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This article provides an overview of an Adjournment Debate in the House of Commons discussing the implementation of recommendations from the Review of patient safety across the health and care landscape. The debate focused on the proposed transfer of functions of the Health Services Safety Investigations Body (HSSIB) to the Care Quality Commission (CQC). What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on. Review of patient safety across the health and care landscape On 7 July 2025, the Department of Health and Social Care (DHSC) published the findings of the Review of patient safety across the health and care landscape in England, chaired by Dr Penny Dash. The review looked at six specific organisations that were established to either assure—or contribute to improving—the safety of care, while also making reference to the wider landscape of organisations influencing quality of care. Its final report issued a number of recommendations, which included several proposed changes organisational changes: Transferring the functions of the HSSIB to the CQC. Closing Healthwatch England, moving its functions to a new directorate for patient experience in DHSC. Combining the statutory functions of Local Healthwatch relating to healthcare with involvement and engagement functions in Integrated Care Boards (ICBs), with social care functions transferred to local authorities. Transferring the hosting arrangement of the Patient Safety Commissioner for England to the Medicines and Healthcare products Regulatory Agency (MHRA). Closing the National Guardian’s Office, transferring its functions to NHS England. Contributions from Bernard Jenkin MP This debate was tabled by Sir Bernard Jenkin MP. He made a number of points concerning the transfer of the functions of the HSSIB to the CQC. He said that safety management is intrinsic to safety and public confidence in other safety-critical activities, such as aviation, but is alien to NHS culture. He asked without HSSIB, which independent body will promote a coherent understanding of safety system management in health, and who is to hold the NHS and Government to account for safety failures. He stated his view that neither the National Quality Board (NQB) nor the CQC should control investigations. He noted that the Air Accidents Investigation Branch cannot be prevented from making independent recommendations by the Civil Aviation Authority, the Transport Secretary or airlines themselves. He asked therefore why should the NQB, which will be subject to political direction, be allowed to decide what safety recommendations should be made and what should be investigated. He highlighted that the Dash Review incorrectly states that HSSIB was originally established to look at specific cases or incidents of severe harm, but it has since broadened its work into making more systemic recommendations. He noted that it was always intended by Parliament that HSSIB should make systemic recommendations arising from the investigation of specific incidents or groups of incidents. He questioned whether the CQC in its role as regulator and compliance enforcer could also be an independent investigator. He said that the Dash Review also says that the CQC internal successor should collaborate through the NQB to agree the scope of any investigations it carries out and agree the recommendations. He described this proposal as a direct attack on the independence of investigations. He stated that the Dash Review fails to look at the comparative cost of HSSIB investigations versus the cost of public inquiries. He noted that HSSIB at the moment only costs £6.3 million per year. He suggested that to save money the Secretary of State should request that HSSIB conducts far more investigations into matters which he thinks are important, provided that he also provides the funding for the necessary capacity. An example he gave was that HSSIB, has conducted eight investigations into mental health suicides since 2023. Each was completed in a few weeks or months, costing a total of £850,000. In comparison, he noted that the Lampard inquiry into the Essex partnership university trust, also investigating patient safety concerns in mental health, is expected to cost more than £5 million. Contributions from other MPs Jeremy Hunt MP highlighted concerns that moving HSSIB into the CQC, which has a legal duty ot act on information it receives, creates a worry for people talking to HSSIB that the information that they give to it may no longer be protected as they currently are. Anna Dixon MP noted that recent inquiries into maternity services, infected blood and pelvic mesh underline that professionals and those working inside the NHS must be able to speak freely when things go wrong in order to learn lessons and that that this is only possible with an independent investigating organisation. James Naish MP stated his concerns about the abolition of Healthwatch. He noted that there is a strong desire to see independent patient voice maintained outside the system and that Healthwatch was established due to issues within health structures, including, notably, the Mid Staffordshire scandal. Jim Shannon MP emphasised the need for lessons learned on data collection, streamlined complaints and patient safety culture are shared with the Northern Ireland Assembly Minister, Mike Nesbitt, as health is a devolved matter. Rachael Maskell MP stated that there was a wider issue, which she felt that the Health Bill completely misses, around the accountability systems within the NHS. She stated that these reforms are not going to deliver accountability, but will weaken it, and as a result we will see more requests for investigations into patient safety. Government response Responding to this debate on the Government’s behalf, Preet Kaur Gill MP, Parliamentary Under-Secretary of State for Health Innovation and Safety, made the following points: The investigation function within the CQC will be expert and full time, and it will be able to conduct investigations in the same cheap and quick way that HSSIB does now. In future, there will be the same opportunity to use the CQC investigation function instead of needing a public inquiry as there is currently with HSSIB. The criteria for disclosing protected information outside the investigative function are set out in the Bill. Those criteria set a high bar for any disclosure—as high as it is currently with HSSIB—and the CQC will publish further guidance setting out much more detail. As the Bill sets out, the CQC will appoint a responsible person who will decide whether the case matches the criteria and whether it warrants information sharing outside the safe space. That person is likely to be the CQC’s chief executive officer. Dash reforms are not about saving money; they are about strengthening patient safety and patient voice across the system. She stated that the abolition of HSSIB and the transfer of its functions to the CQC play an important part in making the system of patient safety much more effective. The NQB has been revitalised by giving it a stronger role in providing a single, authoritative view of quality across the system. That will help reduce duplication, bring greater clarity to recommendations and ensure that effort is focused where it has the greatest impact. The purpose of these reforms is not to weaken investigation, but to strengthen the link between investigation, learning and improvement. The investigation function in the CQC will have autonomy to launch investigations into any part of the health system and will be able to make recommendations on any part of the system, just as HSSIB does now. There will be no barrier to an investigator finding out that CQC inspections are causing unintended harm. The Health Bill also allows for the investigation function to make recommendations to the CQC in its report, and the CQC would be legally required to respond to such recommendations. How to watch the debate You can watch the full debate here and find the full transcript on Hansard at the bottom of this page. Related reading Review of patient safety across the health and care landscape: Patient Safety Learning's response (15 July 2025) The future of the Health Services Safety Investigations Body: a recent discussion at the Patient Safety Management Network Is the patient voice fading? Reflections on patient safety in a changing NHS

Francine Gilmore, a patient with vestibular migraine, has written a report in a personal capacity* examining a patient safety gap where migraine prescribing overlaps with mental health risk. Drawing on Freedom of Information responses from 26 organisations and related evidence, the report identifies fragmented safeguards, unclear ownership and potential barriers to suitable treatment for clinically complex patients. In this blog, Francine shares her experience, the findings from her report and the actions she would like to see taken. The findings point to a clear need for change: migraine pathways must make mental health risk visible, owned in governance, recorded in clinical systems and reviewed for patient-safety learning. *The full report can be downloaded from the attachment at the end of the page. My (wobbly) journey I did not set out to write a patient safety report. I was trying to understand why so many medicines with potential contraindications had been offered to me. Quite literally a year to the date, since returning from the USA after my 30th birthday, I have been living with ongoing symptoms of what is now known to be vestibular migraine. The dizziness is relentless. When the dizziness starts, I am a safety risk. The headache pain can make life unbearable. So can photophobia, when ordinary light becomes too much to tolerate. Sunglasses are my new best friend. Somewhere along the way, I entered a state of medical hypervigilance. I was angry, frightened and exhausted. It felt as though, in trying to repair my physical health, I was once again being asked to risk my mental health. Every treatment decision felt like a game of medical Whac-a-Mole: solve the migraine problem, worry about mental health issues popping up later. Returning to full-time work has been a huge achievement. But doing so while still managing pain, dizziness and photophobia has also shown me how much invisible effort this condition demands. Yet migraine is only part of my picture. I also live with bipolar disorder and have a history of suspected serotonin syndrome (a serious condition caused by medications that build up high levels of serotonin in the body requiring hospitalisation). That means migraine treatment is not simply about whether a drug might help. It is also about whether it could destabilise my mental health, interact with other risks or cause another kind of harm. There. I have disclosed it publicly, likely where my professional networks will see it. But I am saying it because it matters and I know the risks. Managed mental illness should not be a nice to have consideration; it should make joined-up prescribing decisions more important. Before appointments, I print reports listing the medicines I am concerned about. I sit there trying to explain what I can and cannot take, aware that I may sound difficult, but also aware that I am the person who will live with the consequences if those risks are missed. I could probably deliver a TED Talk entitled 10 Things I Hate About Migraine Prophylaxis Options. The trouble is that there are considerably more than ten. The evidence The report is based on Freedom of Information responses and related information routes. The project file covers 26 organisations or evidence routes and more than 30 documents, so 1000+ pages of evidence. I used AI as a research and drafting tool, but every substantive finding was checked against the underlying evidence. Given the volume of material and the impact of disabling migraine, this was an accessibility tool as much as a drafting tool. The Migraine Trust states that migraine affects around one in seven people. My report also cites systematic review evidence showing increased odds of depression in people with migraine, increased odds of anxiety, and estimated bipolar disorder prevalence among people with migraine of 5.9% in population studies and 9% in clinic-based studies. The relationship is clinically relevant because migraine, mood disorders and some preventive medicines can overlap through neurological, psychiatric and medication-safety pathways. For patients already managing mental health medication, migraine prescribing is rarely a cleanly separate issue. There is also crossover in the medicines themselves. Amitriptyline, venlafaxine and nortriptyline are antidepressants and migraine preventives, while topiramate and valproate raise neuropsychiatric or psychiatric safety considerations. Greater occipital nerve blocks may also involve steroid exposure. Only last week I was offered lamotrigine and had to point out that this is also a centrally acting medicine with psychiatric relevance, particularly for someone with bipolar disorder. What I found in my research was a system that could point to safeguards in theory, but not clearly show who owned the risk in practice. NICE guidance, the British National Formulary, product warnings, local formularies, prescribing systems, referral routes and clinical judgement all matter. For patients like me, that gap affects which medicines feel safe to try, how much responsibility we are forced to carry and whether the whole picture is visible to the people making decisions. It also affects access. Some patients cannot safely use standard migraine preventives because of psychiatric history, psychotropic medication, previous adverse reactions or physical contraindications. If access to some specialist treatments depends on trying previous prophylaxis options, pathways need to show how contraindication, intolerance or clinical unsuitability are recorded and counted. Otherwise, patients can fall into a cruel gap: too complex for the standard route but not clearly signposted towards safer alternatives The report makes practical recommendations: clearer flagging of mental health and medication-safety risks defined ownership of the prescribing interface triggers for psychiatry or specialist pharmacy input better documentation and escalation processes recognition of contraindication, intolerance and clinical unsuitability when assessing access to specialist migraine treatments. Parliamentary questions asked On the eve of Patient Safety Learning publishing my report and blog, something unexpected happened. A number of parliamentary questions had already been tabled in the House of Commons about the issues the report raises. To me, the early answers seemed to confirm the gap the report had identified. On 15 June 2026, the Department of Health and Social Care (DHSC) said it had made no specific assessment of national arrangements for identifying, recording and acting on psychiatric history, psychotropic medication or previous psychiatric adverse drug reactions before someone starts a preventive migraine treatment. A second answer pointed to the Getting It Right First Time (GIRFT) programme as a way of reducing variation in migraine access. That sounded promising, until two follow up answers narrowed the position again. The DHSC then confirmed it had no plans to look any further than its 15 June position. Asked whether GIRFT covers governance for this prescribing interface, it confirmed on 1 July that it does not. GIRFT sets no formal governance requirements here. Those decisions are left to local providers and commissioners. Then came the House of Lords answer. On 6 July, the Government confirmed that the Medicines and Healthcare products Regulatory Agency (MHRA) now plans to review the evidence on mental health and related risks for licensed migraine prophylaxis medicines after receiving a report from a patient. It will consider whether product warnings need updating, and will look at suspected adverse drug reactions reported in the psychiatric disorders category. The answer records that this followed a report made to the MHRA. So the question is no longer just whether the risks are recognised. It is this: if the MHRA moves, how quickly will the rest of the system move with it?

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This month marks the fifth anniversary of the Patient Safety Management Network (PSMN)—a significant milestone for a community that has grown into a vital space for connection, shared learning and peer support across the patient safety landscape. What began as a small group coming together to make sense of complex challenges has evolved into a thriving network, bringing together people from across organisations, roles and sectors to learn from one another and improve care. A key part of strengthening that shared learning has been understanding what difference the network makes in practice. We are delighted to share the findings from research led by Elsa, a Masters student at University College London (UCL), who has recently completed an in-depth evaluation of the PSMN. Her work offers important insights into how networks like this support those working in patient safety and how learning is translated into action. Patient Safety Learning doesn’t have the resources to undertake a full evaluation of the PSMN and is very appreciative of the support from UCL and Elsa is undertaking this small scale but invaluable work. Why this review matters Patient safety work is rarely the responsibility of one person, team or organisation. People working in patient safety are expected to learn from problems, improve systems and share good practice, but reports and procedures cannot answer every question that comes up in real work. People also need opportunities to compare experiences, hear how others approach similar challenges and think through difficult issues with those who understand the pressures involved. That is why the PSMN is worth engaging with and supporting, and why we wanted to examine how well its meeting its ambition for shared learning, engagement and driving improvement. This evaluation explored what members gained from the PSMN, how it supported learning and connection, and why useful learning did not always lead to visible local change. What the evaluation looked at The evaluation was based on interviews with 15 PSMN members, supported by background information about how the network operates. It looked at what members valued or found difficult, how taking part shaped the way they thought about patient safety work, and what helped or limited the movement of learning from network discussions into everyday local practice rather than staying within meetings. Findings For many members, the value of the PSMN lay not simply in the information exchanged, but in recognising that others were wrestling with similar problems. Patient safety work can feel lonely, especially when people were trying to influence complex systems from different roles or levels of authority. In that context, hearing familiar concerns and suggestions voiced by others helped some members feel less isolated; one described it as a sense that “you’re kind of all in it together.” Taking part, however, did not always mean speaking often. Some members contributed regularly, while others listened, followed the chat or came along when the topic felt close to their own work. This quieter involvement still seemed meaningful. It suggests that the network’s value should not be judged only through the most visible contributions, but also through the perspective, reassurance and connection it made available. Another important part of the PSMN’s value was the discussion that happened around patient safety issues. Formal information and presentations were useful, but members often seemed to gain just as much from hearing how others made sense of similar problems in practice. These examples helped broad ideas feel more concrete and easier to connect with their own local settings. The value was not simply in picking up tips or ready-made solutions, it was also in comparing interpretations, noticing different ways of framing the same issue, and understanding why a problem might look different across roles or organisations. In this way, the PSMN seemed to help members turn general patient safety ideas into more usable forms of understanding. The learning it supported was not only practical, but also reflective and interpretive. Why useful learning doesn’t always become change Useful learning did not, however, move straightforwardly from the network into local practice. Members could leave PSMN with new ideas, reassurance or a clearer way of thinking about a problem, but what they were able to do with that depended on their local context. Some PSMN members had the authority, time or relationships to share examples, adapt ideas or use the discussion to support conversations in their own organisations. Others had fewer opportunities to act, particularly where workload, seniority or organisational priorities limited what felt possible. As one member put it, “it’s very difficult to just learn something in the network, take it, go into your organisation, do it, and that’s it.” This matters because it challenges a simple view of learning as something that moves directly from discussion to implementation. The PSMN could help members think through problems and sometimes give them the language or confidence to approach them differently; however, it could not remove the local conditions that shaped whether learning became action. Therefore, its influence was useful, but uneven and often indirect. Even when the PSMN did not lead to immediate action, members could still leave with something useful. For some, this was more reflective than practical: the network helped them name a problem, recognise that it was shared or think about what might be possible later. Although this kind of value is less visible than a new project or policy change, it may still shape confidence, judgement and readiness to act. What this means for practice For the PSMN and networks like it, the findings suggest that value lies not just in the material shared, but in the kind of discussions the network makes possible. Networks may need to preserve space to talk honestly about the realities of patient safety work, including uncertainties and frustrations that formal guidance cannot always address. Importantly, this also positions the PSMN as a valuable bridge between frontline practice and the wider patient safety system, helping national bodies such as the Care Quality Commission (CQC), Health Services Safety Investigation Body (HSSIB) and NHS Resolution better understand ‘work as done’ and supporting more informed policy and improvement approaches. At the same time, learning is more likely to become useful beyond the meeting when people have time, support and realistic ways to adapt ideas in their own settings. Participation also needs to be understood broadly. Some members may contribute by listening, reflecting or taking ideas back later, rather than by speaking often. Therefore, the practical task is not simply to generate more activity, but to protect the conditions that make learning usable. This evaluation drew on interviews with members who chose to take part, so it cannot reflect every possible experience of the PSMN. It focused on how members described the network’s value and influence, rather than measuring direct changes in patient outcomes. Still, the findings suggest that spaces like PSMN may matter by helping people discuss, interpret and sometimes act on patient safety work that might otherwise feel harder to navigate alone. As we celebrate five years of the PSMN, Elsa’s research gives us a valuable opportunity to reflect, not just on what the PSMN has achieved, but on why it matters. It highlights the importance of creating spaces where people can come together openly, share uncertainties as well as successes, and build collective understanding. Thank you to everyone who has contributed to, supported and shaped the PSMN over the past five years. Whether you have shared experiences, asked questions or simply joined to listen and reflect, your involvement is what makes this community so powerful. The continued growth of the PSMN reflects a shared commitment to learning and improvement and ultimately to safer care for patients. How to get involved Are you working in patient safety and interested in joining the PSMN? You can join by signing up to the hub today. When putting in your details, please tick ‘Patient Safety Management Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected].

Patients forget up to 80% of what is said in a consultation, and families often act on distorted second-hand accounts. This recall gap sits upstream of medication errors, missed red flags and weak informed consent. Olivier Desloges discusses how digital technology can help patients record their appointments and generate plain-language summaries they can share. The problem Patients forget between up to 80% of the information given to them in a medical consultation.[1] Roughly half of what they do remember is recalled incorrectly and, when families rely on a relative's account, the picture distorts further with each retelling. This isn't a peripheral usability issue. Patients leaving consultations unable to accurately recall or share what was discussed is a recognised patient safety issue and can lead to: Medication errors at home: wrong dose, missed timing, stopped early. Failure to act on red-flag symptoms the clinician explicitly flagged. Care decisions made by family members on the basis of second-hand accounts. Missed follow up appointments. Where it matters most The risk of recall gap can vary depending on the patient, their condition and their environment. For example: Oncology consultations: dense information, distressed patient, time-critical decisions. Older patients leaving GP or outpatient appointments with multiple medication changes and no companion. Parents leaving paediatric A&E with safety-netting instructions to remember overnight. Antenatal advice that needs to translate into action weeks later. Mental health appointments where safety planning is discussed under emotional load. The right to record your consultation Most patients don’t know this, but In the UK patients have a legal right to record their own consultations for personal use. They don't need the clinician's approval, and the right extends even to covert recordings. The British Medical Association and Medical Defence Union both acknowledge this position. However, I would always encourage patients to ask first. It's a matter of courtesy, it sets the tone of the consultation and it tends to produce a better conversation. But the underlying right is established and uncontroversial. How apps are helping patients Smartphone apps, such as Ditto, can be used by patients to record a consultation. It produces a plain-language summary the patient can read, save and share; with a partner, adult child, carer or anyone else they choose. Nothing is shared automatically and it runs under UK GDPR. Summaries can be produced in the patient's preferred language. Limitations to be aware of AI summaries aren't a substitute for the clinician's notes or a follow-up letter, although these too can be uploaded into an app to be summarised in easy language for patients. It depends on the patient having a smartphone and being comfortable using it. Not everyone will. Clinician comfort with being recorded varies. We always encourage patients to ask their clinician first. It's a matter of courtesy, trust and a better consultation overall. But the right itself is established in the UK. How clinicians and safety teams can engage Suggest it to patients facing a consultation where recall is likely to matter most. Pilot it in a service where recall failure is already known to cause harm. Tell us where you think these apps fall short: the critique will help developers ensure apps are designed for the clinician and the patient. Reference Kessels RPC. Patients' memory for medical information. J R Soc Med. 2003;96(5):219–222. About the Author Olivier Desloges is Head of Expansion at Ditto, a free app that allows patients to record their medical conversation and receive a plain text summary that they can then refer back to or share with family, a carer or another clinician. Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.