Articles for tag: catastrophic, culture, failure, harm, insight, learning, lessons, management, mistakes

Key Issues Extracted from the Verita Report: Cambridge University Hospitals NHS Foundation Trust (October 2025)

This AI Assisted summary is fully traceable to the source document, ensuring transparency and accountability. Nobody in their right mind has the time to read all of 302 pages. Therefore, AI was used to assist. There may be errors in this publication. Readers must check all page number references and meanings extracted for accuracy and relevance. The full report (302 pages) is at https://media.cuh.nhs.uk/documents/Verita_report_-_October_2025_1.pdf Some may be wondering, “What has this got to do with psychiatry?” I am deeply sorry ...

The 2024 Southport stabbings: A Case of Risk Lacunae and Protective Nets

The 2024 Southport stabbings refers to a heinous attack carried out Axel Rudakubana. He committed three murders and ten attempted murders. This article is constructed largely from information in the public domain and is being updated at intervals, as new information comes to light. Note again our ‘Fat Disclaimer‘. Rudakubana was 17 years old at the time he committed the offences. Axel Rudakubana was convicted of multiple charges related to the 2024 Southport stabbings. He pleaded guilty to: He was ...

Systemic failures and consequential risks

Conceptual overview: Systemic failures refer to breakdowns that occur within an interconnected set of components or systems, where the malfunction of one element can lead to cascading failures across the entire network. These are not isolated incidents but are often the result of complex interactions between various subsystems, policies, and human actors. The embedded YouTube video contains much of the text in this blog, and may be easier to process.  Introduction The National Health Service (NHS) stands as a beacon ...