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  • Broken trust: making patient safety more than just a promise (PHSO, 26 June 2023)

    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Parliamentary and Health Service Ombudsman
    • 26/06/23
    • Everyone


    There have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS.

    Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice.

    PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.



    PHSO found that the physical harm patients experienced was too often made worse by inadequate, defensive and insensitive responses from NHS organisations when concerns were raised.

    Looking at the direct causes of harm, the report identified four broad themes of clinical failings leading to avoidable death:

    • failure to make the right diagnosis
    • delays in providing treatment
    • poor handovers between clinicians
    • failure to listen to the concerns of patients or their families.

    The report also looked at the further harm – sometimes called compounded harm – that happens when families, who have already experienced the devastating consequences of losing a loved one, try to understand what has happened but are met with a poor response from NHS organisations. It identified several factors that contribute to compounded harm:

    • a failure to be honest when things go wrong
    • a lack of support to navigate systems after an incident
    • poor-quality investigations
    • a failure to respond to complaints in a timely and compassionate way
    • inadequate apologies
    • unsatisfactory learning responses.

    PHSO recommendations

    1. Accountability for a robust and compassionate response to harm, which supports learning for systems and healing for families.

    The Patient Safety Incident Response Framework (PSIRF) offers a new approach to patient safety investigations. It holds great promise but needs to be accompanied by sufficient monitoring and better support for families. 

    Recommendation 1

    • Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is needed. This should include paying special attention to the balance of patient safety investigations versus other learning responses in Trusts (or service areas of a Trust) where there are poor Care Quality Commission (CQC) ratings for safety and leadership, or where other national bodies have raised concerns.

    Recommendation 2

    • As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses This should include where local investigations did not take place, or did not find that things went wrong, but PHSO or another independent oversight body later identified failings.

    Recommendation 3

    • The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.

    Recommendation 4

    • The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or look for answers after an incident.

    2. Evidencing that patient safety is a top Government and NHS priority

    NHS leaders and frontline staff need to be in no doubt of the priority placed on patient safety. But patient voice and leadership for patient safety are fractured. Political leaders have created a confusing landscape of organisations, often in knee-jerk reaction to patient safety crisis points. The Healthcare Safety Investigation Branch (HSIB), the Patient Safety Commissioner, PHSO, NHS England, NHS Resolution and at least a dozen different health and care regulators all play important roles in patient safety. But there are significant overlaps in functions, which create uncertainty about who is responsible for what. The Government must consider the case for streamlining some of these functions, for the benefit of people who use the NHS, their families and carers. This is not about reducing investment in patient safety. It is about creating a system that is coherent and easier to navigate, based on evidence and engagement with patients, families, NHS staff and leaders.

    Recommendation 5

    • The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.

    Patient safety must be a consistent priority over the long term. It must not be subject to changes of emphasis or importance each time there is a new minister or leadership change in the NHS.

    Recommendation 6

    • The Government should seek cross-party support for commitments to embedding patient safety and the culture and leadership needed to support it as a long-term priority.

    It is not possible to prioritise patient safety while avoiding difficult decisions about the workforce the NHS needs. Patient safety will always be at risk in environments that are understaffed and where staff are exhausted and under unsustainable pressure.

    Tackling workforce shortages goes beyond political decisions about resourcing. It is about making the NHS a place where people want to work and stay because they feel valued, not just because it is a vocation. We must break down the false dichotomy between the interests of patients and staff, recognising that a system that does not treat its workforce with humanity and compassion will struggle to extend these qualities to patients and families.

    PHSO recognise the Government has promised to publish a new NHS workforce strategy. At the time of writing, this is expected ‘shortly’. But for this to properly address the underlying causes of NHS staffing pressures, it needs cross-party consensus. In a sector where it can take nearly two decades to train a consultant doctor, a workforce strategy will only succeed if there is support from across the political spectrum, and far beyond one parliamentary term.

    Recommendation 7

     PHSO recommends that the Government should urgently produce its long-awaited long-term workforce strategy, with cross-party support, to increase the numbers entering and staying in the workforce across clinical and non-clinical roles. This strategy must:

    • include independent, evidence-based and fully costed projections of future workforce requirements
    • include detailed plans for training and recruiting new staff, retaining staff already working in the NHS and attracting those who have left to return
    • take account of the mix of different professional skills required, rather than just total numbers in the workforce, and how existing professional skills can be deployed where they are most needed.
    Broken trust: making patient safety more than just a promise (PHSO, 26 June 2023) https://www.ombudsman.org.uk/publications/broken-trust-making-patient-safety-more-just-promise-0
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