• Sidney W A Dekker and Thomas B Hugh.
• School of Psychology, The University of Queensland, , St Lucia, Queensland, Australia.
• BMJ Qual Saf. 2014 May 1;23(5):356-8.

AbstractThere has been much public and media outrage in the wake of the scandal about the standard of healthcare delivered at Stafford Hospital. Using published evidence in the safety literature, we examine the distinction between our need to understand what happened, the practical need for preventing recurrence, and the age-old philosophical need to explain suffering. Investigations of what happened can identify the many detailed explanatory factors behind a particular outcome-including the actions and assessments of individual caregivers. These, however, do not necessarily constitute the change variables for preventing recurrence, as those might lie elsewhere in the governance of a complex system. And neither says much about the nature and apparent randomness of suffering in the particular circumstances of individual patients, even if that might be a most pressing question people want answers to in the wake of such a scandal. To promote safety and quality, we encourage a sensitivity to the differences between understanding, satisfying demands for justice, and avoiding recurrence. This might help a just culture in the wake of Mid Staffordshire, as it avoids expectations of an inquiry-independent or public-to do triple duty.

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