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Learning when things go wrong

  • Organisations we regulate

S6 Are lessons learned and improvements made when things go wrong?

S6.1 Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate?

S6.2 What are the arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong? Are all relevant staff, services, partner organisations and people who use services involved in reviews and investigations?

S6.3 How are lessons learned and themes identified, and is action taken as a result of reviews and investigations when things go wrong?

S6.4 How well is the learning from lessons shared to make sure that action is taken to improve safety across relevant parts of the service? Do staff learn from reviews and investigations by other services and organisations?

S6.5 How effective are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews?

Last updated:
22 January 2020


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