1/n You want my opinion about that PCT woman - it was that she wasn't a very competent investigator, and the complexity of why things happened as they did after my mum's death was simply 'beyond her ability'. When I made my displeasure with her report clear, the PCT invited me
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That is definitely a problem - but change is also difficult, because of the complexity of joining together the behaviour of different 'groups' within the NHS (doctors/nurses/paramedics etc) and getting them to all behave coherently [and differently].
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Whilst I do agree - it is undeniably complex - there's another undeniable truth which I can't ignore: If just half of the effort & resources employed to defend the often indefensible, were instead redirected to learning from the mistakes, we'd have significantly fewer problems.
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Once you formally complain, Trusts protect their reputation, and individual HCPs are nervous of 'being made the scapegoat' - hence 'inefficient learning'. If you 'informally raise a concern' then your concern isn't seriously looked into - hence 'inefficient learning'.
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Failure by design, imho. Everything from the complaint systems locally, to the lack of medical record integrity and on through every confusing layer of limited remit regulation, is all seemingly designed for one purpose: Containment.
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