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Everyone deserves to learn and work in a safe, respectful environment. The new Breaking the Silence: Sexual Safety for Healthcare Students and Trainees e-learning offers practical steps to speak up safely, set clear boundaries and get the right support. Feel more confident about what’s acceptable, what isn’t, and what to do if you see or experience behaviour that crosses the line. Understand where to raise concerns and how to support a colleague who shares an experience. Whether a student, trainee, educator, or staff member complete the e-learning to strengthen your own wellbeing and professionalism and help build a culture where harassment is not tolerated.  The e-learning is accessed via the NHS learning hub or via the e-Learning for Health platform. Find out more from the attachment below.

I have spent much of my career working in patient safety.  I genuinely believe that most people who come to work in the NHS do so with integrity, compassion and a desire to do the right thing. We talk often about learning cultures, just culture and systems thinking. We have national frameworks, thoughtful strategies and well-intentioned leaders. And yet this example I'd like to share with you reminds me of how fragile that progress still is. This blog is not about blame. In fact, it is about the opposite. A patient safety incident A colleague of mine, a doctor, was involved in a patient safety incident relating to a prescribing issue where the patient, sadly, died as a result. The organisation responded appropriately and compassionately, commissioning a patient safety investigation under the Patient Safety Incident Response Framework (PSIRF). The investigation was thorough, systems-focused and mindful of the profound impact on the family and the staff involved. The investigation concluded that the primary contributory factor was the presence of two different digital prescribing systems. It did not identify negligence. The findings were shared with the coroner as part of the evidence bundle, and the coroner reached the same conclusion: the cause of death lay in system design and interoperability (the ability to work with other computer systems or software used by the organisation to exchange and make use of information), not individual fault. Throughout this process, the organisation supported the patient’s family and the staff involved. Openness, compassion and learning were evident. This is precisely what PSIRF was designed to promote—moving away from asking “who made the error?” and instead asking “how did the system make this more likely to happen?”.[1] Self-referral to the GMC? As happens in medical training, the doctor involved rotated to a new organisation. During an early conversation, the incident was openly discussed with their educational supervisor—someone who had not been present during the incident and who worked in a different Trust at the time. Despite the clear findings of the investigation and the coroner’s conclusion, the supervisor suggested that the doctor should self-refer to the General Medical Council (GMC). The doctor contacted me, understandably anxious, asking whether there was documentation from the coroner that required or recommended self-referral to the regulator. I reviewed the material and reassured them that there was no such recommendation. The incident had been formally investigated, reviewed independently by the coroner and conclusively identified as a systems issue rather than professional misconduct or impaired fitness to practise. Doctors can self-refer to the GMC, and in some circumstances that is appropriate. In this case, there was no regulatory threshold met, no negligence identified and no ongoing risk that regulatory action would mitigate. A referral would not create learning; it would simply create fear. Despite PSIRF, and repeated commitments to learning cultures, we still see reflexive thinking that equates involvement in harm with personal culpability. The assumption seems to be that regulatory referral is the safest option “just in case”. But safe for whom? The evidence tells us that regulatory referrals are not a neutral act. GMC data show that fitness to practise enquiries have continued to rise in recent years, with an increase of around 7% between 2023 and 2024, continuing an upward trend.[2] This aligns with broader analyses suggesting annual increases of between 6–8% in referrals, despite the majority of cases closing at triage or with no further action.[3] At the same time, we know from research that the overwhelming majority of employer referrals do not result in sanctions, yet they carry a significant psychological burden for doctors.[4] Being under regulatory scrutiny is associated with anxiety, depression, loss of confidence and, in some cases, doctors leaving the profession altogether.[5] [6] This does not enhance patient safety; it risks undermining it. What concerns me most is that this doctor did exactly what we encourage: they were open, reflective and honest about a traumatic event. And yet that openness appeared to trigger a suggestion of self-referral, as though transparency itself is risky. That is not a learning culture. That is a quiet continuation of blame. PSIRF explicitly asks us to separate accountability from punishment, and learning from fear.[1] It recognises that healthcare is delivered within complex systems where digital design, workload, cognitive load, environment and organisational decisions all interact.[7] Regulators themselves acknowledge this and have repeatedly stated that not every adverse outcome requires regulatory involvement.[4] When we default to “the GMC just in case”, we send a powerful message to staff: even when the system fails, you may still carry the personal risk. That message discourages reporting, reflection and honesty, the very behaviours patient safety depends on.[8] In the end, the doctor did not self-refer. They were reassured, supported and able to continue their training without the added weight of unnecessary regulatory fear. Moving beyond a blame culture If we are serious about moving beyond blame culture in the NHS, then PSIRF cannot stop at investigations. It has to show up in conversations, supervision and how we respond to staff who have already been through something devastating. Otherwise, PSIRF becomes a framework we apply on paper, while old habits persist in practice. True learning cultures are quiet, steady and compassionate. They trust evidence. They resist reflexive blame. And they remember that patient safety is strengthened not just by better systems, but by how we treat the people working within them. Call to action: For those of us in supervisory and leadership roles, the challenge is clear: resist reflexive escalation. Be guided by evidence, not anxiety. Create spaces where clinicians can speak openly about harm without fear that honesty will be turned against them. Every time we default to “just in case”, we reinforce the very culture PSIRF is trying to dismantle. References NHS England. Patient Safety Incident Response Framework (PSIRF).16 August 2022. General Medical Council. GMC Annual Report 2024: Trustees’ annual report and accounts for the year ended 31 December 2024. GMC, 2025. General Medical Centre. Fitness to practise statistics 2024. GMC, 2024. General Medical Council. Deciding whether to refer a matter to the GMC (Doctors). GMC, 2025. Bourne T, Wynants L, Peters M, et al, The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open 2015; 5(1): e006687. Brooks SK, Gerada C, Chalder T. Review of literature on the mental health of doctors: are specialist services needed? Journal of Mental Health 2018; 27(2): 146–56. NHS England. Patient safety learning response toolkit. 16 August 2022. O’Donovan R, McAuliffe E. A systematic review of factors that enable psychological safety in healthcare teams, Int J Qual Health Care 2020; 32(4):,240–50. Further reading on the hub Read all our blogs in our Florence in the Machine series — an area for anonymous health and care staff to blog about the state of the health service as they experience it on a daily basis. If you work in health or social care and would like to share your experience on the hub, you can email [email protected].

In a review shared on the hub, Roger Kline, Research Fellow at Middlesex University Business School, explored the literature on patient safety and speaking up, arguing that staff being able to raise concerns safely and effectively is essential for patient safety, but the NHS continues to struggle with creating a culture where this happens reliably. In this blog, Roger reflects on some of the findings of his review. A critical characteristic of effective teams is whether every member is willing to speak up to share thoughts and ideas to improve processes, to raise concerns and admit mistakes. In healthcare, the failure of those to whom concerns are raised to listen and act on them decisively is a major factor in unsafe and suboptimal care delivery. NHS inquiry findings and recommendations are remarkably consistent on this issue. The Ely Inquiry (and other inquiries in the 1970s),[1] the Bristol Inquiry (2001),[2] the Mid-Staffordshire Hospital inquiries in 2010 and 2013,[3][4] and more recently Ockenden (2022),[5] all highlighted the failure to listen to staff who raised concerns and, worse, the victimisation of some of those who did raise concerns. Yet when the voices of healthcare staff are listened to and acted upon they can improve the safety and quality of services—as well as staff wellbeing.[6] Following the Francis Reports,[7] there was some limited improvement in NHS staff survey responses on whether NHS staff felt willing to raise concerns, whether they would be treated fairly if they did, and whether they felt their managers and employers would listen and act on those concerns. After Covid-19 that limited improvement stopped. Despite the raft of legislation, NHS regulation and exhortation, the 2023 National Guardian Office report entitled 'Fear and Futility' noted a “sharp decline in Freedom to Speak Up Guardians’ perception of the improvements in the Speak Up culture of the healthcare sector…” It noted that: “there is a growing feeling that speaking up in the NHS is futile – that nothing changes as a result.”[8] Staff safety is key to patient safety, so the fact that the majority of concerns raised are about staff safety is not a separate issue from patient safety but intimately linked.[9] So, when staff ought to—and often do—raise concerns what goes wrong? First, it has been repeatedly found by Francis (2015),[7] Kline and Warming (2024)[10] and others, that NHS staff are sceptical that raising concerns is effective and believe that by doing so it makes things worse for them personally due to victimisation.[11] Second, some staff groups are particularly sceptical of the effectiveness and/or safety of raising concerns. Kline and Warmington found that of Black and Minority Ethnic (BME) staff who did raise concerns, only 5.4% said they were taken seriously and that their problem was dealt with satisfactorily.[10] The most common outcome, in 42.7% of cases, to a race discrimination concern was nothing happening.[12] Begeny et al. (2023) revealed that within the UK surgical workforce, two-thirds of women medics (63.3%) had been subjected to sexual harassment, sexual assault and rape from colleagues, but only 16% of those impacted by sexual misconduct made a formal report.[13] Surviving in Scrubs (2023) noted a serious resulting risk to patient care from the silencing of female staff voicing concerns about such behaviours, as female staff reported that their clinical judgements were questioned, decisions were not taken seriously, clinical requests were ignored and referrals were refused.[14] Third, Mannion emphasises the importance of hierarchy in shaping behaviours: "Effective voicing of concerns is but the first stage in reshaping better safer healthcare: those with influence have to hear, and they have to act… In an intensely hierarchical organisation such as the NHS, entrenched status and power differences between professional groups can harm the development of open reporting cultures. Any attempt to address speaking up in the NHS must deal with the challenging organisational dynamic of resistance to bad news."[15] Reitz and Higgins (2020) suggest: "...power imbalance in organisational roles (as) perhaps the most important factor that makes employee silence such a common experience." They conclude that: “...instigating whistleblowing lines and training employees to be braver or insisting that they speak up out of duty, will achieve little therefore, without leaders owning their status and hierarchy, stepping out of their internal monologue and engaging with the reality of others."[16] Fourth, reputation continues to trump candour. Francis (2013) concluded that: “There lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism’; and an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern”.[4] Finally, alongside the refusal to adopt evidenced-based proactive interventions goes a lack of accountability for those whose power creates silence. Ministers have spoken strong words: “NHS managers who silence whistleblowers could be barred from working in the NHS, under proposals being announced this week.” [17] But such statements will only be effective if they are part of a wider evidence-driven strategy. In the meantime, victimisation of those raising concerns remains widespread, as recent reviews of the treatment of whistleblowers by both employers and the largest professional regulators have found.[18][19] Moreover, advice from professional regulators, as with NHS England, is very focused on individual professional accountability rather than system abuse of power.[20] Unfortunately, despite the best efforts of some NHS organisations, the conclusion Pope and Burnes reached a decade ago still stands: “The NHS exhibits too high a level of collective ego defences and protection of its image and self-esteem, which distorts its ability to address problems and to learn. Organisations and the individuals within them can hide and retreat from reality and exhibit denial; there is a resistance to voice and to “knowing.”[21] References Ely Hospital, Cardiff: Inquiry findings, Hansard, 27 March 1969. Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984 -1995. The National Archives, 2021. Mid Staffordshire NHS Foundation Trust Public Inquiry 2010. 24 February 2010. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Vol. 1: Analysis of evidence and lessons learned (part 1) HC 898, Session 2012-2013. Donna Ockenden. Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust. 30 March 2024. Mannion R, Davies H. Understanding organisational culture for healthcare quality improvement. BMJ  2018;363:k4907. Freedom to speak up Review, February 2015. National Guardian Freedom to Speak Up. Fear and futility: what does the staff survey tell us about speaking up in the NHS? June 2023. Patient Safety Learning. Why is staff safety a patient safety issue? 3 September 2020. Written evidence submitted by Roger Kline and Professor Joy Warmington (NHL0074). March 2024. Correspondence. Sir Robert Francis’ Freedom to Speak Up review. 11 February 2015. Kline R, Warmington J. To hot to handle? Why concerns about racism are not heard... or acted on. January 2024. Begeny CT, Arshad H, Cuming T, et al. Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights. BJS, 2023; 110(11): 1518–26. https://doi.org/10.1093/bjs/znad242. Cox B, Jewitt C, MacIver E. Surviving healthcare: sexism and sexual violence in the healthcare workforce. Surviving in Scrubs. November 2023. Mannion R, Blenkinsopp J, Powell M, et al. Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews. NIHR 2018; 6(30). Reitz R, Higgins J. Speaking truth to power: why leaders cannot hear what they need to hear. BMJ Leader 2020; 10.1136/leader-2020-000394. DHSC. Press release. New protections for whistleblowers under NHS manager proposals. 24 November 2024. Patient Safety Learning. The whistleblower playbook. the hub. 26 June 2025. Nursing & Midwifery Council. Independent Culture Review. July 2024. General Medical Council. Speaking up. Pope R, Burnes B. A model of organisational dysfunction in the NHS. 2013. Journal of Health Organisation and Management, 2013; 27(6): 76-697. https://doi.org/10.1108/JHOM-10-2012-0207. Further reading on the hub: Patient safety and speaking up—learning from the literature (Roger Kline) Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Top picks for staff psychological safety

The NHS has served millions of people over decades. It stands as a symbol of collective care, public service and professional commitment. That history matters. It deserves respect. But patient safety does not rest on history alone. It rests on people. And people need safe systems to do safe work. Today, those systems are under strain in ways that should concern us all. This piece is not about blame. It is about learning, and about starting a conversation that is long overdue. Psychological safety is not optional in patient safety The patient safety literature is unambiguous on this point. Staff must feel safe to speak up, to report concerns, to admit uncertainty or error. When they do not, harm follows. Psychological safety is the foundation that enables incident reporting, learning from error, early risk escalation and team-based decision-making. Amy Edmondson's landmark research established this link decades ago,[1] and the NHS has echoed it repeatedly through policy and inquiry.[2] Research confirms that when psychological safety is present, the benefits extend across individuals, teams and organisations. A recent systematic review found that a positive safety culture leads to both workforce wellbeing and improved patient outcomes, including lower rates of surgical site infections, falls and medication errors. Yet when fear enters the system, silence grows. And silence, in healthcare, can be lethal. The exodus: workforce loss as a patient safety risk The NHS is losing people it cannot easily replace. Experienced clinicians are retiring early. Skilled staff are leaving for overseas systems offering better pay and conditions. Capable professionals are exiting after bruising disciplinary or capability processes. Energetic, committed staff are burning out and disengaging, sometimes quietly, sometimes dramatically. The scale is sobering. Recent data indicates that almost 9,000 internationally recruited nurses leave the UK annually, with the largest increases among those with three years or fewer on the register. The UK risks becoming merely a staging post in their careers rather than a destination. Each departure removes institutional memory, clinical judgement built over years, and the informal safety checks that never appear in any policy document. When experienced staff leave, learning leaves with them. This is not simply a workforce planning issue. It is a patient safety issue. Burnout: structural, not individual Burnout is too often framed as a failure of personal resilience, as though the solution lies in yoga classes and mindfulness apps. That framing is wrong, and it is dangerous. The evidence points clearly to system conditions: excessive workload, role overload, constant organisational change, inadequate staffing and fear of blame. The 2024 NHS Staff Survey revealed that 42% of staff felt unwell due to work-related stress in the preceding 12 months, while 30% reported feeling burnt out because of their work.[3] Perhaps most troubling, 29% said they often think about leaving. These are not personal failings. These are system failures manifesting through individuals. The consequences for patient safety are direct. Research demonstrates that clinicians experiencing burnout are approximately twice as likely to make errors in diagnosis or prescribing.[4] A systematic review of 21 studies confirmed an association between burnout and worsening patient safety outcomes.[5] When staff become unwell, the system becomes unsafe. Debanding: devaluing an already stretched workforce As if burnout, role expansion and workforce exodus were not enough, staff now face another threat: debanding. Across the NHS, roles are being downgraded—responsibilities remain or compound, but pay decreases. This is happening against the backdrop of a cost-of-living crisis that has already eroded real-terms earnings for healthcare workers.[6] The message this sends is unmistakable: you are worth less than you were yesterday, even as we ask more of you today. Staff who are already navigating violence from patients and the public, who are already managing unsustainable workloads, who are already questioning whether they can continue, are now being told their contribution merits a lower band. What do the unions say? What do the regulators say? What does this do to morale, retention and, ultimately, patient safety? These are not rhetorical questions. They deserve answers—from policymakers, from employers and from professional bodies. Silence on this issue is complicity in the erosion of the workforce. Role expansion without preparation: a recipe for risk The NHS is undergoing rapid role reconfiguration. New titles are appearing. Responsibilities are expanding. Scopes of practice are broadening. Change itself is not the problem. Unprepared change is. Across the service, staff are being asked to absorb additional responsibilities, sometimes without consultation, often without adequate training, and frequently without recognition that their original role was already demanding enough. Job descriptions expand while support contracts. Expectations inflate while preparation time vanishes. The evidence from healthcare reengineering efforts both in the UK and internationally shows that role redesign fails to deliver safety or efficiency gains when training is inadequate, supervision is stretched, accountability is unclear and time for development is absent. Research has found that reengineering without integrative and coordinative efforts may actually damage an organisation's position rather than improve it.[7] Classic safety literature warns that poorly implemented role substitution increases task overload, decision ambiguity, near misses, and latent safety failures, the hidden vulnerabilities that lie dormant until circumstances align to cause harm. Capability must come before expectation. When it does not, patients bear the risk. When systems fail, individuals pay the price When incidents occur in pressured systems, what happens next matters enormously. Too often, context is stripped away. System factors are minimised. Individuals carry the weight of failure that belongs, at least in part, to the organisation. This creates a chilling effect that radiates far beyond the person directly involved. Staff learn quickly: speak up and risk your career, or stay silent and survive. Neither option protects patients. A learning culture cannot coexist with fear. The Patient Safety Incident Response Framework (PSIRF) was designed to address this: to shift focus from blame to learning, from punishment to improvement. But implementation without genuine psychological safety risks repeating old patterns dressed in new language.[8] The words change; the fear remains. Have we seen this before? Yes. History offers warnings we would be wise to heed. Mid Staffordshire taught us what happens when fear, silence and understaffing converge: catastrophic harm, public inquiry, costly reform, years of recovery and permanent loss of trust.[9] International health systems under austerity have demonstrated the same pattern repeatedly: workforce loss followed by quality collapse. The United States healthcare system offers its own cautionary tale of burnout, defensive practice, litigation spirals and widespread moral injury among clinicians. The aftermath is always the same. And prevention is always cheaper; in money, in lives, and in trust, than repair. Is the NHS crumbling or being stripped of its foundations? This is the uncomfortable question that demands honest consideration. An overwhelmed workforce cannot deliver safe care indefinitely. A fearful workforce cannot learn. A depleted workforce cannot mentor the next generation or preserve the institutional knowledge that underpins safe practice. Lord Darzi's 2024 independent investigation painted a sobering picture, noting grave concerns over staff wellbeing and a sharp decline in the trust, goodwill and discretionary effort of staff.[10] There is a growing sense that healthcare workers are less willing to tolerate poor conditions from their employers, not because commitment has weakened, but because endurance has limits. Patient safety ultimately depends on psychological safety, adequate preparation, just responses to error and valuing people as safety assets rather than liabilities. The NHS still has extraordinary people. But goodwill is not infinite. And we cannot keep drawing on reserves without replenishing them. What needs to change? Drawing on established patient safety principles, action must include: Embedding psychological safety as a measurable safety outcome, not merely an aspiration. Treating workforce attrition as a patient safety signal that demands investigation and response. Matching role expansion with structured capability building, supervision and realistic timeframes. Protecting learning-focused responses after harm, ensuring that system factors receive the same scrutiny as individual actions Capturing knowledge before experienced staff leave, so that learning is not lost with each departure. These are not radical proposals. They are established safety fundamentals that we already know work. The challenge lies not in discovering new solutions but in implementing the ones we have. An invitation to share your thoughts This piece is not a verdict. It is an invitation to reflect and to speak. The NHS belongs to the public. Its safety depends on its people. And its future depends on our willingness to have honest conversations about what is happening and what must change. I would be enthusiastic to hear from colleagues across different cadres and contexts. Frontline clinical staff, middle managers, senior leaders, policymakers, regulators and, crucially, patients and families all hold pieces of this picture. Our perspectives may reveal quite different experiences of workforce changes and their implications for safety. What are you seeing in your part of the system? What feels unsafe that is not being discussed? What learning is being lost? And what is debanding doing to your team, your morale, your ability to deliver safe care? I welcome perspectives from frontline staff, union representatives, regulators, and anyone willing to speak honestly about what is happening. Please comment below. You will need to be a hub member (sign up is free and easy to do) and signed in. References Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Hoboken, NJ: John Wiley & Sons, 2018. West M, Bailey S, Williams E. The Courage Of Compassion: Supporting Nurses And Midwives To Deliver High-Quality Care. The King's Fund, 23 September 2020. NHS England. NHS Staff Survey Results, 2024. Garcia CL, Abreu LC, Ramos JLS, et al. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina (Kaunas) 2019; 30;55(9):553. doi: 10.3390/medicina55090553. PMID: 31480365; PMCID: PMC6780563. Hall LH, Johnson J, Watt I, et al. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLoS One 2016; 8;11(7):e0159015. doi: 10.1371/journal.pone.0159015. PMID: 27391946; PMCID: PMC4938539. House of Commons Health and Social Care Committee. Workforce burnout and resilience in the NHS and social care, 2021. Leatt P, Baker GR, Halverson PK, Aird C. Downsizing, reengineering, and restructuring: long-term implications for healthcare organizations. Front Health Serv Manage 1997;13(4):3-37; discussion 52-4. PMID: 10167281. Patient Safety Learning. Mind the Implementation Gap, 2022. Francis R. Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013. Lord Darzi. Independent Investigation of the National Health Service in England. Department of Health and Social Care, 2024.