Report comment

Alastair NHS must be proactive organisation and must prevent failures in care in the first place by appointing value based leaders who promote good culture, good leadership from top to bottom and have robust governance and effective staff and patient engagement. The values of Board leadership must be patients first and always and happy staff - happy patients. Sadly NHS appoints many poor leaders and many Trusts still do not have robust governance and very poor staff and patient engagement. Of course in spite of all these things do go wrong and NHS must have a culture where all staff are empowered to raise concerns and when they do someone acts and everyone learns lesson when things go wrong.

The role of external inspection or regulator must be to work with the Trust to improve quality and safety and not to blame, shame, name and discipline. Any Trust which fails to learn must be named and shamed but this must be the last options. Most important is to protect patients