No open learning culture
Absence of a culture of openness, honesty, and learning from error within organisations, leading to failures in responding to concerns.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
81match
AFA-2 - Organisational development and cultural reform
The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. Devising a Northern Ireland patient safety strategy would consolidate and clarify the various strands of work in progress....
Matched on
terms: culture, learning, open
Committee recommendation
78match
#18 - Departments remain reluctant to share cyber incident information, hindering collective learning.
We asked the Cabinet Office what the impact was when departments did not share information about their cyber incidents. The Cabinet Office agreed that sharing data is essential to learn lessons, understand vulnerabilities, share best practice and work out what has gone wrong. The Cabinet Office reassured us that if departments find any vulnerabilities that could affect other...
Matched on
terms: culture, learning
Committee recommendation
74match
#20 - Government still faces challenges in robustly evaluating and sharing AI pilot learning.
We questioned DSIT on how it is evaluating and sharing learning from AI pilot activity across government to avoid reinventing the wheel and to support AI adoption at scale. It told us that it was taking a range of approaches including developing guidance and identifying good practice case studies, establishing communities of AI practitioners, and adopting an ‘open...
Matched on
terms: learning, open
Committee recommendation
73match
#4 - Address cultural issues allowing Home Office controls and processes to be overridden too easily.
We are concerned that the Home Office’s culture allowed it to override too easily the controls and processes in place to protect taxpayers’ money. The Home Office appears to have been operating in crisis mode for several years and now asserts that it is moving back to business- as-usual. It argues that its response to an “emergency” meant...
Matched on
terms: culture, learning
IOPC learning recommendation
72match
Recommendations - Metropolitan Police Service, August 2021
The IOPC recommends the MPS ensures that changes implemented to develop a culture of openness, transparency, improve cross-team working and collaboration between teams are embedded and a clear plan is in place to support continuous improvement in this area. An IOPC independent investigation found multiple instances of decisions not being recorded; perceived conflicts of interests not being recorded;...
Matched on
terms: culture, learning, open
Committee recommendation
69match
#25 - Home Office refuses to publish extensive lessons learned review from large site acquisitions.
When we questioned the Home Office about repeated mistakes in its acquisitions of large sites, it explained that it was learning from multiple projects at the same time. The Home Office informed us that its lessons learned review identified over 1,000 lessons. 82 When asked if it planned to publish the review, the Home Office stated that it...
Matched on
terms: learning, open
IOPC learning recommendation
69match
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should take steps to ensure that when it has been identified that an officer has failed to report or challenge improper conduct, whether or not misconduct processes are initiated against that officer, appropriate steps are taken to understand the reasons from a learning perspective. This follows an investigation into allegations of misconduct...
Matched on
terms: culture, learning
Inquiry recommendation
69match
F57 - Care Quality Commission independence strategy and culture
The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of the first inquiry, and open that evaluation for public scrutiny.
Matched on
terms: culture, open
Inquiry recommendation
66match
RHI-36 - Learning from Failures
The Northern Ireland Civil Service should develop a better process to learn from past failures, one that goes beyond the traditional method of revising and circulating internal guidance. Leaders within the Senior Civil Service must be more systematic, persistent and proactive in explaining to staff what changes are needed and supporting staff to adapt their working practices. A...
Matched on
terms: learning
Committee recommendation
66match
#12 - Efficient waste retrieval demands constant iteration, strong performance culture, and sophisticated, transparent target setting.
We explored with the witnesses what Sellafield Ltd needs to do to reach the point where retrieving waste becomes an efficient, routine activity. As well as installing the right equipment, they emphasised the importance of “constant iteration” – addressing problems such as the availability of cranes as they arise and the importance of developing a site culture focussed...
Matched on
terms: culture
HSSIB recommendation
66match
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide guidance on the practical steps to take to decide on the most appropriate learning response to an incident, to help organisations adopt a robust, standard approach to their decision making.
Matched on
terms: learning
HSSIB recommendation
66match
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums.
Matched on
terms: learning
HSSIB recommendation
66match
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you facilitate shared learning opportunities for staff across different organisations?
Matched on
terms: learning
HSSIB recommendation
66match
HSIB’s local investigation pilot: shared learning for local healthcare systems
It may be beneficial if healthcare organisations develop processes to identify safety improvement themes from patient safety investigation reports.
Matched on
terms: learning
HSSIB recommendation
66match
Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of...
NHS England, working with the National Collaborating Centre for Mental Health, is identifying 10 organisations to lead work to co-produce personalised approaches to safety planning in inpatient services. The learning will be shared through national learning networks. This is expected to be complete by March 2026. NHS England is producing national guidance on Safety Assessment and Safety Planning,...
Matched on
terms: learning
HSSIB recommendation
66match
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients...
Integrated care boards and organisations that provide mental health care can improve safety by involving people with lived experience and family carers in coaching for executive leaders. This could include creating learning networks within provider collaboratives. By embedding these roles, executive teams and non-executive directors would receive direct insights from those with personal experience of mental health services,...
Matched on
terms: learning
Committee recommendation
65match
#40 - 2nd Report - Transition to State Pension Age
It is vital that the Department develop a culture of learning from its mistakes. Indications that it has not yet done that include the Department’s response to the Parliamentary and Health Service Ombudsman’s recommendations on 1950s women, repeated problems with communications about changes to the State Pension and the delay in progressing the action plan. (Conclusion, Paragraph 150)
Matched on
terms: culture, learning
Committee recommendation
62match
#4 - Establish mechanism for AI pilot learning and scale successful products across government.
DSIT has no systematic mechanism for bringing together learning from pilots and there are few examples of successful at–scale adoption across government. At the time of the NAO report (March 2024), levels of AI use in government were low, but 70% of surveyed government bodies were piloting or planning AI tools. Examples of pilot activity include use of...
Matched on
terms: learning
PFD report
61match
Doreen Wood
Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. The practice also needs an internal investigation to ensure comprehensive learning among all GPs.
Matched on
terms: learning
PFD report
61match
Vasilis Ktorakis
The report identifies errors in care, including a delay in starting Syntocinon, inadequate recording of a management plan, an error of judgement in allowing passive descent, and a systemic issue in learning from incidents.
Matched on
terms: learning
Inquiry recommendation
61match
AFA-5 - Serious Adverse Incidents
We recommend that: • The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in each Trust. This involves ongoing feedback and backing for Trusts in terms of making the best use of the new framework and training staff to understand it. Departmental...
Matched on
terms: learning
Committee recommendation
61match
#3 - Thirteenth Report: Whole of Government Response to COVID-19
We are concerned that lessons have not been learned ahead of a potential second spike of infections. It is not clear that the government is undertaking the necessary preparatory work for a second peak of infections. The Department for Business, Energy and Industrial Strategy still has nothing convincing to say about what lessons it might have learned from...
Matched on
terms: open
PFD report
57match
Carol Ann Gibson
A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
Matched on
terms: culture
PFD report
57match
Lloyd Butler
A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.
Matched on
terms: culture
PFD report
57match
Tanya Page
Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.
Matched on
terms: learning
PFD report
57match
Wanda Stachurska
Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.
Matched on
terms: learning
PFD report
57match
Stephen Bird
Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.
Matched on
terms: learning
Inquiry recommendation
57match
LADB-17 - Develop a blame-free culture for safety information communication in industry
The development of a culture within the industry in which information is communicated without fear of recrimination, and blame is attached only where this is justified, is commended (para 9.60).
Matched on
terms: culture
Inquiry recommendation
57match
BRIS-107 - Create open, non-punitive NHS environment for reporting sentinel events
Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.
Matched on
terms: open
Inquiry recommendation
57match
MAI-26 - Review international practice on medics with firearms officers
Counter Terrorism Policing Headquarters should review the experience of other jurisdictions that embed medics with police firearms officers, such as Recherche, Assistance, Intervention, Dissuasion (RAID) in France, to understand how their systems operate and whether they ought to be replicated in the UK or some further learning taken from them.
Matched on
terms: learning
Committee recommendation
57match
#13 - 8th Report - Northern Powerhouse Rail
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 the finding. It told us the review found clear and well-designed lessons learned frameworks, but that consistent application...
Matched on
terms: learning
Committee recommendation
57match
#12 - 8th Report - Northern Powerhouse Rail
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 of learning from past failures, such as on HS2. It identified some examples of how it had changed...
Matched on
terms: learning
Committee recommendation
57match
#6 - 8th Report - Northern Powerhouse Rail
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 Two (HS2) and other major rail programmes. It is also learning from the success of programmes like the...
Matched on
terms: learning
HSSIB recommendation
57match
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you enable temporary workers to feed back on their experiences of working in your organisation, to understand the organisational culture in relation to this group?
Matched on
terms: culture
HSSIB recommendation
57match
Electronic patient record (EPR) systems – thematic review
How does your organisation share learning from the implementation and ongoing optimisation of EPR systems to support other organisations?
Matched on
terms: learning
HSSIB recommendation
57match
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It may be beneficial to facilitate shared learning across the NHS so that effective strategies that have been adopted by local NHS organisations for the management of staff fatigue and emotional wellbeing can be shared.
Matched on
terms: learning
HSSIB recommendation
57match
Never events: analysis of HSIB's national investigations
It would be beneficial if significant safety events, such as those presented in this national learning report, continue to be reported and investigated by NHS organisations without apportioning blame or liability, using a recognised systems- based approach such as the Systems Engineering Initiative for Patient Safety (SEIPS) as used in this report. When reading this report HSIB has...
Matched on
terms: learning
HSSIB recommendation
57match
Sexual safety: the implications for patient safety
There is an opportunity for health and care organisations to share learning around implementing the 10 principles of NHS England’s ‘Sexual safety in healthcare – organisational charter’. This would enhance shared knowledge, understanding and mechanisms for embedding the principles.
Matched on
terms: learning
HSSIB recommendation
57match
Mental health inpatient settings
HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations....
Matched on
terms: learning
HSSIB recommendation
57match
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for Health and Social...
HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations....
Matched on
terms: learning
CQC action
57match
Worthing Hospital
The trust must ensure organisational wide learning is shared within the trust to reduce the risk of repeated incidents.
Matched on
terms: learning
CQC action
57match
St Richard's Hospital
The trust must ensure organisational wide learning is shared within the trust to reduce the risk of repeated incidents.
Matched on
terms: learning
CQC action
57match
Royal Victoria Infirmary
The service should continue to act on concerns to improve culture within the Paediatric Intensive Care Unit.
Matched on
terms: culture
ICIBI recommendation
55match
An inspection of contingency asylum accommodation November 2023 – June 2024
Strengthen organisational learning in relation to asylum accommodation by producing a framework, with associated processes and guidelines, for capturing, evaluating and sharing learning (‘best practice’ and pitfalls) from ‘business as usual’ and from new projects, including the findings and recommendations from inspections and reviews. Accepted in full We fully agree that strengthening organisational learning is critical for our...
Matched on
terms: culture, learning
PFD report
53match
Stephanie Daniels
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.
Matched on
classifier match
PFD report
53match
Martin McGlasson
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff were key concerns.
Matched on
classifier match
PFD report
53match
Daniel Williams
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Matched on
classifier match
PFD report
53match
Jackson Chadd
Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.
Matched on
classifier match
PFD report
53match
Anne Sandever
A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids despite renal failure, with no adequate hospital investigation following.
Matched on
classifier match
Inquiry recommendation
53match
R34 - Debriefing policies for aggressive behaviour and restraint
All HSCTs should develop two clear operational debriefing policies. The first should apply to both staff and people with learning disabilities and autistic people who are involved in, or affected by, aggressive behaviour. A separate debriefing after any restraint or seclusion incident should also be developed. This should include both staff and people with learning disabilities and autistic...
Matched on
terms: learning