Open letter to the chief medical officer

Learning from Bristol: the need for a lead from the chief medical officer

Dear Professor Donaldson,

The long awaited report of the inquiry into children's heart surgery at the Bristol Royal Infirmary has now been published. The report echoes many of the themes that you have developed and reiterated since you became chief medical officer. It notes, for example, that “error, once acknowledged, allows lessons to be learned” and that “learning from error, rather than seeking someone to blame, must be the priority.”1

You have also recently explained in the BMJ how clinical governance will facilitate the delivery of quality care, which should be characterised by “a no blame, questioning, learning culture, excellent leadership, and an ethos where staff are valued and supported as they form partnerships with patients.”2 Similarly, in the letter you sent to every doctor last month, you noted that there had not been a real appreciation of the frequency with which, when things go wrong, “the true cause lies in weaknesses within the system rather than culpable actions of an individual.” Your letter also drew attention to a statement recently issued on behalf of the government, the medical profession, and the NHS which emphasised “the need to acknowledge ‘honest failure’” and that “the first response should not be blame and retribution.”3

Few would wish to criticise your frequent promulgation of these principles.2^–6 What puzzles us—and many other doctors—is why you and your colleagues in the civil service and government have not ensured that …