IBI-4c(ii)

Safety Management Systems Coordination

Infected Blood Inquiry · Infected Blood Inquiry Final Report · Issued 20 May 2024 · Addressed to: UK Government

Government responseUK Government: Accepted (May 2025)

DeliveryNo statement from UK Government found

Recommendation, verbatim from the inquiry

●Inquiry recommendation

Regulation:

That the national healthcare administrations in England, Northern Ireland, Scotland and Wales explore, and if appropriate, support the development and implementation of safety management systems (“SMS”s) through SMS coordination groups (as recommended by the HSSIB), and do so as a matter of priority.

Infected Blood Inquiry, Infected Blood Inquiry Final Report · 20 May 2024 Source PDF →

Published evidence summary

AI-generated evidence summary

In May 2025, the UK Government accepted the recommendation, stating that NHS England had established a coordination group in 2023 to explore adapting safety management systems for healthcare (Cabinet Office response, May 2025). It added in that response that the group's work remained ongoing without reaching specific conclusions and was likely to report later in 2025 (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).

Sources

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

About this summary
This recommendation applies across many organisations. The record above reflects central policy activity; adoption in individual organisations may vary.

Government response

●UK Government · Accepted · 14 May 2025

Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025

In relation to Recommendation 4c) ii., DHSC agrees that it is important to explore approaches for enhancing the safety of services. In 2023, NHS England established an SMS coordination group with partners from across the healthcare system including providers, patients, regulators, the Health Services Safety Investigations Body (HSSIB), academia and other safety critical industries to explore the potential for SMS principles and processes to be adopted further in the NHS to improve patient safety. The group’s work is ongoing and has not yet reached specific conclusions about the applicability of SMS principles to healthcare but it is likely to report later in 2025. It is right to ask what more the NHS could learn from other industries and to understand how SMS principles might be appropriately translated into healthcare settings, although we would caution against an approach that seeks to simply adopt a new phrase or framework such as an SMS as the solution to complex patient safety challenges. In support of the SMS Coordination Group in August 2023, NHS England, in collaboration with the Department of Health and Social Care and the National Institute for Health and Care Research, commissioned the Exeter Health and Social Care Delivery Research Evidence Synthesis Centre to conduct research examining the application of safety management systems to patient safety in terms of effectiveness, implementation and experience. The research included publications from five countries (Australia, Canada, Ireland, New Zealand and the Netherlands). The findings highlight that: only the Netherlands had introduced a national patient safety programme explicitly based on a high-risk industry SMS approach, the main components of an SMS were identified, to varying extents, in the patient safety policies and initiatives of other countries included in the review, and other concepts from wider safety science had influenced patient safety approaches in all countries. These findings suggest there is no single most effective approach to patient safety, and emphasise the need for any approach to safety to be operationalised and adapted to fit the healthcare context. These findings will inform ongoing discussions undertaken by NHS England’s SMS co-ordination group.

Extract from: Full Government Response to the Infected Blood Inquiry's May 2024 Report

Delivery

No statement on delivery from UK Government has been found in the sources searched. This is separate from the response above.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.