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Feedback and learning points should be used to direct improvement plans where relevant.¹¹² These learning points should ensure that the objectives of these plans are met within an agreed timescale.

Support and advice should be provided to members of staff who are involved in a complaint to mitigate the negative impact that a complaint can have on staff.

Those who have made a complaint should be informed about changes made as a result of their complaint, and if appropriate, should form part of the review process.¹¹²

The department should encourage all staff to highlight concerns if they arise.

There should be clear processes on how to raise concerns, and how to escalate those concerns, for example, to the Freedom to Speak Up Guardian¹¹³. It should also be clear how concerns raised will be investigated, and what will happen with the findings following review.³⁹

Departments should ensure this process allows for an inclusive, positive, supportive, just culture, which includes demonstrated learning.¹¹⁴

Departments should ensure that staff who whistle blow are treated with respect and not disadvantaged by their action either by members of the department or the wider organisation.

The department should undertake appropriate review of concerns that have been highlighted, and should take timely and proportionate action.^{115,116,117,118}

The anaesthetic department should review clinical and operational risk on a regular basis. This should be done by using information obtained from other sources (e.g. literature and lessons learned from other clinical services) as well as communicating and discussing information they have identified to staff members and other clinical services.^119,120

The anaesthetic department should identify and agree plans to address and mitigate those risks identified in their risk register. The risk register should be a dynamic and responsive document that is regularly reviewed to ensure that all risks are being actively managed and should be disseminated appropriately. Members of the anaesthetic department should be educated in the benefits of using...