Bad things happened at Mid Staffordshire National Health Service (NHS) Trust (mid Staffs). The key question, having determined what, is to ask why. Why do good people do bad things? Upon this depends the sorts of actions that we might propose, extending and realising those made in the Francis report itself.

In their valuable paper, Newdick and Danbury analyse the issues from the perspectives of individuals, systems and then through the lens of cognitive psychology.1 All three perspectives offer food for thought and all three factors contributed to the failure. But which offers insights into the best possibility of progress? Wisely, that is left for us readers.

We are reminded at the outset of the 2001 inquiry into the deaths of children at the Bristol Royal Infirmary.2 That event is now so distant that many younger doctors are entirely ignorant of it and many older doctors will, like me, remember it as primarily a failure of three men, all disciplined by the General Medical Council (GMC). We can recall, for example, the demonstrations outside the GMC building as those accused of substandard practice arrived—perhaps most notably against the surgeon, James Wisheart, an obviously decent man. But return …