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This article provides an overview of an Adjournment Debate in the House of Commons discussing the implementation of recommendations from the Review of patient safety across the health and care landscape. The debate focused on the proposed transfer of functions of the Health Services Safety Investigations Body (HSSIB) to the Care Quality Commission (CQC). What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on. Review of patient safety across the health and care landscape On 7 July 2025, the Department of Health and Social Care (DHSC) published the findings of the Review of patient safety across the health and care landscape in England, chaired by Dr Penny Dash. The review looked at six specific organisations that were established to either assure—or contribute to improving—the safety of care, while also making reference to the wider landscape of organisations influencing quality of care. Its final report issued a number of recommendations, which included several proposed changes organisational changes: Transferring the functions of the HSSIB to the CQC. Closing Healthwatch England, moving its functions to a new directorate for patient experience in DHSC. Combining the statutory functions of Local Healthwatch relating to healthcare with involvement and engagement functions in Integrated Care Boards (ICBs), with social care functions transferred to local authorities. Transferring the hosting arrangement of the Patient Safety Commissioner for England to the Medicines and Healthcare products Regulatory Agency (MHRA). Closing the National Guardian’s Office, transferring its functions to NHS England. Contributions from Bernard Jenkin MP This debate was tabled by Sir Bernard Jenkin MP. He made a number of points concerning the transfer of the functions of the HSSIB to the CQC. He said that safety management is intrinsic to safety and public confidence in other safety-critical activities, such as aviation, but is alien to NHS culture. He asked without HSSIB, which independent body will promote a coherent understanding of safety system management in health, and who is to hold the NHS and Government to account for safety failures. He stated his view that neither the National Quality Board (NQB) nor the CQC should control investigations. He noted that the Air Accidents Investigation Branch cannot be prevented from making independent recommendations by the Civil Aviation Authority, the Transport Secretary or airlines themselves. He asked therefore why should the NQB, which will be subject to political direction, be allowed to decide what safety recommendations should be made and what should be investigated. He highlighted that the Dash Review incorrectly states that HSSIB was originally established to look at specific cases or incidents of severe harm, but it has since broadened its work into making more systemic recommendations. He noted that it was always intended by Parliament that HSSIB should make systemic recommendations arising from the investigation of specific incidents or groups of incidents. He questioned whether the CQC in its role as regulator and compliance enforcer could also be an independent investigator. He said that the Dash Review also says that the CQC internal successor should collaborate through the NQB to agree the scope of any investigations it carries out and agree the recommendations. He described this proposal as a direct attack on the independence of investigations. He stated that the Dash Review fails to look at the comparative cost of HSSIB investigations versus the cost of public inquiries. He noted that HSSIB at the moment only costs £6.3 million per year. He suggested that to save money the Secretary of State should request that HSSIB conducts far more investigations into matters which he thinks are important, provided that he also provides the funding for the necessary capacity. An example he gave was that HSSIB, has conducted eight investigations into mental health suicides since 2023. Each was completed in a few weeks or months, costing a total of £850,000. In comparison, he noted that the Lampard inquiry into the Essex partnership university trust, also investigating patient safety concerns in mental health, is expected to cost more than £5 million. Contributions from other MPs Jeremy Hunt MP highlighted concerns that moving HSSIB into the CQC, which has a legal duty ot act on information it receives, creates a worry for people talking to HSSIB that the information that they give to it may no longer be protected as they currently are. Anna Dixon MP noted that recent inquiries into maternity services, infected blood and pelvic mesh underline that professionals and those working inside the NHS must be able to speak freely when things go wrong in order to learn lessons and that that this is only possible with an independent investigating organisation. James Naish MP stated his concerns about the abolition of Healthwatch. He noted that there is a strong desire to see independent patient voice maintained outside the system and that Healthwatch was established due to issues within health structures, including, notably, the Mid Staffordshire scandal. Jim Shannon MP emphasised the need for lessons learned on data collection, streamlined complaints and patient safety culture are shared with the Northern Ireland Assembly Minister, Mike Nesbitt, as health is a devolved matter. Rachael Maskell MP stated that there was a wider issue, which she felt that the Health Bill completely misses, around the accountability systems within the NHS. She stated that these reforms are not going to deliver accountability, but will weaken it, and as a result we will see more requests for investigations into patient safety. Government response Responding to this debate on the Government’s behalf, Preet Kaur Gill MP, Parliamentary Under-Secretary of State for Health Innovation and Safety, made the following points: The investigation function within the CQC will be expert and full time, and it will be able to conduct investigations in the same cheap and quick way that HSSIB does now. In future, there will be the same opportunity to use the CQC investigation function instead of needing a public inquiry as there is currently with HSSIB. The criteria for disclosing protected information outside the investigative function are set out in the Bill. Those criteria set a high bar for any disclosure—as high as it is currently with HSSIB—and the CQC will publish further guidance setting out much more detail. As the Bill sets out, the CQC will appoint a responsible person who will decide whether the case matches the criteria and whether it warrants information sharing outside the safe space. That person is likely to be the CQC’s chief executive officer. Dash reforms are not about saving money; they are about strengthening patient safety and patient voice across the system. She stated that the abolition of HSSIB and the transfer of its functions to the CQC play an important part in making the system of patient safety much more effective. The NQB has been revitalised by giving it a stronger role in providing a single, authoritative view of quality across the system. That will help reduce duplication, bring greater clarity to recommendations and ensure that effort is focused where it has the greatest impact. The purpose of these reforms is not to weaken investigation, but to strengthen the link between investigation, learning and improvement. The investigation function in the CQC will have autonomy to launch investigations into any part of the health system and will be able to make recommendations on any part of the system, just as HSSIB does now. There will be no barrier to an investigator finding out that CQC inspections are causing unintended harm. The Health Bill also allows for the investigation function to make recommendations to the CQC in its report, and the CQC would be legally required to respond to such recommendations. How to watch the debate You can watch the full debate here and find the full transcript on Hansard at the bottom of this page. Related reading Review of patient safety across the health and care landscape: Patient Safety Learning's response (15 July 2025) The future of the Health Services Safety Investigations Body: a recent discussion at the Patient Safety Management Network Is the patient voice fading? Reflections on patient safety in a changing NHS

The National Maternity and Neonatal Investigation is a landmark moment. Its recommendations, published on 30 June 2026, aim to drive urgent improvements in maternity and neonatal care and safety, reduce inequalities and deliver justice and accountability for families. Every maternity professional needs to understand what this means for their organisation - and act on it. Browne Jacobson have assembled a panel of leading legal, clinical and patient voices to help you do exactly that. During this interactive session, you will gain a clear understanding of the investigation’s key findings and recommendations, insight into what they mean for your organisation in practice and actionable steps you can take back to your team straight away. The session will be chaired by Browne Jacobson’s Kelly Buckley, Partner, and Amelia Newbold, Risk Management Lead, who will provide expert legal analysis and discuss the implications with our panel: Sarah Land - Co-Founder and CEO of the charity Peeps, and mum to Heidi. Sarah set up Peeps to support parents, families and friends affected by HIE (Hypoxic-Ischaemic Encephalopathy). She brings a powerful patient and family perspective, advocating for meaningful engagement with affected families throughout the process of change. Dr Denise Chaffer - CBE FRCN, a highly experienced midwife and healthcare executive specialising in clinical risk and patient safety. Denise is the former Director of Safety and Learning for NHS Resolution and Chair of the Independent Review of Maternity and Neonatal Service at Swansea Bay. She brings unparalleled insight into what effective implementation of systemic recommendations actually requires on the ground. Ms Jyoti Sidhu - Consultant Obstetrician and Gynaecologist at Royal Berkshire NHS Foundation Trust, offering a frontline clinical perspective on the realities of delivering change within a busy NHS trust. Lorraine Cardill - Director of Midwifery and Neonatal Services at George Eliot Hospital NHS Trust and South Warwickshire University NHS Foundation Trust, offering a frontline clinical perspective on the realities of delivering change within two busy NHS trusts. You will have the chance to share experiences and best practice with peers and put your questions directly to the panel. Join this important conversation by registering your free space here. Register

On the 23 June 2025 the Secretary of State for Health and Social Care (DHSC) announced a rapid, national, independent investigation into NHS maternity and neonatal services. This final report highlights key areas of concern, identifies barriers to delivering change and sets out a robust package of eight recommendations aimed at delivering long-term systemic and cultural transformation in maternity and neonatal care. It builds on an interim report published in February 2026. The report makes eight recommendations aimed to address the systemic problems identified in this report: The Department of Health and Social Care (DHSC) must create a statutory Maternity and Neonatal Commissioner, introducing legislation into the Health Bill at the earliest possible opportunity, and appointing a Commissioner within six months of Royal Assent. DHSC, NHS England (NHSE), Integrated Care Boards (ICBs) and NHS trusts must take action to listen to the voices of women, birthing people and families within 12 months. DHSC, NHSE and CQC must drive improvement, within 12 months, of the quality, transparency, oversight and accountability of investigations and ensure learning is captured and acted upon when things go wrong. DHSC/NHSE must design a Modern Service Framework for maternity and neonatal services within 12 months and begin rollout within 18 months. DHSC, NHSE, ICBs, NHS trusts, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) must treat racism, discrimination and inequality as a critical maternity safety issue – within 12 months, with work starting immediately. DHSC/NHSE must clarify existing system governance, oversight and accountability structures and improve the effectiveness of regulatory oversight within nine months. DHSC, NHSE, ICBs and NHS trusts must work with colleges, universities, post graduate educators and others to improve culture and teamworking, and strengthen leadership at all levels of the system and across professions within 12 months. DHSC/NHSE must deliver estates and digital systems that are fit for modern maternity and neonatal care with 12-month, five-year and 10-year investment commitments and implementation deadlines.

On the 18 June 2026, the Health Services Safety Investigations Body (HSSIB) published a new report summarising a rapid investigation focused on patient safety issues within a regional care system. It looked specifically at a case where multiple organisations were involved in providing care across a care pathway. In this blog, Patient Safety Learning’s Associate Director Claire Cox sets out reflections on the report’s findings. The most recent HSSIB learning report on patient safety across regional care pathways offers an important, if uncomfortable, insight into the realities of delivering care across organisational boundaries. While framed as learning, the findings expose fundamental gaps in oversight, clarity and system leadership, which pose significant risks to patient safety. A care pathway is a structured, evidence-based framework that describes the sequence of care and interventions a patient should receive for a particular condition, population group or healthcare need. It sets out how different services and professionals work together to deliver coordinated, high-quality care across the patient's journey. The HSSIB investigation examined a redesigned regional pathway involving multiple organisations and a centralised specialist service. However, the report deliberately omits specific details of the pathway, organisations and patient group involved. While this is understandable from a confidentiality perspective, it creates a key limitation: without a clear understanding of the full patient journey, it becomes much harder to articulate where risks emerge, accumulate and, ultimately, result in harm. The invisible patient journey One of the most striking issues raised by the report is the system’s inability to fully understand or monitor patient harm across the pathway. This is perhaps unsurprising. Care pathways that span multiple organisations are non-linear, dynamic systems, where risks rarely arise at a single point. Instead, harm often reflects latent system failures, decisions, constraints or assumptions made early in the pathway that only manifest much later. The investigation highlights several critical system weaknesses: Differences between how the pathway was designed and how it actually operated. A lack of shared understanding between organisations about what the pathway could realistically deliver. Limitations in the technology and digital systems used to support the pathway. Limited data sharing and inconsistent performance insight across providers. These issues are particularly evident in the technology underpinning the pathway, where a lack of interoperability between organisational digital systems means critical patient information is not consistently shared or visible across services. In practice, this results in manual workarounds, duplication and reliance on incomplete data. The safety implications are significant: clinicians are often making decisions without a full understanding of a patient’s history, delays occur in accessing or transferring information and opportunities for proactive intervention are reduced. Collectively, this creates a scenario where no single organisation holds a complete picture of the patient journey, meaning emerging harm cannot be reliably identified. From a patient perspective, it is reasonable to expect far greater visibility of the pathway they are moving through—not just who is providing their care, but how that care is organised end-to-end. This includes clarity on what the pathway looks like, the key decision points that may affect their treatment, and how and when care may escalate if their condition changes. They might also reasonably expect to know how risks to their safety are being identified, shared and actively managed across organisations. Without this transparency, patients are effectively navigating a system that is opaque, fragmented and difficult to understand. In such circumstances, meaningful collaboration becomes extremely challenging. Shared decision making depends on a shared understanding of both the clinical situation and the system through which care is delivered. Similarly, where risks are not visible to patients, there can be no clear line of accountability for how those risks are mitigated. If care pathways are to function safely across organisational boundaries, they must be understandable not only to professionals within the system but also to the patients who rely on them. The accountability gap A consistent theme throughout the HSSIB report is the absence of sustained oversight. Although a cross-organisational implementation board initially existed, oversight from the Integrated Care Board (ICB) reduced before the pathway was fully embedded. The consequences were predictable: No shared governance framework post-implementation. No agreed evaluation plan. Limited escalation of risks. Disconnected data and performance monitoring. This reflects a classic system failure: accountability without ownership. If no organisation or system leader maintains end-to-end ownership of a pathway, then: Risks fall between organisational boundaries. Mitigations are inconsistent or absent. Learning is localised rather than system wide. As highlighted by another HSSIB report last year, there is a lack of clarity about how patient safety is managed between ICBs other healthcare providers, including lines of safety accountability. This leads directly to gaps in oversight of cross-organisational safety risks. Implementation versus reality: the risk of 'work as imagined' Another critical safety issue is the mismatch between the pathway as designed ('work as imagined') and its real-world operation ('work as done'). The report highlights: A business case that was not fully realised. Resource assumptions (e.g. bed capacity) that did not materialise. Divergent expectations among organisations about pathway capability. This is not a minor operational issue, it is a core patient safety risk. When services are designed based on assumptions that are not delivered in practice: Demand exceeds capacity. Access thresholds shift informally. ·Staff are forced into workarounds. Clinical decision-making becomes inconsistent. Over time, this creates unstandardised care and inequity of access, both of which were flagged as concerns in the investigation. Culture, communication and friction The report also surfaces issues that are often underplayed in pathway redesign, relationships and behaviours between teams. Findings include: Differences in risk perception between organisations. Disagreements affecting clinical decisions. Examples of incivility. Barriers to shared learning. Lack of interoperability between organisation digital systems. These are not 'soft issues', they are direct contributors to patient harm. Where communication breaks down: Information is lost or misinterpreted. Decisions are delayed. Trust erodes across organisational boundaries. In cross-system pathways, psychological safety and collaboration are as critical as infrastructure and process design. What could strengthen learning? While the report provides valuable system-level insights, there is an opportunity to go further in translating findings into practical improvement. Two approaches could add depth: 1. After Action Review (AAR) at system level A structured, multi-agency AAR could: Reconstruct the pathway end-to-end. Identify where assumptions diverged from reality. Surface latent conditions contributing to risk. Build shared understanding across organisations. This would move learning from 'what happened' to 'why it made sense at the time'. 2. Transformative (tabletop) simulation Given the complexity of regional pathways, simulation offers a powerful way to: Test proposed improvements in a safe environment. Explore system stress points (capacity, transfers, escalation). Identify unintended consequences before implementation. In effect, simulation allows systems to experience the pathway as patients do across boundaries, not within silos. The role of integrated care boards: a system risk? Perhaps the most significant implication of this report is what it reveals about the current maturity of system oversight. ICBs are expected to: Commission across pathways. Ensure safety across organisational boundaries. Use data to drive improvement. However, the report evidences: Limited access to consistent safety data. Reduced capacity following structural changes. Difficulty maintaining ongoing oversight of complex pathways. Again this is not an new issue and is a theme that we have seen in previous HSSIB investigations, including a report last year looking at the implementation of the Patient Safety Incident Response Framework. This raises a critical question: do current system structures have the capability and capacity to oversee patient safety at pathway level? If the answer is uncertain, then this is itself is patient safety risk, one that is largely invisible to the public. How might the emerging quality strategy address this? The forthcoming NHS Quality Strategy presents a critical opportunity to address many of the systemic issues highlighted in this report, particularly the fragmentation of safety across organisational boundaries. The 10 Year Health Plan stated that alongside the National Quality Board its aim would be to address a crowded and unclear quality landscape and provide a single and authoritative determination of quality. This aligns directly with the need identified here: clearer expectations, better measurement and more coherent oversight across systems. However, emerging national discussion suggests there are still important gaps to resolve, including concerns about whether patient safety will be given sufficient prominence, and whether expectations for providers and system leaders will be clear enough to drive meaningful change. If the Strategy is to respond effectively to the risks identified in this HSSIB investigation, it must move beyond treating safety as one dimension of quality and instead position it as a central organising principle of system design. This creates a significant opportunity to design cross-system safety into: service planning service delivery accountability frameworks performance management data capture and intelligence. Without this, there is a real risk that existing fragmentation is reinforced: where metrics are numerous but unaligned, accountability remains diffuse, and no single entity holds responsibility for understanding risk across the whole patient journey. Conversely, a coherent and safety-led strategy could provide the support needed for ICBs and providers to jointly own pathway outcomes, supported by shared data, stronger governance and clearer system leadership. The absence of prescriptive targets may offer flexibility but it also increases the importance of how strongly patient safety is prioritised and operationalised in practice. Final reflection This HSSIB report highlights a fundamental truth: patient safety does not solely reside within organisations; it resides within pathways. The 10 Year Health Plan for England envisions a significant shift in the coming years towards more neighbourhood and system-based models. As this transition takes place, the risks identified in this report will only become more pronounced. Without clear end-to-end ownership, shared data and intelligence, robust evaluation, and strong cross-system leadership, we risk designing pathways that look coherent on paper but are fragile in practice, and where safety is too often an afterthought. The forthcoming NHS Quality Strategy could potentially present a opportunity to tackle these issues, designing for safety, to ensure safe outcomes, processes and behaviours. The challenge now is not simply to learn from this report but to recognise that these issues are unlikely to be isolated. They are systemic and they demand a system-level response.