“NHS negligence” isn’t on the ward, it’s in the boardroom

When people talk about “NHS negligence”, they picture a surgeon in theatre, a midwife at the bedside, or a junior doctor on a night shift.

They rarely picture the executive meeting where a backlog of thousands of unreported X-rays is discussed… and then quietly parked.
They don’t see the board papers that never reach the regulator, the whistleblower whose career is dismantled, or the spreadsheet that shows harm escalating while managers debate optics.

Yet again and again, enquiries, inquests, and litigation reveal the same pattern: management failures, evasive governance, and a negligence bill now measured in tens of billions of pounds.

This isn’t just a story about individual error. It’s about how the system treats risk, harm, and truth.

1. Worcestershire: when a backlog becomes a cover-up

Take Worcestershire Acute Hospitals NHS Trust.

By 2014, senior managers knew they had a serious problem. Internal reports to the trust management committee showed an X-ray backlog so large that, if nothing changed, more than 42,000 scans would go unreported by an expert the following year. A review of just 30% of the backlog had already found three missed lung cancers and another 20–30 possible cancer cases.

Options were set out. Outsource the backlog. Bring in extra staff. Reorganise the service. The risks were explicit. The harm was visible.

And then, in practice, nothing effective happened.

The issue did not reach the public domain until radiographer Ken Hall went to the Care Quality Commission (CQC) in 2016, triggering the discovery of around 11,000 unreported X-rays and scans.

The CQC’s published report concluded there was no evidence the board knew about the backlog and said no patient harm had been identified as a result of the delay. That position has become increasingly difficult to reconcile with the existence of those 2014 internal reports, which clearly described missed cancers and catastrophic risk.

Neither the CQC nor Worcestershire Healthwatch was given those reports at the time. Healthwatch’s director later said he now feels misled by the assurances he received from the then chief executive, who in early 2016 had blandly stated there was no backlog.

Meanwhile, the trust pursued the man who had exposed the backlog.

Worcestershire referred Hall to the Health and Care Professions Council (HCPC) for alleged fraud because he worked a handful of shifts in a private hospital while signed off sick with stress from the trust. He was struck off. Only years later, when three previously undisclosed documents surfaced – including evidence the trust already knew about his private work – was he reinstated and the original judgement deemed unsafe.

On any sensible reading, the story contains all the elements of a classic exam question on managerial negligence and institutional bad faith:

clear evidence of risk and missed cancers in 2014
a decision, in effect, to tolerate the backlog
regulators not given crucial documents
a whistleblower punished on a charge that later collapses

Yet no senior manager has faced criminal sanction. The trust was criticised. Conditions were imposed and later lifted. Careers moved on.

The pattern – serious warning, inadequate action, reputational protection, whistleblower retaliation – is painfully familiar across the NHS.

2. The litigation iceberg: £60 billion and climbing

Zoom out to the national picture.

In October 2025, the National Audit Office (NAO) published Costs of clinical negligence, a forensic analysis of what the English NHS now owes for past and future harm. The numbers are sobering: the government’s provision for clinical negligence has quadrupled since 2006–07, from £14.4 billion to £60 billion, making it one of the largest single liabilities on the state’s balance sheet, second only to nuclear decommissioning and ahead of many core infrastructure obligations.

Annual expenditure on clinical negligence has also more than tripled. By 2024–25, the cost of settling claims reached around £3.6 billion a year, according to NAO and parliamentary summaries.

A 10-year speciality-specific analysis of litigation data from 2009/10–2018/19 – published in a surgical journal – found:

total annual negligence costs around £3.6bn by 2018/19
Surgical specialities had the greatest number of claims
obstetrics accounted for the largest share of total cost, with liabilities of around £1.9bn and an average payout of £2.6m per claim

The conclusion was blunt: a relatively small number of high-value, lifelong injury cases, particularly brain injury at birth, are driving a disproportionate share of the cost.

The NAO’s 2025 report and subsequent coverage in the Guardian sharpened the point. Maternity and neonatal cases now account for more than half of all future claim liabilities, despite being only about 10% of claims by number. Average settlements for children with severe brain injury at birth sit at around £11.2m per case, with £1.6bn paid out in a single year for childbirth-related injuries alone.

Medscape’s summary of the latest NHS Resolution data was equally stark: more than £60bn set aside to meet current and future negligence costs, £3.1bn in clinical negligence payouts in 2024–25 alone, and legal fees comfortably over half a billion pounds a year.

This is not a marginal budget line. It is a shadow health service, funded by the same taxpayers who fund the NHS itself.

As Juliet Dobson wrote in a widely read BMJ editorial on “corridor care”, the routine placing of patients on trolleys in hallways because wards are full is “a warning sign from a system in serious trouble”, not an unfortunate quirk.

The question now is not whether negligence is costly. It is whether the current model of risk, harm and compensation is sustainable at all.

3. Maternity and newborn care: predictable, repeated, devastating

If you want to see how quickly harm becomes structural, maternity and neonatal services are the bleakest place to look.

Over the past decade we have had:

Morecambe Bay – where avoidable deaths at Furness General Hospital’s maternity unit, including baby Joshua Titcombe’s, exposed clinical failures, destroyed records and a culture of denial. The Morecambe Bay Investigation found at least 11 babies and one mother who would likely have survived with proper care.
Shrewsbury and Telford (Ockenden Review) – where Donna Ockenden’s final report in 2022 identified catastrophic failures across two decades, with hundreds of babies and mothers harmed. The trust’s pursuit of “normal birth at all costs” was prioritised over safety.
East Kent and Harry Richford – where the inquest into baby Harry’s death concluded it was “wholly avoidable”. The CQC then took the rare step of criminally prosecuting the trust for failures in the care of Harry and his mother; the trust admitted the charges and was fined more than £760,000.
Nottingham and Harriet Hawkins – where Jack and Sarah Hawkins’ daughter Harriet was stillborn after a six-day labour. An independent report later described her death as “almost certainly preventable”. The family eventually received a £2.8m settlement, but only after years of denial and even mockery from colleagues captured on tape – an episode reported in painful detail by the Times and regional media.

In Nottingham, Donna Ockenden is now leading what has become the largest maternity investigation in NHS history, with around 2,500 family cases under review. In parallel, Nottinghamshire Police have launched a corporate manslaughter and gross negligence manslaughter investigation into the trust’s maternity services.

And still the cases keep coming: fines for repeated failings, heartbreaking testimony from parents who were left to give birth alone or whose concerns were dismissed, and new claims emerging from trusts already on their “last chance”.

In June 2025, Health Secretary Wes Streeting announced a national investigation into NHS maternity services in England, focusing initially on the worst-performing trusts and explicitly acknowledging that the NHS now spends more on negligence payouts than on maternity care itself.

These scandals are not aberrations. They follow a script we now know by heart:

Families raise serious concerns and are dismissed or gaslit.
Staff who speak up are marginalised or pushed out.
Data on deaths and harm show outliers, which are explained away.
Only after sustained campaigning and media scrutiny is a genuinely independent review commissioned.
Years later, the review concludes that deaths and injuries were avoidable, management culture was toxic, and warnings were ignored.

If this were aviation, the system would have been grounded long ago.

4. The “fighters”: families who refused to be quiet

Against this backdrop, it has often been bereaved families and individual campaigners, not formal governance structures, who have held the fragile line of accountability.

A non-exhaustive roll call:

James Titcombe OBE, whose son Joshua died of sepsis at Furness General. He spent years fighting a trust that denied and obfuscated, helping to force the Morecambe Bay investigation and later serving as National Advisor on Patient Safety and Culture at the CQC. He is now calling for a fundamental rethink of how the NHS talks about “scandals”.
Rhiannon Davies and Richard Stanton, whose daughter Kate Stanton-Davies died in 2009. Their persistence directly led to the Ockenden Review at Shrewsbury and Telford and exposed repeated failures to learn from serious incident investigations.
Jack and Sarah Hawkins, both NHS professionals, whose daughter Harriet died at Nottingham City Hospital. They uncovered not only clinical mistakes but also a culture in which colleagues mocked them behind their backs and mishandled Harriet’s body. Their case became emblematic of how institutions sometimes respond to their own staff when they become complainants.
The Richford family, who refused to accept bland platitudes after Harry’s death at East Kent. Their determination led to the “wholly avoidable” inquest conclusion, a CQC prosecution and renewed scrutiny of the trust’s wider maternity services via the Kirkup review.
Merope Mills and Paul Laity are the parents of 13-year-old Martha Mills, who died of sepsis at King’s College Hospital after her deterioration was not escalated to intensive care. Their campaign led directly to Martha’s Rule – giving families a formal right to trigger an urgent second opinion if they feel their concerns aren’t being heard.

In a recent BMJ article, James Titcombe argued that we need to “rethink the ‘scandal’ narrative in the NHS”: stop treating each catastrophe as an isolated horror story and instead recognise the repeated, systemic patterns.

He is right. Each time we label a disaster “shocking” and “unthinkable”, we absolve the system of the need to explain why very similar things keep happening.

5. Law, blame and culture: the uncomfortable evidence

The academic and legal literature on negligence and patient safety in the NHS is now extensive – and uncomfortably consistent.

5.1 John Tingle: blame, rights and system duties

Legal scholar John Tingle has done as much as anyone to map the patient safety landscape from a medico-legal angle. In his British Journal of Nursing column, “Big changes to the NHS patient safety landscape expected in 2025”, he outlines a raft of reforms – from the Duty of Candour to the NHS Constitution and Martha’s Rule – and warns that they will only matter if embedded in a genuine safety culture rather than layered on top of a failing system.

In other work, including his paper “The role of blame when errors occur” (which you shared), Tingle dissects how blame is baked into our investigative and legal responses. Even when official rhetoric talks about “systems thinking” and “just culture”, the lived reality for many clinicians is one of fear: fear of disciplinary processes, fear of regulatory sanction, and fear of being scapegoated when a complex system fails.

Blame, he argues, is not just emotional; it is structural. It sits in how we investigate, how we litigate and how we communicate with the public. And a blame-centric system tends to produce:

defensive practice
under-reporting of incidents
reluctance to speak frankly about systemic problems

Exactly the conditions in which repeating harm becomes more likely.

5.2 Orthopaedics and ENT: what the claims data actually show

The orthopaedic claims paper you supplied – “Why do orthopaedic surgeons get sued? An analysis of £2.2 billion in claims against NHS England – examined litigation data from the mid-1990s to 2023/24. It found that a relatively small group of high-severity complications, such as nerve injury, infection, missed fractures and cauda equina syndrome, account for a disproportionate share of the cost. Common themes included delay in diagnosis, inadequate consent, poor documentation and failures in follow-up.

The authors’ conclusion is not that surgeons need to be cowed into defensive medicine, but that systematic improvements – better consent processes, clearer documentation, consistent MDT review and structured follow-up – could markedly improve care and reduce litigation exposure.

A recent medRxiv analysis of negligence claims in ENT (the preprint you linked) tells a similar story: repeated patterns of delay, misdiagnosis and technical error in relatively predictable clinical scenarios, and a failure to use claims data as a structured learning tool.

The striking thing about all of this is how unsurprising it is. If you asked a group of experienced clinicians where things are most likely to go wrong, they would identify exactly these points. The law, the claims data and the clinical instincts are aligned.

It is management and governance that are out of step.

6. Management and governance: the missing defendants

In July 2025, the Department of Health and Social Care published its Review of patient safety across the health and care landscape. Buried among the organisational charts and system diagrams was a brutal conclusion: poor or inadequate management creates a 5% “efficiency gap”, equivalent to over £5 billion a year – or around 330,000 QALYs lost, using standard DHSC cost-per-QALY thresholds.

The review also described a “cluttered landscape” of roughly 40 organisations with formal roles in quality and safety, creating blurred accountability and duplicated effort. Everyone is responsible; therefore, no one is.

The logic is clear enough:

Poor management → unsafe staffing, poor supervision, weak incident response
Weak governance → bad data, slow escalation, minimal external challenge
Fragmented oversight → important signals get lost in the noise

Yet when harm occurs, our legal and regulatory focus overwhelmingly falls on:

individual clinicians (via the GMC, NMC, HCPC and local disciplinary processes), and
the corporate trust entity (via CQC prosecutions, civil claims and sometimes large-scale fines).

Individual senior managers – the people who sat in those meetings, saw those dashboards, and decided not to act – almost never face personal accountability in law.

They may, at worst, lose their job and reappear in another organisation. More often they are quietly moved sideways; sometimes they are promoted.

This is the accountability chasm at the heart of the current debate. The system demands fitness to practise from clinicians but has no equivalent concept of fitness to manage for those whose decisions create the conditions in which clinicians work.

7. Litigation reform: no fault, no blame – or just no change?

Parliament is not blind to the problem. In 2022, the House of Commons Health and Social Care Committee published its report on NHS litigation reform, concluding that the current clinical negligence system is “not fit for ”purpose”—too adversarial, too slow, too expensive, and too weak at driving learning.

The Committee, and later legal commentary, have floated a spectrum of reforms:

moving towards no-fault or administrative compensation, at least in high-cost areas like maternity
focusing on early admission of error, rehabilitation and support rather than years of legal battle
creating stronger links between what claims reveal and how the system changes

Jeremy Hunt, now Chancellor but then Chair of the Committee, has publicly backed a variant of no-fault compensation in maternity, pointing out that we are currently spending more on paying for avoidable brain injury at birth than on delivering safe maternity care.

The NAO and NHS Resolution are at least aligned on the diagnosis. NHS Resolution’s response to the NAO report stresses that 83% of claims are now resolved without formal court proceedings, through early settlement and mediation.

That is progress. It means less trauma for families and lower legal costs.

But resolving claims more “collaboratively” does not in itself stop the harm from happening in the first place. A smoother payout process without upstream reform risks becoming a well-oiled compensation machine for avoidable injuries.

8. What would real prevention and anticipation look like?

If you synthesise:

the legal analysis (Tingle and others),
the claims data (Gill in orthopaedics, specialty-specific work in ENT, maternity and surgery),
the patient-safety inquiries (Morecambe Bay, Ockenden, Kirkup, Nottingham), and
the policy shifts (Martha’s Rule, the national maternity investigations, the DHSC safety review),

A coherent agenda emerges. It is less about heroic whistleblowers and more about boringly reliable systems.

8.1 Governance that can’t look away

1. Statutory duties to escalate high-risk internal findings

What happened in Worcestershire – internal reports describing missed cancers and a dangerous backlog that never reached the regulator – should simply not be structurally possible. There is a strong case for a legal duty on boards to share serious clinical risk findings (from internal audits, Serious Incident reviews, and mortality outlier analyses) with national bodies such as CQC, HSSIB, and NHS England within a fixed timeframe, with personal and corporate penalties for concealment or misrepresentation.

2. Board-level safety dashboards linked to claims

Claims data are not just a cost line. They are a lagging indicator of system failure. Trust boards should receive quarterly dashboards that connect:

litigation claims
coroners’ Prevention of Future Deaths reports
Datix incidents
maternity outcomes
staffing and rota gaps

with explicit discussion of recurrent themes and what is being done about them.

3. Fitness to manage

The law recognises “fitness to practise” for clinicians. There is no reason in principle why we could not create a parallel system for senior managers and directors, with:

a professional register
enforceable standards on candour, data use and response to risk
the ability to disqualify or bar individuals whose decisions repeatedly create unsafe conditions

Such a regime would be uncomfortable. That is the point.

8.2 Clinical and cultural levers: making rules real

Martha’s Rule – hosted in the right culture

NHS England began implementing Martha’s Rule in 143 pilot sites in 2024; by 2025 it had been rolled out to all acute hospitals in England. Early data suggest that thousands of families have used it to seek urgent second opinions, with hundreds of patients moved to intensive care or having their treatment escalated as a result.

But as ethicists and legal commentators have noted, a right is only meaningful if invoking it is safe. If asking for a second opinion is seen as an act of disloyalty, or if staff subtly punish those who use it, Martha’s Rule will become just another laminated poster.

National maternity investigation – with teeth, not just prose

The national investigation into maternity services announced in 2025 must be more than another compendium of what we already know. Its recommendations need to be tied to:

funding (for midwives, obstetricians, neonatal staff and theatres),
legally enforceable standards (e.g. in foetal monitoring, escalation, induction and induction of labour), and
clear consequences for organisations that persistently fail to meet them.

Otherwise, we are simply writing another chapter in the scandal narrative while the underlying conditions stay the same.

Childbirth compensation reform linked to safety investment

Any move towards no-fault compensation in maternity should be explicitly conditional on upfront investment in safer care – not just a cheaper way for the Treasury to manage liabilities. That means:

realistic staffing ratios
rigorous training in CTG interpretation and shoulder dystocia
robust escalation pathways
meaningful psychological support for staff and families after adverse events

Learning from specialty-specific failure modes

The orthopaedic and ENT claims analyses make it clear that harms cluster in predictable places: delays in diagnosing fractures or cauda equina; missed cancers in ENT; poor consent for high-risk surgery. Targeted, specialty-specific safety programs—backed by data and adequately resourced—could reduce harm and litigation at a fraction of the cost of a single catastrophic claim.

8.3 Digital risk and anticipatory compliance

An increasing proportion of NHS negligence risk now lies in digital and data systems: faulty algorithms, unsafe clinical decision support, insecure data, and poor incident response in cyberattacks.

This is why a new generation of compliance platforms has emerged. Naq, for example, markets itself as an automated healthcare compliance engine, helping organisations meet frameworks like NHS DSPT, DTAC, DCB 0129, GDPR, ISO 27001 and HIPAA in a single environment.

Tools like this matter because:

Regulators and plaintiffs’ lawyers increasingly ask, “What did you do to ensure your digital systems were safe, and how can you prove it? ”
“I didn’t know” is no defence when compliance frameworks are explicit and widely publicised

But software alone cannot fix:

a board that never looks at its own risk reports
managers who treat patient-safety warnings as reputational threats to be managed
a culture that punishes the Ken Halls of this world instead of promoting them.

Digital compliance is necessary. It is nowhere near sufficient.

9. From scandal stories to a systems doctrine

If you step back from the grief, the headlines and the pay-outs, a striking consensus has emerged.

The money is unsustainable. £60bn in liabilities, billions in annual payouts, and a disproportionate share of that tied up in preventable maternity harm.
The system is structurally unsafe. Corridor care, chronic understaffing, dilapidated estates and fragmented oversight are not background noise – they are the operating environment.
The culture remains defensive. Despite endless talk of “just culture”, many staff still experience a regime of blame, fear and reputational management.
Accountability is asymmetric. Clinicians and families carry the emotional and professional weight of error; corporate entities pay damages; senior managers rarely face personal consequences, even when their decisions are central to the harm.

If you put a barrister’s wig, a physician’s stethoscope and a policymaker’s pen on the same table and ask, “What would a rational system do? ”, the answer is surprisingly clear:

Use claims data as an early warning system, not just a financial provision.
Hard-wire transparency and duty to escalate into the legal framework for boards and managers.
Reform compensation, especially in maternity, to be faster, fairer and explicitly tied to safety investment.
Invest in management competence, with real personal accountability for those whose decisions repeatedly put patients at risk.
Protect and reward those who speak up – the Titcombes, Davieses, Stantons, Hawkinses, Richfords, Mills and Laitys – instead of forcing them into prolonged, adversarial combat.

Until we do that, each new “scandal” will be quietly filed alongside the last one, the NAO graph will continue its upward climb, and the NHS will keep paying out compensation for harms it already knows how to prevent.

The tragedy is not that the system doesn’t know what to do. It’s that, so far, we have lacked the managerial, legal and political courage to do it at scale – and to hold those in charge to the same standards of accountability as those on the ward.

References

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1. What actually counts as “clinical negligence” in the NHS?

In English law, clinical negligence occurs when three things are true:

The clinician (or organisation) owed the patient a duty of care
That duty was breached – the care fell below the standard of a reasonably competent clinician in that field
The breach caused harm that is more than minimal (the legal tests of causation and loss)

It’s not enough that something went wrong or an outcome was bad. The question is whether the care fell below an acceptable professional standard and that failure made a material difference to what happened.

2. If harm is caused by bad management, can NHS leaders be personally liable?

In theory, yes – senior managers and directors can be personally liable in law (for example, under gross negligence manslaughter or health and safety legislation) if their conduct meets the criminal threshold. In practice, it is rare.

Most negligence cases are framed against:

the trust as a corporate body (for civil damages), and
individual clinicians via their regulators (GMC, NMC, HCPC)

Senior executives often sit behind the corporate veil, unless their actions are so reckless or dishonest that they trigger police or regulatory interest. That’s the accountability gap this article is pointing at: managers make system-level decisions that shape risk, but the law still tends to focus on the frontline practitioner.

3. Why are maternity and newborn cases so dominant in NHS litigation?

Maternity and neonatal claims are a small proportion of total cases but a huge proportion of total cost. The reason is simple: when a baby is left with profound, lifelong disability (for example, after hypoxic brain injury at birth), the law recognises the cost of a lifetime of care, lost earnings and support.

So a single catastrophic maternity case can be worth millions of pounds. From a legal perspective, the damages are driven by:

Life expectancy and future care needs
Specialist equipment and housing adaptations
Lost earnings and pension
The need for round-the-clock support

From a safety and policy perspective, these cases are also among the most predictable and preventable – which is why maternity is now the sharp end of the debate on NHS negligence reform.

4. Why doesn’t the NHS just move to a no-fault compensation scheme?

No-fault compensation – where injured patients are compensated without having to prove negligence – is attractive on paper. It can:

Reduce legal costs and delay
Avoid the adversarial blame culture
Allow more consistent, predictable awards

But there are two big legal and policy challenges:

Cost and eligibility – policymakers worry that if you remove the “fault” gateway, claims could rise sharply. They must define tightly who qualifies and for what injuries.
Deterrence and learning – the fear is that if no one has to admit fault, the system may lose one of the main drivers for exposing unsafe practice.

That’s why most proposals focus on targeted no-fault schemes (e.g., for severe birth injury) rather than a wholesale replacement of negligence law.

5. What is corporate manslaughter, and could it apply to an NHS trust?

The Corporate Manslaughter and Corporate Homicide Act 2007 allows an organisation to be prosecuted where:

the way its activities were managed or organised
caused a person’s death, and
amounted to a gross breach of a duty of care

In principle, this can apply to NHS trusts. The difficulty is evidential: prosecutors must show that senior management decisions were a substantial element in the breach, not just individual clinical mistakes.

We are beginning to see police investigations into maternity services under this framework. Whether they lead to convictions will be a key test of how far the law is willing to go in holding organisations – and by extension their leaders – criminally accountable.

6. Why do enquiries and inquests keep finding the same patterns of failure?

From a legal perspective, each inquiry and inquest looks at a different set of facts. But viewed together, they reveal recurring themes:

Failure to escalate deterioration
Poor communication with families
Suppression or dilution of internal warnings
Defensive responses to complaints and whistleblowing
Weak use of data and incident reports at board level

In negligence law, evidence of repeated similar incidents can be important when assessing whether an organisation met its duty of care or whether there was a systemic rather than one-off failing. The uncomfortable truth is that many NHS tragedies now look more like system failures with individual actors than individual mistakes in a sound system.

7. How does Martha’s Rule sit alongside legal rights patients already have?

Patients already have legal rights to:

Give or refuse consent
Be told honestly when something goes wrong (statutory Duty of Candour)
Complain and escalate concerns

Martha’s Rule doesn’t create a new cause of action in law; it creates a clear, operational mechanism within hospitals to trigger a second opinion when families are worried.

Legally, it’s significant in three ways:

It strengthens the argument that trusts have a duty to respond reasonably to expressed concerns.
It generates documented escalation pathways – which courts can later look at if things go wrong.
It tightens the link between patient voice and clinical decision-making, which is increasingly relevant to both negligence and human rights arguments.

8. What is the legal role of the duty of candour in NHS negligence cases?

The statutory Duty of Candour requires NHS organisations to be open and honest with patients (or families) when something goes wrong that causes moderate or severe harm:

They must inform the patient, provide a truthful account, apologise, and explain what will be done to prevent recurrence.

In a negligence claim, breach of the duty of candour does not by itself prove negligence – but it is relevant. Courts, coroners and regulators are increasingly interested in whether an organisation:

disclosed the incident promptly
gave a full and accurate account
took the incident seriously enough to investigate and learn

A trust that hides or spins events may face greater legal and reputational risk than one that admits failings early and supports the family properly.

9. How can litigation data legally help prevent future harm?

From a legal and governance perspective, claims data are a form of lagging evidence about where the system breaks. Used properly, they can:

Identify patterns of breach (e.g. repeated failure to diagnose a condition)
Inform clinical guidelines and training
Justify investment decisions (e.g. staffing, equipment, digital systems)
Support regulatory intervention when a trust is clearly an outlier

The irony is that many NHS organisations treat claims data purely as a finance problem – a cost to be contained – rather than a forensic map of risk that should be driving prevention. In law, repeated similar claims can also make it harder for a trust to argue that a harm was unforeseeable or that its systems were fundamentally sound.

10. Are we moving towards legal accountability for “fitness to manage”?

Right now, the law has a well-developed concept of fitness to practise for clinicians, but almost nothing equivalent for NHS executives. That may be changing.

We can already see:

Growing interest in directors’ duties, especially around candour and use of safety data
Police willingness to investigate trusts (and occasionally individuals) for gross negligence manslaughter
Policy debates about creating a professional register for NHS managers, with enforceable standards

If that happens, senior leaders could, for the first time, face a regime more like that of doctors: clear duties, investigatory powers and the possibility of being barred from senior roles if they repeatedly preside over unsafe systems. It wouldn’t replace negligence law, but it would close some of the accountability gap the current scandals have laid bare.