Failures in the system: our inability to learn from inquiries

The Rowan report was published in 2003, following an investigation into allegations of abuse on a ward providing longterm care for older people with mental health problems. The factors identified as important were similar to those identified in other inquiries that took place before and after the Rowan inquiry. Why do organisations fail to learn the lessons of the past?This paper examines what happened following publication of the Rowan report and the ensuing publicity. Some positive outcomes are identified but, putting these in context, it seems unlikely that they will prevent further incidents. How do organisations prevent incidents/suspicions of abuse? The author suggests a multi‐level approach and argues that residential and nursing care is at least equally at risk. The fundamental problem lies in society's failure to prioritise and adequately resource the care of older people with dementia and other mental health problems.