THE FINAL report by Robert Francis QC into the Mid Staffs inquiry, published in February, exposed shocking patient care that was tolerated by staff for many years. The report pinpointed an 'institutional culture' that led to warning signs going unchecked at the expense of lives.But this was not an isolated example and scandals have shown institutional failures across many sectors.Given the high level of talent and commitment across the NHS, why do such scandals occur? Why do patients, staff and managers allow levels of care to remain so low for so long when the evidence of failure can be visible daily? More importantly, how can we design better systems and services to support a positive organisational culture and ensure patient needs always come first?
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机译：Robert Francis QC在2月发布的中层员工调查中的最终报告暴露了员工多年来忍受的令人震惊的患者护理。该报告指出了一种“制度文化”，导致以牺牲生命为代价的警告标志得不到遏制。但这并不是一个孤立的例子，丑闻表明许多部门的制度失灵。鉴于NHS的高水平人才和承诺，为什么会发生此类丑闻？当每天都能看到失败的证据时，为什么患者，员工和管理者允许护理水平保持如此低的水平这么长时间？更重要的是，我们如何设计更好的系统和服务来支持积极的组织文化并确保始终将患者需求放在首位？
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