The report of the independent inquiry into Stafford Hospital’s disastrous tragedy is a shocker.

900 pages of grim detail make clear why some 1200 – yes, one thousand two hundred – more patients died than would have been expected to.

The report describes a sorry story of selfish ambition and greed by bullying senior trust managers. It catalogues an obsession with showing how the Trust was meeting the process targets set by Government whilst care standards were collapsing. It chronicles the culture of lies and secrecy which prevented patients and their relatives knowing what was going on.

The report shows how bullying and fear were rife. Unfortunately the report does not go on to explain how and why the supposed regulators utterly failed to detect, challenge and prevent the tragic events. Yet, as relatives said when the report was published, this is surely a crucial factor is knowing whether similar events can be prevented elsewhere.

The West Midlands Regional Health Authority at the time was led by Cynthia Bower, now head of the Care Quality Commission responsible for health and social services. The acting head of Monitor, a Mr Chris Mellor, the body that supposedly regulates individual foundation trusts (which Stafford now is) made a most extraordinary statement in response to the report. He said “there is still more to do especially in terms of embedding a new culture of openness which must be a priority. We continue to work with the CQC to track progress at Stafford.”

Well here is a question for Mr Mellor. If a culture of openness is a priority (which it certainly is) why has it not already been put in place given that the culture of fear, deference, lies and secrecy was at the heart of the unnecessary deaths of 1200 people?

For social workers and their employers, here is another question. The overwhelming majority of nurses, doctors and managers never once blew the whistle on what was going on over an extended period. How do we make sure that social workers would do much better when it is so difficult in some employers to highlight concerns? After all, there would have been hospital social workers in and out of Stafford throughout this tragedy. Did any of them raise the concerns they must have been aware of? If not why not? Why cannot all employers of social workers say, hand on heart, that they encourage staff to raise concerns and treat them seriously?