Broken trust: making patient safety more than just a promise
Systemic investigation into patient safety failings across the NHS, examining how the patient safety system fails to learn from mistakes. Draws on PHSO casework to identify failures in local investigations, duty of candour, patient advocacy, and oversight. Makes 7 recommendations to DHSC, NHS England, ICBs and government.
Government response
Recommendations
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is needed. This should include paying special attention to the balance of patient safety investigations versus other learning responses in Trusts (or service areas of a Trust) where there are poor CQC ratings for safety and leadership, or where other national bodies have raised concerns.
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local investigations did not take place, or did not find that things went wrong, but PHSO or another independent oversight body later identified failings.
The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.
The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident.
The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.
The Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority.
The Government should urgently produce its long-awaited long-term workforce strategy, with cross-party support, to increase the numbers entering and staying in the workforce across clinical and non-clinical roles. This strategy must: include independent, evidence-based and fully costed projections of future workforce requirements; include detailed plans for training and recruiting new staff, retaining staff already working in the NHS and attracting those who have left to return; take account of the mix of different professional skills required, rather than just total numbers in the workforce, and how existing professional skills can be deployed where they are most needed.