I'm surprised that the long awaited report on the Kirkup investigation, into events at the Morecambe Bay FT, attracted so little public attention. By accident or design it arrived on a congested news day, dominated by the Prime Minister's agenda. Smart, careless, clever or happenstance? I guess we'll never know.

The report, crucial to the people whose lives, hopes and dreams have been become entangled in its events, gives us 44 recommendations, little by way of closure and frankly I think could have been written months, if not years ago.

They are a catalogue of the familiar. Managers under pressure, myopic focus on the wrong things. Denial, coteries and everyone involved digging the hole deeper and deeper.

What is there to say when we are told
 (again) recruitment problems impacted the clinical competence of staff and fell significantly below the standard for a safe effective service? Nothing...

What can we do when we find midwifery care becomes... influenced by 'over-zealous' midwives... pursuing natural childbirth 'at any cost'? Nothing...

What is there to say when we discover dysfunction going back to 2004 and in the intervening-past, problems and shortcomings are compounded by wilful neglect, ignorance and naivety? Nothing...

There is nothing we can say when those we trust with oversight and authority to protect us are too busy, too distracted or too gullible to do their job.

Neither are there words to describe the awful consequences of collusion; records 'gone missing', conflicting accounts... an interim report redrafted... and a 'conscious decision to suppress' a key report.

What response can we have when we learn, at the highest levels of management, they failed to grasp the true consequences of what was happening, failed to intervene and confused the systemic with coincidence. There is no adequate response.

What about a dangerous game of pass the parcel between the PHSO and the newly formed CQC; what are we supposed to make of that? What are we to say when the death of a child is squabbled over and eventually ends up in the hands of the police? Yes, the police.

We have, in black and white, major failings at almost every level of our health services. Doors were closed, waggons circled, people silenced and those with a vested interest in not-knowing, made it their business not to know.

This is one of the ugliest five years in the history of the NHS; what can we say? Nothing. We can just read the report and weep. Horrified that history is so easily capable of repeating itself.

If there is nothing to say, what is there to do? Everything... everything must be done to make sure that the people of Morecambe Bay and everywhere else in the NHS can take safe, competent, consistent care for granted. But we can't.

Isolated working, in out of the way places, is not something that can be resolved within a Trust. A wider more embracing perspective is needed to consolidate and share best practice.

Kirkup hints; the days of the CQC finding fault with what doesn't work and discovering no way of sharing what does, must surely be over. The return on our (£100m+) investment in the CQC is a handful of critical reports; we must find better ways of investing in safety and consistency.

Half the Kirkup recommendations are aimed at the Trust and are probably already implemented. The rest are a concoction of more regulation, oversight and checking. Kirkup recommends 'putting quality first'. Really? There's a novelty.

The analysis of real-time data and in-depth case note reviews of all deaths in maternity services seems a better solution.

Handling complains was out-with Kirkup's purview but he touches on its uselessness. I consider it is within my purview, so I will say it; the convoluted complaints system is 24crt gold crap. Made worse, protracted and oppressed by the pseudo-legal-fascism pedalled by the likes of the GMC and the NMC.

Something wrong?  Find out what happened, fix it fast, learn from it and move forward seems beyond the NHS mired in regulation, governance and the blame game.

This report tells us what we know, at the heart of it all; good people are frightened to speak truth to power.

How to fix that? Change who has the power... and what is there to say about that?   Everything.

Have a good weekend.  

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Essential weekend reading at the

Academy of Fabulous Stuff;

What have you struggled with this week? 

There might be a solution here.

Make a note; be a sharer next week. 

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TV doctor, whistle-blower, writer, Private Eye contributor and comedian

 Phil Hammond

 in conversation with Roy Lilley

Not to be missed - and a free drink!

 RCN HQ London 1st April - details here.  

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