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Norman, thank you for this thoughtful and challenging contribution.

Board minutes show that at Mid Staffs long after the disaster had been fully exposed clinicians were still not taking mortality reviews seriously. I've not checked recently, perhaps HSJ could check?

May I suggest, though, that no patient wants to be a set of papers as a preventable/avodable death at a mortality review no matter how good the review?

That's why the Cure the NHS 'Blueprint for a New NHS' presented to Robert Francis in 2011 (ideas first given to politicians in 2009) set out that Zero Harm, Right First Time was the only way to deliver treatment and care. Berwick was sort of a step in that direction.

The NHS and, as far as I can see, healthcare wordwide, now needs to move on from trigger tools, mortality ratios and other backward-looking measures, to eliminating preventable/avoidable deaths, deterioration, and complications, minimising errors, and rehearsing and preparing well for those errors which may still occur.

I have packaged how to start to do that in an iPad app Zero Harm Healthcare.

But it's Zero Harm Behaviours that matter. Having spoken at the Mid Staffs plenary of ASGBI in May a surgeon told me he had no time for checklists and would not want to fly with a pilot so incompetent he needed to be reminded at what speed to take off! He'd rushed off before I could even begin to explain.

Bit of a way to go, Norman, but your work and article moves us all forward. Thank you.
Ken Lownds, former member Cure the NHS. .