I am so saddened to read yet another report on failings that, if seen and acted on in isolation, will not lead to the systemic changes that are needed. I agree with the conclusion.
The approach to patient safety needs to change. This is the 'modernisation' our health and social care services desperately need.
No more 'lessons will be learned' statements without follow up, and no more 'sorry-not-sorry' apologies, we need radical patient-led change, transparency, and accountability.