Commitment 7: We’ll always look into whether group norms or culture influenced an individual’s behaviour before taking action

When things go wrong there will usually be a number of people and different factors involved which contributed to some degree. Holding one individual to account where group norms or culture played a part in what happened may be unfair. It may also give false assurance and direct focus away from a wider problem.

Often incidents, errors or risks to safe care can happen through particular ways of doing things or because of a wider culture within an organisation. Workarounds can sometimes initially be developed because of problems in the working environment. Over time, these may become normalised and turn into a culture of this is how we do it here. Examples of this could be checking controlled drugs for multiple people at once, or pre-potting medication. Other norms can arise that result in unacceptable behaviour occurring in a working environment, such as inappropriate sexual banter.

Before deciding on someone's fitness to practise, we'll explore what role others played (including managers) to establish if there were any group norms or cultural issues that may have influenced their actions or behaviour. It will be important that we know how widespread the poor practice was in the setting (particularly if other health or social care professionals were routinely doing it), and how this came to be the case.

We'll also look at whether people felt safe to speak up, whether the person or others had attempted to raise concerns previously, and at any organisational pressure not to do so. If concerns were raised and dismissed or not responded to it might indicate that a working environment existed which prevented people from doing the right thing. Where there's evidence of this, we'll need to consider sharing information with others who also have a role in preventing future harm to people who use services.