Patient safety: the missing connections

Summary

The UK health service is often criticised for working in silos. Patient safety campaigners, policy makers and support organisations frequently do the same.

This opinion piece sets out a way to supercharge patient safety improvements.

Are you setting up a patient safety event or initiative?

• Have you involved the right people?

• What are your aims and objectives?

• How will you evaluate progress?

This article outlines the 'four pillars of patient safety' approach for patient safety initiatives, workshops and events. It draws together areas that are critical for patient safety. It is based on my experience of working across boundaries on large-scale events and challenges the current practice of working in silos.

The reflection includes how to validate the model and use it in practice. It is a call to action that challenges the patient safety world to be more inclusive, engage openly across professions and disciplines, and to include patients.

Content

The missing connections

Whether you work in healthcare or are a patient, relative or carer, most of us recognise the problems caused by silo working.

As a result of the failure of teams and services to link up, major improvements that can prevent harm are delayed or lost. Hardly a week passes without another example of preventable harm to patients appearing in the media. Reports from investigations and inquiries reveal that records are altered or concealed to hide the facts; staff who attempt to blow the whistle and are bullied out of their jobs; initial investigations are of poor quality (or even not carried out at all); and throughout this whole process patients are kept in the dark.

This problem is not unique to healthcare. In all sectors, from the post office to criminal justice, leadership behaviours that contribute to harm are the same. This 'architecture of harm'[1] spans four areas: duty of candour (telling the truth), attitudes to whistleblowing, the quality of investigations and patient access to records. These areas are generally considered, and acted on, in isolation. This is where the idea of the four pillars for safer healthcare comes from.

What are the four pillars of patient safety?

1. Duty of Candour

The call for an individual legal duty of candour (duty to tell the truth) on public officials was first identified as a legal gap in 2000 by the European Court of Human Rights following the death of Robbie Powell in 1990.[2] As a result, the Robbie’s Law campaign for an individual legal duty of candour in healthcare was set up.[3]

In healthcare, the current NHS duty of candour, created following reviews by Sir Robert Francis, delivered a watered-down duty of candour that mandates organisations rather than individuals to be truthful.[4]

A common misconception is that the Francis’ reforms delivered Robbie’s Law. They did not. The duty of candour introduced in 2008 falls short of what is needed and does not deliver Robbie’s Law, which is individual legal accountability to tell the truth. This wrong view is convenient for politicians, health chiefs and policy makers, several of whom have claimed,or implied that a Robbie’s Law is in place..[5]

The gap, whereby public officials do not have a legal duty to be truthful, first identified in the Powell case[2] was later taken up in the campaign for a Hillsborough Law. Like Hillsborough, exposure of healthcare failings and the decades long struggles that victims are forced to undertake to achieve independent investigations are well documented. When enacted it is anticipated that Hillsborough Law (the Public Office (Accountability) Bill)[6] will meet the requirements of a Robbie’s Law.

2. Protection of whistleblowers

A culture of cover-up means that those who have suffered harm have to rely on staff to speak out and blow the whistle. This does not always happen, because healthcare whistleblowers risk losing their careers and being blacklisted when they expose the truth. UK healthcare failings that have caused avoidable harm, and the exposure of subsequent cover-ups by whistleblowers, link duty of candour to the whistleblowing agenda. Campaigns to support whistleblowers by various individuals and organisations led to demands for changes in the law, including the Whistleblowing Bill which is currently going through parliament.[7]

Both the initiatives on duty of candour and on whistleblower protection legislation are usually dealt with separately. The link between the two in the NHS is under-acknowledged and is rarely recognised in the debates and discussion forums. It is now seldom mentioned in the press or referred to by commentators.[5]

3. Independent investigation process

There is a growing movement advocating an independent investigation process in healthcare to end the practice of the NHS marking its own homework.[8] The importance of a high quality, consistent, independent investigation process is included in the 2025 NHS plan.[9] The most well evidenced example of this unmet need is the Robbie Powell case, which, 36 years after Robbie’s death, remains unresolved. This is despite overwhelming evidence of wrongdoing, much of which is proven.[3]

The NHS complaints process is based on the organisation investing itself in the first instance, and routes to a fully independent investigation (statutory or non-statutory) are unclear. This is compounded because the NHS does not have an overarching competency framework that applies to investigations. Currently, there are no common standards for collecting information, taking and recording statements, or for selecting appropriate expert witnesses.

4. Patients’ access to their medical records

When healthcare failings require scrutiny and action, the accuracy, completeness and timely availability of patients’ medical records are crucial. The 2026 NHS plan refers to linking patient records and giving patients real-time access'[9] This is long overdue. Avoidable harm to patients is caused, or made worse, because patients do not have real-time access to their medical records. Plus, medical records are stored on multiple systems, many of which are not linked. As a result, patients are denied the opportunity to be active participants in their own care and are unaware of clinical red flags which require urgent attention.

In summary, these four areas:

• Individual legal duty of candour legislation.

• Protecting whistleblowers from victimisation.

• An independent investigation process.

• Patient access to their medical records in real-time.

are inextricably connected.

The missing links

As it stands in 2026, health leaders and professionals have no individual legal duty to be truthful; victimising whistleblowers is not (in itself) against the law; the NHS investigation process lacks independence and lacks quality assurance, and patients do not receive all their records in real time.

It is my professional opinion that this is a harmful situation, and that it is dangerously incomplete to discuss duty of candour in healthcare without referring to whistleblowing, to the investigation process and to patient record access.

Progress is being made

Actions are underway on each of the four pillars. The Public Office (Accountability) Bill is expected to become law.[6] Legal protection for genuine whistleblowers and penalties for those who have proven to have victimised whistleblowers is contained in the Whistleblowing Bill[7] and there are a range of proposals to amend related laws, including the Public Interest Disclosure Act.[10] The 2025 NHS Plan signals a need for an independent complaints process, supported by legislative changes, and the need to make all records available to patients in real-time.[9]

Despite all the initiatives, very few people join up the four pillars. I have been unable to find examples where the four pillars are brought together in discussions: meetings, policy forums, round table events, workshops, training sessions, etc. All too often each pillar is studied, reviewed and acted on separately. Very few commentators, policy makers and patient safety organisations step back to take a wider view.[5]

Evaluating the four pillars model

Here are two ways to evaluate the validity of the four pillars of patient safety. These reflective exercises, taken from my inter-disciplinary teaching work, have proven popular. Feedback from teaching sessions conducted using this approach included clinicians stating that what they had learned led them to change their practise, and patients noting that their care and treatment has improved as a result.

1. Retrospective analysis

Take any example of avoidable harm, study the evidence and ask what would have been different if:

• Managers, leaders and healthcare professionals were each legally obliged to tell the truth.

• Staff had been able to speak out and, where necessary, blow the whistle without fear of retribution.

• There was a consistent, high-quality independent investigation process.

• All records had been available to the patient (or their legal representative) in real-time.

2. Relating the four pillars to current practice

First, consider instances you have experienced where preventable harm was avoided, or mitigated, and reflect on this using the four pillars model. By looking in detail at areas of good practice it is possible to confirm if lessons have been learned,and if changes in practice have improved outcomes.

Then go on to consider whether these changes in practise are widely adopted, and what is needed if this is not the case.

Call to action

I urge everyone, in every profession and field of work, with an interest in patient safety and accountability to collaborate and look at it from the perspective of the four pillars of patient safety. These are not new ideas, and they each have an evidence base. The four pillars are not current buzzwords or fads. They have been around for a long time. This is about putting best practice into action by opening the debate to everyone involved, spanning organisational and professional boundaries.

Whilst there are differences of opinion on how to achieve change and prevent harm to patients, the baseline is the same: Who can argue against honesty, fairness, independent scrutiny, and who opposes patients receiving copies of their own records?

My advice to patient safety campaigners, policy makers and healthcare organisations is, before you begin: check your idea, your initiative, your workshop, meeting, teaching session etc., against the four pillars of safer healthcare.

• Have you involved the right people?

• What are your aims and objectives?

• How will you evaluate progress?

Here’s the wake-up call. Consider the four pillars at the outset of all patient safety initiatives. Work across boundaries. Join up initiatives. Always involve patients, carers and relatives, and structure initiatives around this. Set up events that bring people together who would not normally meet.

Adopting the four pillars approach builds links between stakeholders from the outset. It will enhance what you are trying to achieve, and the benefits will soon become clear.

References

1. Newell J. The Architecture of Harm Systems Under Strain & the Search for Accountability – The moment the System Broke. Substack, 2026. https://jennewell1.substack.com/p/the-moment-the-system-broke (Accessed 13.08.2026).

2. European Court of Human Rights (45305/99) (4th May 2000) – (Third Section) – Decision – POWELL v. THE UNITED KINGDOM.

3. Turner S. Robbie’s Law – Telling the Truth in Healthcare. The Campaign for an Individual Legal Duty of Candour. 2026. Available at: www.robbieslaw.com (Accessed 13.08.2026).

4. UK Government. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20 (Duty of Candour). 2008.

5. Turner S. Truth, Accountability, and the State: Revisiting the Robbie Powell Case Through Law, Ethics, and Public Administration. Patient Safety Learning, 2026. Also available at: https://medicinegovorgmedlearninnovationeventnhsblog.wordpress.com/wp-content/uploads/2026/06/truth-accountability-and-the-state-robbie-powell-robbies-law-web-site-v1.pdf (Accessed 13.08.2026).

6.  UK Parliament. Public Office (Accountability) Bill 2024–26. https://bills.parliament.uk/bills/4019 (Accessed 13.08.2026).

7. UK Parliament. Whistleblowing Bill [Bill 151] 2023 – 2026. 2026. https://bills.parliament.uk/bills/3676 (Accessed 13.08.2026).

8. Keeping the NHS Honest. https://www.keepingthenhshonest.co.uk/ (Accessed 13.08.2026).

9. Department of Health. 10 Year Health Plan for England: fit for the future. 2025. ttps://www.gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future (Accessed 13.08.2026).

10. UK Parliament. Public Interest Disclosure Act 1998. https://www.legislation.gov.uk/ukpga/1998/23/contents (Accessed 13.08.2026).

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