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
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
Electronic patient record systems – electronic referrals for ongoing care
Organisations can improve patient safety by ensuring the mandated requirements for digital clinical risk management (under DCB0160) for the deployment of the electronic referral service (e-RS) are achieved. For general practices and integrated care boards this includes agreeing responsibilities for the digital clinical risk management of e-RS. This is to enable identification and mitigation of risks to patient...
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 enforcement action
77match
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued Gloucestershire Hospitals NHS Foundation Trust with a warning notice following an inspection of its surgical services. The inspection was undertaken in response to concerns received about the safety and quality of the services, including staff whistleblowing and the number of never events reported. CQC required the trust to make significant improvements in...
Matched on
terms: governance, patient, safety
CQC enforcement action
77match
Warning Notice: Southern Health NHS Foundation Trust
The Care Quality Commission issued a warning notice to Southern Health NHS Foundation Trust following an inspection in January 2016. The inspection found the Trust had not put in place robust governance arrangements to investigate incidents, including deaths, and had not addressed known risks from the physical environment. The warning notice required immediate action to ensure the safety...
Matched on
terms: governance, patient, safety
CQC enforcement action
77match
Warning Notice: Salisbury NHS Foundation Trust
The Care Quality Commission (CQC) told Salisbury NHS Foundation Trust that improvements needed to be made in its maternity and spinal services at Salisbury District Hospital following an inspection on 31 March 2021. CQC found that governance arrangements were not clear and safety concerns were not consistently identified or addressed quickly enough in maternity services. In the spinal...
Matched on
terms: governance, patient, safety
CQC enforcement action
77match
Warning Notice: Barts Health NHS Trust
Section 29A warning notice served on maternity services at Newham University Hospital. A CQC inspection in September 2018 rated the hospital's maternity service inadequate overall, with concerns that the systems to assess, monitor and mitigate risks to patients and the service's governance systems and processes were not operating effectively. The notice required the trust to make significant improvements...
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
PFD report
73match
Kathleen Cooper
The coroner identified challenges to patient safety arising from split-site commitments and out-of-hours care. Recurring errors in patient management were noted, including poor communication, inadequate supervision, issues with early warning scores, and a failure to escalate deterioration, with insufficient progress made on addressing these issues.
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
GIRFT recommendation
73match
Orthopaedic Trauma
Trusts should reduce litigation costs using the GIRFT programme's five-point plan and by addressing common causes of litigation in orthopaedic trauma with respect to limb injuries, common interventions, such as plastering and splint application, and use of intraoperative tourniquets. GIRFT five-point Plan: a. Clinicians and trust management to assess their benchmarked position compared to the national average when...
Matched on
terms: patient, safety
CQC enforcement action
73match
Warning Notice: Berkshire Healthcare NHS Foundation Trust
Following a review, the Care Quality Commission found that incidents concerning patient safety were not being reported quickly enough to the National Patient Safety Agency. The CQC required that the trust address this issue by 23 March, stating that if improvements were not made, next steps could include prosecution.
Matched on
terms: patient, safety
CQC enforcement action
73match
Warning Notice: Liverpool University Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) told Liverpool University Hospitals NHS Foundation Trust to take immediate action to improve the safety of some of its services following two inspections. Inspectors found a lack of effective systems to ensure all patients received adequate nutrition and hydration, and staff did not always follow national infection prevention and control guidelines. The trust...
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
Kirabo Kiwanuka
The coroner noted a lack of agreement among senior professionals on diagnosing and managing NMS, and uncertainty about the optimal care model for acutely manic patients with physical illness. There were also concerns about limited family involvement in best interest decisions for sectioned patients.
Matched on
terms: patient
PFD report
69match
Barry Dillion
Insufficient resources for the Speech and Language Therapy service at Royal Blackburn Hospital lead to delays in swallow assessments, increasing the risk of aspiration pneumonia for patients.
Matched on
terms: patient
PFD report
69match
Hubert Kelly
Nursing staff lacked space and resources for patients after triage, leading to waits in corridors with no meaningful interaction or permanent medical staff. Emergency department waiting times frequently exceeded national targets, with some patients waiting up to seven hours.
Matched on
terms: 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
GIRFT recommendation
69match
Stroke
All regions will have a fully functioning stroke networks (ISDNs) by April 2021 and must focus on establishing operational and governance best practice. a) ISDNs to fully operational leadership and management teams, with clear governance and reporting structures in place. b) Develop materials on leadership and cultural change that localities can use to enable change. c) Define a...
Matched on
terms: governance, patient
GIRFT recommendation
69match
Diabetes
The MDiT should meet regularly to discuss day-to-day errors and safety issues, and report to a quarterly trust-level diabetes safety board which reviews the overall quality of the inpatient service, with support from IT, based on incident reporting, local and national audits of patient harms, diabetes medication errors, length of stay and readmissions.
Matched on
terms: patient, safety
CQC action
69match
The York Hospital
The service must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided. They must demonstrate improvements in patient outcomes to be in line with national guidance and benchmark against a similar sized service.
Matched on
terms: patient, safety
CQC enforcement action
69match
Warning Notice: Plymouth Hospitals NHS Trust
Following a visit to Derriford Hospital, the Care Quality Commission found that important check-lists recommended by the World Health Organisation and the National Patient Safety Agency were not being used effectively by surgical teams. The CQC required Plymouth Hospitals NHS Trust to address this issue immediately to ensure full and consistent compliance with safety check lists.
Matched on
terms: patient, safety
NCEPOD recommendation
66match
Physical Healthcare in Mental Health Inpatient Settings
Matched on
terms: patient
PFD report
65match
Alwyn Head
The coroner noted concerns regarding the patient's MRSA history not being established pre-surgery, and a lack of prophylactic medication. There was no post-operative wound care plan, insufficient surgical wound inspection, and inadequate documentation of wound status.
Matched on
terms: patient
PFD report
65match
Lea Hunsley
The EAM facility lacked a serious untoward incident protocol, and staff demonstrated insufficient ability to identify deteriorating patients, escalate medical reviews, or use care records effectively. Insufficient action had been taken on recommendations from a CQC inspection, without sustained improvement.
Matched on
terms: patient
Committee recommendation
65match
#8 - 4th Report - Homecare medicines services: an opportunity lost
No one—not the Government, not NHS England, not patient groups, not regulators, knows how often, nor how seriously patients suffer harm from service failures in homecare. This indicates a significant failure of oversight and hinders the ability of NHS England to ensure patient safety.
Matched on
terms: patient, safety
Committee recommendation
65match
#5 - 4th Report - Homecare medicines services: an opportunity lost
Delays in providing homecare services can negatively impact on patients physical and mental health. For some, impacts can be serious safety issues and include patients being admitted to hospital or requiring surgery.
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
GIRFT recommendation
65match
Renal Medicine
Ensure that all acute trusts implement patient safety measures (as set out in NICE NG148) to deliver highly effective prevention, detection and management of AKI. a) All trusts to implement the recommendations set out in NICE NG148. b) All trusts to ensure delivery of AKI care bundles as the first response to an AKI alert (shown to improve...
Matched on
terms: patient, safety
GIRFT recommendation
65match
Children and Young People's Mental Health Services
There must be effective governance and advocacy systems in place in all CYP mental health inpatient units to ensure that young people are able to speak up should they be exposed to inappropriate practices. a Individual inpatient adolescent units to ensure governance and advocacy systems are in place. b Ensure that systems are co-designed with young people. c...
Matched on
terms: governance, patient
CQC action
65match
Westmorland General Hospital
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Matched on
terms: governance, safety
CQC enforcement action
65match
Warning Notice: Essex Partnership University NHS Foundation Trust
The Care Quality Commission (CQC) served Essex Partnership University NHS Foundation Trust with a warning notice following an inspection of two acute wards for adults of working age. The inspection raised serious concerns about patient safety, including staff not always following observation policies and the presence of blanket restrictions. CQC issued the warning notice after the trust's submitted...
Matched on
terms: patient, safety