The Healthcare Commission's damning investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells trust drives home the message of its report last week on the lack of engagement of some acute trust boards with what is happening on their wards.

While, according to the commission, Maidstone and Tunbridge Wells' board was occupying its time with the rarefied issues of finance, targets and reconfiguration and ignoring repeated reports of poor care, patients were lying in their own excrement after being told by staff to defecate in their beds.

This negligence probably killed 60 people in a year.

This is, of course, an extreme example of management and clinical failure. By contrast, the best managers and teams bridge the divide between central demands and local needs brilliantly - this year's HSJ Awards judges have seen hundreds of examples of precisely that.

But the Maidstone and Tunbridge Wells scandal is a powerful reminder of the dangers of, to quote NHS chief executive David Nicholson, looking up and not out.

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