Create open, non-punitive NHS environment for reporting sentinel events

The Index has not yet recorded a verbatim government response to this recommendation.

Every health and care professional has a professional duty to be open and honest when things go wrong.

NHS England have published a national Freedom to speak up policy for the NHS, applicable to primary care, secondary care and integrated care systems, focusing on the importance of inclusive and consistent speaking up arrangements and driving learning through listening. With the National Guardian’s Office NHS England have also published Freedom to speak up (FTSU) guidance and a Freedom to speak up reflection and planning tool, each to help ensure staff have a voice that counts to develop a speaking up culture.

CQC’s well-led framework incorporates review of FTSU arrangements and culture.

NHS England promotes a 'just culture'. The just culture guide encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way.

The NHS Patient Safety Strategy, published in July 2019 and updated in 2021, sets out how the NHS will support staff and providers to share safety insight and empower people – patients and staff – with the skills, confidence and mechanisms to improve safety. An update in June 2023 set out that much progress has been made across the strategy’s main programmes of work. It describes how NHS England will continuously improve patient safety, building on the foundations of a safer culture and safer systems and highlights the importance of a just culture. It states that there are many aspects to a good safety culture and that leaders need to play a key role in championing its development.

The Government agreed with this recommendation.

In its January 2002 response, the Department of Health referred to the work of the National Patient Safety Agency with the clinical governance initiative and the Department’s Risk Management System as aiming to develop a culture where non-punitive reporting of adverse incidents would help to improve patient safety.