Abstract
The 2018 Gosport Independent Panel report into deaths at the National Health Service’s Gosport War Memorial Hospital highlighted numerous organisational failings. With the aid of systems theory, this commentary identifies the root causes of events at Gosport. It is concluded that money spent on patient-safety initiatives will be wasted unless the root causes of error and malpractice are eliminated.
Disclosure statement
No potential conflict of interest was reported by the author.