Final Report > Chapter 21: Introduction > Guiding principles underlying our approach and recommendations > Learning from mistakes

Learning from mistakes

19 The history of the NHS is littered with the reports of Inquiries and Commissions: most have soon been consigned to gather dust on shelves. There must be many reasons for this. Perhaps one significant reason is the prevailing culture of blame and stigma. A serious failure of some sort occurs somewhere in the NHS. An Inquiry is set up. Months, or years, later, a report is published. Almost always, the report singles out an individual, or group, who are held to have been responsible. The individual is condemned. The NHS proceeds on its way, assuming that the matter is resolved: until the next serious failure.

20 The flaw in this approach is obvious. While it may be appropriate to criticise some individual(s), it is often too easy a response to stop at that point. Crucially, it deflects attention from the context in which that individual was working. The individual may be replaced, but the underlying environment, which gave rise to the problem, goes unchanged. It will only be a matter of time, therefore, before the same, or a similar, set of problems arise again in the same place or elsewhere in the NHS.

21 Throughout our Inquiry we have adopted an approach which looks beyond individuals to the systems within which they work. We do not reject the concepts of blame, or of individual accountability. When individuals are held accountable and shown to be guilty of misconduct, blame is both necessary and appropriate. What we reject is recourse to blame as a necessary, almost a reflex action, as if it were a solution in itself. What we also reject is the assumption that if individuals have been blamed, this is proof that an organisation has been held to account. Accountability is a complex notion, calling for a variety of mechanisms, as much active as reactive. Singling out individuals for blame after the event is an entirely different exercise. Its contribution to the effective performance of an organisation is at best limited and it can sometimes be counterproductive. It certainly is not a proxy for a proper, rigorous process of accountability.

22 One important lesson from Bristol is how, by concentrating on this or that person, by seeing things simply in terms of people, even those in Bristol who wanted action left the larger issues unaddressed. This is crucially important. Our aim is to encourage change, with a view to empowering and assisting professionals within the NHS to serve those for whom it exists: the public. In doing so, criticisms may be made. But they are made constructively, to clear the air, to offer a prospect of healing divisions, of rebuilding trust and starting again.