The NHS Ombudsman has come up with a report about the lessons unlearnt by the NHS. Dame Julie Mellor did not mind calling prevailing condition in the NHS as toxic cocktail.

Mellor said a number of things are taking place in the NHS. They have assessed the condition and have found that patients are scared to complain in the NHS. They fear that by doing so the care they will get will be affected.

On the other hand, if complaint is made then a culture of defensiveness is witnessed. "This defensiveness is one of the most important things we need to overcome - that is about changing the culture, not about the procedure", said Mellor.

In all these situations, things that should be known remain unheard. This is the reason that that Mellor has asked that some drastic changes are needed so that complaints are not only heard, but action is also taken on them.

Some of the changes that have been suggested by Mellor are free patients' advice service 24 hours in a day. Every patient should be recommended to senior person so that he can clear his concerns. Mellor said while carrying out investigation, she found that a number of serious incidents take place in the NHS. But no lesson is learnt from them.