“The role of a good culture isn’t just to protect good people; it’s also to protect the good in people.”
These last week’s my reading has steadily increased. I’m not one for the crime novel or sci-fi story. More I focus on building my professional knowledge, so I am better able to share an approach that is so misunderstood and often used badly. As another blog earlier this week highlighted my focus on early harm is seen by some as being too ‘woke’. These last days the title of this blog began to develop in my head and today it seems so relevant.
It is a title that feels painfully relevant in the wake of the latest report into maternity services at Nottingham University Hospitals NHS Trust. Donna Ockenden’s review into maternity care at the trust lays bare an appalling pattern of avoidable harm: 444 women and 76 babies suffered potentially avoidable death or injury over a 13-year period. The report describes not only poor clinical care, but something deeper and more corrosive, a toxic workplace culture, bullying, hierarchy, failures to listen to women, weak leadership, poor incident learning and repeated missed opportunities to act on warning signs.
Families described being ignored, dismissed and gaslit. Staff described a culture in which problems were known but not properly confronted. This is not simply a story about bad outcomes in a pressured system. It is a story about what happens when organisational culture stops protecting the very human qualities that safe care depends on: honesty, humility, curiosity, courage, compassion and the willingness to challenge. It is a story about what happens when the good in people is worn down and that is why culture matters so much.
Not just bad people. Bad conditions for good people.
When scandals like this emerge, there is a temptation to look for villains. Let’s face it we live in a society where we want a head on a pole. Whether its media outlet looking for clicks or a politician looking for power we focus on blaming someone. Sometimes there are individuals whose conduct is plainly unacceptable and who should be held to account. However, if we stop there, which we tend to do, we miss the bigger and more uncomfortable truth.
Large-scale organisational harm is rarely explained by a handful of bad actors alone. It is usually sustained by a culture that makes it harder for ordinary, decent people to do what they know is right. It’s the same in policing, the military and other similar high-risk settings.
In Nottingham, the findings point to exactly that sort of environment: one in which women’s concerns were too often not heard, risks were not escalated, lessons were not learned, and staff operated within cultures shaped by intimidation, hierarchy and fear. The review found that bullying and toxic behaviours impeded improvement and that leaders had been repeatedly warned about serious concerns over many years without effective action being taken. For a few seconds out yourself in the shoes of staff who were trying to report concerns, and nothing was done. You would be excused in thinking what’s the point. Apathy kills culture dead.
That matters because the role of culture is not merely to keep obviously harmful people in check. It is to create the conditions in which good instincts survive pressure. A good culture protects the midwife who senses that something is wrong and feels able to escalate. It protects the junior doctor who notices a risk and challenges a senior decision. It protects the consultant who is willing to pause, listen carefully to a mother’s fear, and reconsider. It protects the manager who chooses transparency over defensiveness when harm has occurred. It protects the colleague who sees a dismissive interaction and decides to intervene rather than walk past.
In short, a good culture protects the good in people.
The Rob Behrens warning: toxic culture kills truth before it kills patients
This is where the work of former hospital trust ombudsman Rob Behrens is so important. Behrens has repeatedly warned that parts of the NHS have been trapped in a “cover-up culture” in which hospitals bury evidence of poor care, deny bereaved families the truth and prioritise institutional reputation over candour. In one stark intervention, he warned that avoidable deaths were being sustained by a culture of defensiveness and concealment rather than learning and accountability. Furthermore, he identified a ‘culture is king’ mentality. We know from vast academic research that hierarchies both formal and informal present challenges for those who witness harm.
Behrens warning should sit beside the Nottingham findings, because the pattern is similar. When organisations become defensive, the first casualty is not only truth; it is conscience. People begin to adapt to the culture around them. They learn what is safe to say and what is dangerous to say. They learn which concerns will be welcomed and which will be punished. They learn whether challenge is seen as care or as disloyalty.
Over time, the effect is profound.
Staff who entered healthcare with compassion and conviction can become quieter. People who once would have spoken up can begin to second-guess themselves. Managers can start protecting the organisation from scrutiny rather than protecting patients from harm. Teams can normalise conduct they would once have found shocking. No one needs to wake up intending to be cruel for harm to spread. A toxic culture does not require monsters. It merely requires enough people to become silent, deferential, exhausted or afraid.
That is why the question raised by Nottingham is not simply, “Why didn’t individuals do better?” It is also, “What kind of culture made doing better so much harder?”
Maternity care makes this especially stark
Maternity care is one of the clearest examples of why culture matters because safety is so dependent on relationships, listening, escalation and teamwork. A woman in labour may know that something is wrong before any monitor confirms it. A birth partner may spot deterioration before a clinician does. A midwife may sense a change in the room before it becomes a measurable emergency. A junior doctor may notice that a delay has become dangerous. A healthcare assistant may witness a disrespectful interaction that signals a wider problem. None of these moments are “just clinical”. They are cultural moments too.
Will the woman be believed?
Will the partner be listened to?
Will the junior colleague be taken seriously?
Will the staff member feel safe to challenge?
Will the concern be treated as valuable information or as an inconvenience?
The Nottingham report suggests that too often the answer was the wrong one. That is not simply a technical failure. It is a failure of culture.
Why active bystandership has to be part of the response
If the problem is a culture in which people do not speak, do not challenge, do not escalate and do not feel heard, then part of the answer must be to build cultures in which they can and not only feel able to officially report after the fact. That is where active bystandership training matters.
Done well, active bystandership is not a glossy add-on or a poster campaign about “speaking up”. It is practical training in how to recognise harm, interrupt harmful behaviour, challenge poor decisions, support colleagues, receive challenge well, and escalate concerns before harm deepens. In a healthcare setting, that means equipping staff to intervene not only when they witness obvious abuse or bullying, but also when they see the quieter, more normalised behaviours that allow harm to grow:
- the senior doctor dismissing a junior concern without reflection
- the colleague speaking over a woman who says something feels wrong
- the pattern of “not quite right” incidents that no one joins up
- the demeaning joke, eyeroll or humiliation that tells others to stay silent
- the reluctance to call for help because “we don’t want to make a fuss”
- the pressure to protect the team or the trust rather than confront the problem.
Active bystandership training helps because it makes intervention a shared professional responsibility rather than an act of personal heroism. It gives people language, permission and practical tools. It helps teams rehearse what challenge sounds like before the high-stakes moment arrives. Crucially, it teaches not just how to intervene, but how to receive intervention without retaliation or humiliation. That last point matters enormously in hierarchical organisations like the NHS. If a junior midwife, trainee or newly qualified nurse raises a concern and is shut down, the lesson they learn is not “speak up next time.” The lesson is “keep your head down.” Active bystandership training only works when it is tied to leadership behaviour, psychological safety and accountability.
Someone who is prepared to be intervened on is way more likely to receive the intervention than one who works in a culture where intervention is simply seen as a challenge. In an active bystandership culture early action is a supportive one where colleagues are being truly loyal to both colleagues and patients. When people intervene early everyone benefits.
The challenge for NHS leaders
The response to Nottingham cannot be limited to policy statements, apologies and another set of action plans. Those things matter, but they are not enough on their own.
The deeper task is cultural. NHS leaders need to ask:
- Do our people feel safe to challenge poor care in real time?
- Do we reward candour or punish it?
- Do families experience us as open and curious, or defensive and closed?
- Do we train staff not just to deliver care, but to interrupt harm?
- Do our hierarchies help people think clearly, or stop them speaking honestly?
- When concerns are raised, do we treat them as threats to reputation or opportunities to prevent tragedy?
If the answer to those questions is uncomfortable, then that discomfort is where the work begins. The lesson from Nottingham, and from Rob Behrens’ wider critique of NHS culture, is that patient safety is never only about procedures, staffing models or governance structures. It is also about whether the culture protects the moral courage of the people inside it.
A good culture does not merely stop bad people doing bad things. It protects good people from becoming silent. It protects compassionate people from becoming numb.
It protects thoughtful people from becoming compliant. It protects brave people from becoming afraid. It protects the truth from being buried beneath status, hierarchy and self-protection.
In the end, that may be the clearest test of culture there is. So back to my title – “Its role is not just to protect good people. It is to protect the good in people.”
Over to you……….
grahamgoulden.com 