Committees

Follow-up to PHSO report 'Learning from Mistakes' inquiry

Inquiry

The government must do more to coordinate its efforts to establish a culture of open-minded learning and investigation within the NHS in England, says the Public Administration and Constitutional Affairs Committee in its report.

The Committee inquiry followed the PHSO report, "Learning From Mistakes", which highlighted systemic problems with clinical incident investigations, where a fear of blame inhibited open investigations, learning, and improvement.

Reports, special reports and government responses

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7th Report - Will the NHS never learn? Follow-up to PHSO report 'Learning from Mistakes' on the NHS in England
Inquiry Follow-up to PHSO report 'Learning from Mistakes' inquiry
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HC 743
Report

Oral evidence transcripts

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22 November 2016
Inquiry Follow-up to PHSO report 'Learning from Mistakes' inquiry
Witnesses Philip Dunne MP, Minister of State for Health, William Vineall, Director of Quality, Department of Health, and Chris Bostock, Policy Leader for NHS complaints, Department of Health
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Oral Evidence
8 November 2016
Inquiry Follow-up to PHSO report 'Learning from Mistakes' inquiry
Witnesses Dr Steve Shorrock, European Safety Culture, Programme Leader, and Scott Morrish, father of late Sam Morrish and Member of Healthcare Safety Investigation Branch Expert Advisory Group; Professor Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission , Keith Conradi, Head, Healthcare Safety Investigation Branch, and Helen Buckingham, NHS Improvement.
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Oral Evidence

Written evidence

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Department of Health (LFM0024)
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Claire Slater (LFM0022)
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Scott Morrish (LFM0020)
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Other publications

Correspondence
Committees exchange letters with government departments and others, often to request information or follow up on recommendations.
1 published

Contact us

  • Email: pacac@parliament.uk
  • Phone: 020 7219 3268 (general enquiries) | 07523 800011 (media enquiries)
  • Address: Public Administration and Constitutional Affairs Committee, House of Commons, London SW1A 0AA