To place too much emphasis on individual blame is to risk perpetuating the illusion that removal of particular individuals is all that is necessary…To focus, therefore, on blame will perpetuate the cycle of defensiveness, concealment, lessons not being identified and further harm.
However, isn’t it axiomatic that when something has gone wrong systemically, removing the people who broke the system is a first step to fixing it?
Except the system isn’t broken. What I believe we are seeing at Mid-Staffordshire is the trialling of a program to dispose of economically unproductive human beings, a program whose results did not produce one referral of a health professional to the Nursing and Midwifery Council or General Medical Council.encouraged foot-soldiers to see their victims as "less than human", and I believe we are seeing a form of this in mid-Staffs, with patients on geriatric wards famously left in their own excreta and having to drink from vases. Case in point: Bonka Kostova, a midwife treating a 73-year old man (?) told him "you are no longer a human being but an animal. Chief Nursing Officer Jane Cummings perhaps revealed more than she realised when she said people like Kostova "do not have the capacity to be compassionate".
Wildlife enthusiast David Attenborough recently caused controversy by saying that humanity "is a plague on the earth",echoing the Georgia Capstones' exhortation: "be not a cancer upon the earth. If the Establishment considers vulnerable human beings a disease, was the corporate massacre at Mid-Staffordshire NHS Trust a clinical trial for the cure?
Mid-Staffordshire NHS Trust Public Enquiry:
Executive Summary No referrals to NMC or GMC - p59
Volume 1 No blame to be laid - para 108, p41
Volume 2 Lack of training for inspectors to spot another Mid-Staffs - para 11.217, p984 (p299 of the .pdf)
Volume 3 Doctors and nurses reminded of their most basic duties of care - paras 21.9-21.14, pp1403-1406 (pp54-57 of the .pdf)