The Commission for Health Improvement continues to cut a swathe through poor practice in the NHS - and through south west London in particular. Local people there must feel especially let down by their health service after CHI's report exposed the weaknesses of St George's Hospital's heart and lung transplant unit hard on the heels of its investigation into nearby St Helier Hospital.
Poor communication between managers and clinicians was one important factor cited at St George's and highlighted as a result of concerns about the hospital's transplant record, which included the deaths of 10 patients in 10 months that were 'very unlikely to have occurred purely as a statistical coincidence'. Communication problems were compounded by lack of investment, leading to a dilapidated environment in which patients' privacy and dignity were compromised. Low morale followed, which in turn eroded clinical effectiveness.
Lest we forget, in an organisation as complex as the NHS the picture is rarely all bad.
Sometimes literally along the corridor from decay and chaos, beacons of excellence somehow manage to thrive. CHI found things to praise at St George's too, such as the high quality of its patient information.
But for a once-proud London teaching hospital it is a poor showing. St George's has much work to do - and will protest, no doubt, that it has already begun. CHI will return in 12 months to assess its progress.
In how many other acute units throughout the NHS is this picture replicated? We will gradually find out as CHI continues its work. The challenge may be to resist becoming inured to litanies of failure but strengthen the resolve to do something about them.