Published: 05/02/2004, Volume II4, No. 5891 Page 27

As a clinician, I am surprised at the organisational failures that occurred at places such as Royal United Hospital Bath trust. There is a pile of regulation and governance documents that should prevent such management failures from ever developing ('All fall down', pages 28-30, 15 January).

These documents include the corporate governance codes of conduct and confidentiality for NHS boards; the Accountable Officer Memorandum for Chief Executives of NHS Trusts; the Treasury's regularity and propriety handbook; and the most recent code of conduct for NHS managers.

If these organisational failures occur and managers are not properly held to account under the current system of regulation (as would appear to be the case), it is perhaps time to reconsider the introduction of an independent register and regulatory body for all senior managers at board level in both the private and public sectors.

Lessons should have been learned from the Bristol inquiry about unacceptable management cultures. But the recent Deloitte Touche report on nearby North Bristol trust highlighted dysfunctional management and a 'culture of fear'.

The NHS Leadership Centre offers the opportunity to create a certificate of completion of specialist training for managers, so the public can have trust and confidence in those who lead organisations.

Nurses, therapists and doctors can all be properly held to account under the codes of their professional bodies. They can be retrained, restricted or even struck off if required to protect the public.

What is so special about senior managers that makes it impracticable for ministers to deliver similar safeguards to the public in 2004?

Dr Nigel Dudley Consultant in elderly medicine St James University Hospital