Lessons from death of Joshua Titcombe. CQC + ombudsman pass the buck. Parents left in dark. Internal reviews pointless.The background is summarised in the document he cites.
Managers work more with each other than they do with any particular patient. Patients come and patients go. But when the next case turns up, it will be the same groups of managers dealing with each other.
So it's easy for them to become too close.
There are no management structures or checks and balances which can avoid this. Familiarity breeds content, they've dealt with the other managers before, the other managers know the systems, the complainant is a stranger and an outsider. All this comes across in the case summary.
If structures can't avoid these problems of culture, what can? Ther's only one answer. Managers have to know that if they misbehave, there will be consequences.
This has to mean penalties and sackings pour encourager les autres. It absolutely doesn't mean another rule book. It means if you fail badly in your job, you'll be penalised or you'll be out.
No more playing the long game. No more pulling up the drawbridge and waiting till the complainant gives up. No more skulking in the fortress and then emerging untouched, and often to a promotion.
If an ombudsman finds against a hospital, the chief executive should expect deep trouble.
Of course this isn't a complete answer. The NHS is far too big to manage. But when managers choose to hunker down in their fortress, they have to know there's a risk that a management search squad might turn up and turf them out
It's less elegant than crafting a new strategy and then moving on, but any organisation the size of the NHS needs a ruthless bruiser near the top, with powers and status to ensure that a knock out punch isn't going to let the manager go rushing to the courts like the Director of Social Sevices in the Baby P case.
Then misbehaving managements will be running a real risk.
Oh and of course those managements know they're misbehaving. If they don't, they're not fit to be in charge of a hospital anyway.