Final Report > Chapter 26: The Safety of Care > Messages from Bristol

Messages from Bristol

• The absence of a culture of safety and a culture of openness meant that concerns and incidents were not routinely or systematically discussed and addressed and thereby unsafe practices continued unchecked.
• The physical environment and working arrangements were as important to the safe care of patients as the technical skills of clinicians.
• The absence of systems for monitoring the safety of clinical care at national or local level put the care of patients at risk.
• The absence of a systematic approach to learning from things that went wrong prevented effective remedial action from being taken.