BBC News. Shrewsbury maternity scandal: better care might have saved 201 babies. 2022. (accessed 12 April 2022)

Care Quality Commission. Opening the door to change. 2018. (accessed 12 April 2022)

Care Quality Commission, Survey Coordination Centre. NHS staff survey 2021. National results briefing. 2022. (accessed 12 April 2022)

Department of Health. An organisation with a memory. 2000. (accessed 12 April 2022)

Report of the Mid Staffordshire NHS Foundation Trust public inquiry. Executive summary. 2013. (accessed 12 April 2022)

The report of the Morecambe Bay investigation. 2015. (accessed 12 April 2022)

Ockenden report: final. Findings, conclusions, and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust. 2022. (accessed 12 April 2022)

Failures in NHS lesson learning

21 April 2022
Volume 31 · Issue 8


John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses patient safety in the light of the recently published Ockenden report

There are several apparently intractable patient safety issues that currently plague the NHS and have done so for decades. These issues strike at the core of NHS care delivery. There is a patent failure of some nurses, doctors and other health carers to properly learn from past adverse healthcare events and to change practices. The NHS has a defensive nature when it comes to responding to complaints, claims of harm and patient safety error reporting. There is a lack of a comprehensive NHS patient safety culture and nurses and doctors fail to put the patient first.

Ensuring that the patient's interests and wellbeing are protected should be the guiding beacon for everything that is done in health care.

Current and past patient safety crises show that these issues have not been sufficiently addressed in the past and are constant themes that require urgent attention in the NHS today.

An almost stoic refusal by sections of the NHS to engage with these issues can be seen in many reports. Care Quality Commission (CQC) inspection reports often lament the lesson learning failures in trusts, with trusts failing to advance patients' rights and interests, along with predominantly defensive cultures. Major reports into NHS patient safety crises such as at Mid Staffordshire (Francis, 2013), Morecambe Bay (Kirkup, 2015), and now Shrewsbury and Telford (Ockenden, 2022) all tell largely the same story.

Register now to continue reading

Thank you for visiting British Journal of Nursing and reading some of our peer-reviewed resources for nurses. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to clinical or professional articles

  • Unlimited access to the latest news, blogs and video content