Special article A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary

When a major failure happens in a healthcare organisation in the British NHS an inquiry of some kind usually ensues, tasked with finding out what happened, diagnosing the problems or causes of the failure, and making recommendations for changes in policy or practice which would prevent or make such a failure less likely in the future. The inquiry is akin to an organisational post-mortem, intended to move beyond a simple description of the symptoms and eVects of the failure and to provide a more insightful analysis of its pathology and aetiology. While the symptoms of failure are often clinical in nature—poor standards of care, avoidable mortality and morbidity, distressed patients and their families, and so on—the pathology of failure is usually organisational, concerned with things such as organisational leadership, management structures and systems, organisational culture, interprofessional relationships and teamwork. This paper presents an analysis of a recent and tragic example of failure at an acute hospital in the south west of England, and explores what lessons it oVers for those involved in quality improvement and clinical governance in health care.