Roger M Livermore

As a former regulator of healthcare and social care, 'man-made' disasters usually have two characteristics - the absence of compliance with the law and the absence of regulation. This is not with a view to endless prosecutions but for the law to be the driver to achieve the legally-required standards of safety. Our group ASAP-NHS has been concentrating on Scotland where the systematic problems on pateint and worker safety are vastly worse (e.g NHS Ayrshire & Arran). What the report misses is that the UK-wide law of the Health and Safety at Work etc, Act 1974 (HSWA) applies (by sections 1 and 3(1)). It translates as the trusts and senior officers must do all that is reasonably practicable to ensure the health and safety of those affected by how they carry out their work. HSWA is comprehensive, systematic, proportionate- and being the law it is binding. HSWA provides both the means and the requirement to 'solve safety'. It addresses front-line failures, management systems, and culture. HSWA application has been totally missed, not a mention of the law or the regulator - the Health and Safety Executive (HSE). Note CQC is not the regulator of HSWA. HSE fails to discharge its statutory responsibilities in the biggest area of risk covered by its legislation. Scotland has no regulator at all, not even a CQC . In Scotland deaths are covered-up, there is no coroner system or the equivalent. It is the veritable dark ages of safety; and of the law. The CEO of HSE Sarah Albon was well aware of their failings to act on patient safety. They knew of Ockenden and that HSWA applied, that HSWA should solve the problems, and that HSE accepted that legally it is the regulator of patient safety and so to materntiy safety. HSE defies parliament and the law by not acting. Sadly it appears that in addition to HSE's failings being unlawful, it has lost its moral compass and is being amoral.