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On the 18 June 2026, the Health Services Safety Investigations Body (HSSIB) published a new report summarising a rapid investigation focused on patient safety issues within a regional care system. It looked specifically at a case where multiple organisations were involved in providing care across a care pathway. In this blog, Patient Safety Learning’s Associate Director Claire Cox sets out reflections on the report’s findings. The most recent HSSIB learning report on patient safety across regional care pathways offers an important, if uncomfortable, insight into the realities of delivering care across organisational boundaries. While framed as learning, the findings expose fundamental gaps in oversight, clarity and system leadership, which pose significant risks to patient safety. A care pathway is a structured, evidence-based framework that describes the sequence of care and interventions a patient should receive for a particular condition, population group or healthcare need. It sets out how different services and professionals work together to deliver coordinated, high-quality care across the patient's journey. The HSSIB investigation examined a redesigned regional pathway involving multiple organisations and a centralised specialist service. However, the report deliberately omits specific details of the pathway, organisations and patient group involved. While this is understandable from a confidentiality perspective, it creates a key limitation: without a clear understanding of the full patient journey, it becomes much harder to articulate where risks emerge, accumulate and, ultimately, result in harm. The invisible patient journey One of the most striking issues raised by the report is the system’s inability to fully understand or monitor patient harm across the pathway. This is perhaps unsurprising. Care pathways that span multiple organisations are non-linear, dynamic systems, where risks rarely arise at a single point. Instead, harm often reflects latent system failures, decisions, constraints or assumptions made early in the pathway that only manifest much later. The investigation highlights several critical system weaknesses: Differences between how the pathway was designed and how it actually operated. A lack of shared understanding between organisations about what the pathway could realistically deliver. Limitations in the technology and digital systems used to support the pathway. Limited data sharing and inconsistent performance insight across providers. These issues are particularly evident in the technology underpinning the pathway, where a lack of interoperability between organisational digital systems means critical patient information is not consistently shared or visible across services. In practice, this results in manual workarounds, duplication and reliance on incomplete data. The safety implications are significant: clinicians are often making decisions without a full understanding of a patient’s history, delays occur in accessing or transferring information and opportunities for proactive intervention are reduced. Collectively, this creates a scenario where no single organisation holds a complete picture of the patient journey, meaning emerging harm cannot be reliably identified. From a patient perspective, it is reasonable to expect far greater visibility of the pathway they are moving through—not just who is providing their care, but how that care is organised end-to-end. This includes clarity on what the pathway looks like, the key decision points that may affect their treatment, and how and when care may escalate if their condition changes. They might also reasonably expect to know how risks to their safety are being identified, shared and actively managed across organisations. Without this transparency, patients are effectively navigating a system that is opaque, fragmented and difficult to understand. In such circumstances, meaningful collaboration becomes extremely challenging. Shared decision making depends on a shared understanding of both the clinical situation and the system through which care is delivered. Similarly, where risks are not visible to patients, there can be no clear line of accountability for how those risks are mitigated. If care pathways are to function safely across organisational boundaries, they must be understandable not only to professionals within the system but also to the patients who rely on them. The accountability gap A consistent theme throughout the HSSIB report is the absence of sustained oversight. Although a cross-organisational implementation board initially existed, oversight from the Integrated Care Board (ICB) reduced before the pathway was fully embedded. The consequences were predictable: No shared governance framework post-implementation. No agreed evaluation plan. Limited escalation of risks. Disconnected data and performance monitoring. This reflects a classic system failure: accountability without ownership. If no organisation or system leader maintains end-to-end ownership of a pathway, then: Risks fall between organisational boundaries. Mitigations are inconsistent or absent. Learning is localised rather than system wide. As highlighted by another HSSIB report last year, there is a lack of clarity about how patient safety is managed between ICBs other healthcare providers, including lines of safety accountability. This leads directly to gaps in oversight of cross-organisational safety risks. Implementation versus reality: the risk of 'work as imagined' Another critical safety issue is the mismatch between the pathway as designed ('work as imagined') and its real-world operation ('work as done'). The report highlights: A business case that was not fully realised. Resource assumptions (e.g. bed capacity) that did not materialise. Divergent expectations among organisations about pathway capability. This is not a minor operational issue, it is a core patient safety risk. When services are designed based on assumptions that are not delivered in practice: Demand exceeds capacity. Access thresholds shift informally. ·Staff are forced into workarounds. Clinical decision-making becomes inconsistent. Over time, this creates unstandardised care and inequity of access, both of which were flagged as concerns in the investigation. Culture, communication and friction The report also surfaces issues that are often underplayed in pathway redesign, relationships and behaviours between teams. Findings include: Differences in risk perception between organisations. Disagreements affecting clinical decisions. Examples of incivility. Barriers to shared learning. Lack of interoperability between organisation digital systems. These are not 'soft issues', they are direct contributors to patient harm. Where communication breaks down: Information is lost or misinterpreted. Decisions are delayed. Trust erodes across organisational boundaries. In cross-system pathways, psychological safety and collaboration are as critical as infrastructure and process design. What could strengthen learning? While the report provides valuable system-level insights, there is an opportunity to go further in translating findings into practical improvement. Two approaches could add depth: 1. After Action Review (AAR) at system level A structured, multi-agency AAR could: Reconstruct the pathway end-to-end. Identify where assumptions diverged from reality. Surface latent conditions contributing to risk. Build shared understanding across organisations. This would move learning from 'what happened' to 'why it made sense at the time'. 2. Transformative (tabletop) simulation Given the complexity of regional pathways, simulation offers a powerful way to: Test proposed improvements in a safe environment. Explore system stress points (capacity, transfers, escalation). Identify unintended consequences before implementation. In effect, simulation allows systems to experience the pathway as patients do across boundaries, not within silos. The role of integrated care boards: a system risk? Perhaps the most significant implication of this report is what it reveals about the current maturity of system oversight. ICBs are expected to: Commission across pathways. Ensure safety across organisational boundaries. Use data to drive improvement. However, the report evidences: Limited access to consistent safety data. Reduced capacity following structural changes. Difficulty maintaining ongoing oversight of complex pathways. Again this is not an new issue and is a theme that we have seen in previous HSSIB investigations, including a report last year looking at the implementation of the Patient Safety Incident Response Framework. This raises a critical question: do current system structures have the capability and capacity to oversee patient safety at pathway level? If the answer is uncertain, then this is itself is patient safety risk, one that is largely invisible to the public. How might the emerging quality strategy address this? The forthcoming NHS Quality Strategy presents a critical opportunity to address many of the systemic issues highlighted in this report, particularly the fragmentation of safety across organisational boundaries. The 10 Year Health Plan stated that alongside the National Quality Board its aim would be to address a crowded and unclear quality landscape and provide a single and authoritative determination of quality. This aligns directly with the need identified here: clearer expectations, better measurement and more coherent oversight across systems. However, emerging national discussion suggests there are still important gaps to resolve, including concerns about whether patient safety will be given sufficient prominence, and whether expectations for providers and system leaders will be clear enough to drive meaningful change. If the Strategy is to respond effectively to the risks identified in this HSSIB investigation, it must move beyond treating safety as one dimension of quality and instead position it as a central organising principle of system design. This creates a significant opportunity to design cross-system safety into: service planning service delivery accountability frameworks performance management data capture and intelligence. Without this, there is a real risk that existing fragmentation is reinforced: where metrics are numerous but unaligned, accountability remains diffuse, and no single entity holds responsibility for understanding risk across the whole patient journey. Conversely, a coherent and safety-led strategy could provide the support needed for ICBs and providers to jointly own pathway outcomes, supported by shared data, stronger governance and clearer system leadership. The absence of prescriptive targets may offer flexibility but it also increases the importance of how strongly patient safety is prioritised and operationalised in practice. Final reflection This HSSIB report highlights a fundamental truth: patient safety does not solely reside within organisations; it resides within pathways. The 10 Year Health Plan for England envisions a significant shift in the coming years towards more neighbourhood and system-based models. As this transition takes place, the risks identified in this report will only become more pronounced. Without clear end-to-end ownership, shared data and intelligence, robust evaluation, and strong cross-system leadership, we risk designing pathways that look coherent on paper but are fragile in practice, and where safety is too often an afterthought. The forthcoming NHS Quality Strategy could potentially present a opportunity to tackle these issues, designing for safety, to ensure safe outcomes, processes and behaviours. The challenge now is not simply to learn from this report but to recognise that these issues are unlikely to be isolated. They are systemic and they demand a system-level response.

Supporting the adoption and sustainability of innovation at scale is essential for improving health and care systems to implement innovation to create a healthier population. Yet, successful innovation often depends on retiring old practices. This session will include: Health Innovation Wessex's evidence-based four pillars model and how you can apply it Insights and strategies to de-risk transformation Practical tools to save time, reduce costs, and enable innovation to flourish. Speakers: Philippa Darnton, Director of Insight, Health Innovation Wessex Andrew Sibley, Programme Manager, Evaluation (Mixed Methods), Health Innovation Wessex Patrick Arnold, Programme Manager, Innovation Adoption, Health Innovation Wessex. Register

This page advises healthcare professionals working within the community, care homes or hospital environments on how to reduce the risks of hot weather to the health of people they provide care for.

Some people will rejoice at the thought of hot weather coming our way. But for nursing staff, keeping hydrated while at work can bring another challenge to already busy days. Royal College of Nursing Head of Health, Safety and Wellbeing Kim Sunley answers your questions on this key subject.

In operating theatres and other high pressure clinical environments, clear identification shouldn’t be a nice ‘extra’, it is a patient safety need. When staff cannot quickly recognise names and roles, communication becomes harder, escalation can be delayed and patients are left unsure who is caring for them. Reviews of patient safety repeatedly show that poor teamwork and unclear roles can contribute to avoidable harm. Danielle Checketts, Managing Director of Eco Ninjas, discusses why being able to identify staff by their names and roles is so important not only for the staff themselves but also patients. She explains how a simple idea, reusable hats with detachable name badges that can be removed before laundering, can support safety and teamwork. In theatre, everyone can look the same. Masks, gowns, visors and lead aprons often cover name badges, while lanyards are easily hidden or turned around. Theatre teams include surgeons, anaesthetists, students, agency staff and industry representatives, yet patients and colleagues are still expected to know who is who. When names, roles and seniority are unclear, questions may go to the wrong person, and valuable seconds can be lost. Even when introductions are made during the WHO surgical safety checklist,[1] names and roles can quickly be forgotten once a procedure is underway. In an emergency, it must be immediately clear who is who. This lack of clarity can lead to: Miscommunication at critical moments. Delays in escalation. Reduced patient confidence and psychological safety. Errors due to misunderstood roles or instructions. This isn’t just theoretical. Liz Fitzhugh, net zero lead and former theatre manager at University Hospitals Coventry & Warwickshire (UHCW), put it simply: “If a patient arrests and someone asks for the crash trolley, either everyone goes or no one goes.” In critical moments, teams need to be immediately identifiable so they can act without hesitation. Liz’s team at UHCW were among the first to introduce name and role theatre caps in 2019. It feels fitting that she was also the person who once asked me to write my name on my disposable cap with a marker pen, quietly sparking the idea that grew into this work. For years, poor identification in theatre has become accepted and been treated as normal. But it shouldn’t be. Patients want to know who is caring for them, and staff work more safely when names and roles are clearly visible. That is why the ‘theatre cap challenge’ gained momentum internationally, highlighting a simple idea: if the hat remains visible when wearing sterile attire, it can help make names and roles visible too. Patient perspectives: what matters most Patients consistently say they want to know who is in the room, who is leading their care and who they can turn to for reassurance. Feedback from surgical and maternity care journeys, including caesarean births, shows that visible names and roles help people feel safer, calmer and better able to engage in what is happening around them. Patients describe feeling more reassured when: Staff introduce themselves clearly. Visible names and roles help patients and colleagues remember who is who after introductions, rather than relying on memory alone. There is consistency in communication throughout their care. When identification is unclear, patients can feel anxious and excluded at the point they are most vulnerable. Visible names and roles do more than support courtesy, they strengthen communication, teamwork and reassurance for patients and families. Infection prevention, hygiene and practical constraints Efforts to improve identification must also align with infection prevention standards. Theatre attire cannot simply be adapted without considering contamination risk, laundering processes and the wider pressure to reduce reliance on single use items. The challenge with current approaches The current embroidered theatre caps improve visibility of names and roles, but they are difficult to manage at scale and fail to support consistent identification for all staff. Students, visitors and temporary staff are often excluded, and new starters can wait months before receiving one. They also create ongoing operational challenges, including time-consuming bespoke ordering, poor fit, loss and replacement costs, outdated roles, and complications with laundering. As Alan Dickens, Theatre Manager at MMUH Birmingham, explains: “Bespoke embroidered caps are hard to manage over time. When staff leave or change roles, the hats issued to them often leave with them or need replacing. This creates ongoing cost for the trust and delays in maintaining accurate identification.” Emerging responses across the NHS Several NHS organisations are now testing a more practical approach: reusable hats with detachable name badges that can be removed before laundering. This keeps identification visible while fitting more easily into real hospital systems. In Somerset, a pilot at Musgrove Park showed how a simple change can support safety and teamwork. Mr Andy Stevenson, orthopaedic consultant at Somerset NHS Foundation Trust, said: “In theatre, there can be a really high turnover of colleagues at times, with new people coming and going all the time. This can make it really difficult to know who is who, let alone what jobs they have. Some days, it will be the first time working with half the people in the room. The badge hats have helped to positively transform communication and safety.” A similar message has come from maternity services. Kathryn Harrison, delivery suite manager at Great Western Hospital, said: “Despite staff introducing themselves in the morning, remembering everyone’s name and role throughout the day is challenging, especially when more than 12 people can be in the room at any one time. The badge hats reinforce this critical stage in safe surgery, improve teamwork and communication, and help break down hierarchical barriers. They can be worn by all staff, students, birthing partners and even the patients wear them on our unit”. Building the evidence base There is growing research interest in identification in healthcare.[2][3][4] We have started to work with medical schools on exploring the impact on training environments, role visibility and communication. This is helping to strengthen the evidence base for scalable, system-wide approaches. Students can be included simply using a badge with their name and role alongside a standard fitted hat. Towards integrated, system-based solutions The challenges across current approaches show the need for solutions that fit existing NHS processes, including laundering and distribution, while also identifying temporary staff, visitors and students. The most effective solutions will improve safety without creating new inefficiencies. A call to action Clear identification in healthcare is not optional. It is a practical safety intervention. When people can immediately see names and roles, communication improves, hierarchy softens, patients feel more reassured and teams are better able to act quickly when it matters most. If the NHS is serious about reducing avoidable harm, improving teamwork and strengthening patient experience, visible identification should be part of the solution. Wearing a detachable badge on a reusable theatre cap sounds very simple but this is a small change that can make a very big difference to the safety of patients. References World Health Organization. WHO Surgical Safety Checklist. Kouba LP, Fabi A, Bayer S, et al. Labeled surgical caps improve perioperative patient safety and interprofessional communication in the operating room: a scoping reviewe. Patient Saf Surg, 2026; 20:(9). Liverpool University Hospitals NHS Foundation Trust (LUHFT) and Warwick Med. Case study – Switching to Reusable Theatre Caps. NHS England. Douglas N, Demeduik S, Conlan K. Surgical caps displaying team members' names and roles improve effective communication in the operating room: a pilot study. Patient Saf Surg 2021;15:27. doi: 10.1186/s13037-021-00301-w.