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Tragedies are powerful motivators for learning and improvement. The only honourable response to the victims is to try to ensure that similar tragedies are not repeated in the future. In the NHS the report that led to the National Reporting and Learning System was entitled ‘An Organisation with a Memory’ precisely because of the ambition to capture the learning inherent in tragic incidents. The recent Berwick review into patient safety in the NHS similarly speaks of ‘A Promise to Learn’ but also, tellingly, of a ‘Commitment to Act’. We clearly need a capacity for intelligent, thoughtful reflection on the causes of tragic events and, still more, a capacity for using this hard won knowledge to build a safer healthcare system. In this paper we suggest that this would be most effectively achieved by the creation of a small, permanent independent agency charged with coordinating major inquiries and safety investigations in the NHS. Such a model, if successful, could be applied in other healthcare systems.

Learning from failure: the need for independent safety investigation in healthcare