Lucian Leape, a physician and renowned pioneer in patient safety, once said: “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” He was right. In my experience as Health Secretary, the biggest barrier to safer care in the NHS wasn’t a lack of resources, expertise, or dedication. It was culture - specifically, the way blame too often got in the way of learning from mistakes.
On 2 March 2015, the day before I was due to make a statement in Parliament on the Morecambe Bay Investigation into baby deaths at Furness General Hospital, I met families who had lost loved ones due to what Dr Bill Kirkup, who chaired the inquiry, described as a “lethal mix of failures” in the care of mothers and babies between 2004 and 2012. It was one of the most difficult meetings of my time as Health Secretary. The families’ grief was overwhelming, and their anger entirely justified. They wanted learning from what happened - to prevent others from suffering similar trauma. But they also wanted to understand how staff whose actions had contributed to devastating harm were still practising.
I left that meeting with a heavy heart. On one hand, I shared their sense of disbelief. On the other, I knew that if errors-even those with the most tragic consequences-automatically ended someone’s career, we would never build a culture where staff felt safe enough to admit mistakes in the first place. And if staff don’t speak openly, patients don’t get safer. That tension between justice and learning is one I wrestled with time and again.
The Human Cost of Blame
Few people have shown this tension more powerfully than James Titcombe, who lost his baby son, Joshua, after serious failures in care at Furness General in 2008. His fight for the truth exposed not only clinical failings, but something deeper: a culture of concealment. Notes went missing. Staff colluded on accounts. Protecting reputations took precedence over being honest about mistakes.
James once told me about a meeting he had, years later, with one of the midwives involved in Joshua’s care. She had missed critical opportunities to escalate concerns - but James recognised there was no intent to cause harm. The midwife was doing what made sense to her at the time and not acting with malice or neglect. Had she known Joshua’s condition was deteriorating and required urgent medical attention, she undoubtedly would have acted differently.
Still, James was angry. The inconsistencies between his family’s account and the midwife’s later statements created a perception of dishonesty- of someone who didn’t care, and who had washed her hands of any responsibility.
But that meeting became a moment of profound healing. The midwife explained how she still thinks about Joshua - that she wishes she had acted differently, and that she is deeply sorry for what happened and for its impact. They ended up crying together. She was later supported to return to practice.
That encounter taught me something important: sometimes, honesty and forgiveness can heal more than punishment ever could. But James’s story also shows the immense harm caused when fear and blame dominate. Families suffer - but staff do too, often carrying guilt and shame in silence, afraid of the consequences of speaking openly.
Why Blame Stifles Learning
Punitive responses rarely achieve what they set out to do. Instead, they create fear and drive defensiveness. When staff feel under threat, the instinct is to retreat - to minimise, rationalise, or protect colleagues and reputations.
But learning requires the opposite. Harvard professor Amy Edmondson, who coined the term “psychological safety”, defines it as the belief that people can speak up about mistakes or concerns without fear of humiliation or punishment. This is the oxygen of a learning culture.
After a patient safety incident, we need staff to describe what really happened - the “work as done”, not the “work as imagined” in policy manuals. Only when people feel safe to share the realities of clinical practice - the pressure, the trade-offs, the missed cues - can we begin to build safer systems.
Other industries have shown us the way. In aviation, unless there has been recklessness, pilots are encouraged to report mistakes without fear of sanction. That culture of honesty fuels systemic learning - and it’s driven an extraordinary improvement in safety over the past four decades. Healthcare is more complex, but the principle should be the same.
But Accountability Still Matters
A just and learning culture is not a culture without accountability. It’s often said that healthcare professionals don’t go to work to cause harm, but staff must be accountable for more than good intentions alone. Competence and behaviour matter too. So does how we respond when things go wrong.
Honesty, reflection, insight, and learning must be non-negotiable. A just and learning culture doesn’t mean letting people off the hook - it means making sure we’re using the right hook. That means holding people accountable for their behaviour, performance, and integrity - not punishing human error itself.
This culture must be set from the top. Senior NHS managers and leaders who act to put reputation and PR above the safety of patients, must have no place in the NHS.
The State of Play
After the Morecambe Bay Investigation, influenced by James and others, I set up what is now the Health Service Safety Investigation Body (HSSIB), which undertakes system wide patient safety investigations in a “safe space’ where staff can speak openly without fear or repercussions and blame. I also introduced a programme of new independent investigations for term stillbirths, neonatal and maternal deaths. It’s a model that other countries are now adopting and real progress has been made.
In maternity services, between 2013 and 2020, stillbirths fell by 23% and neonatal deaths by 18%, with overall extended perinatal mortality down by 20%. That means around 700 fewer families every year suffer the unimaginable grief of losing a baby – that's nearly two fewer deaths every day.
But since the pandemic, progress has stalled: stillbirths and neonatal deaths have plateaued, and maternal mortality has risen. Deep inequalities remain and 65% of maternity services are currently rated as “Requires Improvement” or “Inadequate” by the CQC. In their national review of maternity services published last year, CQC warned that “a blame culture”, where managers did not listen to concerns, was still impacting the safety of maternity care - there remains more to do. The 2024 NHS Staff Survey found that only 62% of staff felt safe to speak up about concerns, and fewer than half believed their organisation would act on them. If more than a third of NHS staff don’t feel safe to raise concerns, how can we be confident that patients are safe?
Nor is culture change just about what happens on the frontline. If a nurse or doctor is open about a mistake but then faces disproportionate sanctions from the GMC or NMC, the principle collapses. If candour in a hospital investigation leads to hostile questioning at a coroner’s inquest - or even a police investigation- then fear will prevail, and learning will suffer. That’s why a positive learning culture must extend to professional regulators, coroners, the legal system, and even the criminal justice system.
Creating a just and learning culture is not a soft option – it is the hard, necessary work of building a safer NHS. It demands courage from leaders, honesty from professionals, and trust from the system itself. But it also demands that we, as a society, rethink our instinct for blame.
Getting someone fired may feel like justice in the moment. But if is as a result of the ordinary errors that any human could make, it becomes the enemy of safer care. It silences staff, distorts the truth, and leaves families with partial answers instead of real change. If we truly want to honour those whose lives were lost at Morecambe Bay and in other tragedies, the tribute cannot be punishment alone. It must be progress: a culture where staff are safe to be honest, where accountability is transparent, consistent and fair, and where learning never stops. Only then will the NHS be able to deliver the safer care that patients deserve, families expect, and staff themselves so desperately want to provide.