A promise to learn – a commitment to act

Professor Don Berwick · work from 2013 · published 2013

What this was

National advisory group on the safety of patients, convened after Francis. It argued that the NHS should become a learning system, and that criminal sanctions should be reserved for wilful neglect rather than honest error.

Why it sits in the hub

Berwick is the counterweight to a purely regulatory reading of Francis. Thirlwall later said the 'no blame' turn had gone too far and had avoided necessary conversations about conduct.

Findings

Finding 1
Safety depends on culture, staffing and learning, not only on rules after the event.
Culture and conduct Learning from harm Safe staffing

Recommendations in this hub

Paraphrase of the public recommendations, not the official text.

1Partly doneNHS
Make the NHS a learning system, with patients and carers in the work of improvement.
Learning from harm Listening to patients and families
2Partly doneNHS providers
Set staffing levels that match the work, and be transparent about them.
Safe staffing
3AcceptedGovernment
Reserve criminal prosecution for wilful or reckless neglect, so that staff can still be honest about error.
The Williams review later revisited gross negligence manslaughter and fear among clinicians.
Candour Culture and conduct