Northern and Yorkshire regional office recorded more serious incidents than any other region in 1998, Organisations with a Memory reveals.

But the fact the region has 361 incidents on its books doesn't mean that the area is littered with death-trap hospitals.

In fact - and this is where one takes the 'no-blame'ethos to its limit - it is a sign of good practice, according to Professor Donaldson's report.

Pity Trent region, then, which admitted to just 82 incidents over the same period.

Under the system in place at Northern and Yorkshire region, trusts and health authorities are asked to notify the regional office as soon as possible after any (broadly defined) serious adverse incident. An electronic database was established in 1997 to facilitate the reporting and review of incidents.

Current director of public health Dr Bill Kirkup, one of the contributors to Organisations with a Memory, pays 'all the credit'to Professor Donaldson for the system he took on in 1998.

He says mechanisms at the moment are 'reasonably good at making sure that individual occurrences are properly investigated, that lessons are learned, action plans created and put in place'.

He adds: 'Where we need to do a lot more work is in systematic tracking, to make sure we spot systems failures, and failures that could apply in other settings. '

Dr Kirkup warns against removing a role for the regions in tracking incident reports.

'I think it would be a pity if we lost our role in picking up problems but then had to deal with the communications issues and fallout when things went wrong. '

The region has learnt two key lessons from its experience: 'There are two big dangers - and they are almost at opposite ends of the spectrum. One is to say, that was a one-off, a fluke. The other is to throw the book at an individual and not spot the wider failings. '