When learning is still mistaken for blame

Summary

I have spent much of my career working in patient safety.  I genuinely believe that most people who come to work in the NHS do so with integrity, compassion and a desire to do the right thing.

We talk often about learning cultures, just culture and systems thinking. We have national frameworks, thoughtful strategies and well-intentioned leaders. And yet this example I'd like to share with you reminds me of how fragile that progress still is.

This blog is not about blame. In fact, it is about the opposite.

Content

A patient safety incident

A colleague of mine, a doctor, was involved in a patient safety incident relating to a prescribing issue where the patient, sadly, died as a result. The organisation responded appropriately and compassionately, commissioning a patient safety investigation under the Patient Safety Incident Response Framework (PSIRF). The investigation was thorough, systems-focused and mindful of the profound impact on the family and the staff involved.

The investigation concluded that the primary contributory factor was the presence of two different digital prescribing systems. It did not identify negligence. The findings were shared with the coroner as part of the evidence bundle, and the coroner reached the same conclusion: the cause of death lay in system design and interoperability (the ability to work with other computer systems or software used by the organisation to exchange and make use of information), not individual fault.

Throughout this process, the organisation supported the patient’s family and the staff involved. Openness, compassion and learning were evident. This is precisely what PSIRF was designed to promote—moving away from asking “who made the error?” and instead asking “how did the system make this more likely to happen?”.[1]

Self-referral to the GMC?

As happens in medical training, the doctor involved rotated to a new organisation. During an early conversation, the incident was openly discussed with their educational supervisor—someone who had not been present during the incident and who worked in a different Trust at the time. Despite the clear findings of the investigation and the coroner’s conclusion, the supervisor suggested that the doctor should self-refer to the General Medical Council (GMC).

The doctor contacted me, understandably anxious, asking whether there was documentation from the coroner that required or recommended self-referral to the regulator. I reviewed the material and reassured them that there was no such recommendation. The incident had been formally investigated, reviewed independently by the coroner and conclusively identified as a systems issue rather than professional misconduct or impaired fitness to practise.

Doctors can self-refer to the GMC, and in some circumstances that is appropriate. In this case, there was no regulatory threshold met, no negligence identified and no ongoing risk that regulatory action would mitigate.

A referral would not create learning; it would simply create fear.

Despite PSIRF, and repeated commitments to learning cultures, we still see reflexive thinking that equates involvement in harm with personal culpability.

The assumption seems to be that regulatory referral is the safest option “just in case”. But safe for whom?

The evidence tells us that regulatory referrals are not a neutral act. GMC data show that fitness to practise enquiries have continued to rise in recent years, with an increase of around 7% between 2023 and 2024, continuing an upward trend.[2] This aligns with broader analyses suggesting annual increases of between 6–8% in referrals, despite the majority of cases closing at triage or with no further action.[3]

At the same time, we know from research that the overwhelming majority of employer referrals do not result in sanctions, yet they carry a significant psychological burden for doctors.[4] Being under regulatory scrutiny is associated with anxiety, depression, loss of confidence and, in some cases, doctors leaving the profession altogether.[5] [6] This does not enhance patient safety; it risks undermining it.

What concerns me most is that this doctor did exactly what we encourage: they were open, reflective and honest about a traumatic event. And yet that openness appeared to trigger a suggestion of self-referral, as though transparency itself is risky.

That is not a learning culture. That is a quiet continuation of blame.

PSIRF explicitly asks us to separate accountability from punishment, and learning from fear.[1] It recognises that healthcare is delivered within complex systems where digital design, workload, cognitive load, environment and organisational decisions all interact.[7] Regulators themselves acknowledge this and have repeatedly stated that not every adverse outcome requires regulatory involvement.[4]

When we default to “the GMC just in case”, we send a powerful message to staff: even when the system fails, you may still carry the personal risk. That message discourages reporting, reflection and honesty, the very behaviours patient safety depends on.[8]

In the end, the doctor did not self-refer. They were reassured, supported and able to continue their training without the added weight of unnecessary regulatory fear.

Moving beyond a blame culture

If we are serious about moving beyond blame culture in the NHS, then PSIRF cannot stop at investigations. It has to show up in conversations, supervision and how we respond to staff who have already been through something devastating. Otherwise, PSIRF becomes a framework we apply on paper, while old habits persist in practice.

True learning cultures are quiet, steady and compassionate. They trust evidence. They resist reflexive blame. And they remember that patient safety is strengthened not just by better systems, but by how we treat the people working within them.

Call to action:

For those of us in supervisory and leadership roles, the challenge is clear: resist reflexive escalation.

Be guided by evidence, not anxiety.

Create spaces where clinicians can speak openly about harm without fear that honesty will be turned against them. Every time we default to “just in case”, we reinforce the very culture PSIRF is trying to dismantle.

References

1. NHS England. Patient Safety Incident Response Framework (PSIRF).16 August 2022.
2. General Medical Council. GMC Annual Report 2024: Trustees’ annual report and accounts for the year ended 31 December 2024. GMC, 2025.
3. General Medical Centre. Fitness to practise statistics 2024. GMC, 2024.
4. General Medical Council. Deciding whether to refer a matter to the GMC (Doctors). GMC, 2025.
5. Bourne T, Wynants L, Peters M, et al, The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open 2015; 5(1): e006687.
6. Brooks SK, Gerada C, Chalder T. Review of literature on the mental health of doctors: are specialist services needed? Journal of Mental Health 2018; 27(2): 146–56.
7. NHS England. Patient safety learning response toolkit. 16 August 2022.
8. O’Donovan R, McAuliffe E. A systematic review of factors that enable psychological safety in healthcare teams, Int J Qual Health Care 2020; 32(4):,240–50.

Further reading on the hub

Read all our blogs in our Florence in the Machine series — an area for anonymous health and care staff to blog about the state of the health service as they experience it on a daily basis.

If you work in health or social care and would like to share your experience on the hub, you can email [email protected].

About the Author

The author of this blog wishes to remain anonymous.