Articles for tag: change, change management, education, inquiry, investment, lessons, patients, people, risk, safety, standards, waste

The Great Training Robbery: Why Lessons Are Not Learnt

Every NHS trust maintains a mandatory training matrix. Staff are tracked, chased, and occasionally threatened until compliance rates hit the target — typically 85% or above. The annual study day is booked. The e-learning is clicked through. The tick goes in the box. And then, overwhelmingly, nothing changes. This pattern is not unique to the NHS. In 2016, Beer, Finnström and Schrader published a landmark Harvard Business School paper they titled The Great Training Robbery. Their argument was blunt: billions ...

The Ockenden Report – a tale of pathogenic system failures

The Ockenden Report, published on 24 June 2026, lays bare the human cost of systemic failure. It examines maternity services at Nottingham University Hospitals NHS Trust (NUH) over more than a decade, making it the largest inquiry of its kind in NHS history. More than 2,500 families came forward to share their experiences [Acknowledgements, p. iii]. The findings are shattering. For years, warning signs were ignored. Staff shortages were chronic. A culture of bullying silenced those who tried to speak ...

When Deference Becomes Deadly: The Accumulation That Killed Preston Davey

The death of thirteen‑month‑old Preston Davey, murdered just four months after his adoption, has prompted one of the most searching safeguarding reviews in recent years. In the weeks leading up to his death, Preston was seen repeatedly by health professionals and social workers, and was taken to hospital on several occasions with injuries that should have raised the highest level of concern. Yet, as later emerged in court, those encounters did not interrupt the sequence of events that ultimately led ...

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 ...

Fires in Los Angeles compels review of tail risk

The tranquillity of a sunny afternoon can quickly transform into a scene of chaos when a wildfire erupts, engulfing homes and livelihoods in its path. Recent events, such as the devastating fires in Los Angeles, serve as stark reminders of the ever-present danger of tail risk. While cutting costs might seem prudent in the short term, history teaches us that neglecting tail risk can lead to disastrous and costly consequences. This article goes deeper into concept tail risk whilst exploring ...

No new lessons here: Retired consultant killed by son who suffered with schizophrenia.

The case of Daniel Harrison, who was convicted of manslaughter by diminished responsibility after killing his father, Dr Nicholas Kim Harrison, highlights significant failings in mental health care management.  The Coroner gave a narrative verdict on 16/04/2024. The homicide had happened in March 2022. [References and sources at the end] Daniel Harrison, diagnosed with paranoid schizophrenia, experienced a deterioration in his condition. He was lost follow-up care from Swansea Bay University Health Board in 2018 after he was removed from a ...

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The crossover between CPIA and Mental Health Act

This is a somewhat obscure part of the law in England & Wales that may cause some confusion. Experience this week (on 16/05/2024) shows how misunderstanding and errors can occur. This is where an individual is found to be ‘under disability’ in the Criminal Procedure (Insanity) Act 1964 and is disposed of by the court. While the publisher and author(s) have used their best efforts in preparing information at this website, they make no representation or warranties with respect to ...

Why lessons are not so easy to learn

The context of this exploration is twofold a) to examine how lessons may not be learned by individuals and b) difficulty for organisations in learning lessons. Repeatedly many UK organisations resolve to learn lessons. However the evidence shows that they are not learning lessons. What ordinary people expect Let us start by understanding how ordinary people might decide what is a lesson learned. I suggest that they may expect the following: The deeper reality Determining if an individual or organisation ...