RT Journal Article SR Electronic T1 Public inquiries, patient safety and the implementation gap JF Future Healthcare Journal JO Future Healthc J FD Royal College of Physicians SP 7 OP 9 DO 10.7861/fhj.2023-FR103 VO 10 IS 1 A1 Helen Hughes YR 2023 UL http://www.rcpjournals.org/content/10/1/7.abstract AB A decade on from the Francis report, avoidable patient harm continues to occur and we have continued to see new inquiries and reviews into serious patient safety scandals. A failure to listen to patients or learn from previous investigations, a corrosive blame culture, a lack of effective leadership and an unresponsive regulatory framework are alarming and often reported themes that we review here.