Blame the system not staff for NHS mistakes, says Berwick report

Blame the system not staff for NHS mistakes, says Berwick report Patient safety expert says 'no single person, party or administration' cause problems

NHS staff should not be blamed for mistakes that harm patients, because in the vast majority of cases it is the systems that are at fault, says a watershed report on patient safety.

Prof Don Berwick, a world-renowned expert on patient safety, urged the government and other leaders to work towards a culture that supports dedicated staff, listens to patients and embraces transparency. The NHS, he said, had the potential to be a world leader in patient safety.

• NHS Confederation and NHS Employers respond to Professor Don Berwick's report on patient safety
• GMC statement on the Berwick review
• Chief Nursing Officer and National Director of Patient Safety Welcome Berwick Report
• NHS England pledges further action to protect patient safety following Berwick Report publication
• Our response to Don Berwick's report on patient safety Kings Fund

"Even while leaders speak out clearly and with courage, as they should when things go wrong, it is helpful to avoid drama, accusation and overstatement either in the Mid Staffordshire case or in other lapses in patient safety," says the report. "No single person, party or administration caused the problems that need to be solved and everyone can help guide the next steps if they work together."

At a press conference to launch the report, the health secretary, Jeremy Hunt, said he agreed with its conclusions. "I have never blamed NHS staff in any of my speeches," he said.

Hunt said he had been looking at whether NHS structures were right "and whether we need to recalibrate what our definition of a successful hospital is".

Berwick recommended that all hospitals should know the right level of staffing for every ward. The National Institute for Health and Care Excellence (Nice) should draw up guidance on the right nursing-to-patient ratios, which would inform local decisions.

Berwick said he did not support a legal duty of candour on individual staff but strongly advocated an open and transparent culture where acknowledging mistakes would be seen as a learning opportunity.

He proposed a new criminal offence where staff were guilty of willful neglect of a patient in the NHS or a care home, but he said it would be applied very rarely. Guardian