The report of the committee of enquiry into Ely Hospital, Cardiff, in 1969, was the first major inquiry into quality failures in the National Health Service.1 Thirty years later the report of the expert group chaired by the chief medical officer, An Organisation with a Memory, emphasised the need for the NHS to learn from its mistakes, and to be more systematic in acting on inquiry reports.2 A new analysis by the Healthcare Commission builds on these reports by summarising lessons from 13 major investigations it has undertaken since 2004.3

Readers of the commission’s report can be forgiven if they experience a strong sense of déjà vu. Although the investigations it undertook covered a wide range of services in different parts of the country, the general themes that emerge are depressingly familiar. The quality failures examined resulted from the interplay of several factors, including weak leadership, conflicting targets, inadequate use of data, and lack of teamwork. One of the problems highlighted in the commission’s report is the poor standard of care found on general hospital wards, including examples of patients …