“The Committee supports the recommendations made in the CQC’s report that training should be provided to staff across the health service in England on how to conduct investigations.” Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England, 2017“It is clear from the evidence reviewed during the course of this inquiry that the investigative processes in the health service in England remain obscure and difficult to navigate for patients and families. As a result, patients and families are excluded by the system, which must become open and learning-focused if investigations are to lead to positive changes in the system. Families and patients should, as a matter of course, be included in investigations and should feel confident that lessons will be learned as a result of clinical incidents.” Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England, 2017This masterclass, which is designed for commissioners and providers who are responsible for the quality assurance of incident investigation reports, aims to improve the quality and consistency of RCA investigations by providing guidance on common challenges to those who are responsible for monitoring and feedback. This interactive and practical course will commence with an overview of Root Cause Analysis. The common mistakes that investigators make will be explored in detail. Delegates will use the lessons learnt throughout the course to constructively critique the reports. There will also be a session on amending local policies and procedures to prevent these mistakes from happening in the first place.