• Patients are coming to harm where follow-up actions are needed after discharge from hospital and discharge planning has not accounted for constraints and challenges in the local health and care system (referred to here as ‘the local system’). This means actions are not always undertaken or completed within expected timeframes.
• A lack of integration – as evidenced by limited collaboration between primary, community and secondary care providers – contributes to discharge planning and communications that do not always ensure patients receive continuity in their care.
• Risks to patient safety associated with the quality and timeliness of discharge correspondence, most notably the discharge summary, have been “normalised”. There is unclear accountability for the safety of patients early after discharge.
• The current regulatory approach for inspection of care quality does not lend itself to effective scrutiny of cross-provider pathways, such as transitions of care between providers.
• Oversight mechanisms in providers and integrated care boards do not always exist or function to ensure that end-to-end discharge communication is achieved through the creation, sending, receipt and actioning of correspondence.
• A lack of interoperability between IT systems within and across providers means information does not pass seamlessly, increasing the risk of information being lost, delayed or missed.
• The design/configuration of the parts of electronic patient record for correspondence, including discharge summaries, can introduce the potential for errors and does not always support staff to create, send and process correspondence.
• Discharge correspondence may not be accurate in scenarios where patients continue to receive care in hospital after discharge correspondence has been sent.
• Discharge summaries are not actively sent to, or accessible to, all the providers of ongoing care who need to know the clinical information they contain.
• The content of discharge correspondence, including discharge summaries, does not always meet the information needs of recipients to ensure safety-critical actions for a patient’s ongoing care are handed over, understood and achieved.
• Medical staff writing discharge summaries recalled no specific education on the writing of user-centred and safe discharge correspondence during undergraduate and postgraduate education.
• The availability of discharge correspondence in different systems, for example shared care records, varies across the country with limited opportunities for primary and community care staff to access it via other routes if correspondence has not arrived.
• Patients do not always receive a copy of their discharge summary which removes this ‘backup’ option for providers to access information. It also means patients do not have information to support their own understanding of their care needs.

HSSIB makes the following safety recommendations

Safety recommendation R/2025/065:

• HSSIB recommends that the NHS England/Department of Health and Social Care, in collaboration with relevant national bodies including the Professional Record Standards Body, adopts user-centred design principles to develop and validate new discharge correspondence templates for primary and community care settings. This is to provide standards for discharge correspondence that support recipients’ access to high-quality safety-critical clinical information, and that can be contextualised to local system needs.

Safety recommendation R/2025/066:

HSSIB recommends that the Department of Health and Social Care, through its future strategic and policy programmes, sets specific expectations for NHS healthcare providers to ensure that:

• high-quality safety-critical information about patients is accessible after discharge, and
• processes exist to complete safety-critical actions for ongoing patient care within required timeframes.

This is to enable providers to deliver continuity in patient care after discharge from hospital.

HSSIB makes the following safety observation

Safety observation O/2025/074: 

Primary, community and secondary healthcare providers can improve patient safety by working collaboratively to recognise and mitigate local system challenges and constraints that prevent the:

• communication of high-quality safety-critical information about patients
• completion of actions for ongoing patient care within required timeframes.

HSSIB suggests safety learning for Integrated Care Boards

HSSIB suggests that integrated care boards support collaboration between primary, community and secondary care providers across their local systems to:

• jointly validate the quality of discharge correspondence
• plan for the constraints and challenges faced by different parts of their local systems
• assure themselves that risks to patient safety on discharge from hospital are mitigated as far as is practicable.

Local-level learning prompts

HSSIB investigations include local-level learning where this may help providers/organisations and staff to identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has identified learning to help consider and mitigate risks around creating, sending and processing discharge correspondence.

For providers creating and sending discharge correspondence

• How does your organisation ensure staff recognise discharge correspondence as safety-critical information for the clinical handover of care?
• Do your staff know who are the recipients of and users of your discharge correspondence, particularly discharge summaries?
• How does your organisation know that its correspondence meets the needs of those receiving and acting on the information?
• How does your organisation ensure important information about medication changes are reliably and accurately described in discharge correspondence?
• How does your organisation support staff to ensure the contents of discharge correspondence meets the needs of all likely recipients and is of high quality?
• How does your organisation know that all required discharge correspondence is reliably produced, sent and received by all necessary recipients, not just GPs?
• How does your organisation ensure patients and their families/carers (if appropriate) are given an accessible copy of any discharge correspondence?
• How does your organisation ensure discharge correspondence is updated if a patient has further clinical input after the correspondence was written?
• Do your staff recognise that capacity and resource issues in primary and community care mean time-critical actions after discharge may be delayed or unable to be actioned?
• How does your organisation support staff to communicate time-critical actions to providers of ongoing care so they are undertaken within the required time?
• Does your organisation have pathways for primary and community care to troubleshoot incomplete or ambiguous information in discharge correspondence?
• How does your organisation involve staff in the development and testing of EPR templates to ensure they are easy to use and do not contribute to incidents?
• Does your organisation include digital and clinical input in the training of staff to write discharge correspondence to help them understand what ‘good’ looks like?

For providers receiving and processing discharge correspondence

• Does your organisation have processes for identifying and prioritising safety and time-critical actions requested by secondary care?
• How does your organisation manage seemingly ‘duplicate’ correspondence to ensure it is not an updated version with further information or actions?
• Does your organisation have processes for effectively feeding back concerns and incidents to secondary care when discharge communications do not meet your needs?
• How does your organisation involve staff in the development and testing of software and processes to ensure they are easy to use and do not contribute to incidents?
• How does your organisation assure your internal processes for the administration of correspondence to ensure thoroughness of review while looking to be efficient?

To support NHS organisations and local investigation staff, HSSIB identified an opportunity to model approaches to patient safety incidents investigations (PSIIs) under the NHS Patient Safety Incident Response Framework (PSIRF). HSSIB have also used this opportunity to identify learning that may help to improve how PSIRF can support staff in carrying out incident investigations.

These three investigations used the PSII report template and PSIRF tools to investigate incidents involving patients who developed sepsis. Findings and areas for improvement are listed for the organisations that were involved in these incidents. However, the learning may be relevant to other organisations.

Areas of improvement

Patient with a urine infection

The investigation of a patient with a urine infection identified three areas of improvement which the nursing home and hospital could develop safety actions to address.

• Area of improvement 1 Variability in the medical support accessed by nursing staff due to the medical care arrangements for the nursing home.
• Area of improvement 2 Difficulty for nursing staff getting medicines prescribed by GPs on the electronic patient record system.
• Area of improvement 3 Lack of involvement of families to support the assessment of confusion in patients.

Patient with abdominal pain

The investigation of a patient with abdominal pain identified five areas of improvement.

• Area of improvement 1 There is limited understanding and awareness of processes to support family and carer involvement in clinical decision making about deterioration.
• Area of improvement 2 New confusion in patients is not consistently accounted for in NEWS2 scores.
• Area of improvement 3 Staff perceive that a diagnosis of infection is needed before completing the sepsis screening tool.
• Area of improvement 4 There are challenges in how tools and processes enable the care of deteriorating patients to be escalated to, and overseen by, senior medical and nursing staff.
• Area of improvement 5 There is variation in the understanding of the role of the critical care outreach team in managing the care and treatment of deteriorating patients.

Patient with diabetes and a foot infection

The investigation of a patient with diabetes and a foot infection identified two areas of improvement which Hospital A and Hospital B could develop safety actions to address.

• Area of improvement 1 Review and update the requirements of vascular service provision between Hospital A and Hospital B.
• Area of improvement 2 Out of hours expertise in diabetes and foot problems at Hospital A.

Related reading on the hub:

• Top picks: 11 resources about sepsis
• Top picks: PSIRF tools, templates and examples

• Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024)
• Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024)
• Mental health inpatient settings: out of area placements (21 November 2024)
• Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024)
• Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025)

Findings

Safety, investigation, and learning culture

• There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn.
• Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations.

System integration and accountability

• The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness.
• The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned.

Physical health of patients in mental health inpatient settings

• There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness.
• The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes.
• National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely.
• Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness.
• There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs.
• There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place.
• Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity.

Caring for people in the community

• Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations.
• Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement).
• Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care.
• Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed.
• There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients.
• Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country.

Staffing and resourcing

• Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care.
• In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’.
• Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services.
• There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model.

Digital support for safe and therapeutic care

• A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers.
• Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure.
• Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots).
• Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones.
• Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe.

Suicide risk and safety assessment

• ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this.
• Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them.

Safety recommendations

1. HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention.
2. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems.

Safety observation

1. National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.

• Staff fatigue contributes directly and indirectly to patient harm. However, there is little evidence available to help understand the size and scale of the risk, how it impacts on patient safety, and those staff groups who may be most at risk of fatigue.
• There was variation in how the concept of fatigue was understood and the impact it could have on patient safety and staff safety across the healthcare system. This inconsistent understanding prevented fatigue risks being addressed.
• The risks posed by staff fatigue are not always clear to trusts. The systems and processes needed to provide the information to assess staff fatigue risk are not always well developed or well used. However, some trusts were starting to explore these risks.
• A positive safety culture was a key enabler to support healthcare organisations to recognise and manage fatigue risk.
• Staff fatigue is not routinely captured as part of patient safety event reporting or routinely considered as part of patient safety event learning, or other governance processes.
• Fatigue was perceived by organisations and staff as an individual staff risk, with limited organisational accountability. This sometimes led to a blame culture and punitive actions when staff were fatigued, and limited actions to drive improvement.
• Fatigue arises from a number of personal and organisational factors, which can overlap. Organisational factors that contributed to staff fatigue included workload, long shifts, insufficient rest facilities and inadequate rest breaks during and between shifts. Personal factors that contributed to an increased risk of fatigue included caring responsibilities, menopause, pregnancy, religious practices and socioeconomic factors.
• Fatigue was found to have a negative impact on staff safety. A key risk related to this was staff driving home after a long shift and being involved in fatal car accidents or near misses.
• There are barriers to acknowledging the risk posed by staff fatigue. These include historical beliefs and norms around working long and additional hours, pride and ‘heroism’ of NHS staff.
• The demands on healthcare services, and workforce and financial constraints, limited the ability of some organisations to address fatigue risks.
• There is limited regulatory and national oversight of the risks posed to patient safety by staff fatigue in healthcare.
• There was limited consideration of the risk of staff fatigue in national initiatives addressing workforce challenges and care delays.
• The systems-based approach and supporting materials provided to trusts implementing the NHS England Patient Safety Incident Response Framework (PSIRF) helped to prompt consideration of staff fatigue in safety event learning, but this was not routine in all organisations.

Safety recommendations

• HSSIB recommends that NHS England/Department of Health and Social Care identifies and reviews any current processes that may capture staff fatigue related data. The output of the review should identify how information about factors impacting on staff fatigue can be collated and further enhanced to aid the understanding of fatigue risk in healthcare. This data will help inform the development of any future strategy and action to address staff fatigue risk and its impact on patient safety.
• HSSIB recommends that the NHS Staff Council, via the Health, Safety and Wellbeing subgroup, convenes fatigue science experts and other key stakeholders to develop and test a consensus statement defining fatigue for all healthcare staff. The group should work with existing networks to promote the definition and a shared understanding of the causes and impacts of fatigue. This will help to support a consistent understanding of fatigue among healthcare providers and improve the understanding of factors that may impact on staff fatigue and patient safety.

Safety observations

• Research funding and commissioning bodies can improve patient safety by prioritising future research to measure and assess the impact of staff fatigue on staff and patient safety. This should include patient experience and the health economics of staff fatigue due to reduced performance and productivity.
• Healthcare organisations and professional bodies can improve patient safety by including aspects of fatigue when conducting staff surveys in order to help build an understanding of the level of fatigue and any impact on staff performance and patient safety. This will help organisations assess and understand the risks associated with staff fatigue, and to monitor and manage the risk of staff fatigue.
• Healthcare regulators and professional bodies can improve patient safety by: considering how they can contribute to driving improvement in the understanding and awareness of staff fatigue; considering how they can support and share best practice on mitigations for the risk of staff fatigue; considering organisational and individual factors that may have contributed to staff fatigue when making decisions about regulatory assessment and action.
• Government and national organisations can improve patient safety by accounting for the impact of staff fatigue on patient safety when developing national priorities for NHS services.
• Healthcare organisations can improve patient safety by considering the principles and activities for a systems approach to fatigue risk management and the roadmap to implement this as described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’.

Related reading on the hub:

• Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan
• Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett
• CIEHF: Fatigue risk management for health and social care

HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.

Their latest report looks at primary and community care co-ordination for people with long-term conditions, specifically considering the role of ‘care coordinator’ in this context.[1] While language around the care coordination is varied, the role of care co-ordinated is defined by NHS England as follows:

“Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.”[2]

In this blog we set out our reflections on the findings and recommendations in this HSSIB investigation.

Challenges navigating the healthcare system

Navigating the healthcare system in the UK can be complex and frustrating for patients, families and carers. At Patient Safety Learning we hear time and time again about the lack of joined up care and communication within and across organisations. 

Failing to share the right information at the right time can create significant patient safety risks. Poor communications, both with patients and between healthcare professionals, can result in misunderstandings and mistakes resulting in poor outcomes and potentially patient harm.

In a recent series of blogs published on the hub, patients and their relatives shared with us the challenges and barriers they have faced when trying to navigate the healthcare system.[3] The concerns and issues raised in this HSSIB investigation echo many of the key themes we identified in our new blog series.

Confusing communications

HSSIB’s report refers to the case of a child prescribed anti-epileptic medication by a specialist hospital to reduce the number and severity of their seizures. It then details the difficulties the parents subsequently found in getting this medication through their GP or consultant. The parents highlighted concerns about the lack of communication between the separate services, with the report noting:

“The parents told the investigation that they were ‘exhausted’ because of the effort they had had to put in over the years to connect services together, having to tell the same story over and over again, while having to provide care for their child.”

Delays to treatment

The investigation report also highlights the case of a middle-aged professional working man who suffered a stroke. He received hospital care to treat and manage his healthcare needs; however, once discharged he encountered significant difficulties when seeking appropriate support for his additional healthcare needs. HSSIB highlighted how he had told them it required significant effort from him directly to ensure the right level of care was maintained for his needs. Recounting his experience, the report states:

“He said that these multiple agencies ‘all operate in their own silos’ and not as a team, and that ‘there was nobody to create that team [a cross-system team aware of all his health and care concerns]’. The way that he and his wife cope with this situation is that they ‘manage the team’ to connect the individual parts of the system and get the care he needs.”

Impact on mental health

HSSIB also spoke to a man in his late seventies who is the main carer for his wife. She has multiple long-term conditions that require primary, secondary and community care. Reflecting on the impact that coordinating her care had on their lives, the report noted:

“The husband explained that his role of care co-ordinator had placed a considerable burden on him, which led him to ‘feel overwhelmed’. He said that because he needing to act as her ‘co-ordinator’ he was unable to spend time with his wife as her husband. He also described having to administer medication and dress his wife’s wound which caused her considerable pain.”

HSSIB’s investigation also highlights broader areas of concern relating to the coordination of care in the healthcare system, again mirroring themes raised we heard from patients in our recent blog series.

Difficulties sharing information

The investigation highlights a recurring concern around problems sharing patient information and the negative impact of this on coordinating a patient’s care. It highlights both issues of digital systems in different organisations not being compatible with one another and other barriers, stating:

“Healthcare professionals described the challenges in information sharing. Digital patient records could not be viewed across primary, community, secondary and tertiary care because information technology systems are unable to ‘talk to each other’. They also said that sometimes they were unsure whether patient information could be shared as it was ‘protected information’. This was a particular problem when trying to share information between health and social care.”

A complex and confusing system

The report also reflects more broadly on how accessing and navigating health and care services can be difficult and complex, and potentially overwhelming for patients. This was highlighted by examples such as this from the investigation:

“A GP practice told the investigation that it had tried to put together an easy-to-read document explaining the care pathway for patients with dementia, including contact numbers and ways to access services. The GP practice went on to say that the system was so complex that it was unable to bring together all the information. It stated: ‘We are healthcare professionals and we can’t do this, so how can patients cope?’”

Safety recommendations

A theme that runs throughout HSSIB’s investigation is that there is a clear need and support for the role of care co-ordination. It highlights that while patients and carers can, and often do, themselves act in this role, when they are unwell or unable to do so a patient’s care can be significantly impacted. The report states that the availability of care co-ordination varies widely across the system. This is a particular issue for those living with multiple long-term conditions as there is no single centralised care co-ordination function to span across primary, secondary and tertiary care.

Concluding its investigation, HSSIB recommends that:

• NHS England/Department of Health and Social Care, working with other relevant organisations, reviews and evaluates the implementation of the care co-ordinator role. This is to ensure that all patients with long-term conditions have their care co-ordinated and that they have a single point of contact 24 hours a day, 7 days a week, to help them with any queries or concerns that they may have.
• The Department of Health and Social Care works with NHS England and other stakeholders to develop a strategy that ensures that all diseases are given parity and that all people with a long-term condition in primary, secondary, tertiary and community or social care have their care effectively co-ordinated across multiple agencies. This is to ensure that people with long-term health conditions have co-ordinated care plans with effective communication between services and a single point of contact for concerns or questions.

Patient Safety Learning agrees that there needs to be greater time and investment into care coordination.

On the first recommendation, we would note that seeking to ensure all patients with long-term conditions have a single point of contact 24 hours of day, 7 days a week, would be a significant shift from the status quo. This would require a clear commitment of both financial and workforce resources from NHS England and the Department of Health and Social Care to deliver. In considering how this might be approached, it would also be important to consider:

• How this can be flexible depending on the long-term condition in question. Different conditions will require different levels and types of coordination.
• Systemic barriers that result in many of the difficulties navigating the care system would not be addressed by implementing this recommendation. For example:
  – We would continue to have various digital systems in primary, secondary and tertiary care that lack interoperability (the ability of computer systems or software to exchange and make use of information).
  – Non-digital communication barriers that prevent cross-organisational sharing of information in the NHS, ranging from data sharing restrictions to cultural attitudes within organisations, would also remain.

On the second recommendation we agree with the principle of this, that there needs to be parity for people with a long-term condition and an expectation that their care is effectively co-ordinated across multiple agencies. Poorly coordinated care is not only confusing and frustrating for patients but also creates safety risks that can result in serious avoidable harm.

Concluding comments

The challenges of navigating the healthcare system discussed in this report are not a new issue, but a long-standing set of problems that do not have a simple solution. Their impact on patient experiences and outcomes is exacerbated in the current environment, when our healthcare system that is under increasing pressure and in a “critical condition”.[4]

Patient Safety Learning believes that care co-ordination should form an important area of focus for the UK Government’s forthcoming 10 Year Health Plan. If it is to achieve its strategic ‘shift’ of moving the future of the NHS from "hospital to community" this will require a healthcare system where patients aren’t simply left to "join the dots for patient safety".[5] This will require organisational and leadership commitment to take forward the issues raised in this HSSIB investigation. The needs of patients should be central to improving health and care services, actively listening and acting on their experiences and insights when things go wrong for safety improvement.

References

1. HSSIB. Workforce and patient safety: primary and community care co-ordination for people with long-term conditions, 10 April 2025.
2. NHS England. Care co-ordinators, Last accessed 10 April 2025.
3. Patient Safety Learning. The challenges of navigating the healthcare system, 24 February 2025.
4. UK Parliament. NHS: Independent Investigation, Hansard, Volume 753, 12 September 2024.
5. Department of Health and Social Care, Independent report: Review into the operational effectiveness of the Care Quality Commission, 15 October 2024.

Related reading

• Digital-only prescription requests: An elderly woman sent round the houses
• How the Patients Association helpline can help you navigate your care
• Lost in the system? NHS referrals
• Navigating the healthcare system as a university student: My personal experience
• The challenges of navigating the healthcare system: David's story
• The challenges of navigating the healthcare system: Sue's story

Share your story

What has been your experience of navigating the healthcare system? What is and isn’t working? How does it feel as a patient or carer when you hit barriers?  Has your health been affected?

Share your story in our community forum or contact our editorial team at content@pslhub.org.

• The NHS has produced a definition of the professional role of NHS care co-ordinator. However, there is variation in how this role is implemented.
• Other national organisations have different definitions of care co-ordination and care navigation, which can create ambiguity for people overseeing these roles.
• There is not a single person/role/organisation responsible for co-ordinating care for people with long-term or complex health and care needs across multiple health and care organisations.
• The health and care system frequently fails to support care co-ordination across multiple care pathways and instead focuses on individual diseases or issues. This can leave people who have complex long-term conditions with uncoordinated care.
• Accessing and navigating health and care services can be difficult and complex, and patients and carers would like improved service integration and care co-ordination.
• Patients and carers act as a central point for information and contact for providers, but when they are unwell or unable to do this, care can be impacted.
• People who are unable to navigate the health and care system can experience deterioration of health, miss appointments or their care may become delayed or forgotten about, meaning they may need more intense treatment in the future or longer stays in hospital.
• Patients and carers have to retell their health history to different health and care providers. They believe the system is not joined up and that information does not flow across health and care organisations, or that different parts of the system cannot access information from other providers.
• When patients are discharged from a health or care setting out of normal working hours they do not always know who they can speak to about any concerns or their ongoing care.
• Different methods of sharing health and care information can create an information gap, particularly out of hours and at the weekend, resulting in a situation where not all health and care staff have the appropriate information to make decisions.
• Patients and carers can feel exhausted, burnt out, frustrated, angry and guilty, among other emotions. Patients and carers physical and mental health may deteriorate because of the extra burden of navigating the health and care system.
• Patients and carers may disengage with the health and care system because they are exhausted and frustrated. This may lead to poor outcomes for both patients and carers.
• There are different ways of supporting care co-ordination across the system, some of which are assisted by the charity sector.

Safety recommendations

• HSSIB recommends that NHS England/Department of Health and Social Care, working with other relevant organisations, reviews and evaluates the implementation of the care co-ordinator role. This is to ensure that all patients with long-term conditions have their care co-ordinated and that they have a single point of contact 24 hours a day, 7 days a week, to help them with any queries or concerns that they may have.
• HSSIB recommends that the Department of Health and Social Care works with NHS England and other stakeholders, to develop a strategy that ensures that all diseases are given parity and that all people with a long-term condition in primary, secondary, tertiary and community or social care have their care effectively co-ordinated across multiple agencies. This is to ensure that people with long-term health conditions have co-ordinated care plans with effective communication between services and a single point of contact for concerns or questions.

Safety observation

• Health and care organisations can improve patient safety by allocating a point of contact for patients and/or their carers when people are discharged from services out of normal working hours. This will ensure patients and their carers are able to escalate any concerns relating to their ongoing care and drive improvements in care co-ordination.

Related reading on the hub:

Read Patient's Safety Learning's response to the findings and recommendations of this HSSIB report

HSSIB recommends that the Health and Care Professions Council and the College of Paramedics work in collaboration with relevant stakeholders to improve the undergraduate teaching of 12-lead electrocardiograms by reviewing and updating any relevant standards, guidance, and curricula to provide clarification on:

• the level of education and expected level of competency and assessment required of student paramedics in relation to electrocardiograms
• any minimum expected standards for electrocardiogram education in higher education institutions, including the time spent on electrocardiogram learning, methods used, and subject matter expertise required of teaching staff
• how patient protected characteristics, health inequalities and other specific patient factors are taught in relation to electrocardiograms
• how effective feedback mechanisms can be developed between higher education institutions and ambulance services.

This is to help improve consistency in the way paramedic students are educated about electrocardiograms.

HSSIB makes the following safety observations

• Ambulance services can improve patient safety by including patient protected characteristics, health inequalities and other specific patient factors that can impact on the task of carrying out and interpreting a 12-lead ECG, when developing refresher training.
• Ambulance services and national organisations can improve patient safety by providing and supporting protected time and resources for paramedic training and continuous professional development, while understanding the potential impact on operational performance.
• Ambulance services can improve patient safety by providing additional support to paramedic students and paramedics through exposure to a range of clinical scenarios that help develop and maintain 12-lead ECG competency on a regular basis.
• Acute hospitals and ambulance services can improve patient safety by developing local mechanisms to share information about patient outcomes where paramedics have undertaken a 12-lead ECG. This can help to support learning for paramedics and provide feedback on where their practice may be improved.

The patient was taken to hospital with shortness of breath and nose bleeds. He was transferred from the emergency department to a medical ward while waiting for a procedure. The medical team paused the patient’s regular apixaban, initially because of his nose bleeds. The apixaban continued to be paused while the patient was waiting for his procedure. However, delays to the procedure taking place meant that apixaban was not given for a total of 10 days. After the procedure, the apixaban was not restarted as intended. Two days after the procedure the patient had a stroke and later died.

Medical staff needed to make informed prescribing decisions, balancing the patient’s risk of developing a blood clot, his everyday risk of bleeding, with the risk of bleeding from the required medical procedure. The investigation explored the range of complex, dynamic and interacting clinical and wider hospital factors that led to the difficulties in managing the patient’s anticoagulation.

Findings

• The patient’s apixaban was appropriately paused in the emergency department.
• Past clinical information about the patient that would have supported anticoagulant risk assessments was not easily available to staff.
• Variations in the hospital care processes supported some working practices, but created uncertainty about when the patient’s procedure could happen. This made dynamic clinical decision making challenging.
• A lack of specialist nursing and/or administrative support limited the ability for respiratory referrals to be followed up by the respiratory team in a timely way.
• There was no reassessment of the ongoing decision to pause the patient’s apixaban when the procedure did not happen as expected.
• It was clear to staff that the patient’s apixaban was paused on the ePMA system, but the system did not prompt staff to re-review the paused apixaban.
• An assessment of the risks and benefits of pausing the patient’s apixaban was not documented which prevented a shared understanding of the decision for other staff involved in the patient’s care.
• Workforce challenges created conditions on the acute general medical ward that limited the resources available to follow up on the patient's medication status and delayed discussions around the patient’s transfer to the respiratory ward.
• A mismatch between demand and capacity within the respiratory service prevented the patient being transferred to the respiratory ward or receiving regular specialty respiratory input while he was being cared for on the acute general medical ward.
• Some local clinical guidance available to staff on the management of patients’ anticoagulant medication was overdue for a review and did not reflect updated national guidance.
• Local clinical guidance was sometimes hard to access using the Trust’s computer systems and some staff were unaware of relevant guidance that was in place.
• There were no cues in the post-procedure documentation to prompt staff to consider restarting the patient’s anticoagulation medication.
• Phased implementation of the Trust’s EPR system meant that sometimes staff were duplicating entries across paper and electronic record systems.

Local level learning prompts for acute hospitals

HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. The following prompts are provided by HSSIB to help acute hospitals to improve the safety of patients who are taking anticoagulation medication who need to have a procedure. These prompts may also be useful in other settings.

Anticoagulant prescribing

• How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed?
• How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication?
• Does your organisation have systems and processes in place that support regular risk assessment of anticoagulants that have been paused?
• Does your organisation have a process for ensuring that guidelines that cross-refer to other relevant guidelines are reviewed together to ensure they provide consistent advice?
• How do you ensure that all members of the multidisciplinary team with relevant expertise are included in clinical guideline reviews?
• Does your organisation have processes in place to ensure that when new evidence on newer anticoagulants becomes available it is considered for inclusion in local guidance as soon as possible?
• How does your organisation support staff to find and readily access anticoagulation related guidelines?

Care processes supporting inpatients on anticoagulants

• Do your organisation’s bed management meetings include a review of patients who have been waiting more than 24 hours for transfer to a specialty ward?
• Does your organisation have effective processes in place to ensure inpatients accepted by a speciality, but awaiting a specialty bed, receive a specialty review on a regular basis?
• Does your organisation have a process in place for the prioritisation of inpatient transfer to specialty services?
• Does your organisation have a process in place for the prioritisation of inpatients who need investigations (including imaging) and procedures?
• Do your organisation’s post procedure processes include a prompt to review anticoagulation?

EPR/ePMA systems supporting anticoagulation

• Does your organisation ensure it is easy for staff to access information in patients’ records relevant to decision making about anticoagulant medication?
• Does your ePMA system identify patients with paused time-critical medication that may warrant a review?
• How does your organisation consider factors relating to equipment which may affect the successful implementation of EPR/ePMA systems?

The investigation engaged with patient safety and quality teams within Integrated Care Boards (ICBs) to understand how patient safety risks were managed at this level of the health and care system. The investigation also engaged with NHS England regional and national teams to understand the risks that were escalated to them and how they were managed.

Findings

• There are no overarching principles that all healthcare providers and ICBs can use which enable a consistent and collaborative approach to the management of patient safety.
• There is a difference in the perception of how patient safety is managed between ICBs and national health and care stakeholders, including the lines of safety accountability.
• National organisations’ expectations of how ICBs manage patient safety are not in line with what ICBs can currently achieve due to challenges with resourcing and the usability of safety data.
• Patient safety risks may be escalated from the regional to the national level but there is variability in how these risks are managed at a national level and how responses to escalations are fed back.
• Cross-organisational safety risks are not always being escalated to ICBs and there may be limited resources and capability to identify, define and investigate such risks.
• Learn from Patient Safety Events (LFPSE) is the national learning service for the NHS; however, challenges in the usability of LFPSE data means that system level risks may not be visible to ICBs and the wider health and care system.
• Existing informal ‘good relationships’ between individual providers and an ICB facilitate the effective sharing and management of risks. Where these ‘good relationships’ do not exist or change, formal governance processes do not always ensure information sharing continues.
• Patients and carers are an important source of feedback to ICBs about patient safety risks across organisational boundaries. However, this can create inequities as some people are more able than others to make their voice heard.

Recommendations, observations and suggestions

HSSIB makes the following safety recommendation:

• Safety recommendation R/2025/057: HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety.

HSSIB makes the following safety observations:

• Safety observation O/2025/061: Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management.
• Safety observation O/2025/062: Health and care organisations can improve patient safety by having clear lines of safety accountability and assurance of risk management processes. Currently patient safety risks are not managed in line with established UK government risk management principles.

HSSIB makes the following safety suggestions:

• Safety learning for Integrated Care Boards ICB/2025/011: HSSIB suggests that integrated care boards seek assurance of how health and care providers will work together when commissioning services, so that patient safety can be managed across health and care providers. This is to help support the visibility and management of patient safety risks across an integrated care system.
• Safety learning for Integrated Care Boards ICB/2025/012: HSSIB suggests that integrated care boards develop their patient safety capability and expertise to ensure they can effectively analyse safety data and intelligence about patient safety risks. This would help to identify and understand patient safety risks that exist across multiple providers in order to proactively investigate and manage these risks.

The investigation highlighted system-level issues in service commissioning, patient flow, integrated working and accountability, compounded by a lack of system-level learning and application. The investigation found there is a culture of blame in which individuals and organisations are afraid about safety investigation processes. The report emphasises the need for a systemic approach to safety investigations and learning with a focus on collaboration, transparency and oversight, with a shift from procedural practices to a culture rooted in empathy, person-centred care and active involvement of families.

Findings

Understanding how providers ensure timely and effective investigations

• Investigations into patient safety incidents in mental health do not always take a system-wide perspective, limiting the ability to capture the full complexity of care.
• The current national framework for incident response faces implementation barriers in mental health settings, due to the differences in care requirements compared to acute physical health settings.
• Training for the implementation of the Patient Safety Incident Response Framework includes developing knowledge of systems thinking and system-based approaches to learning from patient safety incidents. However, some organisations described their training focused on acute physical health contexts and does not sufficiently account for the mental health care context.
• There is no national system to track and ensure the implementation of investigation recommendations, resulting in limited strategic oversight of patient safety investigations and a lack of structured learning for improvement.
• Many families feel marginalised and excluded from the investigation process, experiencing investigation processes as a ‘tick box’ exercise and without a culture of transparency, learning, and accountability.
• Processes for learning from deaths are feared by families, staff and organisations because of a reported focus on blame which does not align with the stated goals of an effective safety culture that is orientated around learning to support systemic change.
• Families often feel excluded from care processes, with their concerns about safety planning and risk mitigation often overlooked, which complicates their ability to help keep their family member safe.
• Legal processes within organisations may unintentionally shut down opportunities for learning, fostering a culture of defensiveness rather than reflection.
• Staff lack the time, permission and safe spaces to support open, reflective conversations about patient safety incidents, which are essential for learning and improvement.
• Patient safety incident investigations, and other associated investigation processes if a death occurs, often do not consider the emotional distress experienced by all affected. This results in compounded harm.

The investigation also became aware of areas of mental health inpatient care where investigations had not effectively addressed ongoing concerns about inpatient mental health care:

• Gaps were identified in discharge planning, crisis service accessibility and community therapy provision, and staff skilled in mental health, resulting in people being left in unsafe situations where they may self-harm.
• There is significant variability in therapeutic engagement and a lack of personalised care which has left some patients feeling hopeless and disconnected.
• The term ‘therapeutic engagement’ may be interpreted differently across mental health services. This has resulted in some approaches becoming clinically focused rather than person focused.
• Providers told the investigation that incidents of people using items of clothing to ligature resulting in catastrophic self-harm was increasing. However, the investigation did not identify specific guidance on how to reduce and respond to non-anchored ligature risks, or on managing access to known ligature risk items.
• Staff face ongoing challenges in balancing ‘least restrictive approach’ policies and the therapeutic benefit of decisions about care, with the need to ensure patient safety, often creating tension in care delivery.

Examining national, regional, and local oversight and accountability frameworks for deaths in mental health inpatient services

• Many previous national recommendations to improve the care of patients with mental health needs have not been taken forward to date, leaving no clear plan for implementing the recommendations.
• Some integrated care boards do not have full oversight of patient safety risks across all the services they oversee. Instead of having a clear, formal structure for accountability in patient safety investigations, they often rely on informal relationships or collaborations between providers.
• This lack of complete oversight can make it difficult to ensure that patient safety investigations are thorough and standardised across different organisations, leading to potential inconsistencies in addressing safety issues.
• Some integrated care boards and regional teams struggle with gathering and analysing data on patient safety due to resource and reporting limitations. This means they do not always have a complete picture of the risks at a system-wide level.
• Data gaps limit the ability of integrated care boards to identify co-morbidities (when patients have multiple health conditions) and understand health inequalities, especially among people with serious mental illness. This creates challenges for integrated care boards to address broader health trends and inequities within their regions effectively.
• The involvement of patient safety partners and people with lived experience in safety meetings is variable, limiting their ability to contribute.
• Some non-executive directors with responsibility for safety and quality struggle to scrutinise and interpret complex data sets on patient safety and deaths due to the volume and lack of triangulation of information presented. This limits meaningful oversight and learning.

Examining the mechanisms that capture data on deaths (and near misses) across the mental health provider landscape, including up to 30 days after discharge

• There is inconsistency in data reporting. Mental health providers report deaths and near misses in varied ways, using different definitions and methods. This inconsistency makes it difficult to compare data across providers and understand overall trends in patient safety.
• There is not a standardised national system requiring providers to report deaths in the same way. This means that each provider’s reports may look different, which reduces the reliability of data for understanding patient safety across the board.
• There is not a single, comprehensive database that includes all deaths and near misses within mental health services, including those occurring within 30 days after a patient’s discharge. This makes it hard to see the full picture of patient safety outcomes and identify patterns or risks.
• There is not a centralised organisation or process effectively overseeing and co-ordinating data on deaths. This lack of oversight limits the ability to identify systemic issues, reduce duplicated efforts, and drive consistent improvements across mental health services.
• There is currently limited co-ordinated effort among organisations that produce data relating to deaths, and individual providers may be collecting and analysing similar data on their own. This leads to duplicated work, wasting time and resources that could be better used if there was improved collaboration. It also results in considerable variation in the data being presented.

Recommendations and observations

HSSIB makes the following safety recommendations:

• Safety recommendation R/2025/052: HSSIB recommends that the Department of Health and Social Care works with NHS England and other relevant stakeholders, to clarify national expectations for meaningful and restorative learning from patient safety events and deaths in mental health services. This is to ensure effective learning is supported through processes that provide high-quality and transparent investigations within a culture of compassion.
• Safety recommendation R/2025/053: HSSIB recommends that NHS England works with other stakeholders to define the term ‘therapeutic relationship’. This is to support building trust and compassionate relationships between staff and patients from admission to inpatient settings through to discharge, to improve patient outcomes.
• Safety recommendation R/2025/054: HSSIB recommends that NHS England, working with other relevant national bodies, develops guidance on how to reduce and respond to non-anchored ligature risks. This will help staff to support people who attempt to hurt themselves with non-anchored ligatures and improve patient safety whilst maintaining a therapeutic environment.
• Safety recommendation R/2025/055: HSSIB recommends that the Department of Health and Social Care creates a national oversight mechanism that supports co-ordination, prioritisation and oversight of safety recommendations to implementation across the system. This is to ensure that recommendations from public inquiries, independent patient safety investigations and other patient safety investigation reports, as well as prevention of future death reports from inquests, are analysed and monitored and reviewed until their implementation using a continuous quality improvement approach to learning.
• Safety recommendation R/2025/056: HSSIB recommends that the Department of Health and Social Care working with NHS England, and other relevant stakeholders, develop a comprehensive, unified data set with agreed definitions for recording and reporting deaths in mental health services to include deaths that occur within a specific time period after discharge. This will support any revisions required to the current NHS England Learning from Deaths Framework. The creation of a comprehensive, unified data set would enhance system-wide visibility, co-ordination and collaboration, reduce duplication of effort, and maximise the impact of improvement work through strategic oversight.

HSSIB makes the following safety observations:

• Safety observation O/2025/057: Integrated care boards and organisations that provide mental health care can improve patient safety by working together to support the facilitation of cross-organisational investigations and learning. This should be achieved in a way that enables people involved in an investigation to come together to share perspectives and build relationships to enable learning. This may provide opportunities for effective and meaningful organisational learning and facilitate reparation and trust-building for everyone involved.
• Safety observation O/2025/058: Organisations that provide mental health care can improve patient safety by adopting a comprehensive person-centred care approach that prioritises the individual needs, preferences and rights of each patient. This approach should ensure consistent access to meaningful therapeutic activities, actively involve families in care planning and decision making, and create supportive environments tailored to the sensory and emotional needs of neurodivergent individuals.
• Safety observation O/2025/059: NHS boards can improve patient safety by supporting their non-executive directors (NEDs) with responsibility for quality and safety to attend NED-specific training on quality of care and patient safety. This may include modules on compassionate leadership, the importance of psychological safety, safety science in investigations and techniques for supportive challenge. By fostering these skills, NEDs can better understand the complexities of healthcare delivery, engage meaningfully with staff, and ensure that patient safety and quality care remain at the forefront of their governance role.
• Safety observation O/2025/060: Integrated care boards and organisations that provide mental health care can improve safety by involving people with lived experience and family carers in coaching for executive leaders. This could include creating learning networks within provider collaboratives. By embedding these roles, executive teams and non-executive directors would receive direct insights from those with personal experience of mental health services, helping them to co-produce learning from deaths and drive improvements in care.

Related HSSIB reports

• Learning from inpatient mental health deaths and near misses: assessment of suicide risk and safety planning (September 2024)
• Mental health inpatient settings: creating conditions for the delivery of safe and therapeutic care to adults (October 2024)
• Harm caused by mental health out of area placements (November 2024)
• Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (December 2024)

Table setting out criteria for HSSIB investigations (Click on table to enlarge it)

Key principles for investigation

1. HSSIB do not attribute blame or liability in our investigations.
2. HSSIB underpin investigations with the most appropriate and robust safety science methodologies.
3. HSSIB investigations take a system perspective and aim to reduce the likelihood of incidents happening.
4. HSSIB involve patients, families, and healthcare staff in our investigations.
5. HSSIB consider how to improve care for those subjected to health inequalities in all our investigations.
6. HSSIB will have a multidisciplinary team approach to investigations using skilled investigators.
7. HSSIB involve appropriate subject matter advisors in our investigations.
8. HSSIB recommendations will be impactful, and will work with the system to ensure there is maximum effect.
9. HSSIB will be open and transparent about how they work whilst protecting the disclosure of specific evidence that they gather during the investigations.
10. HSSIB will undertake investigations in a timely manner, and in the most cost-effective way.

Strategic theme one: Deliver high-quality, impactful independent safety investigations.

To achieve this, HSSIB will:

• Be experts in healthcare safety investigations and ensure our safety recommendations make a positive impact across healthcare.
• Partner with experts and safety leaders to ensure our safety recommendations address risks effectively.
• Develop new and innovative ways of investigating to address urgent and emerging risks, with capability for rapid action.
• Strive to address and reduce health inequalities through our investigations.

Strategic theme two: Place people at the core of our work.

To achieve this HSSIB will:

• Ensure the voice and experience of all people affected by a patient safety incident are embedded in all we do.
• Support healthcare systems to create a safe, inclusive and secure environment which listens to and acts on peoples concerns.
• Recognise that the wellbeing and safety of the entire healthcare workforce is critical to safe care.
• Champion an inclusive just learning culture with a supportive and safe approach for all those involved in the investigation process.

Strategic theme three: Be a strong, inclusive voice for patient safety across healthcare.

To achieve this HSSIB will:

• Optimise our influence to shape perspectives on safety, ensuring that our safety recommendations make a tangible impact through effective implementation.
• Use the latest developments in safety science to inform our investigation methods.
• Work closely with partners, patients and the public to share insights that advocate for improvements in patient safety.
• Apply and develop pioneering investigation models.

Strategic theme four: Promote and professionalise healthcare investigations.

To achieve this HSSIB will:

• Establish principles for system safety investigations that drive actionable outcomes and measures.
• Develop and deliver a collaborative healthcare safety investigation education programme.
• Define key attributes and competencies for professional healthcare safety investigators.
• Advancing healthcare safety investigation as an evidence-based discipline and profession on a global scale.

Strategic theme five: Embed a compassionate, inclusive culture across our organisation.

To achieve this HSSIB will:

• Ensure effective leadership through strong governance and policies across all teams, promoting and reinforcing our strategic aims.
• Be sustainable, environmentally and operationally.
• Support team wellbeing through listening and reflection and opportunities for development and peer support.
• Create a workplace culture which is inclusive, respectful, and collaborative for all.

• Young people may be discharged from inpatient children and young people’s mental health services because they have reached ‘transition age’ and not because their mental health care needs have changed.
• Adult mental health services criteria for ongoing care as an ‘adult’ inpatient may mean young people are discharged from inpatient children and young people’s mental health services to an alternative setting which is not suitable to meet their ongoing needs, for example bed and breakfast hostels, with community services providing more limited mental health care and support.
• Young people, families and carers are not reliably informed of, or prepared for, the differences in care approach between inpatient children and young people’s mental health services and inpatient adult mental health services.
• Health, social care, local authorities and education do not always work together in a consistent and integrated way to support positive outcomes for young people who are transitioning from inpatient children and young people’s mental health services to adult mental health services.
• There is currently no alignment, equity of access, or clear responsibility and accountability for children and young people’s health, education and social support that spans their transition from childhood to adulthood.
• In many children and young people’s mental health services, ‘blanket’ safeguarding measures are implemented overnight for people reaching 18. These measures are not based on a change in individual behaviours or risks. Perceived safeguarding challenges are a driver for rigid aged-based transitions.
• Young people, their families, and carers described that communication and information sharing changed when the young person reached 18. This meant safety risks were not always discussed and families and carers were not involved in safety planning or risk mitigation.
• NHS England service specifications and commissioning guidance for inpatient children and young people’s mental health services do not support needs-based flexible transitions. More flexible, developmentally appropriate needs-led transitions were seen to have more positive patient outcomes.
• Definitions of ‘children’, ‘young people’ and ‘adults’ vary across legal and professional guidance. This contributes to challenges in defining these groups across services.
• In comparison with young people in mainstream education, the education needs of young people transitioning from inpatient children and young people’s mental health services due to reaching 18 are not always being met.
• A robust training needs analysis and competency assessment of the inpatient mental health workforce is required if changes to the specifications and delivery of inpatient mental health services are made.

Report recommendations

• HSSIB recommends that NHS England reviews and updates its inpatient children and young people’s mental health services specifications and commissioning guidance to ensure they support developmentally appropriate, needs-based transitions. Any changes to service delivery will require a review of funding lines to enable successful implementation.
• HSSIB recommends that NHS England reviews and revises its guidance and policies to ensure consistency regarding the language used for age ranges (for example children, young people, young adults and adults). This is to support a consistent approach to healthcare delivery that aligns services and mitigates gaps.
• HSSIB recommends that the Care Quality Commission work with the Department of Health and Social Care to understand prioritisation for assessing transitions in mental health care within Integrated Care System assessments. Any subsequent work should include the development of a methodology to identify the challenges described in the investigation report relating to transition from inpatient children and young people’s mental health services, to adult mental health services. This is to improve the safety, quality and consistency of transitions across England.
• HSSIB recommends that the Department of Health and Social Care works across government to identify opportunities to support closer cooperation between local government, education and health systems for the safe and effective transition of young people into adulthood. This is to ensure alignment, equity of access, and clear responsibility and accountability for their health, education and social support that spans the ages of 16 to 25. Cross governmental work would be supported by the adoption of consistent language for age ranges of children, young people, and adults.
• HSSIB recommends that NHS England provides guidance regarding communication of essential safety and risk mitigation information when patients transition from inpatient children and young people’s mental health services due to reaching transition age. This is to safeguard vulnerable people and may include how to share information with families and carers, health and social care providers, and third sector organisations.

The patient had attended hospital for an outpatient appointment where he mentioned he had back pain following a fall at home the previous day. He was advised to attend the ED and went there immediately after his outpatient appointment.

The patient spent 3 days in the ED. During this time he should have received a total of 18 doses of his Parkinson’s medication, which was a time critical medication. However, seven doses were not given and three doses were given late. This meant that only 8 of 18 doses of Parkinson’s medication were provided to the patient on time.

The patient was transferred to a medical ward where his Parkinson’s symptoms deteriorated and he lost the ability to swallow. The patient died 4 weeks after his admission to the ward. The causes of death identified on his death certificate included bronchopneumonia (severe chest infection), Parkinson’s, and frailty of old age.

Findings

• The patient required time critical medication for Parkinson’s but did not receive, or received late, 10 of 18 doses during his time in the ED. The coroner reported Parkinson’s as a factor leading to the patient’s death.
• There were no defined roles or responsibilities in the ED to ensure patients who required time critical medications were identified, and medications prescribed, as soon as possible.
• The ED had no dedicated pharmacy support to help staff in providing care to patients who required time critical medications.
• The patient spent 52 hours in the ED; for 44 of these he was cared for in a corridor because of demand on ED services. Corridor care created additional challenges for ED staff and specialty teams and may have limited opportunities to store the patient’s medication which he had brought from home.
• The Trust did not participate in the Royal College of Emergency Medicine Quality Improvement Programme on time critical medication.
• The ePMA system did not include a function to alert staff about patients who required time critical medications to be prescribed or administered.
• An outage in the ePMA system meant the patient required both an electronic and paper prescription chart. This may have caused additional confusion about the patient’s medication.
• Staff had adapted their practice to ensure they could effectively use the ePMA in the ED setting. This was because of challenges in accessing computers and medication rooms in the ED environment.
• The patient self-administered some doses of his Parkinson’s medication, but this was not planned and self-administration by patients was not widely supported by clinical staff or local guidance.
• Staff were not able to check neurology clinic letters because there was a backlog in these letters being uploaded to the electronic patient record system.
• Staff were not able to check information with the patient’s GP practice or Parkinson’s specialty team at the time the patient’s medication was prescribed in the ED, as this was outside of these services’ working hours.
• Staff received contradictory information from the patient’s son and the GP summary care record about the dosage of medication the patient required. The GP summary care record was taken as the most accurate record, but the information it contained was incorrect.
• Once the patient’s medication information was entered onto the ePMA system, no further attempt was made to contact the GP practice or Parkinson’s specialty team to confirm it was correct.
• Some information about the patient’s medication within the GP patient record was transferred to the GP summary care record, but other information was not.

Safety observation

• NHS trusts can improve patient safety by using the information contained in the information pack for the Royal College of Emergency Medicine’s Quality Improvement Programme on time critical medications to assess their preparedness and make local improvements in identifying, prescribing, and administering time critical medications in emergency departments.

Local-level learning prompts for acute hospitals

Delays in identifying and prescribing time critical medication in the ED

• How does your organisation ensure that patients who need time critical medications are identified as soon as possible on arrival to the ED?
• Who in your patient pathway is responsible for identifying patients who need time critical medications?
• Who in your patient pathway is responsible for prescribing time critical medications?
• How does your organisation ensure that once a patient’s need for time critical medications is identified, they are prescribed?
• What aids or tools are available in your organisation to help staff to identify patients who need time critical medications?
• What pharmacy support is available to staff in ED to support in the care of patients who need time critical medications?

Missed and delayed doses of time critical medication in the ED

• How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications?
• How does your organisation support patients to self-administer time critical medications, when appropriate?
• How does your organisation capture information when patients self-administer time critical medications?
• How does your organisation receive and consider information from families and carers to help avoid missed or delayed doses of time critical medications?

ePMA systems and time critical medication in the ED

• How does your ePMA system help to alert staff to patients who need time critical medications?
• How does your organisation train staff to use local ePMA systems and record when patients require time critical medications?
• How does your organisation prepare and support staff to work safely when ePMA systems may not be functioning to ensure time critical medications are not missed?
• How does your organisation audit delays or omissions in time critical medications and use this to improve delivery of time critical medication?
• Is your organisation aware of any adaptations that staff are required to make to ensure they can use the ePMA system effectively in local environments?

Further reading on the hub:

• Professionals with Parkinson’s tackle time critical patient safety issue: a blog by Sam Freeman Carney
• Parkinson's UK: Time critical medication guides for health professionals
• Medication delays: A huge risk for inpatients with Parkinson’s

Findings of this report include:

• ‘Did not attend’ (DNA) rates for outpatient appointments for patients in prison during 2024 were high, at 52% and 57% for males and females respectively. This compares to a DNA rate in the general population of 26% for both sexes.
• Female prison patients are often taken to outpatient appointments by male prison officers or a mix of male and female officers. This can affect the patients’ decision making about whether to go or not, particularly for appointments that are for sensitive female clinics such as obstetrics and gynaecology.
• The use of telemedicine in prison healthcare has declined since the end of the COVID-19 pandemic and it is used rarely in comparison to face-to-face appointments. Telemedicine has the potential to reduce the burden of prison officer escort duties for outpatient appointments (which costs £48m to £50m per year), increase the number of outpatient appointments available per day to patients in prison, and reduce the number of appointments that patients refuse to go to.
• Patients in prison may not attend pre-arranged appointments because of a lack of information about the appointment caused by privacy and security issues. For example, they may not be informed about timings, the nature of the appointment, or the health reasons and importance of attending. This means they are not able to make an informed decision about their health and whether they want to attend or not.
• Patients in prison are more likely to miss outpatient appointments than patients in the community, due to the prison regime and logistics beyond the control of the patient.
• Prison healthcare departments rely on relationships they have developed and maintained with hospital booking teams in order to arrange appointments that fit in with the prison regime. This is due to a lack of formal arrangements between prisons and their local hospitals.
• Patients who are released following a court appearance, who had treatment planned, are not routinely given information about upcoming appointments they may have. This means they may unknowingly miss booked appointments, delaying their care and treatment.
• Details about patients who are being transferred to different areas are not always communicated effectively between prison healthcare teams and hospital booking teams. Often hospital booking teams are not made aware that a patient has been transferred until an appointment is missed, which means treatment is delayed.

In this report HSSIB recommends that:

• HM Prison and Probation Service updates Prison Service Order 3050, ‘Continuity of healthcare for prisoners’, including guidance on communication of information about prison patients when transferring between prisons, and on the process when prison patients are released from court. This will reduce variation and ensure better continuity of care for patients when being transferred or on their release.
• HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood of patients refusing to attend healthcare appointments, while balancing appointment availability, thus improving the continuity and equality of care.
• NHS England, via regional commissioning teams, works with HM Prison and Probation Service to identify barriers to using telemedicine for outpatient appointments, and then implements local solutions to promote and enhance the capability and usability of telemedicine. This aims to reduce the burden on prisons of providing escorts and the likelihood of patients not attending appointments.

Relating to patient, family and carer experiences

• The investigation found that harm (including dying by suicide, physical, psychological, distress and anxiety) was happening to patients, families and carers because of OAPs and the impact of being far away from their normal support network. There was also significant anger, frustration and loss of trust in the mental health system as a result of their experiences.
• Patients, families and carers rarely want an OAP and their choice and opinions are not always taken into consideration when decisions about sending someone to an OAP are made.
• The investigation found that OAPs can increase patients’ length of stay in hospital and therefore contribute to harm to patients.
• Patient, family and carers’ wishes and preferences, as required in the Mental Health Act 1983: Code of Practice, are not documented by health and care staff or routinely monitored during Care Quality Commission inspections. This leaves patient, families and carers feeling they are not listened to and increases anxiety, frustration and anger, leading to harm for people and creating distrust in the system.
• Advocacy services are vital for a patient to be able to put forward their views for consideration in decision making about their care, but advocacy is not always offered to patients.

Relating to conditions in the health and care

• There is a national drive to reduce OAPs, but there continues to be an increasing trend in their use.
• OAPs may be the only option for patients if they are acutely unwell and need admission to inpatient services and there are no beds available in their local NHS mental health hospital. If OAPs are not utilised in this situation, people will remain unwell in the community and potentially present a high risk of harm to themselves or others.
• The rules, governance and legal framework within which health and social care organisations work differ. This can create friction in the system, preventing integration and pooling of funds across organisations, slowing down discharge and patient flow, and is a significant factor in the use of OAPs.
• It is impossible to look at the mental health inpatient system in isolation; consideration must be given to other health and care services such as community mental health services, social care and social housing provision by local authorities.
• When patients are sent to OAPs, the sending hospitals do not maintain responsibility for the welfare or clinical oversight of those patients.
• Limited patient flow through mental health and other services reduces trusts’ ability to discharge patients from hospital, which can increase the use of OAPs.
• NHS mental health trusts do not always have local authority social workers embedded in their organisations, as used to be the case under previous working arrangements. Embedding social workers within trusts was viewed by social workers and healthcare staff as a benefit to patients and improved patient flow and discharge planning.
• Some NHS trusts are undertaking some of the functions of local authorities relating to social housing, in order to enable patients to be discharged and reduce the need for OAPs.
• Beds and patients are managed in an impersonal way without seeing patients as having individual requirements. They are both treated as “commodities” when deciding on the need for an OAP because of the pressure on services and need for acute mental health beds.
• Crisis resolution and home treatment teams can have a significant influence in the early discharge of patients, that then creates a bed for the most mentally unwell patients in the community.
• Hospitals that send patients out of area sometimes rely on Care Quality Commission rating to base OAP decisions on, but many of these ratings are out of date and may not reflect the current situation.
• Many acute mental health patients have neurodevelopmental conditions and would benefit from early testing when they are in contact with community and acute mental health settings. Early assessment makes sure people are placed on the right pathway and may reduce admissions to acute mental health settings and the need for OAP.

HSSIB makes the following safety recommendations

• HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are considered in decisions relating to where the patient identifies they would like to be close to, for example the patient’s home or a family member, specifically when an out of area placement is needed.
• HSSIB recommends that the Department of Health and Social Care works across government to review the statutory instruments, business processes and regulations that govern mental health services, social care and housing services impacting on mental health out of area placements and creates a proposal for the future accountability and integration of health and social care. This is to ensure that they are operating to consistent statutory, financial and regulatory frameworks. By addressing system integration and nd local authorities will define accountability and reduce or prevent out of area placements.

HSSIB makes the following safety observations

• NHS organisations can improve patient safety by maintaining clinical and welfare oversight and responsibility for patients being treated in an out of area placement. This can ensure harm is minimised and that patients are returned to their sending hospital as soon as possible.
• Mental health inpatient services can improve patient safety by offering advocacy to all mental health inpatients at the point of admission, and ensuring that the patient’s decision about whether or not to have an advocate is continually reviewed as their treatment continues and needs may change. This can ensure that patients’ needs and views are taken into account by health and social care staff when decisions about their care are being made, particularly when in an out of area placement.
• Crisis resolution and home treatment teams can improve patient safety by joining quality networks for crisis resolution and home treatment teams and could consider using continuous clinical reviews of mental health acute inpatients. This can ensure that appropriate patients are discharged early and could maximise acute care bed availability for patients in the community who are at high risk because of their mental health problem, and reduce the need for out of area placements.
• Health and social care organisations can improve patient safety by working together and embedding mental health social workers from the local authority in mental health acute hospitals. This can ensure that patients’ holistic health and social care needs are considered throughout their acute mental health admission and on into the community, and improve efficiency of working, patient flow and discharge and reduce the use of out of area placements.
• Mental health services can improve patient safety by reviewing their community mental health services to see if they meet the needs of their population with the aim of keeping as many people as possible out of inpatient services and thus preventing the use of out of area placements.
• Healthcare services can improve patient safety by conducting assessments for neurodevelopmental conditions such as autism and attention deficit hyperactivity disorder, where it is safe and clinically indicated, at the earliest opportunity when a person is in contact with community and acute mental health services. This can ensure that patients are put on the appropriate pathway early. This can prevent harm that may be caused by receiving inappropriate treatment and reduce admissions to mental health inpatient settings, thus reducing the need to use out of area placements.

• Health and care organisations can improve patient safety by capturing the impacts, events and circumstances where sexual safety incidents have affected the provision of safe care. This would help organisations to understand and assess the risks posed to patient safety.
• Health and care organisations can reduce duplication of effort within sexual safety improvement work by increasing co-ordination and collaboration. This should accelerate and enhance the potential improvements across organisations.
• There is an opportunity for health and care organisations to share learning around implementing the 10 principles of NHS England’s ‘Sexual safety in healthcare – organisational charter’. This would enhance shared knowledge, understanding and mechanisms for embedding the principles.

Mental health inpatient workforce

• Patients in mental health inpatient settings did not always feel safe and staff were not always able to develop therapeutic relationships with patients in support of their care and safety. Best practice standards for care were not embedded across inpatient settings.
• Some inpatient models of safety continued to focus on restrictive approaches, rather than relational approaches. Approaches were influenced by the ability of the workforce to form therapeutic relationships with patients.
• Workforce challenges across the multidisciplinary workforce had negatively influenced the ability of staff to develop therapeutic relationships with patients and therefore patient safety had been affected.
• Workforce challenges included difficulties recruiting staff and retaining experienced staff, and concerns around the knowledge and skills available to support therapeutic relationship formation and trauma-informed care.
• The mental and physical health care needs of patients cared for in acute inpatient settings may have changed and acuity may now be greater than in the past. Staff were not always equipped with the required knowledge and skills to understand and meet the mental and physical needs of patients.
• Wards were not always staffed to ensure patients could access the knowledge and skills of a multidisciplinary team. Some patients had no or limited access to professionals such as dietitians or speech and language therapists.
• Workforce challenges varied across regions. Barriers to region-wide coordinated workforce planning included unclear national expectations, difficulties predicting workforce needs, limited provider engagement, and a lack of available staff.
• The goals of the NHS Long Term Workforce Plan may be unattainable if barriers to implementation are not recognised and addressed. Barriers found included education capacity to build the workforce and poor working conditions affecting retention.
• There were conflicting views about how best to educate pre-registration nursing (mental health) students and where responsibility should lie to support their development of mental and physical health care skills.
• Registered nurses (mental health) may be being promoted to supervisory roles with limited experience. Inexperience influenced the supervision and development of new staff, and leaders may be reluctant to challenge attitudes that undermine the quality of care.

Built mental health inpatient environments

• The built environments (estates and physical environments) of inpatient settings varied. Some environments were not therapeutic, did not contribute to formation of therapeutic relationships, and had created situations where patients and staff could and had been harmed.
• The short-, medium- and long-term investment requirements for safe and therapeutic built environments across mental health inpatient settings were not always known at regional and national levels.
• Capital funding for the NHS to maintain, improve and create new built environments was finite and unable to meet the needs of mental health inpatient settings. Hazards in built environments could not always be removed or mitigated, and environments could not be improved to be therapeutic.
• There were concerns about the long-term ability of some high-secure built environments to maintain patient, staff and public safety. There was no specific process for high-secure services to access the capital funds they required for long-term estate planning.
• There was limited evidence around how best to design therapeutic built environments to meet potential changes in patients’ needs and acuity. Providers wanted clarity on design standards and on the role of technology to support the safety of patients experiencing mental health problems.

Social and organisational factors influencing mental health inpatient care

• The development of psychologically safe and therapeutic social environments was not always possible because of demands on services, workforce constraints, workforce knowledge and skill development, and cultural influences.
• Providers of mental health inpatient care were not always able to accommodate patients in single-sex spaces. Best practice standards in relation to ensuring sexual safety were not always embedded.
• Approaches to accommodating patients who were transgender and non-binary varied in mental health inpatient settings. Staff wanted to meet the needs and preferences of all patients but this was not always possible.
• Digital systems had contributed to incidents where patients had been harmed. Clinical information was not always easily accessible in electronic patient records or had not been shared across different care providers’ systems.
• Availability and access to physical healthcare services for mental health inpatients varied. Access was influenced by how providers designed and set up their services, the knowledge and skills of staff, and collaboration between acute and mental health care providers.
• In some locations, care pathways between different care providers were limited. This reduced continuity of care and made it more difficult to access physical health services, which increased the need for patients to be transferred to acute physical health hospitals.
• Inequalities continued to exist in the care of patients experiencing mental health problems. Availability and access to services for different patient groups further influenced the ability of inpatient providers to deliver safe and therapeutic care.
• Some organisational cultures and individual beliefs surrounding people experiencing mental health problems continued to negatively influence attitudes towards their care, including access to physical healthcare.

Safety recommendations

HSSIB makes the following safety recommendations

Mental health inpatient workforce

• HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes in patients’ needs and the level of care they require, and to support providers to make decisions about workforce requirements that support therapeutic and therefore safe care.
• HSSIB recommends that NHS England works collaboratively with relevant national bodies and stakeholders including professional regulators, the Department of Health and Social Care, and relevant royal colleges to:

1. Identify and clarify the goals of acute mental health inpatient care and the roles, required skills and ongoing professional development needs of the multidisciplinary workforce team.
2. Review and update the NHS Long Term Workforce Plan with consideration of the concerns around changes in patients’ needs and the need for a multidisciplinary approach to ensure therapeutic care is provided.
3. Develop a strategic implementation plan to address workforce issues in mental health inpatient settings that identifies the social and technical barriers to implementation and sets out actions to address them.
   
   This is to develop, enable, support and retain a future multidisciplinary mental health inpatient workforce that is able to deliver therapeutic and safe care to patients.

Built mental health inpatient environments

• HSSIB recommends that the Department of Health and Social Care, with input from stakeholders including NHS England, identifies the short-, medium- and long-term requirements of NHS mental health built environments to ensure they enable delivery of safe and therapeutic care to patients, and create a supportive working environment for staff. This is to support the development of a strategic and long-term approach to capital investment and prioritisation for NHS built environments.
• HSSIB recommends that the Department of Health and Social Care undertakes assessment of the capital requirements of the built environments across high-secure services in England and develops plans to ensure the long-term safety of patients, staff and the public.

Social and organisational factors influencing mental health inpatient care

• HSSIB recommends that NHS England, working with relevant stakeholders, develops guiding principles for providers of mental health inpatient care to support local decision making when accommodating patients, including patients who are transgender and non-binary. This is to ensure a provider’s equality and human rights obligations are considered, and all patients are cared for in environments where they feel safe and that are therapeutic.

Safety observations

HSSIB makes the following safety observations

• Providers of mental health inpatient care can improve patient safety by ensuring that where professional judgement is used to help make workforce decisions, this accounts for ward physical environments, changes in patient acuity, and the individual mental and physical health care needs of patients that require support from a multidisciplinary workforce.
• Those involved in the provision of undergraduate and pre-registration education (educational institutions and placement providers) and preceptorship/induction programmes can improve patient safety by collaboratively ensuring that staff entering mental health related professions are developing the required knowledge and skills, including in trauma-informed care, to care for patients with mental and physical health care needs.
• Those involved in healthcare research can improve patient safety by seeking to understand the design principles for mental health inpatient settings that underpin safe and therapeutic care. Research should include consideration of sensory environments, the role of technology, and the changing needs of patients.
• Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients and staff) and experts in human factors and ergonomics. Any design should also consider the changing needs of patients.
• Providers of mental health inpatient care can support patient safety by evaluating and addressing local barriers to the effective use of technology to support patient care, including through gaining insights from people with lived experience (patients and staff) and ensuring the digital infrastructure is available, usable and reliable.

Safety responses

HSSIB proposes the following safety responses for integrated care boards

• HSSIB suggests that integrated care boards work collaboratively with the NHS and independent sector to review their system-level workforce plans to ensure they recognise and mitigate the safety challenges in mental health inpatient settings and agree how variation across a geographical area can be mitigated.
• HSSIB suggests that integrated care boards: 1) ensure system-level infrastructure strategies clearly reflect the risks across their mental health inpatient built environments, and 2) ensure prioritisation of capital funding is equitable across different healthcare settings in a geographical area.
• HSSIB suggests that integrated care boards: 1) work with mental health inpatient providers to identify patient needs that require input from other providers and agencies, and 2) facilitate cross-provider working arrangements between mental health, acute and primary care providers to minimise the need for transfers of care unless clinically necessary.

• Failure to implement actions following recommendations can impact public confidence in the healthcare system and compound harm to patients.
• The ‘noise’ created by the significant volume of recommendations being made to the healthcare system means that providers struggle to prioritise and implement recommendations, concentrating on those which are addressed directly to the provider, or where there are immediate patient safety risks.
• Some recommendations duplicate or contradict others. The development of a searchable repository which includes recommendations made across the healthcare system may help to reduce this.
• It may reduce the ‘noise’ and help with prioritisation if organisations refer to each other’s recommendations, or group together in support of one organisation’s recommendation rather than repeating it. The development of an agreed system to identify recommendations for cross-referencing would assist this.
• There is currently a lack of visibility of ongoing work across arm’s length bodies that would enable collaborative working on related workstreams. A searchable repository of ongoing work may assist this.
• Recommendations differ in terms of the evidence on which they are based, and their structure and language. This can affect their relevance and how they are interpreted.
• It is unclear how some recommendations are intended to impact the patient, which should be a key consideration in their development where possible.
• Most recommendations made to the healthcare system are not costed, either in relation to the cost of implementing the proposed actions or their longer-term cost effectiveness. This may affect providers’ ability to implement them and means there is a lack of information to support prioritisation decisions.
• Some recommendations may be of limited relevance to certain providers and could promote inequalities by negatively impacting certain patient groups if implemented. However, providers can feel they are not empowered to reject recommendations, especially those related to safety.
• Few recommendations require a formal response from the recipient organisation, and there is a lack of monitoring of the actions planned or taken to address recommendations. A monitoring system could help to track actions and identify opportunities for escalation where changes have not been made.

Recommendations

The Recommendations to Impact Collaborative Group recommend further work in this area to develop:

• guidance on the creation and implementation of recommendations
• a proposal for a repository for recommendations
• a proposal for a repository for ongoing workstreams
• a proposal for a monitoring system with a multi-agency board feeding into the Department of Health and Social Care to provide oversight and a route of escalation for recommendations that are not implemented.

Related reading

Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022.