NHS managers implicated in serious care failings are too often focused on targets and mergers instead of patients, the Healthcare Commission has warned.

The finding has been made repeatedly in the watchdog's investigations into some of the highest-profile NHS scandals in recent years. It said poor leadership was a problem in nearly all of the formal investigations it carried out.

And it had this warning for NHS managers: "It is not acceptable -nor is it necessary - for the safety of patients to be compromised by any other objectives, no matter how compelling they may seem."

Investigators found there was a fine line between "a firm management style" and "bullying". The report says, "Too often, management styles are perceived as autocratic."

The commission has drawn together lessons from 13 formal investigations in its first three years and a 14th probe, into outbreaks of C difficile at Maidstone and Tunbridge Wells trust, in its Learning from Investigations report.

The commission's chief executive Anna Walker said the document contained crucial lessons for managers. "A board and its chief executive do need an overview and must not lose sight of any element of the business," she told HSJ.

She said the investigations had highlighted the serious consequences of a poor flow of information from the front line to managers and board level. It was also important managers had the right skills and training.

She added: "We have been really surprised by the extent to which some trust boards are not systematically collecting information about all of their streams of activity and asking themselves what that means."

Of 200 cases referred to the commission, only 14 resulted in a formal investigation.

NHS Confederation chief executive Gill Morgan stressed the majority of boards were doing a good job.

But she said the key to good governance and leadership was giving NHS organisations "the real autonomy necessary to enable them to take ultimate responsibility". Pursuing a foundation trust model helped attract more "high-calibre" leaders, she said.

Lessons for managers and boards

The report gave tips for management style changes

  • Understand reported incidents and ensure action is taken

  • Ensure systems for clinical governance are "built in" to the running of trusts

  • Allocate time to assess whether needs of most vulnerable patients are being met

  • Encourage "a culture of openness"