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According to Bismark et al,1 complaints that are brought to a Commissioner in New Zealand offer a potentially valuable “window” on serious threats to patient safety. In Italy, the Consultative and Conciliatory Commissions (“Commissioni miste conciliative”) and the ombudsmen (second level organisations) supply unsatisfactory results or are not even established.2 Furthermore, epidemiological data such as those of the NZQHS are very scarce. We therefore carried …