64th Report - Costs of clinical negligence

The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England’s approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing … Read more The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England’s approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing and unresponsive complaints system. Neither the Department nor NHS England know how 3 much cost the NHS incurs treating patients it has harmed each year, but research suggests it could be significant. There is also evidence to suggest that a better initial response to harm, such as timely apologies or explanations, could reduce both the number of claims and cost of clinical negligence. We were also told during our informal private roundtable that effective compassionate, local resolution is both ethically right and fiscally responsible. Recent reviews have found that the NHS is overwhelmed by safety recommendations that it cannot action and one person we spoke to as part of our roundtable referred to the NAO’s findings on this as the NHS drowning in recommendations. Despite the Department’s stated commitment to improve patient safety and reduce harm, it has yet to outline any of the specific measures it will take to achieve this. It is also not clear how the abolition of NHS England will impact future patient safety arrangements and the little progress made to date. recommendation a. The Department must set a national framework for improving patient safety with clear targets for annual improvement. b. The Department must review the NHS complaints system and improve the number of cases that are resolved without recourse to litigation. c. The Department should estimate and track the costs to the NHS of treating avoidable harm. d. The Department should write to the Committee to set out progress in implementing the Dash Review and its assessment of the impact of abolishing the Health Services Safety Investigations Body (HSSIB) on patient safety. e. The Department and NHS England should have a clear system of accountability fo Show less

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We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. Behind every clinical negligence claim is a tragic incident of patient harm. We were disappointed … Read more We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. Behind every clinical negligence claim is a tragic incident of patient harm. We were disappointed that neither the Department nor NHS England could adequately explain how the NHS uses its extensive data on patient harm to identify and address the underlying causes of clinical negligence. Data is not routinely reviewed at a national level as NHS England claim there is no direct connection between data on patient harm 4 and clinical negligence claims. NHS Resolution has committed to making better use of its extensive claims database and to explore options to extract more detailed insight on the causes of harm to prevent the same things happening again. However, we remain concerned that poor investment in data analytics will leave the NHS lagging behind the private sector, where legal firms are now using artificial intelligence to triage clinical negligence claims on an industrial scale. One person we spoke to at our private roundtable described the English NHS having a plethora of data and no information, adding that we need more NHS data in one place. recommendation a. The Department should establish a national system for sharing data between trusts and analysing trends. If there are barriers to sharing protected data, it should develop analysis on an anonymised basis to pull out lessons and provide early warning alerts to trusts. b. The Department, NHS England and NHS Resolution should explore the use of artificial intelligence to analyse live data, detect discrepancies and outliers quickly, and improve the speed of early warning systems. Show less

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The Department’s failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. Over the last 20 years the cost of settling claims involving infants and children has increased significantly. In 2024–25, costs for … Read more The Department’s failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. Over the last 20 years the cost of settling claims involving infants and children has increased significantly. In 2024–25, costs for claims involving brain injury at birth were £1,554 million, with the total cost of claims for paediatric failings reaching £325 million. Damages awarded in these cases are higher than most clinical negligence claims as they typically include compensation for lifelong health and social care, future lost earnings and any necessary adaptations to accommodation. Court rulings on the eligibility of innovative or novel treatment options have also increased the value of damages awarded in recent years. NHS Resolution settles around 120 to 130 brain injury cases involving children every year but it can take an average of 11-12 years to resolve each claim. In response, NHS Resolution has developed an innovative early notification scheme to provide more timely support to families and improve the speed at which lessons are learned. NHS England told us that it expects the final part of the Amos Review into England’s maternity and neonatal services in 2026, but this does not mean it is waiting to act on its recommendations. 5 recommendation a. The Department and the organisations it funds need to learn lessons from its failure to improve maternity care in England. Where problems arise the Department and the wider NHS should look for systemic failings in care and tackle these problems at their cause. b. The Department should publish the Amos Review within two months alongside its response and set out how it plans to reduce the incidence of harm and the costs of claims in maternity care. Show less

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Legal costs in clinical negligence claims are disproportionate for medium and low volume claims. Legal costs in clinical negligence claims have risen sharply, with claimant legal fees increasing in real terms from £148 million in 2006–07 (in 2024–25 prices) to … Read more Legal costs in clinical negligence claims are disproportionate for medium and low volume claims. Legal costs in clinical negligence claims have risen sharply, with claimant legal fees increasing in real terms from £148 million in 2006–07 (in 2024–25 prices) to £538 million in 2024–25. At 19% of total settled claim costs it is unacceptable that so much taxpayers’ money continues to be spent on legal fees. NHS Resolution has worked hard to increase the number of claims resolved without litigation (83% in 2024–25, up from 66% in 2006–07). It has also expanded its use of alternative dispute resolution and mediation. There are considerable financial benefits to these approaches which have been well received by the legal sector. However, we are extremely concerned that low-value clinical negligence claims (damages of £25,000 or less) cost far more in legal fees than victims receive in damages, with a 3.7:1 cost-to-damages ratio. The Department’s previous plans to limit the amount paid to lawyers in lower-value cases were not implemented as planned in April 2024 and remain under review. recommendation The Department should a. develop alternative dispute mechanisms to speed up decisions and reduce costs for less complex cases. As part of this, the Department should look at international examples (such as in New Zealand and Sweden) of non-adversarial and ombudsman models and assess how our ombudsman system could be improved; and b. clarify its position on a fixed recoverable costs scheme for lower-value clinical negligence cases at the earliest opportunity. Show less

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Clinical negligence claims are settled on the basis of costs of care in the private sector and yet there is nothing to stop the claimant using the NHS or publicly funded social care in the future, potentially inflating the costs … Read more Clinical negligence claims are settled on the basis of costs of care in the private sector and yet there is nothing to stop the claimant using the NHS or publicly funded social care in the future, potentially inflating the costs of claims. It is not clear the extent to which the taxpayer is paying twice for clinical negligence – once through compensation for injury 6 and then again by providing subsequent health and social care. A law from 1948 states that damages must be calculated on the presumption that care will be provided by the private sector and not the NHS or local government. NHS Resolution identified this as a major contributory factor to the increasing cost of very high-value cases (£1 million or more), where about 60% of the damages relate to future care. Although claimants can be asked to declare in court if they plan to use the NHS for treatment, this rarely happens in practice and cannot be mandated. NHS Resolution is unable to ask successful claimants for information on how they spend their award or whether they subsequently access state funded services to manage their condition. Local authorities are also not able to consider clinical negligence compensation awards when assessing eligibility for publicly funded social care. recommendation The Department should develop, within six months, proper estimates of the impact of assuming health and social care for clinical negligence victims will be provided exclusively by the private sector. It should by the same deadline set out additional measures—including any requiring changes to legislation—which it judges would effectively guard against the risk of paying twice for the care of those it has harmed and an indicative timeline for their potential implementation. 7 1 The rising costs of clinical negligence Introduction Show less

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On multiple occasions the Department told us that it was unable to comment on many aspects of current policy as a recent review into clinical negligence by David Lock KC was still being considered by ministers.9 5 C&AG’s Report, paras … Read more On multiple occasions the Department told us that it was unable to comment on many aspects of current policy as a recent review into clinical negligence by David Lock KC was still being considered by ministers.9 5 C&AG’s Report, paras 6, 7, 1.18 6 C&AG’s Report, para 14 7 Q 35 8 C&AG’s Report, para 8 9 Qq 35, 47, 63, 97, 100 10 As a result it would also not comment on whether it thought the current steps being taken to reduce clinical negligence costs would make a difference.10 The Department repeatedly assured us that the review would cover all aspects of clinical negligence, including when we asked about policies on legal costs, international comparisons, options for alternative dispute resolution, the assumptions around provision of private health and social care and the overall causes of rising costs.11 Underlying causes of harm to patients Show less

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The NHS reports around 2.4 million patient safety incidents annually, most of which (70%) cause no harm to patients, but around 0.5% of patient safety incidents result in severe harm or death. The 2025 Dash review identified considerable overlap and … Read more The NHS reports around 2.4 million patient safety incidents annually, most of which (70%) cause no harm to patients, but around 0.5% of patient safety incidents result in severe harm or death. The 2025 Dash review identified considerable overlap and duplication in the current patient safety landscape with relatively little improvement over the last five to 10 years.12 The Department told us it had set out a new plan to oversee quality and safety as part of the 10-Year Health Plan,13 but did not outline any of the specific measures it will take to achieve this.14 In 2025 the Department announced the planned abolition of NHS England and the Health Services Safety Investigations Body.15 NHS England told us that there is a lot of change going on and it is working to rationalise the patient safety system but that it must take a cautious approach to ensure important functions are not lost.16 The NHS is being asked to find at least £1 billion in savings over the next three years. The ambition is to reduce central staff numbers by up to 50% across the Department, NHS England and Integrated Care Boards by March 2028 and is expected to cost between £1 billion and £1.3 billion.17 Show less

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The cost to health services of treating cases involving clinical negligence specifically or cases of avoidable harm to patients is unknown. The Organisation for Economic Co-operation and Development estimates that treating cases where harm was avoidable costs developed countries 8.7% … Read more The cost to health services of treating cases involving clinical negligence specifically or cases of avoidable harm to patients is unknown. The Organisation for Economic Co-operation and Development estimates that treating cases where harm was avoidable costs developed countries 8.7% of their health expenditure each year, on which basis the costs in England could run to tens of billions.18 Both the Department and NHS Resolution told us the most important thing is therefore to prevent 10 Q 97 11 Qq 61, 64, 75, 85, 100 12 C&AG’s Report, paras 1.2, 1.4 13 Fit for the future: 10 year health plan for England, July 2025 14 Q 97 15 C&AG’s Report, Figure 1 16 Q 94 17 Billions to be redirected back into patient care with NHS reform - GOV.UK; and Letter from DHSC, dated 11 December 2025 18 C&AG’s Report, para 13 11 harm from happening to patients in the first place.19 NHS England told us it is making considerable efforts around patient safety and that there is no evidence that the levels of harm are increasing.20 Show less

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The 2025 Dash review of patient safety found that the current system for raising complaints and concerns is confusing, with issues often poorly handled and patients subject to delays and poor-quality responses. Research commissioned by NHS Resolution found that improving … Read more The 2025 Dash review of patient safety found that the current system for raising complaints and concerns is confusing, with issues often poorly handled and patients subject to delays and poor-quality responses. Research commissioned by NHS Resolution found that improving the NHS’s initial response to harmful incidents could reduce the number of patients who pursue clinical negligence claims.21 However, in their written submissions to us, multiple organisations raised concerns about how inconsistently NHS trusts apply the statutory requirement to be open and transparent with patients, known as ‘duty of candour’.22 NHS Resolution told us that in its experience openness and transparency are the best way to prevent a claim in the first place.23 When questioned about inadequacies in the existing complaints system, NHS England told us it is very keen to do more to improve patient experience and is looking at alternative models for the NHS complaints system. When asked about how it is learning from complaints, NHS England told us that complaints are collected centrally in themes with around 200,000 to 250,000 reviewed each year nationally.24 NHS Resolution explained that it is also working across all areas locally with NHS trusts to identify complaint issues that might escalate into clinical negligence claims further down the line.25 Show less

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In 2024, the Health Services Safety Investigations Body reported that the broader health system was drowning in patient safety recommendations rather than taking affirmative actions to improve it.26 NHS England told us that there are over 1,500 recommendations in the … Read more In 2024, the Health Services Safety Investigations Body reported that the broader health system was drowning in patient safety recommendations rather than taking affirmative actions to improve it.26 NHS England told us that there are over 1,500 recommendations in the system and that managing those centrally is a huge task. NHS England told us that the new National Quality Board will look at how the NHS can access stronger, smarter recommendations.27 19 Qq 35-36 20 Q 38 21 C&AG’s Report, para 16 22 Switalskis Solicitors (CCN0014); Action against Medical Accidents (CCN0018); Slater & Gordon (CCN0023) 23 Q 83 24 Q 78 25 Q 99 26 C&AG’s Report, para 1.4 27 Q 80 12 Learning from available data Show less

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It is generally accepted that learning from past incidents is fundamental to improving patient safety, but the 2025 Dash review found that insufficient use is made of the NHS’s data resources to generate insights and support improvement.28 NHS England told … Read more It is generally accepted that learning from past incidents is fundamental to improving patient safety, but the 2025 Dash review found that insufficient use is made of the NHS’s data resources to generate insights and support improvement.28 NHS England told us that although it aims to learn from litigation and wishes to see it reduced through the reduction of harm, there is no direct connection between patient safety incidents and clinical negligence claims.29 Where patient safety incidents increase with age, clinical negligence claims are skewed towards middle-aged claimants. The relative balance of specialties also differs, with claims weighted towards maternity and emergency care, compared with general medicine and secondary care for safety incidents.30 Show less

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Written evidence submitted to us raised concerns about a lack of centralised learning leading to incidents being repeated across multiple trusts.31 When asked what it was doing to improve systemic learning from patient safety incidents, NHS England told us it … Read more Written evidence submitted to us raised concerns about a lack of centralised learning leading to incidents being repeated across multiple trusts.31 When asked what it was doing to improve systemic learning from patient safety incidents, NHS England told us it had a “variety of mechanisms” but did not provide any detail on what these were.32 Show less

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Some clinical negligence firms are reportedly using artificial intelligence to triage claims more efficiently and effectively. NHS Resolution holds almost 30 years of experience and data concerning compensation claims.33 NHS Resolution told us it is starting to explore how technology … Read more Some clinical negligence firms are reportedly using artificial intelligence to triage claims more efficiently and effectively. NHS Resolution holds almost 30 years of experience and data concerning compensation claims.33 NHS Resolution told us it is starting to explore how technology can mine its database to learn more about how claims are made up in terms of damages and the underlying causes of claims.34 It also explained how it has been working with the Getting It Right First Time programme, which is part of NHS England, to bring claims data together with other NHS metrics to better understand what causes claims in different clinical specialties.35 28 C&AG’s Report, para 3.24 29 Q 83 30 C&AG’s Report, para 3.27 31 Society of Clinical Injury Lawyers (CCN0005); Switalskis Solicitors (CCN0014) 32 Q 81 33 C&AG’s Report, paras 3.25, 3.28 34 Q 36 35 Q 53 13 2 Putting the costs of clinical negligence on a more sustainable path Problems with maternity care in England Show less

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Over the last 20 years the cost of settling claims involving infants and children has increased significantly. The highest-value claims are typically those associated with brain injuries suffered in maternity care. In 2024–25, costs for these claims were £1,554 million, … Read more Over the last 20 years the cost of settling claims involving infants and children has increased significantly. The highest-value claims are typically those associated with brain injuries suffered in maternity care. In 2024–25, costs for these claims were £1,554 million, and costs for paediatric claims were £325 million.36 Show less

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NHS Resolution told us that harmed children require care costs for decades into the future.37 Damages can include compensation for pain and suffering, care costs, future lost earnings, educational support and accommodation adaptations. They are calculated based on a claimant’s … Read more NHS Resolution told us that harmed children require care costs for decades into the future.37 Damages can include compensation for pain and suffering, care costs, future lost earnings, educational support and accommodation adaptations. They are calculated based on a claimant’s specific circumstances and to reflect differing needs throughout their remaining life. Compensation awards for these claims have also increased due to new precedents set by the courts, for example around access to innovative or novel treatment options.38 NHS Resolution told us that these changing precedents have driven up costs over time.39 One participant in our roundtable questioned whether the current tort based legal system was fit for purpose and whether there should be changes. Others suggested possible lessons to be learned from the private sector and how commercial insurers go about assessing high value claims. It was also suggested that an amendment to the Pre-Action protocol to better reflect the complexities of clinical negligence claims by providing a more realistic framework than it currently does for the investigation of those claims.40 Secondly, adopting 36 C&AG’s Report, paras 8, 2.19-2.10 37 Q 35 38 C&AG’s Report, paras 1.11, 2.8 39 Q 35 40 Pre-Action Protocol for the Resolution of Clinical Disputes – Civil Procedure Rules – Justice UK, updated March 2024 14 a similar approach to rehabilitation, specifically the Rehabilitation code.41 Also, the cost of expert reports in clinical negligence average £3,100 and quite often two reports are needed. Significantly we heard about the case of Wiseman, currently before the Supreme Court relating to lost years.42 We await the outcome of this case to understand its implications. Show less

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NHS Resolution told us it settles around 120 to 130 brain injury cases involving children every year, but historically it has taken an average of 11 or 12 years to settle each claim.43 We asked NHS Resolution what action it … Read more NHS Resolution told us it settles around 120 to 130 brain injury cases involving children every year, but historically it has taken an average of 11 or 12 years to settle each claim.43 We asked NHS Resolution what action it was taking to try to manage the cost of maternity claims. In response, NHS Resolution told us it has introduced an innovative early notification scheme for obstetric cerebral palsy.44 The scheme trials ways of managing maternity incidents to ensure a decision on liability is reached as early as possible.45 NHS Resolution told us this means it can learn from incidents more quickly and, where appropriate, make early interim payments to better support affected families. NHS Resolution hopes that the scheme will make the experience better for the victims of clinical negligence and reduce the costs in the longer term.46 Show less

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Around three-quarters of clinical negligence claims settle for £25,000 or less, but the legal costs for these claims vastly exceed the damages payable to claimants. In 2024–25, there was a 3.7:1 ratio of claimant and NHS legal costs compared with … Read more Around three-quarters of clinical negligence claims settle for £25,000 or less, but the legal costs for these claims vastly exceed the damages payable to claimants. In 2024–25, there was a 3.7:1 ratio of claimant and NHS legal costs compared with damages payable for low-value claims.58 NHS Resolution agreed that legal costs were disproportionate for low-value cases.59 Show less

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The previous government announced plans to place limits on how much lawyers receive from lower damages clinical negligence claims of under £25,000 where 85% of cases fall within this category from April 2024, but 51 Q 50 52 C&AG’s Report, … Read more The previous government announced plans to place limits on how much lawyers receive from lower damages clinical negligence claims of under £25,000 where 85% of cases fall within this category from April 2024, but 51 Q 50 52 C&AG’s Report, paras 2.12-2.13 53 Q 64 54 Q 67 55 C&AG’s Report, paras 3.12, 3.13 56 Q 64 57 Fletchers Solicitors (CCN0013); Switalskis Solicitors (CCN0014) 58 C&AG’s Report, paras 12, 2.16 59 Q 60 16 the required legislation was not introduced.60 We understand the Civil Rules Committee has put all its work on hold and there is no ongoing work in this area. Critics of these plans have raised concerns that they would impact access to justice for legitimate victims of clinical negligence.61 NHS Resolution agreed that access to justice for people who are severely harmed but who may have a low-value claim is an important consideration that needs to be part of decision making.62 The Department told us options to reduce legal costs in low-value cases form part of the ongoing review by David Lock KC.63 Assumptions around private care Show less

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On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department), NHS England and NHS Resolution on the costs of clinical negligence.1 Our predecessor committees reported on clinical negligence in 2002 and 2017, and both this …

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Clinical negligence is the second largest provision on the government balance sheet after nuclear decommissioning. Over the period 2006–07 to 2024–25, the total provision for clinical negligence increased by £45.6 billion in real terms, from £14.4 billion at 31 March 2007 to £60.0 billion at 31 March 2025. Since 2006–07, …

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NHS Resolution told us that clinical negligence is putting pressure on NHS budgets and is a significant cost to the public purse. The Department told us the reasons for the rising costs were complex. NHS Resolution explained that the increasing costs of compensation for claims of £1 million in damages …

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Evidence from the Royal College of Obstetricians and Gynaecologists suggested that the maternity workforce is struggling under the pressure of delivering increasingly complex care, with more than half of births involving medical intervention, such as a caesarean section or the use of instruments such as forceps.47 Similarly, evidence from Sands …

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Claimant legal fees have increased in real terms from £148 million in 2006–07 (in 2024–25 prices) to £538 million in 2024–25 and now represent 15% of all settled costs. During the same period, NHS’s legal costs increased in real terms from £76 million to £159 million, but fell as a …

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Over the last 10 years, NHS Resolution has introduced several new approaches to help keep claims out of court. These alternative dispute resolution initiatives are typically less adversarial and more collaborative than conventional litigation and provide greater opportunities for claimants seeking non-monetary redress such as an explanation or apology. The …

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The government may effectively be paying twice in some instances of clinical negligence, once through the compensation given to claimants and once again through providing NHS treatment and publicly funded social care. Section 2(4) of the Law Reform (Personal Injuries) Act 1948 provides that defendants who pay for the future …

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There is no estimate of the extent to which successful clinical negligence claimants then go on to use publicly funded health or social care services for their conditions.67 We asked NHS Resolution why there is no clear data on the number of people who are paid compensation and go on …

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Written evidence from the Medical Defence Union told us that Section 2(4) of the Law Reform (Personal Injuries) Act 1948 is based on a recommendation made in 1946, two years before the establishment of the NHS, which was caveated that it “might need to be radically altered if a comprehensive …

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