Intended for healthcare professionals

Rapid response to:

Opinion Taking Stock

Rammya Mathew: Lucy Letby and the limits of a no blame culture

BMJ 2023; 382 doi: (Published 29 August 2023) Cite this as: BMJ 2023;382:p1966

Rapid Response:

No Blame Policy is not No Blame Culture

Mathew’s headline1 talks of ‘[t]he limits of a no blame culture’ but the text mentions ‘worrying about breaching a “no blame” policy’ thereby demonstrating the toxic nature of blame and the absence of a true ‘no blame culture’ within the NHS. Leary2 and Oliver3 go on to provide ample evidence of a blaming culture and its harmful effects on good care.

These articles, Good Medical Practice itself, and discussions of conflict of interest more generally, for example Coombes4, do not adequately acknowledge the enormous conflict of interest managers and clinicians experience in simply attempting to act in the best interests of other people rather than themselves. This conflict applies to all people in every aspect of life. Discussions of the cases of Letby, East Kent, and others overlook the extraordinary universal difficulty individuals experience in acknowledging and managing the conflict between avoiding embarrassment, humiliation or distress for themselves or their colleagues, and honestly and openly examining behaviour that does not meet expectations for which they might be responsible (and blamed). The more blame a person expects, the greater this conflict becomes. As such, aspiring to a true no blame culture is essential to facilitating early action to stop similar problems in future.

Veale and colleagues5 outline the importance of emotional safety in healthcare. The absence of fear of blame is a crucial part of emotional safety. The updated version of Good Medical Practice6 which stipulates doctors must not cause ‘offence, embarrassment, humiliation or distress [and must act with] kindness, courtesy, and respect’ is contradicted by the GMC’s own actions which recently extended to pursuing a doctor’s apology as evidence of guilt7. Ultimately this leads to fear in those ‘threatened with referral’1 and undermines safety.

A culture of blame is a societal rather than an NHS-specific problem. The solution starts with examining whether our own behaviour is conducive to openness and safety, and if not, then what motivates our actions. Blame may feel good, and occasionally even be necessary, but we don’t need to blame people in order to prevent or minimise tragedies. People do not need to be blamed in order to take responsibility and do better. We can and must make changes to improve care without needing to find someone to blame first. This starts from a place of curiosity and respect, keeping in mind the appropriate roles of the justice and regulatory systems and striving to improve both.

1: BMJ 2023; 382:p1966
2: BMJ 2023; 382:p1943
3: BMJ 2023; 382: p1957
4: BMJ 2023; 382: p1938
5: Veale D, Robins E, Thomson AB, Gilbert P. No safety without emotional safety. Lancet Psychiatry. 2023 Jan;10(1):65-70
6: General Medical Council. Good medical practice, 2024.
7: (accessed 2/9/23)

Competing interests: No competing interests

02 September 2023
Andrew J Belford