Beyond Blame: Can Healthcare Really Build a Just Culture When the Outside World Still Wants Someone to Blame?
People rarely come to work intending to cause harm. Yet when something goes wrong, the search for an individual to hold responsible can begin before anyone has properly examined the system in which they were working.
This article responds to a meaty question raised by Ross Wyatt during Tuesday’s webinar,“Beyond Blame: The Second Victim and Compassionate Patient Safety Responses”:
People do not come to work intending to cause harm or to work outside policy and procedure. How can we create a culture that acknowledges system constraints and influences when regulators, coroners and the media often focus on individual actions and blame?
It is a difficult question because healthcare organisations do not operate in isolation.
They sit within systems of regulation, commissioning, professional accountability, public scrutiny, political pressure and limited resources. Leaders may want to support system-based learning, but they must also answer questions from boards, regulators, coroners, patients, families and the media.
So, can an organisation genuinely move beyond blame when the wider environment may still appear to demand it?
The answer is yes, but not through policy statements alone. A fair and compassionate safety culture depends on four things:
Making system-based learning the default response.
Practising restorative, rather than purely retributive, accountability.
Separating patient safety learning from individual conduct processes.
Building governance that can explain and defend proportionate decisions under scrutiny.
The challenge is not to choose between compassion and accountability. It is to create a form of accountability that helps people, repairs harm and makes future care safer.
People do not work outside a system
When an incident occurs, attention is naturally drawn towards the person closest to the outcome.
What did they do?
What should they have done?
Did they follow the procedure?
Who signed off the decision?
These questions may be relevant, but they are rarely sufficient.
Human factors asks us to examine the person in the context of the work. That includes the task, equipment, information, environment, team, staffing, supervision, organisational priorities and pressures operating at the time.
The Health and Safety Executive describes human factors through the interaction of job, individual and organisational influences, all operating within a wider societal context. It is explicit that these elements should not be considered in isolation.
This means asking not only what someone did, but also:
What were they trying to achieve?
What information did they have at the time?
What equipment and technology were available?
What competing demands were they managing?
How did workload, fatigue, interruptions or staffing affect the work?
Did the procedure reflect how the job could realistically be done?
What normally helped the work go well?
Was any of that support missing on this occasion?
The purpose is not to excuse unsafe conduct. It is to distinguish deliberate or reckless behaviour from the predictable adaptations people make when trying to deliver care in a difficult or poorly designed system.
Tools such as Accimaps can help make these different levels of influence visible. Instead of stopping at the actions of an individual practitioner, they allow organisations to explore how decisions, constraints and controls across the system shaped the event.
PSIRF changes where responsibility sits
The NHS England Patient Safety Incident Response Framework, or PSIRF, represents a significant change in how organisations are expected to respond to patient safety incidents.
PSIRF is built around four central aims:
compassionate engagement and involvement;
system-based approaches to learning;
considered and proportionate responses; and
supportive oversight focused on improvement.
It replaces a threshold-driven approach with one in which providers are expected to understand their incident profile, plan their responses and select appropriate learning methods.
Under the previous Serious Incident Framework, an external organisation could appear to determine whether an incident met a particular threshold and whether the resulting investigation was “good enough”.
PSIRF removes the Serious Incident classification. It does not prescribe a single list of incidents that must receive a particular type of investigation. Instead, providers must develop a patient safety incident response plan based on their services, risks, available data and improvement priorities.
This gives providers greater control, but also greater responsibility. When external criticism risks pushing an organisation towards an older, blame-focused response, leaders should be able to explain why they selected a particular learning method and why that response was reasonable and proportionate.
This requires more than confidence. It requires sound governance. An organisation should be able to demonstrate:
how the response was selected;
what organisational information informed the decision;
why the response was proportionate;
how patients, families and staff were involved;
what evidence was considered;
how system conditions were examined;
what was learnt;
who owns the resulting actions; and
how the effectiveness of improvement will be monitored.
The 2026 patient safety incident response standards reinforce this connection between patient safety and governance. They require alignment with related clinical governance processes, clear governance and reporting structures, proportionate responses and policies that promote a just culture. They specifically caution against automatic suspension or removal from normal duties following an incident.
A system-based response is therefore not a softer alternative to proper scrutiny. Done well, it is a more demanding form of scrutiny because it requires the organisation to examine its own decisions, resources and controls, not simply the actions of the person at the sharp end.
Accountability should lead somewhere useful
The language of accountability is frequently used after harm, but its meaning is rarely examined.
In a retributive model, accountability tends to mean identifying:
which rule was broken;
who crossed the line; and
what consequence should follow.
A restorative approach asks different questions:
Who has been harmed?
What do they need?
Who has a responsibility to meet those needs?
These questions are reflected in the NHS England Being Fair tool, which replaced the previous Just Culture Guide in 2025. The tool should not be used routinely. It is intended for the relatively rare circumstances in which a system-based patient safety learning response raises a concern about an individual’s conduct or fitness to practise.
That sequence matters. The starting point is not an individual decision tree. The starting point is learning about the system and responding to the needs of those affected. Restorative accountability does not mean that nobody is held responsible. It asks people and organisations to:
give an honest account;
listen to those affected;
acknowledge and respond to harm;
repair relationships where possible;
rebuild trust;
provide appropriate support; and
change the conditions that made the event more likely.
That can be more challenging than assigning blame.
Blame can create the impression that action has been taken while leaving the underlying conditions intact. Restorative accountability asks whether the organisation has understood what happened and whether it has made care meaningfully safer.
Learning and conduct are not the same process
There will be occasions when concerns about individual conduct, capability or fitness to practise genuinely remain.
A systems approach does not prevent those concerns from being addressed.
However, if learning and disciplinary processes become intertwined too early, staff may reasonably believe that the purpose of an investigation is to build a case against someone. That reduces trust, discourages openness and weakens the quality of evidence available to the organisation.
The safer sequence is:
Begin with a system-based learning response.
Understand the context and conditions in which the work took place.
Identify the needs of everyone affected.
Establish what wider learning and improvement are required.
Consider any remaining individual concern separately and proportionately.
If credible evidence of deliberate harm, recklessness, impairment or repeated unacceptable conduct emerges, it should be addressed through an appropriate process.
The important point is that the conduct process should not become a substitute for understanding the event.
This is both a human factors issue and a governance issue. Good governance protects the integrity of each process. It defines their purposes, controls how information is used, establishes appropriate decision-making authority and ensures that conclusions are supported by evidence.
Risk appetite is where governance becomes real
Risk appetite is sometimes treated as a specialist board topic, disconnected from the realities of frontline care.
In practice, it can be central to creating a fair safety culture. Healthcare workers make decisions within constraints that they often did not create. They may be working with limited capacity, unfilled vacancies, ageing equipment, competing priorities or services that cannot meet every demand at the same time.
If an organisation has tolerated those conditions, explicitly or implicitly, it should not transfer the full burden of the resulting risk onto an individual practitioner.
A meaningful risk appetite should help boards and teams determine:
what activity must stop;
what can continue with additional controls;
what can be tolerated temporarily;
what requires executive escalation;
who has authority to accept a risk; and
when resource constraints require a fundamental change to the service.
This is where governance moves from a document to a lived organisational control.
A risk appetite that looks impressive in a board paper but does not influence staffing, investment, prioritisation or escalation is not protecting anyone. When risk appetite is genuinely embedded, it gives practitioners and leaders a shared basis for making difficult decisions. It also helps the organisation explain why a decision that later attracted criticism may have been the safest available option in the circumstances.
External scrutiny does not have to mean individual blame
Organisations cannot control how every regulator, coroner or journalist will interpret an event.
They can control the quality of their evidence, the transparency of their reasoning and the clarity of their response. Prevention of Future Deaths reports offer one example. Coroners have a statutory duty to issue a report when an investigation reveals circumstances creating a risk of future deaths and action should be taken. The recipient is normally required to respond within 56 days.
The purpose of a Prevention of Future Deaths report is not to express opprobrium or punish an individual. Chief Coroner guidance describes their public health purpose and their role in promoting learning and practical action.
This gives organisations an opportunity to respond with evidence about:
the system conditions identified;
existing and additional controls;
immediate risk reduction;
sustainable improvement;
named ownership;
realistic timescales; and
how effectiveness will be tested.
A defensive response may protect the organisation’s position in the short term but do little to build public trust.
A blame-focused response may appear decisive but fail to prevent recurrence. A mature response acknowledges harm, explains the context, describes the reasoning behind decisions and demonstrates what the organisation is doing differently.
The media creates a different challenge
Complex safety events do not always fit comfortably into public reporting.
A systems explanation may involve staffing, commissioning, demand, technology, procedures, supervision, organisational priorities and national policy. A headline may focus on one person and one action.
Healthcare organisations should therefore prepare for media scrutiny before an event occurs.
Patient safety teams, governance leaders, executive teams and communications professionals need a shared understanding of system safety. Without that shared language, a carefully designed learning response can be undermined by public statements that prematurely attribute fault or promise simplistic solutions.
Good communication following an incident should:
acknowledge the harm experienced by patients, families and staff;
avoid premature conclusions about individual responsibility;
explain the purpose of the learning response;
distinguish accountability from blame;
protect confidentiality;
avoid speculation;
describe improvement without making unrealistic promises; and
show how the organisation will monitor whether change has worked.
This is not about controlling the narrative. It is about communicating responsibly when the facts are still being established.
Culture is often experienced locally
Organisational culture can feel too large for one practitioner or team to influence.
However, culture is experienced through local climate: the actions leaders take, the questions colleagues ask and what happens when somebody speaks up.
Frontline staff and local leaders can influence this climate by improving the way events are described and explored.
An event report should capture context and competing goals, not simply record who did what. A learning response should compare work as imagined in policy with work as done in practice.
Those closest to the task should be involved because they often understand the adaptations, dependencies and informal controls that keep everyday work functioning.
Improvement actions should then address the conditions identified. This might include changes to:
task and pathway design;
staffing and workload;
equipment and technology;
handovers;
supervision;
access to information;
decision-making authority; or
escalation arrangements.
Reminders, retraining and rewritten procedures may sometimes be appropriate. They should not be automatic responses. If the system still requires people to succeed through memory, vigilance and goodwill, the risk has not necessarily been controlled.
Human factors must be experienced, not only explained
One of the most effective ways to engage senior leaders with human factors is to let them experience it. Concepts such as workload, cognitive bias, uncertainty, competing priorities and limited situational awareness can sound abstract in a presentation. When leaders experience those pressures themselves, the conversation changes.
The purpose is not to catch people out. It is to create a safe and memorable experience that reveals how ordinary human performance is shaped by the conditions around it.
At Promethean HD, we use experiential methods to help teams examine not only how people make decisions, but also how organisational structures and governance arrangements influence those decisions.
LEGO® SERIOUS PLAY®
The LEGO® SERIOUS PLAY® methodology allows participants to build and explain models representing their experience of a system, risk or organisational challenge.
The method was developed to encourage participation, contribution and commitment to solutions. It helps turn complex or abstract issues into visible models that can be explored collectively.
In a healthcare workshop, participants might build:
what safe care looks like in their service;
what prevents staff from speaking up;
how a patient experiences the system;
where information is lost;
what a fair response to an incident should involve; or
how governance is experienced from the frontline.
The value is not in producing an attractive model. It is in the discussion the model enables. Metaphor can reveal assumptions and relationships that are difficult to express through conventional meetings. Participants can point to a physical representation of a barrier, dependency or missing control. Different models can then be connected to show how individual perspectives form part of a wider system.
It also changes participation. Rather than discussion being dominated by the most senior or confident person, each participant has something to build and a story to tell. Used carefully, this can surface knowledge that formal governance structures do not normally hear.
Matrix decision games
Matrix decision games place participants in a changing scenario where they must make decisions with incomplete information, limited resources and competing objectives.
As the scenario develops, new information is introduced. Participants may experience:
time pressure;
uncertainty;
conflicting priorities;
information overload;
communication failures;
unclear authority;
changing risk;
resource constraints; and
pressure to act before the full picture is available.
T
he learning does not come from identifying who made the “correct” decision. It comes from examining why particular decisions made sense at the time.
The debrief can explore:
Which information was noticed or missed?
What assumptions influenced the group?
Who was heard and who was not?
Was decision-making authority clear?
How did the group respond to uncertainty?
Did governance support timely decisions or create delay?
Which controls helped?
Where did people have to improvise?
This creates a bridge between human factors and governance. Participants can see that performance is shaped not only by individual competence but also by information flows, escalation routes, role clarity, authority and the design of assurance processes.
Pre-mortem approaches
A pre-mortem asks a team to imagine that a planned change has already failed and then identify the reasons why.
The method is associated with psychologist Gary Klein. Instead of asking whether anyone can see a problem with a preferred plan, the group assumes failure has occurred and works backwards to identify plausible causes.
For example:
It is 12 months from now. This service redesign has failed, patients have been harmed and staff confidence has fallen. What happened?
This framing gives people permission to raise concerns that might otherwise appear negative, disloyal or obstructive.
In healthcare governance, a pre-mortem can help teams identify:
hidden dependencies;
unrealistic assumptions;
weak controls;
insufficient capacity;
implementation risks;
unintended consequences;
groups whose needs have been overlooked;
measures that could give false assurance; and
early warning signs that should trigger escalation.
The insights must then be converted into action. Risks should be assessed, controls agreed, owners identified and warning indicators built into the governance arrangements.
Otherwise, the exercise becomes an interesting conversation rather than a risk control.
The debrief is where experience becomes governance
Experiential learning is only as useful as the conversation that follows it.
A good debrief connects the activity to real organisational decisions:
How are services staffed?
How is equipment selected?
Are procedures usable?
Who can stop or change unsafe work?
How quickly can concerns be escalated?
What information reaches the board?
Whose perspective is absent from governance discussions?
How do leaders know whether an intervention has worked?
The task is to move from“That was interesting” to“What does this tell us about the way our system is designed and governed?”
Human factors training is not a complete solution. It cannot compensate for insufficient resources, weak leadership or poorly designed governance.
It can, however, help leaders recognise how their own decisions create the conditions in which care is delivered.
From individual blame to shared responsibility
Changing organisational culture takes time. Changing wider public expectations may take even longer.
Structural changes are nevertheless moving healthcare in the right direction.
PSIRF gives providers greater ownership of proportionate, system-based learning. Restorative approaches offer a more constructive understanding of accountability. The Being Fair tool establishes that system learning should precede any exceptional consideration of individual conduct. Stronger quality governance can help boards connect safety with resources, workforce, risk and organisational design.
But policy alone will not create a fair culture.
Change has to come from both directions.
It must come from the top through leadership, resources, risk appetite, governance and a willingness to defend good system-based decisions.
It must also come from the bottom through better questions, stronger event reporting, honest learning and the confidence to challenge an automatic return to blame.
The aim is not to remove accountability. It is to create accountability that leads somewhere useful: support for those affected, fair treatment of staff, stronger governance, safer system design and a reduced risk of the same harm happening again.
That is how we move beyond blame.
About Promethean HD
Promethean HD helps healthcare organisations strengthen patient safety, human factors and governance.
We support organisations to understand how work is really done, learn effectively from patient safety events and design practical governance arrangements that support safer and more reliable care.
Our work includes:
human factors and ergonomics training;
systems-based learning and investigation;
just and restorative culture development;
experiential leadership development;
facilitated LEGO® SERIOUS PLAY® sessions;
matrix decision games;
pre-mortem and risk workshops; and
bespoke coaching and consultancy.
Contact Promethean HD to discuss a bespoke workshop, leadership session or governance review.
References:
Chief Coroner. (2026, May 10). Reports to prevent future deaths (PFDs). Courts and Tribunals Judiciary.
Dekker, S., Oates, A., & Rafferty, J. (Eds.). (2022). Restorative just culture in practice: Implementation and evaluation. Productivity Press.
Health and Safety Executive. (n.d.). Introduction to human factors. Retrieved September 10, 2026,
Klein, G. (2007, September). Performing a project premortem. Harvard Business Review, 85(9), 18–19.
LEGO Group. (n.d.). What is LEGO® SERIOUS PLAY®? Background. Retrieved September 10, 2026,
National Quality Board. (2026). Quality strategy for NHS-funded care in England. NHS England.
NHS England. (2022). Patient Safety Incident Response Framework.
NHS England. (2025). Being fair tool: Supporting staff following a patient safety incident.
NHS England. (2026). Patient safety incident response standards (Version 1.3).
NHS Improvement. (2018). A just culture guide: Supporting consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents. National Health Service.
Rasmussen, J. (1997). Risk management in a dynamic society: A modelling problem. Safety Science, 27(2–3), 183–213.
Reason, J. (1997). Managing the risks of organizational accidents. Ashgate.
Roos, J., & Victor, B. (2018). How it all began: The origins of LEGO® SERIOUS PLAY®. International Journal of Management and Applied Research, 5(4), 326–343.
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