Culture and conduct

Fund the Patient Safety Incident Response Framework properly, and build a learning culture that families can recognise as compassionate.

NHS England and trusts

Issue a one-page protocol for when staff suspect a colleague may be causing deliberate harm. Concerns raised in good faith must be acted on, and moving the person can be a neutral step to protect patients.

NHS England

Remember the victims, and change the culture that preferred institutional reputation.

Government and NHS

Rebuild leadership and culture so that abuse is not explained away as a difficult ward.

The trust and NHS England

Improve retention by changing how work is organised, not only by recruiting more people.

NHS employers

Set and enforce standards of clinical behaviour, including how colleagues treat each other.

Royal colleges and trusts

Strengthen how complaints about a senior clinician are handled.

Trusts and the Department

Make multidisciplinary team discussion a real check on individual practice, including in the private sector.

NHS and independent providers

Treat bullying and an unrealistic savings programme as patient-safety risks.

Boards and regulators

Separate a just approach to error from the need to act on conduct that endangers patients.

Regulators and employers

Reserve criminal prosecution for wilful or reckless neglect, so that staff can still be honest about error.

Government

Make openness the default, and protect staff who speak up.

NHS providers