Rec Open 36
Review prior delivery of open code by applicants During a period of transition to new ways of working it is important that those leading by example are enabled to drive change; and prior delivery in this comparatively new space will likely be a strong predictor of future delivery. Particular caution …
Health & Social Care
Flanagan Review of Policing — Rec 18
The NPIA should work with forces on a post implementation review of the SOLAP workplace assessment and accreditation process, which the Greater Manchester Constabulary has offered to lead.
Policing & Security
Flanagan Review of Policing — Rec 12
The NPIA should produce an interim evaluation report from the workforce modernisation pilot sites by autumn 2008 so that the service is not denied valuable learning pending the final report.
Policing & Security
McNulty Rail Review — Rec 28-asset-management
Recommendations on asset management, programme and project management, and supply chain management focus on stronger partnership working from inception through to the supply chain, identifying the optimum approaches to maintain, renew or enhance the railway, followed by delivery of the necessary engineering work or equipment in the most efficient manner. …
Other
Allen Early Intervention Review (Part 1) — Rec 19
I recommend that a new rigorous methodology for evaluating and assessing Early Intervention programmes should be instituted and developed for the UK, aimed at identifying the best, most effective programmes to help our babies, children and young people.
Other
Field Review on Poverty and Life Chances — Rec 14
Local Authorities should ensure use of services which have a strong evidence base, and that new services are robustly evaluated. Central Government should make a long term commitment to enable and support the bringing together of evidence around interventions, learning from examples such as the National Institute for Clinical Excellence …
Other
Maude Civil Service Review — Rec 38
Recommendation 38: Sir Martin Read should now be invited, together with the Government Lead Non-Executive Director, to revisit his findings, and assess the extent to which his recommendations have been implemented.
Other
Maude Civil Service Review — Rec 11
Recommendation 11: Anyone invited to conduct a review into any aspect of the Civil Service should be invited back two years after submitting their recommendations to assess progress in implementation. Their follow-up assessment should be published. Ministers should have the opportunity to receive written or oral updates directly from the …
Other
Oakervee Review — Rec 38
Conclusion 38: Systems integration in HS2 Ltd needs to be strengthened now and maintained throughout the life of the project and beyond into asset management. It also needs to be ensured there is a single point of accountability for systems integration. This is a vital lesson from Crossrail. Clear accountability …
Other
Oakervee Review — Rec 26
Conclusion 26: Lessons from the Phase One Main Works Civils contracts, and indeed from Crossrail and other major transport projects, need to be learnt and applied by HS2 Ltd. Revised procurement and contracting models should be considered, especially for any future HS2 construction contracts including on Phase 2a. In any …
Other
Oakervee Review — Rec 20
Conclusion 20: HS2 Ltd and Network Rail to engage with each other to ensure that cost estimating methodologies are used in a consistent fashion including on an ongoing basis for future projects. There is an opportunity to learn from each other.
Other
Oakervee Review — Rec 19
Conclusion 19: HS2 Ltd and the DfT need to deploy benchmarking more consistently and more uniformly. The DfT, with the support of the IPA, should build on the useful multi-project benchmark which the DfT has developed. Any benchmarking should be UK-specific where relevant, but look to include and learn from …
Other
Selous Review — Rec 90
The Armed Forces Covenant Fund Trust to: • support the use of a range of robust, validated and appropriate evaluation tools to measure outcomes, benefits and the effectiveness attributable to each project/programme of work • consider the appropriateness and modifications needed to use the Outcomes Measurement Framework with UK Serving …
Other
Farmer Review (Women) — Rec 4
The Ministry of Justice's evidence landing page and the National Concordat to include the learning from successful pilots, so future commissioners know what is proven good practice.
Justice & Legal
Cunliffe Water Commission — Rec 88
Recommendation 88: An independent review of the follow up to the Commission's report should be carried out in 2 years' time.
Other
Cunliffe Water Commission — Rec 78
Recommendation 78: A review of the current PCD framework in England and Wales should be completed before the end of AMP8, to inform a more robust and flexible framework, broadly set at programme level spending.
Other
Cunliffe Water Commission — Rec 77
Recommendation 77: The delivery assurance frameworks (Delivery Plans and Delivery Monitoring Framework) that cover infrastructure capital spending across England and Wales should be reviewed during AMP8 and rationalised.
Other
Cunliffe Water Commission — Rec 65
Recommendation 65: The regulator in England should continue the essential steps that Ofwat is taking to address issues with DPC and SIPR. A full evaluation of both schemes should be undertaken in 5 years when a broader evidence base has been accumulated. The Commission recognises that given different views on …
Other
Cunliffe Water Commission — Rec 60
Recommendation 60: The UK Government should conduct a full post-implementation review of the BRM. The Welsh Government may also wish to consider a post-implementation review of the BRM, although the Commission recognises policy towards the BRM is different in Wales than England.
Other
Carter Legal Aid Review — Rec 4.30
There should be no major changes in the current civil representation ex post facto remuneration scheme for the time being, but it should be kept under close review by DCA and the Legal Services Commission, together with the profession, and DCA and the Legal Services Commission should produce a report …
Justice & Legal
Wachter NHS IT Review — Rec 10
A Robust Independent Evaluation of the Programme Should be Supported and Acted Upon. In light of the likelihood of unanticipated consequences, the high cost of digitisation, and the chequered history of past efforts to digitise the secondary care sector, the NHS should commission and help fund independent evaluations of the …
Health & Social Care
Litchfield WCA Review Year 4 — Rec 4
Give due consideration to whether piloting is required for interventions and, if so, to design pilots with particular attention to the means of evaluation. There should be suitable and sufficient analytical input to any pilots at the design, implementation and evaluation stages.
Employment & Work
Litchfield WCA Review Year 4 — Rec 2
The Evidence Based Review and the actions taken by the Department as a result of its findings should be evaluated as part of the Year 5 Independent Review.
Employment & Work
Winsor Review Part 2 — Rec 22
The direct entry scheme for superintendents should be reviewed after a period of five years.
Policing & Security
Goldacre Review — Rec Open 26
Proactively address sharing during the pandemic Academic researchers have played an essential role in the response to the global COVID-19 pandemic. Yet, despite the global nature of the emergency, not all research, code, and other outputs have been made openly available for others to re-use or learn from. In some …
Health & Social Care
Goldacre Review — Rec S29
Build TRE capacity by taking a hands- on approach to the components of work common to all TREs. Avoid commissioning multiple closed, black box data projects from which little can be learned, or framing these as “experiments”. Experimentation is only powerful where it delivers openly shared working methods, code, outputs …
Health & Social Care
Goldacre Review — Rec S20
Seek expert help from academia and industry, but ensure all code and technical documentation is openly available to all, procuring newly created “intellectual property” on a “buy out” basis. Commission “Best Practice Guidance” on outsourcing data analytics to cover: where external collaborations can be most helpful; the role of skilled …
Health & Social Care
Harris Review: Deaths in Custody — Rec 107
Each body to which a recommendation in this Review is directed should produce an action plan on implementing those recommendations within three months of the Government’s response to this review being published. These action plans should contain SMART targets. The IAP should have responsibility for discussing these action plans with …
Justice & Legal
Allen Early Intervention Review (Part 1) — Rec 26
I recommend that the Foundation should be given the following roles: • to lead and motivate the expansion of Early Intervention with initial emphasis on the 15 Early Intervention Places; • to evaluate Early Intervention policies on the basis of a rigorous methodology and a strong evidence base, and encourage …
Other
Allen Early Intervention Review (Part 1) — Rec 21
I recommend that a growing number of excellent well-regarded UK programmes should be assisted in joining the list as proven programmes able to help our children the most.
Other
Allen Early Intervention Review (Part 1) — Rec 13
I recommend that future expansion of Early Intervention programmes should favour those which combine strong evidence bases with impact on crucial stages in the development of social and emotional bedrock in children, and that the present national network of children’s centres should use such approaches, including evidence- based evaluation systems, …
Other
Selous Review — Rec 91
The Ministry of Defence to: • take into account the learning from welfare approaches elsewhere • encourage increased international research to build the evidence base of ‘what works’ in providing welfare support for Service families • encourage further research into the effectiveness of early intervention programmes which aim to enhance …
Other
Coates Prison Education Review — Rec 31
Evaluation of the education reforms should be considered as part of the evaluation strategy for overall programme of prison reform
Justice & Legal
Farmer Review (Women) — Rec 21
The recommendations from this Review to be added to the implementation plan for the original Farmer Review, with progress monitored and reported on in the same way. This recommendation has already been accepted by the MoJ.
Justice & Legal
Cunliffe Water Commission — Rec 81
Recommendation 81: Water companies, through Water UK, should share best practice on supplier contracts and procurement strategies to help improve water company relationships with the supply chain in England and Wales.
Other
Levene Defence Reform Report — Rec 13
Key recommendation 13. The new Defence Board should ensure that the implementation of the Defence Reform proposals is properly resourced, coordinated from Head Office and driven by both Ministers and the senior leadership of the Department.
Other
Levene Defence Reform Report — Rec 7d
In implementing the Joint Forces Command, the Department should systematically review joint or potentially joint capabilities and functions across the Services against the criteria set out below to determine which might be rationalised, the merit of further joint organisations, and which should transfer to the Joint Forces Command and which …
Other
Levene Defence Reform Report — Rec 4c
The Department should take stock of progress in implementation in two years’ time, and consider whether the proposed role and structure of the Head Office, including the requirement, role and seniority of the 2nd PUS and VCDS remain valid.
Other
Domestic Homicide Reviews(107)— showing 50 strongest matches
Bury — recommendation 1.
Line Managers to implement individual actions plans in relations to PK and MM to ensure implementation of learning from this DHR
Cheshire & Greater Manchester CRC
Bromley — recommendation 4.5.10
That this review, when finalised, be forwarded to the CSP at Bexley for them to consider the learning opportunities possible from the evidence of the perpetrator’s possible needs when a child within that borough.
Bexley Community Safety Partnership
Doncaster — recommendation 3
To share the lessons learnt from this DHR with Adult Social Care staff, to highlight any missed opportunities.
Doncaster Adult Social Care
Doncaster — recommendation 17.5
The learning from this review should be shared with Doncaster Safeguarding Adult Board.
Doncaster Safeguarding Adult Board
Doncaster — recommendation 17.4
South Yorkshire Police should provide the Community Safety Partnership with a presentation outlining their implementation of recommendations 14 – 18 of the Vulnerability Knowledge and Practice Programme (VKPP) report – Domestic Homicides and Suspected Victim Suicides 2021 – 2022 Year 2 Report (December 2022).
South Yorkshire Police
South Yorkshire Police
Norfolk — recommendation 7
That Norfolk CSP review any targeting awareness campaigns arising from the DHR into the death of “April” in 2019 and consider whether learning from this review can be used to develop work in that area.
Norfolk Community Safety Partnership
Kent — recommendation 7
Upon completion and review/audit of the IRIS project, dependent of the findings, consideration is to be given to the rolling out IRIS within other parts of Kent and Medway.
Kent and Medway ICB
NHS Kent and Medway …
Wokingham — recommendation 4
We recommend that the findings, conclusions and recommendations of this DHR be disseminated widely and used to directly inform service change and practice improvement processes. In particular the similarities between this case and DHR1 should be reviewed and used to inform the approach to assessments and service delivery to older …
Wokingham Community Safety Partnership
Haringey — recommendation 8
It is recommended that this review be forwarded to Detective Superintendent Sean Oxley, for the lessons learned to be considered by the ‘Offender Management Working Group’.
Metropolitan Police Service
Metropolitan Police Service
Haringey — recommendation 7
It is recommended that this review be forwarded to Simon Tee, Head of the Criminal Justice Offender Managers Services (CJOMS), for the lessons learned to be considered by the Judicial Order Working Group.
Metropolitan Police Service
Metropolitan Police Service
Wigan — recommendation Four
When WBSCP submit this report to the Home Office DHR Unit they ask them to consider undertaking research into other DHRs to establish whether the phenomenon concerning separation whilst living in the same household is also present and if so to take appropriate action.
WBSCP
Leicester
Share learning from Domestic Homicide Review lessons learnt from DHRs and SCRs at the joint safeguarding board and domestic violence delivery group conference on the 4th November 2014 aimed at frontline professionals, students and academics.
Leicester Safeguarding Adults Board
Kingston upon Thames — recommendation 46
To ensure that lessons learned from this Domestic Homicide review are considered in the development of the remit, terms and conditions of the Kingston Strategic Board for Domestic Violence.
Domestic Violence Strategic Board
Kent — recommendation 1
Kent Police must examine its initial response to calls made by the victim between 2 November and 7 November and amend policies and guidance in order to ensure that the lessons learned from this review are incorporated.
Kent Police
Kent Police
South Gloucestershire — recommendation 27
To discuss the outcomes of this report with all Senior Practitioners.
South Gloucestershire Council: Children, Adults and …
South Gloucestershire — recommendation 19
Undertake a ‘lessons’ learnt meeting with the team in relation to this case, to include the lessons learnt above, plus potential assumptions about risk, boundaries of role in supporting client in relation to person in treatment i.e. where they are not directly working with the person in treatment
Developing Health and Independence
South Gloucestershire — recommendation 14
Training provision to be reviewed in light of lessons learned through DHR process
Bristol Drugs Project
South Gloucestershire — recommendation 10
Learning from this incident to be shared with the BSDAS teams, particularly in relation to more inquisitive questioning about potential risk issues.
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Rochdale — recommendation 10.1
That the Rochdale Safer Communities Partnership (SCP) is assured that a process is in place to identify “domestic abuse victim suicides”; That the Rochdale Safer Communities Partnership (SCP) share the learning from this DHR with the Greater Manchester Bereavement Service; That the Rochdale Safer Communities Partnership (SCP) supports the recommendations …
Rochdale Safer Communities Partnership (SCP)
Buckinghamshire — recommendation SCAS-2
Learning from the review will be shared with staff to inform future practice.
South Central Ambulance Service NHS Foundation …
South Central Ambulance Service …
Wigan — recommendation 4
That Wigan Council’s Building Stronger Communities Partnership publishes this report and shares the learning with colleagues within the Borough and also across Greater Manchester.
Wigan Building Stronger Communities Partnership
Wigan — recommendation 2
Feedback learning from DHR 6 to GPs and Practice Managers.
Wigan Borough Clinical Commissioning Group
Wigan Borough Clinical Commissioning …
Basildon — recommendation 18
That the Essex Domestic Abuse Board considers the learning from this DHR process and uses it to inform the Essex guidance for future DHRs.
Essex Domestic Abuse Board
Durham — recommendation 11
The Safe Durham Partnership Board should consider the opportunity to establish priority stakeholder workshops to examine this DHR as a case history from reporting to conclusion in a useful table-top exercise.
Safe Durham Partnership Board
Chelmsford — recommendation 1
Share the report with relevant partners and confirm to the Chelmsford Community Safety Partnership that the lessons learnt have been disseminated as appropriate within three months of receipt of the report
London Safeguarding Children Board
Knowsley — recommendation 6.3
Agencies who have a statutory duty to participate in the Domestic Homicide Review process should be reminded that their involvement should be comprehensive and timely. In co-operation with the Community Safety Partnership, each agency involved in this DH Review will be invited to develop and implement a learning action plan.
Knowsley Community Safety Partnership
Birmingham — recommendation 4
This report should be shared with the employing organisation formally by the BCSP to enable learning to take place in the organisation. The Employing organisation should be supported to develop and implement a domestic violence policy and procedure that ensures a safe, empowering and supportive response to victims, and assists …
The Employing organisation
Bristol — recommendation 4
Review not only what recommendations have been made and completed by DHR’s in Bristol, but also what difference that has made
Bristol Community Safety Partnership
Solihull — recommendation 5
Solihull Safer Partnership to ensure that the lessons learnt during this review and previous learning from Domestic Homicide Reviews locally, regionally and nationally be disseminated to all agencies, managers and practitioners by way of learning events to be held across the Borough.
Solihull Safer Partnership
Central Bedfordshire — recommendation 2
The CSP to work with partners in the BDAP to agree a mechanism for collating and sharing findings and recommendations systematically from local DHRs.
Central Bedfordshire Community Safety Partnership
Stoke-on-Trent — recommendation Stoke-on-Trent Child
A “seven-minute” briefing will be rolled out to inform of the Lessons Learned from this review to both Children’s Social Care and Early Help.
Stoke-on-Trent Children and Young People’s Service
Stoke-on-Trent City Council
Stoke-on-Trent — recommendation 7
The Safer Derbyshire community safety partnership should consider whether the DHR has identified any learning that is additional to the DHRs previously completed in the county.
Safer Derbyshire community safety partnership
Plymouth — recommendation 5
The panel considered that this case be written as an anonymised case study to help professionals understand the often hidden nature of control, and its danger when challenged. This case would also highlight some of the specific problems facing elderly people in our communities. The Independent Chair will write a …
Safer Plymouth
Manchester — recommendation 9.2 d
Contact the civil justice group in the Manchester area and request that they are made aware of the learning from this case.
civil justice group in the Manchester …
Milton Keynes — recommendation 4
The learning from this review should be brought together with the learning from other domestic homicide reviews in Hertfordshire to inform strategy and practice
Hertfordshire Domestic Abuse Partnership
Chorley and South Ribble — recommendation 4
Each Agency involved in this particular case should take time to reflect on their involvement in the DHR and develop any necessary action learning points in order to satisfy themselves that their procedures are sufficiently robust to manage the delivery of information to any future domestic homicide review. In co-operation …
Each Agency involved in this particular …
Dorset — recommendation 1
That Safer Somerset Partnership and Dorset Community Safety Partnership widely disseminate the learning from this review locally but also consider preparing a briefing derived from the learning from this case and circulating it nationally.
Safer Somerset Partnership | Dorset Community …
Somerset Partnership NHS Foundation …
Islington — recommendation 11
As this case has some similarities with other serious cases involving family carers, the Islington Safeguarding Adults Partnership Board should examine together all such cases in the last 24 months to identify any areas for development or concern.
Islington Safeguarding Adults Partnership Board
Wirral — recommendation 1
This review and its findings to contribute to the review of MERIT, particularly in reference to responses to Bronze victims.
Merseyside Police
Merseyside Police
Croydon — recommendation 26
The Joint Strategic Needs Assessment on domestic violence should reference the findings of the two domestic homicide reviews
Croydon Council Public Health
Croydon — recommendation 19
Update the Trust Policy on Domestic Violence and Partner Abuse (2008) to reflect current best practice and findings from the two domestic homicide reviews conducted in Croydon.
South London & Maudsley NHS Foundation …
South London and Maudsley …
Croydon — recommendation 3
Disseminate learning from the two domestic homicide reviews widely across the partnership. This should be in the form of a written briefing to all staff and dissemination sessions and incorporating findings into any domestic violence training that is commissioned and delivered locally.
Croydon Community Safety Partnership
East Sussex — recommendation 40
The specification and monitoring of the new integrated Health Visiting and Children’s Centre service should be informed by any learning from this DHR.
East Sussex County Council
East Sussex County Council
East Sussex — recommendation 39
MASH and TAF administrative processes and systems should be informed by any learning from this DHR.
East Sussex County Council
East Sussex County Council
Liverpool — recommendation 17.1.6
That Liverpool Community Safety Partnership should share the learning from this review with CHAMPS Public Health collaborative, to inform their ongoing work on suicide prevention.
Liverpool Community Safety Partnership
Liverpool — recommendation 17.1.4
That all agencies that have contributed to this review, should provide evidence to Liverpool Community Safety Partnership on how the learning on this case – around the indicators of increased risk of suicide, including where individuals no longer have contact and access with their children, and when this contact is …
All contributing agencies
Liverpool — recommendation 17.1.3
Current work to develop a new domestic abuse strategy for Liverpool should take into account the learning from this review, with particular reference to the use of professional curiosity and a ‘believe and verify’ approach when providing services to domestic abuse victims.
Liverpool Community Safety Partnership
Liverpool — recommendation 17.1.2
That Liverpool Community Safety Partnership requests evidence and assurances from agencies, as to how the learning from this case has been disseminated and embedded into practice. This could be achieved through the submission of a report that details how the learning has been embedded and the outcomes of case audits …
Liverpool Community Safety Partnership
Wolverhampton — recommendation 1
Ensure the learning from this review is disseminated to all agencies and services that are likely to encounter domestic abuse.
Safer Wolverhampton Partnership
Doncaster — recommendation 1
Training for primary care staff to include learning from previous DHRs.
NHS South Yorkshire ICB (Doncaster)
NHS South Yorkshire ICB