Page 19 - When Things Go Wrong

medicines and medical devices. Recognising that the State’s enhanced
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investigative duties arising under Articles 3 and 4 ECHR are of a very similar
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nature to those arising under Article 2, we consider that a number of our
recommendations will have broad application beyond investigations into
fatalities.

25 Baroness Cumberlege, First Do No Harm – The report of the Independent Medicines and Medical
Devices Safety Review, (July 2020): We have found that the healthcare system...is disjointed, siloed,
unresponsive and defensive. It does not adequately recognise that patients are its raison d’etre. It has
failed to listen to their concerns and when, belatedly, it has decided to act it has too often moved
glacially. Indeed, over these two years we have found ourselves in the position of recommending,
encouraging and urging the system to take action that should have been taken long ago, at p. ii.

26 On the State’s investigative obligations under Article 3 ECHR, see Commissioner of Police of the
Metropolis v DSD and another [2018] UKSC 11.
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