The "No Blame" culture invented by the establishment is a neat method where negligent managers and corrupt professionals can get away with ending lives by substandard service. It is well known that without accountability, there is no learning or deterrent. The government have written more neat little documents. See here https://www.gov.uk/government/publications/learning-not-blaming-response-to-3-reports-on-patient-safety . It is called "Learning not blaming". What is interesting is that despite this concept being circulated everywhere, the system has not learned. If this concept worked, we wouldn't have a high death rate and a high litigation rate would we? I don't think its fair for negligent managers to swan off into paradise with their pensions intact and sit at another Trust creating the same mistakes. If this kind of ridiculous concept worked then the criminal system would do it too. The fact is this, a without sanctions and penalties, there is no learning. The net result is of course, higher death rates and even more litigation.Then that is what you get when you have a government with their head in the sand.