• How are you resourcing your organization to learn from failure?
• How do you ensure learning happens and is applied widely from the board room to the frontline?
• How are you partnering within your organisation and the broader healthcare community to empower in-house leaders to achieve improvements?
• How are you engaging decision-makers to commit to sustained improvement?
• How do you demonstrate your responsibility and accountability to engage with front-line staff and patients if the momentum for improvement initiatives is lagging?
• How are you tracking constant, emerging, and future operational, cultural, and clinical risks to prepare for them?
• How are you ensuring the transparency needed to drive learning and improvement?

• Spending on clinical negligence is escalating, constituting a major threat to the sustainability of the NHS.
• In England, payments for negligence awards are resourced from the same funds used to provide care.
• Improvements in quality and patient safety might help to reduce litigation costs but need to be evidence based.
• Solving the crisis in litigation costs will require a system-wide effort, with engagement and coordination of stakeholders across the health system.

Giving evidence at inquest: a well prepared witness - The purpose of this film is to demonstrate how it feels for a clinician to present evidence in the court, covering typical questions legal representatives may ask.

A conversation with a coroner - In this video a coroner provides oversight on their role and share insights on how behaving candidly and with transparency can boost the credibility of a witness.

• tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong
• apologise to the patient (or, where appropriate, the patient’s advocate, carer or family)
• offer an appropriate remedy or support to put matters right (if possible)
• explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.

Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. They must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns

• Put a duty on the Government to produce and regularly review an autism strategy to meet the needs of autistic adults in England. The first ever strategy for autistic people in England, Fulfilling and rewarding lives, was published in 2010 with a commitment to review this strategy three years later. The new strategy, Think Autism, was published in April 2014.
• Put a duty on the Government to produce statutory guidance for local authorities to implement the strategy locally.