Learning from harm

No final recommendations have been published. Interim recommendations on observation, monitoring technology and resuscitation were under consideration after the October 2026 hearings, and had not been issued by 21 October 2026.

To be determined

Improve the quality and transparency of investigations, and show that learning is acted on.

DHSC, NHS England and CQC

Fund the Patient Safety Incident Response Framework properly, and build a learning culture that families can recognise as compassionate.

NHS England and trusts

Apply sudden-unexpected-death procedures to babies who have never left hospital, and shorten the paperwork.

NHS England and DHSC

Create a panel of independent clinical experts who can be sent quickly when harm by an individual is suspected.

DHSC

Give medical examiners a clear neonatal checklist, and review whether their funding is adequate in 2027.

National Medical Examiner and DHSC

Ask the National Audit Office to audit whether statutory inquiry recommendations are implemented, starting by September 2027.

Government and the National Audit Office

Rebuild the National Quality Board so that it owns a quality strategy and a way to collect, prioritise and track recommendations.

DHSC and NHS England

Keep HSSIB as a specialist investigation function, hosted inside CQC, with its independence from providers protected.

DHSC

The final report is expected to cover water, ventilation, infection and the current safety of the Glasgow hospitals, and to recommend how future NHS infrastructure projects avoid the same mistakes.

Scottish Government

Build a research and data infrastructure so outcomes are actually followed up.

NHS England and NIHR

Stop commissioning new recommendation lists as a substitute for implementing the old ones.

Government and NHS England

Investigate incidents properly and share the learning across the local system.

Trusts and ICBs

Replace the old serious-incident process with a response framework based on learning.

NHS providers

Improve the quality of expert advice to coroners and prosecutors in healthcare cases.

Government

Make rapid, multi-professional learning from incidents routine.

Local maternity systems

Investigate deaths of people with a learning disability or mental illness to the same standard as other unexpected deaths.

NHS trusts

Investigate deaths and serious harm with a standard that looks for system failure, not a narrative that protects the unit.

NHS trusts

Make the NHS a learning system, with patients and carers in the work of improvement.

NHS

Treat complaints as a way the organisation learns, with board ownership.

NHS providers

Reform death certification so that deaths are scrutinised by someone independent of the doctor.

Government

Investigate unexpected child deaths with the right pathology, and give consultants the post-mortem findings.

Hospitals and coroners

Use one written route for reporting serious incidents, so fragments of evidence are assembled.

Hospitals