| Description | This case study is provided as a cautionary tale to board members. It demonstrates the importance of ensuring that service quality and patient safety are at the heart of the organisation’s strategy and are not secondary to other objectives. It points to the role of the Board in ensuring that organisational systems reflect this commitment to patient safety and service quality. Significantly, it identifies the risks for NHS boards that remain insulated from processes of engagement that would allow them to triangulate board performance reports with the reality of staff concerns and the patient experience of care. |