Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England Contents

---

Contents

Terms of Reference

Summary

1 Introduction

Terminology

2 The Investigative Landscape in the NHS in England

PHSO Report ‘Learning from Mistakes’

Culture

Multiple body investigations and the involvement of patients and families in investigations

3 HSIB and the learning culture

The role of HSIB and ‘safe space’ investigations

HSIB legislative framework

4 Learning and accountability: implementation of the ‘safe space’

A local ‘safe space’

A system-wide ‘just culture’

Improving local competence

Measuring improvement

Conclusions and recommendations

Appendix: PACAC response to Department of Health’s Consultation on ‘Providing a ‘safe space’ in healthcare safety investigations’

Formal Minutes

Witnesses

Published written evidence

List of Reports from the Committee during the current Parliament

---

---

27 January 2017