This podcast is a recording of a webinar, presented by Oonagh Gilvarry, CTO at HCI. HCI has completed detailed research of a number of seminal reports into catastrophic failings in healthcare across the UK and Ireland to identify the repeated failings that have directly impacted on the quality and safety of patient care. This webinar provides a summary of this research, including the identification of the prevalent themes that predicated tragic outcomes for patients, including inadequate governance, system and processes failures, poor communications and disempowerment of staff and patients. The webinar will also consider the controls and responsive models required by healthcare services to prevent recurrence of these tragedies.