In everything we have done and the discoveries we have made, we have been amazed by the total lack of accountability of any NHS managers, consultants and main board directors.

Harry's case, and we have no doubt many more, will prove that senior managers, consultants and main board directors failed in their duty.  They failed to investigate properly, they failed to learn from mistakes and they actively avoided any outside scrutiny.

In the "outside" world, any manager or director presiding over such failings would be held to account.  Why is this not so in the NHS?   Instead of accountability, people are "moved on" to work on different projects or are retired early with no consequence for their actions or lack of actions.

These people are paid exceptionally well to run huge businesses.  Make no mistake, a Trust, is a huge business with company cars, expenses and bonus schemes.  

Until and unless there is proper accountability, very little will change.  Staff deserve good managers and directors as well as patients and service users, this situation of no accountability and a merry go-round of senior staff has to stop.

We look forward to the publication of the Kirkup inquiry in 2022.