One of the classic tactics of “spin”—telling a story so that listeners hear the message you want to convey—is to preannounce a report and what you are going to do about it a day or two before the report comes out. That way you get your reaction in first, and, because no one else has read the report, the media describe it in your terms.
Alan Milburn, secretary of state for health, is a fine master of spin, and he showed his skills again last week over a report on learning from adverse events in the NHS by Liam Donaldson, England's chief medical officer (see pages 1683 and 1689). In the process, he obscured one of the key lessons for any organisation that is serious about reducing errors.
As An Organisation with a Memory (the report's evocative title) points out, adverse events in the NHS—indeed, any health system—are common. And most of them are not caused by bad individuals: “In the great majority of cases, the causes of serious failures stretch far beyond the actions of the individuals immediately involved.” A key message of this report and of the BMJ's recent theme issue on medical error (18 March) is that when things go wrong the roots of the failure are usually systematic—they lie in the team, the work environment, the organisation, and the organisation's culture. The point of an error reporting system, which is what the report recommends, is therefore to gain greater understanding. In most cases errors are not caused by reckless individuals, so simply shooting the person at the sharp end is not only unfair—it's not effective. Thus Donaldson's report emphasises the importance of a reporting and questioning culture in the NHS—a “safety culture” rather than a “blame culture.”
So how did Donaldson's report reach the public? Almost entirely in the context of blame—of high profile individuals who had done blameworthy things.
The report was published on Tuesday 13 June, but the story started on Sunday 11 June with an article in the News of the World written by Milburn himself. Under the headline “My alarm bells will trap the dodgy docs,” Milburn referred to Donaldson's early warning system and named Harold Shipman—a mass murdering general practitioner—as an example of the sort of “error” the system was designed to pick up. The BBC that day, and several newspapers the next day, added the example of Rodney Ledward, a gynaecologist recently struck off the medical register for “bungling operations” (Independent). The story appeared under headlines like: “Warning system to catch Shipmans and Ledwards set up by the NHS” (Independent); “Early warning system to catch bad doctors” (Guardian); “Warning system to put the spotlight on killer doctors” (Express). All this prompted the Conservative spokesman on health, Dr Liam Fox, to fear that the proposals signalled that “whistle-blowing and finger pointing will be the culture of Labour's NHS.”
On Tuesday the report was published, and Liam Donaldson was allowed to talk on the radio about what it actually said. At the same time, however, the news broke that James Elwood, a locum pathologist, had been the subject of an inquiry into misdiagnoses at a hospital in Swindon. So he was added to the list of examples. Nevertheless, once journalists actually read the report the headlines became less focused on individual bad practice. “Reports of ‘near misses’ to end culture of secrecy” from the Times and “Database will tackle NHS's £2bn ‘mistakes’” from the Daily Telegraph were typical examples, though the Express still managed “Staff ordered to report botchers,” and its editorial saw the “blunders register” entirely in terms of negligent doctors and their silent colleagues.
The most helpful piece for illustrating the “systems” message of the report was a small box in the Guardian, quoting a case study from Donaldson's report. This outlined the many antecedent actions that led to a child being given vincristine intrathecally rather than intravenously. Donaldson's report said there had been 12 similar cases—the risks were known, but the lessons weren't being learnt. 
Once the report was out stories continued to the end of the week, many of them linking the recommendations about error reporting to General Medical Council reforms, appraisals for doctors, and revalidation. These measures are indeed linked in that they are all designed to ensure that the “system” is better managed. Appraisals and revalidation may well stop future Ledwards or Elwoods, while Donaldson's recommendations could prevent the far greater number of errors made by competent, hard working staff working in haphazard systems.
On Friday 16 June Sarah Boseley in the Guardian highlighted the conflict between the “blame free culture” message of Donaldson's report and the “pointing the finger” subtext to Shipman, Ledward, et al. She wondered why the report had come out on the same day as James Elwood was “thrown to a baying press pack.” But the problem had started before that, when Milburn set the report off on the wrong foot. And he, of course, has reason to be ambivalent. “Botchers” are good for politicians—someone else takes the blame. “Blunders” are trickier—the causes are wider, the blame more diffuse, and some of the responsibility inevitably lies at the top.