Patient safety governance
Lack of well-protected and defined resources for national patient safety agencies and insufficient awareness among healthcare professionals of the Duty of Candour.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
99match
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure shared governance forums are appropriately established and resourced, and are effective?
Matched on
terms: governance, patient, safety
Committee recommendation
91match
#2 - Establish a national framework for patient safety with clear targets and improved complaints system.
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...
Matched on
terms: patient, safety
HSSIB recommendation
91match
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Use the patient safety incident response standards and national guidance on engaging and involving those affected to assess practice and identify where additional resource and support is needed.
Matched on
terms: patient, safety
Inquiry recommendation
87match
F41 - Use of information about compliance by regulator from: Patient safety alerts
The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety alerts should continue following the transfer of the National Patient Safety Agency's functions in June 2012 to the...
Matched on
terms: patient, safety
Committee recommendation
87match
#15 - Lack of centralised learning causes repeated patient safety incidents across trusts.
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
Matched on
terms: patient, safety
Committee recommendation
87match
#13 - Health system overwhelmed by patient safety recommendations, hindering affirmative action.
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...
Matched on
terms: patient, safety
HSSIB recommendation
87match
Temporary staff – involvement in patient safety investigations
HSSIB recommends that NHS England updates the agency worker framework agreement criteria to explicitly require framework agreements to adhere to the staff support principles of the NHS England Patient Safety Incident Response Framework. This will improve patient safety as there is a recognised link between staff having wellbeing concerns and the delivery of patient care.
Matched on
terms: patient, safety
Inquiry recommendation
86match
AFA-4 - Governance
The Inquiry recommends a programme of work by the Trust to: • Consolidate governance improvements into a clear, prioritised programme overseen by the Board. This will ensure that the large number of improvement plans do not become overwhelming or get lost due to time pressure. • Develop a comprehensive data and information strategy to support assurance, learning and...
Matched on
terms: governance, patient, safety
PHSO recommendation
86match
Broken trust: making patient safety more than just a promise
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.
Matched on
terms: patient, safety
Committee recommendation
83match
#17 - Department fails to outline specific actions for reducing patient harm and improving safety.
The previous Committee were concerned that the Department was spending billions of pounds of taxpayers’ money without an effective plan to minimise future costs of the clinical negligence scheme.25 In April 2024, the Committee recommended that, by summer 2024, “the Department should set out the key reasons for patient harm and the actions it will take to address...
Matched on
terms: patient, safety
Committee recommendation
83match
#10 - Patient safety system suffers from duplication and minimal improvement amidst reforms.
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...
Matched on
terms: patient, safety
HSSIB recommendation
83match
Online prescribing: challenges and opportunities to improve patient safety
Independent prescribing organisations can improve patient safety by ensuring that patient information contained in the NHS App is not used as a sole source of verification when making clinical decisions, as this is outside the purpose of the App and can result in patient safety risks.
Matched on
terms: patient, safety
HSSIB recommendation
78match
Patient care in temporary care environments
NHS regional and national organisations can improve patient safety by enhancing understanding of the use of temporary care environments across all hospital settings. This may include agreeing definitions of temporary care environments and enhanced information gathering on their use and impact on patient safety.
Matched on
terms: patient, safety
HSSIB recommendation
78match
Insulin: supporting safe administration in inpatient settings
HSSIB recommends that NHS England/Department of Health and Social Care sets out the expectations and responsibilities of NHS trusts, integrated care boards and NHS England for the oversight and assurance of inpatient diabetes care. This should support organisations to implement and act on improvements shared in national guidance, recommendations and audit data. It should also include how existing...
Matched on
terms: patient, safety
HSSIB recommendation
78match
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums.
Matched on
terms: patient, safety
Inquiry recommendation
77match
R79 - Board member learning framework
The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in governance (including both financial and clinical/social care governance, including patient safety). Annual assessments as to the effectiveness of Board performance should be undertaken by PHA.
Matched on
terms: governance, patient, safety
CQC action
77match
The County Hospital
The provider must ensure there are systems and processes to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities. It must assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and others who may be at risk which arise from the...
Matched on
terms: governance, patient, safety
CQC action
77match
Royal Sussex County Hospital
The trust must ensure improvements are made to governance systems and processes by conducting regular audits to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity. This includes auditing of the accuracy and quality of patient records, pathways and assessments.
Matched on
terms: governance, patient, safety
Committee recommendation
74match
#4 - Develop a plan to reduce patient harm and manage escalating clinical negligence costs.
It is unacceptable that the Department is yet to develop a plan to deal with the cost of clinical negligence claims, and so much taxpayers’ money is being spent on legal fees. The Department has set aside an astounding £58.2 billion to cover the potential costs of clinical negligence events occurring prior to 1 April 2024, the second...
Matched on
terms: patient, safety
HSSIB recommendation
74match
Electronic patient record systems – electronic referrals for ongoing care
Use of advice and guidance may introduce risks to patient safety and how they may be mitigated.
Matched on
terms: patient, safety
PFD report
73match
Rosalind Baird
There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
Matched on
terms: patient, safety
PFD report
73match
Alwyn Head
Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Matched on
terms: patient, safety
Inquiry recommendation
73match
AFA-2 - Organisational development and cultural reform
The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. Devising a Northern Ireland patient safety strategy would consolidate and clarify the various strands of work in progress....
Matched on
terms: patient, safety
HSSIB recommendation
70match
Lack of timely monitoring of patients with glaucoma
It is recommended that NHS England and NHS Improvement require commissioners to agree, under their service contracts, the action that providers will take to ensure compliance with the Portfolio of Indicators for Eye Health and Care follow-up performance standard. Where the standard has not been met, there should be a requirement for providers to demonstrate that they have...
Matched on
terms: patient
PFD report
69match
Barry Dillion
Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
Matched on
terms: patient
PFD report
69match
Annette Krasinsky-Lloyd
Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.
Matched on
terms: governance, patient
Committee recommendation
69match
#2 - Acknowledge general practice crisis and detail short-term steps to improve patient safety and access.
In response to this Report the Government and NHS England should be clear in acknowledging that there is a crisis in general practice and set out in more detail the steps they are taking in response to this crisis in the short term, to protect patient safety, strengthen continuity, improve access and reduce GP workloads.
Matched on
terms: patient, safety
Committee recommendation
69match
#1 - General practice in crisis due to poor patient access and safety risks, unacknowledged by government.
The first step to solving a problem is to acknowledge it and we believe that general practice is in crisis. It is clear from the latest GP Patient survey results that despite the best efforts of GPs, the elastic has snapped after many years of pressure. Patients are facing unacceptably poor access to, and experiences of, general practice...
Matched on
terms: patient, safety
HSSIB recommendation
69match
Medication related harm
HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to: supporting healthcare providers to access digital clinical safety knowledge, capacity and capability integrating digital clinical safety and patient safety, including the associated terminology supporting robust assurance of whether electronic prescribing and medicines administration (ePMA) manufacturers comply with relevant...
Matched on
terms: patient, safety
HSSIB recommendation
69match
Piped supply of medical air and oxygen
The National Patient Safety Alert Committee should set standards for all issuers of patient safety alerts that require an assessment for unintended consequences, the effectiveness of barriers in the alert, and the advice the alert issuers give providers on implementation and ongoing monitoring.
Matched on
terms: patient, safety
HSSIB recommendation
69match
Inadvertent administration of an oral liquid into a vein
It is recommended that NHS Improvement support the development of necessary knowledge, skills and capacity for the effective operationalisation of hazard identification and risk analysis at a national, regional and local level, as an integral part of the National Patient Safety Strategy.
Matched on
terms: patient, safety
PFD report
65match
Kirabo Kiwanuka
Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.
Matched on
terms: patient
PFD report
65match
Lea Hunsley
The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Matched on
terms: patient
PFD report
65match
Hubert Kelly
Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.
Matched on
terms: patient
Inquiry recommendation
65match
F32 - Interim measures
Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary measures to ensure such protection while any investigation required to make a final determination is undertaken.
Matched on
terms: patient, safety
HSSIB recommendation
65match
Digital tools for online consultation in general practice
HSSIB recommends that NHS England develops mechanisms for assuring that integrated care boards support general practices when implementing online consultation. This is to ensure online consultation tools are procured and implemented in ways that best support patient safety.
Matched on
terms: patient, safety
HSSIB recommendation
65match
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System.
Matched on
terms: patient, safety
CQC action
65match
Royal Victoria Infirmary
The trust must ensure there is full clinical engagement to support operational performance and that challenges are resolved with a focus upon patient safety across the organisation.
Matched on
terms: patient, safety
Inquiry recommendation
62match
R81 - Expert clinical governance advisory function
The DoH should establish an expert clinical/social governance advisory function to support providers.
Matched on
terms: governance
Inquiry recommendation
62match
R77 - Triennial Board governance reviews
The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.
Matched on
terms: governance
Inquiry recommendation
62match
R76 - NED with clinical governance expertise
NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as a senior independent director with that responsibility. The DoH should make training in Board-level clinical and social governance available to all NEDs.
Matched on
terms: governance
Inquiry recommendation
62match
R75 - Executive Director of Clinical and Social Care Governance
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...
Matched on
terms: governance
Inquiry recommendation
62match
F62 - Improved patient focus
For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.
Matched on
terms: patient
HSSIB recommendation
62match
Electronic patient record (EPR) systems – thematic review
How does your organisation proactively identify new and emerging risks associated with an EPR system, and ensure these are reviewed and mitigated as far as is practicable?
Matched on
terms: patient
PFD report
61match
Stephen Ellis
A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Matched on
terms: patient
PFD report
61match
Natasha Raghoo
The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Matched on
terms: patient
PFD report
61match
Mary James
Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
Matched on
terms: patient
PFD report
61match
Sharon Henshall
The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.
Matched on
terms: patient
PFD report
61match
Stephen Taylor
Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.
Matched on
terms: patient
Inquiry recommendation
61match
F59 - Care Quality Commission independence strategy and culture
Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.
Matched on
terms: patient