Learning from investigations

The Healthcare Commission has urged boards of all NHS trusts in England to heed the lessons from serious failings in healthcare services. It has highlighted the importance of good leadership, effective management and systematic use of information. The Learning from investigations report reviewed all investigations undertaken by the Commission under its statutory powers from August 2004 to April 2007. Investigations are undertaken where patient safety is seriously at risk. The report highlights clear common trends in the investigations the Commission has undertaken: poor leadership; ineffective management; inadequate teamwork with staff feeling unable to communicate problems; and a lack of clarity about who was responsible for what across the trust.

(Published 2008, 64 pages)