Root causes of organisational failure: look up, not down

Journal of Medical Ethics 48 (10):678-679 (2022)
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Abstract

‘Organisational failure’ is central to medical ethics. In the National Health Service (NHS), we usually examine failures at hospital level. We have had around 100 hospital inquiries since the first in 1969, into Ely Hospital, Cardiff. This year, we had the Ockenden Report into Shrewsbury and Telford Hospital. Last year, we had the Outram Inquiry into West Suffolk Hospital. In 2020, the James Inquiry into Ian Paterson. And, before that, Morecombe Bay, Gosport War Memorial, Mid Staffordshire, Liverpool Community Health, Winterbourne View, Anthony Ledward, Stoke Mandeville, Bristol Royal Infirmary and so on. As Taylor says, these reports teach us clinical failure usually has an institutional setting and that blaming individuals overlooks working ‘culture’. They have also led to: (a) new regulatory bodies to manage, investigate and improve NHS standards, (b) new codes of conduct to mandate reporting of serious accidents—backed up by the Whistle-blower’s Act and explicit statutory duties of disclosure, (c) root cause analysis to encourage consistent investigations so we can learn from reliable data and (d) new ‘Speaking Up Guardians’ and a Patient Safety Commissioner to encourage informal discussion about patient safety. What is so surprising is how little these inquiries and reforms have achieved on the larger scale. Of course, we must …

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