• Patient safety
• Patient-centred care
• Quality improvement

Sir Robert Francis, in his inquiry into failings at the Mid Staffordshire NHS Foundation Trust,1 has described ‘action plans’ as the worst disease of the English National Health Service (NHS). He noticed that whenever a tragedy occurs, the NHS produces excellent action plans. But they then fail to produce any action. It's as if the production of the action plan is an end in itself, requiring no further steps.

When you've made mistakes I bet you've committed to action, usually to avoid making the same mistake again. Of course then you've often made the same mistake again, but over your career I expect you've also successfully changed your practice so that the same mistakes are far less likely to occur, or when they do are far less likely to cause harm.

The challenge for any healthcare organisation should arguably be the same: to make real changes that avoid, trap or mitigate against the threats or potential errors that occur day to day. If some individuals seem to be able to do this, why is it that healthcare organisations often struggle? And what are the ingredients that help make it happen? If feedback is ‘the breakfast of champions’, why, in healthcare, is it usually flushed away and forgotten the next day?

In trying to answer these questions, I'm only really qualified to talk about one particular case. It involves a compelling story, a well-established evidence base (although one that is largely unfamiliar in healthcare), and passionate professionals who could see the value of change.

Ten years ago at 23:15 on the evening of 11 April 2005, a patient in a coma died in the intensive care unit (ICU) of a hospital in England. The death was not unexpected: the patient's life support had been withdrawn 6 days earlier. What was unexpected …