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The King’s Speech 2026 sets out the programme of legislation that the UK Government intends to pursue in its next parliamentary session. This blog highlights six key takeaways from this speech from a patient safety perspective. On Wednesday 13 May 2026, Kings Charles III delivered his annual speech in the Lords Chamber at the State Opening of Parliament.[1] Written by the Government and delivered by the Monarch, the speech presents opportunity at the start of a new parliamentary session for a government to set out its plans for the year ahead. This year’s speech includes two pieces of proposed legislation that have, potentially, significant implications for patient safety: NHS Modernisation Bill Public Office (Accountability) Bill In this blog, we highlight six takeaways from these proposed bills from a patient safety perspective. 1. Future of the Health Services Safety Investigations Body The NHS Modernisation Bill includes several changes to the patient safety landscape in England. These involve the implementation of several key recommendations put forward in Dr Penny Dash’s Review of patient safety across the health and care landscape last year.[2] This includes the recommendation to transfer the Health Services Safety Investigations Body (HSSIB) functions to the Care Quality Commission (CQC). In our response to the Dash Review, we stated our belief that HSSIB has an important independent role in the health system which should be retained.[3] There are understandable concerns about the potential for its independence to be compromised by its functions being transferred to the CQC.[4] [5] More broadly, we know that many staff working in healthcare do not feel confident raising concerns. As NHS Staff Survey results continue to illustrate, nearly two-fifths of staff say they do not feel safe to speak up about concerns.[6] Recognising the importance of staff feeling able to speak freely in investigations, HSSIB currently conducts these using a ‘safe space’ approach. This prohibits, on a legal basis, the unauthorised disclosure of protected material. Even if this legal assurance is maintained under these proposed changes, there still may be concerns that moving HSSIB into the CQC could potentially undermine staff confidence that confidentiality will be maintained. If confidence in the independence and confidentiality of HSSIB’s investigations is undermined, whether in reality or perception, this could compromise understanding of what is really happening on the ground. HSSIB’s ability to do this is an essential prerequisite to understand what the risks to patient safety are and the action needed to address these. We await further detail in the NHS Modernisation Bill on how these challenges will be addressed. 2. Embedding patient voice in national decision making Other notable recommendations from Dr Penny Dash’s review expected to feature in the NHS Modernisation Bill include: Transferring the functions of Healthwatch England to the Department of Health and Social Care. Developing a new Patient Experience Directorate in the Department. In our response to the Dash Review, we welcomed the proposal to create a new National Director of Patient Experience, alongside a Patient Experience Directorate. A new central body offers potential benefits for pooling expertise and resources. However, questions remain as to whether these changes could risk making the routes through which patient experience and concerns influence decision making less visible and more diffuse.[7] [8] [9] [10] It is vital that these changes improve the health systems capacity to listen and respond to patient experiences. We believe that an important element of this will be ensuring this new Patient Experience Directorate can benefit from regional and local experience and expertise. We would expect to see further detail setting this out in due course, considering how this will connect with local models for engaging with patients, families and carers. Specifically, we would also seek clarity on how this Directorate will work with local and national Patient Safety Partners, whose roles were not mentioned in the Dash Review. 3. Creating a new single patient record Another key strand of the NHS Modernisation Bill will be plans to create a new Single Patient Record. This is intended to “enable people to see their own health records securely on the NHS App, empowering them to make informed decisions about their own health”.[11] In our response to the 10 Year Health Plan for England, we stated our support for this initiative.[12] It is broadly acknowledged that if implemented effectively, this could make a real difference in improving joined-up communication in the NHS.[13] Patients not only need easy access to their records, but simple mechanisms to flag concerns and address any inaccuracies in a timely manner. Mistakes in records can create significant patient safety risks, and as illustrated by patient experiences shared with us on our patient safety platform the hub, amending these is often not a simple process.[14] 4. Introducing the Hillsborough Law The proposed Public Office (Accountability) Bill would put in place a new professional and legal Duty of Candour—meaning public officials must act with honesty and integrity at all times. This was previously announced in September 2025 and the Bill itself has already been tabled in Parliament.[15] We welcome this legislation. Patient Safety Learning believes it should be a requirement to be honest and transparent with patients and their families when something goes wrong, and this should be fundamental for all staff. The proposals in this new legislation have greater scope than the existing statutory Duty of Candour in the NHS, with a focus on systemic institutional behaviour. It is also notable that these provisions of the Bill will apply to the whole of the UK, not just England and Wales. 5. Abolition of NHS England The NHS Modernisation Bill will legislate to integrate NHS England’s functions into the Department of Health and Social Care, as first announced last year.[16] While we are still waiting further detail of what this will look like in practice, the existing National Patient Safety Team at NHS England is likely to be impacted by these changes. This Team is currently responsible for owning various patient safety programmes and policies and issuing safety warnings and recommendations. As stated in our response to the 10 Year Health Plan for England, an area of concern for us remains the lack of significant capacity to intervene if necessary for the purposes of improvement at a national level. Alongside this, there is also currently no national body able to commission or develop solutions that all organisations can use and adapt to improve patient safety. If healthcare providers identify a systemic issue that needs to be addressed because it affects other organisations, there is no national organisation that has the role or capacity to act on this. Instead, providers are left to find local solutions to system-wide concerns without a vehicle for widespread dissemination and evaluation. We believe this gap places a serious limitation on the healthcare system’s ability to reduce avoidable harm. It does little to address the inconsistencies in care across the country, with multiple different responses and workarounds to system-wide problems with varying levels of success. It is also a significant missed opportunity if we fail to take learning gained from provider organisations and apply this nationally for improvement in a meaningful way. This is an issue we think should be considered and addressed in the future merger of NHS England and the Department of Health and Social Care. 6. Changes to Integrated Care Boards Finally, the NHS Modernisation Bill will also include several changes for Integrated Care Boards (ICBs), including: Refine the membership of ICBs. Placing new requirements for mayoral nominees to be on ICBs. Confirming their role as strategic commissioners, by transferring responsibilities for all but the most specialised commissioning functions to ICBs. In a joint blog with the Advancing Quality Alliance (Aqua) earlier this year, we noted that there is huge opportunity for ICBs to drive a systemic approach to patient safety through their strategic commissioning responsibilities.[17] [18] [19] However, there is currently significant variation in ICBs involvement in safety management activities.[13] With the right support ICBs have the potential to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. We would hope to see this included in these changes considered in the provisions of the NHS Modernisation Bill, and in the forthcoming new NHS Quality Strategy. References Prime Minister’s Office. 10 Downing Street. Oral statement to Parliament: The King’s Speech 2026. 13 May 2026. Department of Health and Social Care. Review of patient safety across the health and care landscape. 7 July 2025. Patient Safety Learning. Review of patient safety across the health and care landscape: Patient Safety Learning‘s response. 15 July 2025. Macrae C. Failing to learn? The NHS is losing its capacity for system-wide safety investigation. Journal of the Royal Society of Medicine, 2025; 118(10). Health Service Journal. Merging watchdog into CQC will ‘destroy’ independence. 26 February 2026. Patient Safety Learning. Patient Safety Learning’s response to the NHS Staff Survey Results 2025. 13 March 2026. Martin G, O’Hara J. Hope over experience? Patient and staff voice in the NHS after the Dash review. 1 2025;390:r1514. Cox C. Is the patient voice fading? Reflections on patient safety in a changing NHS. Patient Safety Learning. 28 January 2026. Morris L, et al. The Kings Fund. The future of patient voice: learning from the Healthwatch model. 18 March 2026. Patient Safety Learning. Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026. 23 March 2026. Prime Minister’s Office. 10 Downing Street. King’s Speech 2026: background briefing notes. 13 May 2026. Patient Safety Learning. 10 Year Health Plan: Patient Safety Learning’s response. 14 August 2025. The Kings Fund. The King’s Fund responds to the King’s Speech and the introduction of the NHS Modernisation Bill. 13 May 2026. Anonymous. The digitalising of patient records – why patients MUST be involved. Patient Safety Learning. 16 April 2024. House of Commons. Public Office (Accountability Bill), Session 2024-26. Last updated 5 May 2026. Department of Health and Social Care. World’s largest quango scrapped under reforms to put patients first. 13 March 2025. Patient Safety Learning and Aqua. Patient safety and the new NHS Quality Strategy. 25 February 2026. Aqua. What Should Safety Look Like at a System Level. 6 April 2023. Patient Safety Learning. The elephant in the room: Patient safety and integrated carer systems. 11 July 2023. Health Services Safety Investigations Body. Safety management: accountability across organisational boundaries. 13 February 2025.

This course will explain and discuss the statutory duty of candour in principle, in practice, and in context, using real examples of good and poor practice. Openness, trust and good communication are at the core of the relationship between health and care professionals and their patients / families. But the duty of candour is widely misunderstood, and often misapplied, which can leave practitioners feeling exposed and patients / families feeling frustrated and, perhaps, push them towards other legal processes to get answers. This course will help attendees to understand the relationship between the statutory and professional duties of candour, in the wider context of the importance of good communication and the reasons why complaints and claims are made. We will look at each element of the legal test for a notifiable safety incident to trigger the duty of candour, and the next steps that are necessary, reflecting in particular on the importance of distinguishing fault and blame as irrelevant to the duty of candour. Examples will be given of regulatory consequences where the duty of candour has not been implemented appropriately and we will discuss the part of the duty of candour that requires an apology to be given, and consider the legal implications of this as well as good practice and examples to avoid where a poor apology has made things worse. Who should attend: Health and social care professionals, front line practitioners and managers, including those dealing with complaints and claims. Key learning objectives Understanding the importance of communication in a clinical context and the role of the duties of candour Appreciating the difference between the statutory and professional duties of candour The key elements of the statutory duty of candour for a notifiable safety incident, and the overarching duty to be open and transparent Understanding the process when the duty of candour is triggered Understanding the relationship between the duty of candour and fault / blame / liability The legal implications of an apology and what makes a good apology Register

Any staff with responsibility for implementing the duty of candour and/or PSIRF and those responsible for quality; safety; clinical governance; safety investigations; complaints; CQC compliance; or patient experience/ involvement would benefit from attending this one-day training. The course will provide participants with an in-depth knowledge and understanding of how to not only comply with the duty of candour and the Patient Safety Incident Response Framework (PSIRF), but to do so in an emotionally intelligent way, with empathy and compassion for all involved. Practical guidance on complying with the regulations and guidance The “grey areas” and what people most often get wrong Using emotional intelligence to understand the difficult emotions experienced by patients/those closest to them and staff following patient safety incidents What empathy and compassion mean in practice Handling difficult and emotive conversations well Making a meaningful apology How Duty of Candour and PSIRF work alongside other policies and procedures including complaints; litigation; Martha’s Rule and the soon to be introduced “Hillsborough Law” How the new “Harmed Patient Pathway” can help you get it right 7 How to ensure communication moves beyond compliance and frameworks but remains emotionally intelligent and personal Register hub members receive a 20% discount. Email [email protected] for discount code.

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Since launching in 2019, the hub now has over 19,000 resources, 8000 members from 98 countries, and we have had over 1.7million visits and over 3 million page views. In this blog, the hub's Editor, Samantha Warne, reflects on our most popular pieces of original content published on the hub in 2025. These are a mix of our original blogs, interviews and resources shared by patients, frontline staff and leaders in patient safety. It shows the breadth of content we have on the hub, including collaborations we have with other organisations and people, patient stories, the challenges healthcare staff face and insights from an international perspective. Keep an eye out for more end of year content from our team at Patient Safety Learning, including a policy roundup. 1 Speaking up for patient safety: A new interview series about raising concerns and whistleblowing At the beginning of 2025, we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive. In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life, or from those who work to help staff raise concerns through their own experience and advice. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. One thing that we often hear is the common tactics that some organisations use when dealing with people who speak up or blow the whistle. To highlight these tactics we created 'The whistleblower playbook' infographic, illustrating how some organisations respond to staff raising concerns about patient safety. 2 Patient Safety Learning: World Patient Safety Day 2025 The theme of this year’s World Patient Safety Day was ‘Safe care for every newborn and every child’. In a blog to mark the day, Patient Safety Learning reflected on this theme, highlighting the World Health Organization goals for this event and shared a series of guest blogs from healthcare professionals, patient campaigners, organisation leaders and safety experts on the hub, each exploring a different aspect of the theme. 3 Duty of Candour: Frequently Asked Questions Through the joint efforts of the Patient Safety Management Network in collaboration with experts from the Care Quality Commission (CQC) and NHS Resolution, these FAQs were produced to address the most pressing concerns about Duty of Candour. The collaborative approach ensured that the FAQ tool reflects the insights and expertise of those actively engaged in the regulation, implementation and oversight of candour practices. This is an example of the ‘how to’ resources that Patient Safety Learning, the networks and partners are developing to guide the implementation of good practice in patient safety. 4 Working in a toxic culture: Doing the right thing is often the least popular and hardest thing to do… In this blog, Clare Wade, Patient Safety Learning's Director, draws attention to the impact toxic cultures have on staff and how, sadly, most often nothing is done about it. Clare shares her own personal reflections from past experiences in her career. There is a clear link between toxic cultures and patient safety, and while there are no easy answers these behaviours must be acknowledged, challenged and cured if the NHS is to survive. 5 Top 10 priorities for patient safety in surgery Patient Safety Learning asked the Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top tips for patient safety in surgery to share on the hub. They came up with three useful resources for surgeons and surgical trainees: Top 10 priorities for patient safety in surgery Top 10 tips for surgical safety: Think Safety, think SEIPS Top 10 patient safety tips for surgical trainees These resources are an example of the effectiveness of collaborating with partners such as the RCSEd to develop resources that will help practitioners better understand patient safety and how they can access resources to help reduce avoidable harm. 6 What do Patient Safety Incident Response Plans tell us about how the NHS is approaching safety investigations? From Autumn 2023, NHS organisations in England began to change the way they investigated cases of avoidable patient harm and near misses, introducing the Patient Safety Incident Response Framework (PSIRF). As part of PSIRF, organisations are required to create and publish a Patient Safety Incident Response Plan. Drawing from a sample of 13 Patient Safety Incident Response Plans, Patient Safety Learning considers what they can tell us about the implementation of PSIRF. This is intended to support organisations who are currently reviewing their PSIRPs to ensure that their prioritisation of investigations and reviews meets national guidance and provides an evidence based rationale to inform patients, families and staff. 7 Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect? Post-SSRI Sexual Dysfunction (PSSD) is a long-term adverse effect of Selective Serotonin Reuptake Inhibitors (SSRIs), a type of antidepressant medication. In this opinion piece, Harriet Vogt, Patient Safety Partner at NHS Sussex Integrated Care Board, outlines the need for recognition and research into PSSD to allow patients to make truly informed choices when considering SSRIs. She argues that while the health system is beginning to recognise the value of placing patients at the heart of efforts to improve safety, this focus on listening is rarely given to individual patients who express concern about the impact of their medication or treatment. 8 SEIPS in action In this blog, Patient Safety Learning’s Associate Director Claire Cox shares a video with associated training resources developed for the Patient Safety Management Network Symposium. Claire explains how they used it to facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. It's now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action. 9 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist working in an ambulance service, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 10 Exploring the barriers that impact access to NHS care for people with ME and Long Covid For healthcare to be safe it needs to be accessible. But what does this look like for people with ME (myalgic encephalomyelitis) and Long Covid? This blog from #ThereForME explores the barriers that impact access to NHS care for people with ME and Long Covid. 11 Bridging the gap between policy and practice: A Safety-II approach to patient transfers In this anonymous blog, a patient safety lead shares how they implemented a Safety-II approach to patient transfers, highlighting the disconnect between 'work as imagined' and 'work as done', and the importance of listening to frontline voices. The author worked with subject matter experts to develop a visual, easy-to-use risk stratification tool designed to support decision making on the appropriate level of clinical escort required for safe transfer. While the tool is applicable to most adult acute settings, certain areas—such as maternity, paediatrics, and specialist theatres—require their own local adaptations. This could have wider applicability to a range of different clinical settings. 12 Evidencing the impact of culture on patient safety – a new tool from MNSI In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. 13 Improving safety in healthcare—is quality improvement the answer? The healthcare landscape is evolving rapidly, with increasing complexity in patient needs, technological advancements and regulatory requirements. As this complexity grows, ensuring patient safety remains a top priority. One of the most widely adopted strategies for enhancing safety is quality improvement (QI), but is QI the right tool for navigating and improving safety in an increasingly complex health system asks Patient Safety Learning’s Associate Director Claire Cox. Claire reflects on the need for a safety management systems approach, as highlighted in Healthcare Safety Investigation Branch (HSSIB) reports, essential to embedding a proactive, system-wide perspective on patient safety. Additionally, aligning QI efforts with patient safety standards and Patient Safety Learning standards ensures a structured, evidence-based approach to mitigating risks and driving sustainable improvements. 14 Preventing patient falls in healthcare settings: The need for fall risk assessment Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. 15 Patient barcode scanning in NHS hospitals: safety, snags and workarounds. A nurse’s perspective As a nurse working in the NHS for over 25 years, Claire Cox has seen first-hand how technology has transformed patient care. One of the biggest changes in recent years has been the introduction of electronic scanning. In this blog, Claire talks about the opportunities to improve patient safety and the risks associated with the use of barcode technology in healthcare. 16 Corridor care and patient safety Corridor care can broadly be defined as care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity. It is increasingly being used in the NHS as demand for emergency care grows and hospital departments struggle with patient numbers. In a series of blogs for the hub, we shine a light on some of the key patient safety issues surrounding corridor care. Share your experiences on the hub I would like to take this opportunity to thank everyone who has contributed to the hub this year. the hub is a platform for everyone with a professional or personal interest in patient safety to share and learn from one another. Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? Or are you a patient and would like to share your experience to improve patient safety? We would love to hear from you and share on the hub your stories. This can be done anonymously if you prefer. If you are a member, you can share directly on the hub or please contact [email protected] to discuss further. See all our 'Top picks' Our ‘Top picks’ are collections of resources, blogs and tools around a specific topic or theme. You can view them all here: Top picks.

The forthcoming Public Office (Accountability) Bill 2025, known informally as ‘Hillsborough Law’, presents a landmark shift in public sector accountability. The Bill introduces a new ‘duty of candour’ on public sector officials and a legal duty to assist in inquests and public inquiries, backed by criminal sanctions. Joanna Lloyd, Carlton Sadler and Priyesh Patel are experts in advising organisations engaged in inquests and public inquiries. Join us as we explore what these reforms mean in practice for healthcare providers and local authorities, and the likely impact of expanding legal aid for bereaved families to all inquests where a public authority is an interested person. Register

The course will provide participants with an in-depth knowledge and understanding of how to not only comply with the duty of candour and the Patient Safety Incident Response Framework (PSIRF), but to do so in an emotionally intelligent way, with empathy and compassion for all involved. Practical guidance on complying with the regulations and guidance The “grey areas” and what people most often get wrong Using emotional intelligence to understand the difficult emotions experienced by patients/those closest to them and staff following patient safety incidents What empathy and compassion mean in practice Handling difficult and emotive conversations well Making a meaningful apology How Duty of Candour and PSIRF work alongside other policies and procedures including complaints; litigation; Martha’s Rule and the soon to be introduced “Hillsborough Law” How the new “Harmed Patient Pathway” can help you get it right 7 How to ensure communication moves beyond compliance and frameworks but remains emotionally intelligent and personal Register hub members receive a 20% discount. Email [email protected] for discount code.

This course will explain and discuss the statutory duty of candour in principle, in practice, and in context, using real examples of good and poor practice. Openness, trust and good communication are at the core of the relationship between health and care professionals and their patients / families. But the duty of candour is widely misunderstood, and often misapplied, which can leave practitioners feeling exposed and patients / families feeling frustrated and, perhaps, push them towards other legal processes to get answers. This course will help attendees to understand the relationship between the statutory and professional duties of candour, in the wider context of the importance of good communication and the reasons why complaints and claims are made. We will look at each element of the legal test for a notifiable safety incident to trigger the duty of candour, and the next steps that are necessary, reflecting in particular on the importance of distinguishing fault and blame as irrelevant to the duty of candour. Examples will be given of regulatory consequences where the duty of candour has not been implemented appropriately and we will discuss the part of the duty of candour that requires an apology to be given, and consider the legal implications of this as well as good practice and examples to avoid where a poor apology has made things worse. WHO SHOULD ATTEND Health and social care professionals, front line practitioners and managers, including those dealing with complaints and claims. KEY LEARNING OBJECTIVES Understanding the importance of communication in a clinical context and the role of the duties of candour Appreciating the difference between the statutory and professional duties of candour The key elements of the statutory duty of candour for a notifiable safety incident, and the overarching duty to be open and transparent Understanding the process when the duty of candour is triggered Understanding the relationship between the duty of candour and fault / blame / liability The legal implications of an apology and what makes a good apology Register hub members receive a 20% discount. Email [email protected] for discount code.

Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend: Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Facilitator: Jo Perruzza is a former mental health nurse and has been a clinician, a clinical leader and a senior manager in mental health provider organisations. With a passion for patient safety and an expert in psychological safety she brings experience of leading internal and external investigations. hub members receive a 20% discount. Email [email protected] for discount code.

This course will explain and discuss the statutory duty of candour in principle, in practice, and in context, using real examples of good and poor practice. Openness, trust and good communication are at the core of the relationship between health and care professionals and their patients / families. But the duty of candour is widely misunderstood, and often misapplied, which can leave practitioners feeling exposed and patients / families feeling frustrated and, perhaps, push them towards other legal processes to get answers. This course will help attendees to understand the relationship between the statutory and professional duties of candour, in the wider context of the importance of good communication and the reasons why complaints and claims are made. We will look at each element of the legal test for a notifiable safety incident to trigger the duty of candour, and the next steps that are necessary, reflecting in particular on the importance of distinguishing fault and blame as irrelevant to the duty of candour. Examples will be given of regulatory consequences where the duty of candour has not been implemented appropriately and we will discuss the part of the duty of candour that requires an apology to be given, and consider the legal implications of this as well as good practice and examples to avoid where a poor apology has made things worse. Who should attend Health and social care professionals, front line practitioners and managers, including those dealing with complaints and claims. Key learning objectives Understanding the importance of communication in a clinical context and the role of the duties of candour. Appreciating the difference between the statutory and professional duties of candour. The key elements of the statutory duty of candour for a notifiable safety incident, and the overarching duty to be open and transparent. Understanding the process when the duty of candour is triggered. Understanding the relationship between the duty of candour and fault / blame / liability. The legal implications of an apology and what makes a good apology. Register hub members receive a 20% discount. Email [email protected] for discount code.

This course will explain and discuss the statutory duty of candour in principle, in practice, and in context, using real examples of good and poor practice. Openness, trust and good communication are at the core of the relationship between health and care professionals and their patients / families. But the duty of candour is widely misunderstood, and often misapplied, which can leave practitioners feeling exposed and patients / families feeling frustrated and, perhaps, push them towards other legal processes to get answers. This course will help attendees to understand the relationship between the statutory and professional duties of candour, in the wider context of the importance of good communication and the reasons why complaints and claims are made. We will look at each element of the legal test for a notifiable safety incident to trigger the duty of candour, and the next steps that are necessary, reflecting in particular on the importance of distinguishing fault and blame as irrelevant to the duty of candour. Examples will be given of regulatory consequences where the duty of candour has not been implemented appropriately and we will discuss the part of the duty of candour that requires an apology to be given, and consider the legal implications of this as well as good practice and examples to avoid where a poor apology has made things worse. WHO SHOULD ATTEND Health and social care professionals, front line practitioners and managers, including those dealing with complaints and claims. KEY LEARNING OBJECTIVES Understanding the importance of communication in a clinical context and the role of the duties of candour. Appreciating the difference between the statutory and professional duties of candour. The key elements of the statutory duty of candour for a notifiable safety incident, and the overarching duty to be open and transparent. Understanding the process when the duty of candour is triggered. Understanding the relationship between the duty of candour and fault / blame / liability. The legal implications of an apology and what makes a good apology. Register hub members receive a 20% discount. Email [email protected] for discount code.

The Duty of Candour, introduced in 2014, requires healthcare professionals to be honest with patients when things go wrong. They must also be open with colleagues, employers, and relevant organisations and participate in reviews and investigations when requested. Our training developed with industry experts - Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. The training focuses on empathy and compassion and equips you to navigate the Duty of Candour effectively. The training will cover the following areas: Overview of the Duty of Candour Legislation Requirements and expectations of the Care Quality Commission (CQC) The importance of empathy and compassion in implementing the Duty of Candour Balancing compliance with the human side of the duty Empowering and supporting individuals responsible for the Duty of Candour Understanding the emotional component behind the duty Providing evidence of compliance with the legislation Impact of meaningful interactions on patients, families, and colleagues Avoiding harm when providing an apology Price: £245 + VAT per person Discounted rate for bookings of 3 or more: £220 + VAT per person Event details and booking page Discount Code – Early bird 10% discount code valid until 2 April Hub discount code: DoC-Hub-10 Alternatively, the training can be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing [email protected]

This popular training day covers the must-dos and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices: £245 (plus vat) per person. Discounted rate for bookings of 3 or more: £220 (plus vat) per person AvMA is offering a 10% discount for delegates referred via the hub. Use code: DoC-Hub-10 Register for the training Training can also be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing [email protected]

Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm. Hi Derek, thank you for speaking to me today. Firstly, can you describe the attitude of managers and senior clinicians at the Trust towards your family after Harry’s death? Leaders and staff at EKHUFT were closed off to us from the beginning. At every step, it very much felt like they were saying, “There’s nothing to see here.” Looking back, I realised very soon after Harry’s birth that we needed to start documenting what was happening because the Trust was not being honest. When I arrived at the hospital, we asked a nurse for the name of the doctor who had overseen my daughter-in-law Sarah’s care, and who my son Tom had expressed concerns about. The nurse told us, “You can’t have that information, it’s confidential.” At that point I started photographing Sarah’s notes as I wanted to make sure we had a record. Once the Trust’s internal investigation into Harry’s death started, they told us they couldn’t talk to us while it was ongoing. When we said that we wanted to contribute, we were totally shut out. It was upsetting that the investigation was used as a reason to avoid engaging with us, but we allowed them to get on with it for four months until they released the root cause analysis report into Harry’s death. We were offered a meeting at the Trust in March 2018, so we requested to see the report beforehand. After initially saying they would just show us the report at the meeting, they eventually agreed to send us a hard copy by post, saying they couldn’t send it by email. When we finally got to read it, the report was full of errors and just didn’t add up. At the meeting, it became clear that we knew more about their report than the consultants in the room did. They were totally in denial that Harry’s death could have been avoided and were told that there was no way it needed to be referred to the Coroner. I couldn’t put my finger on exactly what was going on, but I just knew something was wrong with the way Harry’s death was being treated. I began to suspect that what happened to us had happened to many, many families before us—the Trust had avoided taking responsibility and failed to make referrals to the Coroner for years, saying that baby deaths were ‘expected’. Their argument that Harry’s death was expected was that they didn’t have to factor in anything that happened more than 24 hours before they withdrew life support. Later we found that, on their internal notes, Harry’s death was described as an unexpected outcome. It is undoubted that there had been a cover up in the maternity department for many years and I don’t think anyone would deny that now. To quote the Kirkup report, “This pattern of behaviour by the Trust, clearly evident in this case, recurred in many others that we examined. It included denying that anything had gone amiss, minimising adverse features, finding reasons to treat deaths and other catastrophic outcomes as expected, and omitting key details in accounts given to families as well as to official bodies. Although we did not find evidence that there was a conscious conspiracy, the effect of these behaviours was to cover up the truth.” When it came to Harry’s inquest, the Trust didn’t expect or want it to happen and were obstructive throughout the process. When the Coroner suggested that it should be an Article 2 inquest, the Trust disputed it, arguing that it didn’t even come close to the criteria, which was obviously untrue. If the hospital had been upfront with us about what had happened in Harry’s case right at the beginning, we would have been able to forgive the staff and move on. But they didn’t do that. Instead, it felt like a battle from day one and I had to force myself into areas they did not want me to look. At times, I have been painted by Trust staff as a trouble maker. The Trust’s Chief Executive had to apologise to me after writing to our local MP Sir Roger Gale that I was trying to “undermine the reputation of the entire hospital.” This was in response to a letter Roger wrote to the Trust when I raised concerns that they were rating their maternity department 10/10. When NHS Resolution finally investigated, they found that the Trust was actually only scoring 6/10, and the Trust had to repay the large rebate the maternity department had been awarded for their self-audited high score. How were you able to keep pushing for answers in the face of the Trust’s attitude to your family? As Harry’s grandfather, I was one step removed from the situation. That enabled me to stand back and look at what was going on, to ask questions and raise issues that newly bereaved parents would struggle to raise. I call it ‘the grandparent effect’, and it made a huge difference in this case. I was able to be an advocate for Harry’s parents Sarah and Tom, who were obviously severely affected by losing their baby. I looked into the various reviews and audits the maternity unit had been through, and kept uncovering more evidence. The Trust was lacking in so many areas—I dug and dug and with every layer of the onion I took off, I found more rot beneath. I feel it’s so important to share what we’ve been through and what we managed to achieve by not backing down. Once the inquest was over, I learned how to set a website up and published Harry’s Story. I wanted to collect all the information and evidence we had gathered in one, accessible place. I’m still working with EKHUFT now, trying to help them make improvements and deliver Bill Kirkup’s Reading the Signals report, but there’s still such a long way to go. How easy was it to find out which organisations you could refer your concerns about Harry's care to? The Trust left us to our own devices, so I took any route I could to try and find out the truth about what happened to Harry. I went to many organisations such as AvMA and kept being told, “Yes, we hear of these things happening, have you tried X organisation?” We were being sent from pillar to post, but kept trying to find out how we could take it further. I happened to have a relative working for an unrelated department of the Care Quality Commission (CQC) and she recommended that I make a report to the CQC. It was an uphill struggle to be heard by them and I initially found that they really didn’t want to engage with me. They eventually, after 10 months, got back to me saying there was nothing for them to investigate, and at that point I replied by copying in Professor Ted Baker, then Chief Inspector at the CQC. At that point, things started to change! Although the CQC eventually started to engage with us, I’m struck by how we were expected to go to them. We were invited to a meeting in London—we paid our own train fares and Tom had to take a day off work, which is difficult as a teacher. Were there individuals who engaged with you and your family well? What was it about their response that was positive? The individuals who engaged well with us were honest and listened to what we had to say. The Director of Maternity for Healthcare Safety Investigation Branch (HSIB), Sandy Lewis, was so helpful. She would call me with regular updates and communicate how much Harry’s case mattered to her. I could sense her commitment to seeing change. HSIB in general were exceptionally helpful, but there were hurdles to overcome there too. Harry was born in November 2017, but HSIB only had the remit to investigate cases from April 2018. I spoke with various individuals at the organisation including the medical director, who was keen to take on Harry’s case as he recognised its seriousness. They eventually found a way to take it on, by carrying out a learning investigation rather than a maternity investigation. The coroner’s officer was also fantastic—she listened and was so encouraging. I was constantly emailing new evidence over and in every email I would apologise for the extra reading, but she was so affirming and would say, “Send me whatever you want, I’ll make sure the Coroner sees everything.” The Coroner was also very respectful and told me what a difference I was making; after Harry’s inquest, he said to me, “You’ve done a good thing. Without you this wouldn’t have come before me Mr Richford.” I get very emotional thinking about it even now. You and your family suffered a terrible loss. How did the responses of the Trust following Harry's death affect your family further? We’ve discussed this as a family before. The loss of Harry was on one level, but the denial and the way we were treated by the Trust was almost worse—I would say it added at least 50% to the trauma. The approach taken by the Trust was to deny, delay and defend, and the damage that has caused us as a bereaved family is immense. Have you seen any positive change in how bereaved families are treated by the system? One positive move is that I was recently involved in the panel to appoint the new Chief Midwife for England. It was a privilege to be part of the process, and it felt like being told, “You are welcome at this table.” So maybe we are making a difference, but progress is far too slow. For patients and families, the cost of engaging is far more than it should be, both emotionally and financially, as I mentioned earlier. It’s only because I run my own business that I was able to do what I did. I spent hours and hours investigating Harry’s death. We need the NHS to actively help make it easier for people to engage, and to overcome barriers such as financial cost and working hours. During our first meeting with the CQC, I realised that we had access to information that they didn’t—for example, they weren’t aware of a Royal College of Gynaecologists (RCOG) report about EKHUFT that was referenced in the Trust’s board papers. I had done the legwork to draw all the evidence together, which none of the statutory organisations had done. Eventually the CQC agreed to prosecute the Trust for unsafe care and treatment. The prosecution was successful, and the evidence we had collected contributed significantly to that. Lots of families whose babies have died due to harm in or after labour get in touch with me, and their experiences tell me that bereaved families are still being treated with suspicion and a lack of care. I recently discovered that some of the families who took part in the EKHUFT Kirkup investigation—and whose cases featured in the final report—are having to go through a whole new investigation process to claim compensation through NHS Resolution. That means reopening case notes and revisiting yet again the harrowing events that led to the deaths of their babies. The level of trauma this will cause for parents who had hoped the inquiry would bring the justice they need is huge. It is yet another example of how the system is not designed to support victims of harm, and how it fails to place compassion and dignity for patients and their families at the centre of pathways and processes. What do we still need to see change in how organisations respond to families when a loved one dies due to avoidable harm? We need people like me (but not me!) at the top of the NHS—‘real-life’ people who can represent the patient perspective at local board level and right up to the top of the NHS. Most of the people who are currently in leadership have only ever worked for the NHS or have worked there for years, and they don't know any other way of working. There’s an extent to which NHS leaders are institutionalised—they accept the foibles of the system as normal. In the face of serious patient safety concerns many seem to simply say, “No, that’s not what goes on here.” We need leaders who are upfront and honest and will say, “We made a mighty mistake and we’re sorry. We’ll do something about it.” We also need to see trust leaders being held to account. During our experience, we heard the phrase, “the Trust has done this,” a lot, with no individuals taking ownership of actions and decisions. Ultimately, people in leadership were responsible for so many of the lies we were told, but they never had to answer for that. In any other business, people would be held to account, but I am concerned that NHS leaders are allowed to do whatever they want. If this doesn’t change then very little else will. You can read more about the investigations into Harry’s death and Derek’s work to improve the safety of maternity care on the Harry’s Story website.

In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report. In the report Broken trust: making patient safety more than just a promise, PHSO examines 22 NHS complaints cases where patents died due to avoidable errors.[1] After analysing these cases, they have identified four broad themes of clinical failing leading to avoidable deaths: failure to make the right diagnosis, delays in providing treatment, poor handovers between clinicians and failure to listen to the concerns of patients or their families. The report also considers the issue of compounded harm, the additional harm that people experience when interactions following patient safety incidents feel closed and defensive. From their findings, they identify the following scenarios that are likely to contribute to compounded harm: 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. Considering these findings, the PHSO make several recommendations at the end of their report aimed at tackling these issues. Patient Safety Learning’s reflections We welcome this new report from the PHSO. Sadly, the patient safety themes that it raises are all too familiar. Avoidable harm resulting from delays in providing treatment and failing to listen to patient concerns come up time and time again in reports into patient safety incidents. As do failures to respond appropriately after harm occurs, such as poor-quality investigations that do not result in learning or improvement. We see many of the issues that this report raises also feature prominently in recent reports into major patient safety scandals, such as those in East Kent and Shrewsbury and Telford.[2] [3] Below we share our thoughts specifically on the report’s recommendations for change. Investigations and PSIRF The report highlights that while there have been some positive developments in seeking to improve investigations in the NHS, and welcomes the introduction of the new Patient Safety Incident Response Framework (PSIRF), there remains “a gap between the welcome rhetoric in PSIRF guidance documents and the defensive behaviours from some NHS leaders we still see in our casework”.[1] PHSO note concerns about the additional flexibility that PSIRF offers, suggesting that this may present a risk at Trusts with poor cultures who do not carry out investigations when they should. In response to these concerns, it makes recommendations around the need for close monitoring of the rollout of PSIRF by Integrated Care Boards and Board members who lead on PSIRF in their organisations. Patient Safety Learning agrees with these recommendations. Although there are many welcomed elements to PSIRF, its success to a large part will depend on having the right organisational leadership and resources to support the transition to this new approach to investigations. We believe that this initiative should be judged on its implementation in supporting culture change and in translating learning from investigations into reduction of avoidable harm. Duty of candour and support for patients Duty of candour is intended to ensure that healthcare providers are open and transparent with the public. In legislative terms, it sets specific requirements for organisations to follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.[4] PHSO state that from evidence gathered through their casework that they find that this duty is not always implemented as it should be and state they think this requires more attention and monitoring. The report recommends that: “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.”[1] We agree with this recommendation. As part of this reviewing problems with compliance, we believe that there are also broader questions that also need to be addressed concerning how the implementation of this is monitored and what remediation and redress is available to patients and the families when these obligations are not met. The report also notes that despite a statutory duty for local authorities to commission NHS complaints advocacy, these services can be limited and are often restricted to helping people navigate the NHS complaints process. It recommends that: “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 seek answers after an incident.”[1] At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. Access to advocacy services is an essential part of this, helping address the power imbalance between patients and the healthcare system when things go wrong. We fully support this recommendation. Complex and fragmented patient safety landscape Discussing the national patient safety picture, the report points to the confusing landscape of patient safety roles and responsibilities that currently exist. It highlights how organisational functions can often overlap, creating confusion over who does what and undermining patient safety leadership. It recommends that: “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”[1] This is not a new concern. Five years ago, in its report Opening the door to change, the Care Quality Commission (CQC) raised similar issues, noting the lack of clear understanding of how patient safety is organised nationally and who is responsible for what tasks.[5] The Professional Standards Authority for Health and Social Care also pointed this out in their report last year, Safer care for all, stating: “For too long, individual organisations with different and specific remits have been expected to work together to address workforce and patient and service user safety issues. This approach is structurally flawed as there is generally no accountability for joint working and collaboration; bystander apathy and differing organisational priorities also present significant barriers. Everyone understandably looks at the problem through the lens of their own remit, but no one has the overview.”[6] Patient Safety Learning agrees with the PHSO’s assessment of this problem. We also highlighted this issue in our report last year, Mind the implementation gap. As stated then, we believe that with the current fragmented approach to patient safety leadership, the Secretary of State for Health and Social Care lacks the levers and means to fundamentally improve our national approach to patient safety.[7] Workforce strategy The report also makes a recommendation around the Government producing its long-term workforce strategy and sets out what the PHSO think this document must include, which was subsequently published the day after the report. Workforce shortages and pressures in the NHS and social care have serious implications for patient safety. We will be looking closely detail of the new NHS Long Term Workforce Plan, in the coming days and weeks from this perspective.[8] Patient safety as a core purpose of health and social care In this report, PHSO make the case that patient safety must be a consistent priority over the long term. It recommends that the Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority. We agree with this recommendation. Patient Safety Learning believes that the persistence of avoidable harm is the result of our failure to address the complex systemic causes that underpin it. In our report A Blueprint for Action we set out the need for a transformation in approach to patient safety. This sets out how too often patient safety is typically seen a strategic priority, which in practice will be weighed (and inevitably traded-off) against other priorities.[9] To transform our approach to this it is important patient safety is not just seen as another priority, but as a core purpose of health and care. This applies to all parts of the system. We need everyone politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders involved in this effort. References PHSO, Broken trust: making patient safety more than just a promise, 29 June 2023. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. Public Health England, Duty of candour, Last updated 5 October 2020. CQC, Opening the door to change: NHS safety culture and the need for transformation, December 2018. Professional Standards Authority for Health and Social Care, Safer Care for All: Solutions from professional regulation and beyond, 6 September 2022. Patient Safety Learning, Mind the implementation gap: the persistence of avoidable harm in the NHS, 7 April 2022. NHS England, NHS Long Term Workforce Plan, 30 June 2023. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019