There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance for complex systems requires specialist skills. While this is largely recognised within finance governance, only superficial consideration is given to clinical and social care governance. Boards should appoint an Executive Director of Clinical and Social Care Governance because of their specialist training and expertise in this area (rather than assign it to the existing clinical or social care leads and then provide top-up training). The DoH must produce guidance in relation to the necessary competency and skills for this role.