TMLEP’s lead healthcare investigator Nina Vegad asks if we’re learning from clinical incidents and if fit-for-purpose safeguards are being put in place to ensure history doesn’t repeat itself.
In healthcare, clinical incidents are an unfortunate but inevitable part of delivering complex, high-pressure care. When something goes wrong, whether it is a missed diagnosis, a medication error or a communication breakdown, organisations have a duty to understand what happened and why.
However, identifying what went wrong is only part of the story. To make healthcare safer, we must ask a deeper question; are we truly learning from what we find?
At TMLEP, our work centres on independent clinical investigations. These investigations aim to deliver objective insights into the root causes of patient harm, exploring potential breaches of duty, causation, and systemic failings. But over the years, we’ve noticed a pattern: organisations often commission investigations with the best of intentions, yet the resulting insights are not always fully integrated into their wider learning culture.
This article explores how healthcare providers can move from investigation to transformation – embedding findings into training, clinical governance, and organisational development.
The limits of a “box-ticking” approach
All too often, healthcare organisations treat investigations as an end in themselves: an action taken to meet regulatory requirements, satisfy duty of candour obligations, or respond to a complaint. The investigation is completed, the findings are logged, and perhaps a few changes are recommended. But without strategic follow-through, the deeper value of the investigation is lost.
This approach can lead to recurring incidents, staff disengagement, and missed opportunities for improvement.
Creating a learning culture means refusing to see investigations as isolated events. Instead, they must become part of a dynamic, ongoing process of organisational learning.
From insight to action: Five ways to embed learning
- Translate findings into training priorities
If a clinical investigation highlights knowledge gaps or repeated errors in judgement, those findings should directly inform workforce education. For example:
- A case involving delayed escalation should lead to refresher training on early warning scores and sepsis protocols.
- A medication error linked to distraction should trigger scenario-based training on cognitive load and interruption management.
Staff training must be reactive to actual patterns of harm, not generic or tick-box driven.
- Incorporate themes into governance frameworks
Clinical governance should not operate in a vacuum. Investigation findings should feed into:
- Quality dashboards tracking not just incident volumes, but recurring themes such as documentation errors or missed handovers.
- Board reports that reflect not only what went wrong, but how learning has been actioned.
- Policy reviews, where investigation insights highlight the need for clearer protocols or process redesign.
Governance must be a bridge between insight and implementation.
- Create cross-departmental learning mechanisms
The same issues often occur in different departments. An investigation in A&E may reveal a communication flaw that is also relevant in maternity, surgery, or mental health.
Consider:
- Hosting regular “learning huddles” across departments to share investigation themes.
- Using case-based discussions to bring investigation insights into clinical team meetings.
- Encouraging departments to audit their own risk areas in light of wider organisational findings.
This helps foster a collective responsibility for safety, rather than leaving learning separate within specific services.
- Use investigations to strengthen culture, not just correct process
Often, underlying cultural factors, fear of speaking up, blame culture, lack of psychological safety, play a role in patient harm.
Investigations that identify cultural issues should lead to:
- Leadership development around inclusive and transparent decision-making.
- Initiatives to improve multidisciplinary collaboration and flatten hierarchies.
- Forums where staff feel safe to discuss near misses and learning moments.
Creating a learning culture means building emotional and professional safety alongside technical competence.
- Establish feedback loops with frontline staff
Staff involved in investigations often never hear what happened next. This can fuel disengagement or the perception that investigations are punitive or performative.
Leaders should commit to:
- Closing the loop with clear, accessible communications: “You said, we did.”
- Sharing positive outcomes from learning – reduced incidents, improved processes, team reflections.
- Involving clinical teams in co-designing changes based on investigation outcomes.
Empowering staff with outcomes strengthens the safety culture and reaffirms the value of learning from harm.
The role of independent investigation in driving change
At TMLEP, we see our independent clinical investigations not as end points, but as launchpads for learning. We work with organisations not just to deliver factual, legally robust analysis, but to help them use those insights to strengthen their systems, people, and governance.
By bridging the gap between investigation and improvement, healthcare organisations can:
- Reduce the likelihood of repeat harm
- Build trust with patients and regulators
- Develop more reflective, resilient clinical teams
- Shift from a reactive model of safety to a proactive one
Final thoughts: Learning is a practice, not a policy
Creating a culture of learning is not about having the right buzzwords in board papers. It is about what actually happens after harm has occurred, who learns, what changes, and whether those lessons stick.
Clinical investigations are rich with insight. But without integration into governance, training, and team culture, even the best reports gather dust.
Learning must be continuous, visible, and shared. That is when real safety transformation begins.
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