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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].

Adverse event reporting is critical for advancing patient safety within healthcare systems. A significant factor in enhancing reporting rates is establishing a 'just culture'; a framework that emphasises accountability and learning over punitive measures. While just culture significantly enhances adverse event reporting, its successful implementation requires robust commitment at all organisational levels. Reporting adverse events is essential for ensuring patient safety and fostering a culture of continuous improvement in healthcare. Adverse events, defined as unintended injuries or complications arising from healthcare management, offer crucial insights into systemic weaknesses that, if addressed, can prevent future harm. However, underreporting such events remains a significant challenge, often driven by fear of punitive actions, reputational damage or legal repercussions. To address these concerns and promote a robust reporting culture, healthcare organisations must adopt a just culture by implementing standardised frameworks for evaluating errors and establishing robust reporting systems. Transparency in handling reported incidents is critical for building trust among healthcare professionals. Understanding just culture Just culture represents a shift from a blame-oriented approach to one that balances accountability with a focus on systemic improvement. Originating in high-risk industries such as aviation, the concept emphasises that errors result from flawed processes rather than individual negligence. In a just culture, individuals are held accountable for their actions within a fair and transparent system that prioritises learning and improvement. Central to the philosophy of just culture is the idea of psychological safety. When healthcare professionals feel confident reporting errors will not lead to unjust punishment, they are more likely to disclose incidents. This openness enables organisations to identify trends, address root causes and implement preventive measures. Moreover, just culture recognises the distinction between human errors, at-risk behaviours, and reckless conduct, advocating for tailored responses that align with the nature of the behaviour. Barriers to adverse event reporting Despite its potential, the implementation of just culture faces several obstacles. A predominant challenge is the deeply ingrained blame culture within many healthcare organisations. Historical reliance on punitive measures has created an environment where professionals fear repercussions, discouraging transparency. Additionally, managerial inconsistency in addressing errors often undermines trust in the system. For instance, discrepancies in how similar incidents are handled can create perceptions of unfairness, further discouraging reporting. Another barrier is the lack of understanding and awareness of just culture principles among healthcare staff. Without proper training and education, employees may misinterpret the approach as being lenient or as failing to hold individuals accountable. Legal and regulatory pressures also pose challenges, as concerns about litigation can deter organisations from fully embracing non-punitive reporting frameworks. Strategies for implementing just culture Implementing a just culture in healthcare requires a multifaceted approach that addresses organisational, managerial and individual factors. Leadership commitment is paramount; leaders must model just cultural behaviours, demonstrate accountability and prioritise safety over blame. Developing clear policies and guidelines for error classification and response is equally important as it ensures consistency and fairness in how incidents are addressed. Education and training programmes are vital in promoting awareness and understanding of just culture principles. These programmes should emphasise the distinction between human errors, at-risk behaviours and reckless conduct, providing staff with the tools to respond appropriately. Role-playing scenarios, workshops and case studies can help reinforce these concepts and demonstrate their practical application. The integration of non-punitive reporting systems is another critical component. Such systems should be designed to facilitate easy and confidential reporting, with mechanisms to protect the anonymity of reporters when appropriate. Feedback loops are essential for ensuring that staff are informed about the outcomes of reported incidents, which can reinforce the value of reporting and build trust in the system. Measuring the impact of just culture Assessing the effectiveness of just culture initiatives requires the development of standardised metrics and evaluation tools. Key performance indicators may include reporting rates, staff perceptions of psychological safety and the frequency of systemic improvements resulting from reported incidents. Periodic surveys and interviews can provide valuable insights into staff attitudes and identify areas for improvement. Case studies from organisations that have successfully implemented just culture can also serve as benchmarks for best practices. For instance, hospitals that report significant increases in adverse event reporting rates following the adoption of just culture principles often attribute their success to strong leadership, comprehensive training, and consistent application of policies. Sustaining cultural change Sustaining a just culture requires ongoing commitment and adaptability. Organisations must regularly evaluate their policies and practices to ensure alignment with just culture principles. Staff feedback should be actively sought and incorporated into decision-making processes, fostering a sense of ownership and engagement. Continuous education and training are essential for reinforcing just culture behaviours and addressing emerging challenges. Additionally, leadership succession planning should prioritise candidates who are committed to upholding just culture principles, ensuring continuity in organisational values. Conclusion Adverse event reporting is a fundamental component of patient safety, and the principles of just culture provide a robust framework for enhancing reporting rates and fostering systemic improvements. By balancing accountability with a focus on learning and improvement, just culture creates an environment where healthcare professionals feel empowered to report incidents without fear of retribution. Leadership commitment, staff education and integrating non-punitive reporting systems are critical for overcoming barriers and sustaining cultural change. A just culture represents a paradigm shift in addressing adverse events, emphasising systemic improvement over individual blame. Its successful adoption has the potential to transform healthcare organisations, making them safer and more resilient. Future research should focus on developing standardized metrics to evaluate just culture initiatives and exploring their applicability across diverse healthcare settings.

On 23 October 2024, the Patient Safety Commissioner for England published a set of Patient Safety Principles. In this blog, Patient Safety Learning sets out its reflections on these principles, highlighting key points included in its response as part of the public consultation process earlier this year. The Patient Safety Commissioner’s new Patient Safety Principles are intended to act as a guide for leaders at all levels on how to design and deliver safer care for patients and reduce avoidable harm, in a just and learning culture.[1] They are as follows: Create a culture of safety Leaders have a responsibility to lead by example to inspire a just and learning culture of patient safety and quality improvement. They should set out to keep people safe through the adoption of a safety management system and by embedding continuity of care, a culture of compassion and civility, effective listening, and restorative practice. Put patients at the heart of everything Leaders should put the patient at the heart of all the work that they do, with patient partnerships the default position at all levels of the organisation. They should consider the needs of patients and communities to deliver person-centred care. Leaders should ensure that the patient voice is central in the design of services, in obtaining fully informed consent and to the implementation of shared decision making. Treat people as equals People should be treated with respect, equity and dignity. Leaders should incorporate the views of all, and proactively seek and capture meaningful feedback from patients, workers, and communities, acknowledging that those from disadvantaged groups may need specific support and encouragement to contribute. They should act upon feedback, to embed equity of voice. Identify and act on inequalities Health inequalities, and their drivers, should be identified and acted upon at every stage of healthcare design and delivery to drive improvements in patient safety and experience. Identify and mitigate risks Targeted and coordinated action should be directed towards patient safety risks. Patients, workers and communities should be encouraged and empowered to proactively identify and speak up about risks, hazards and potential improvements. Leaders should promptly escalate new and existing risks to the most appropriate person or body. Be transparent and accountable Leaders should acknowledge that creating a culture of safety requires honest, respectful and open dialogue, where candour is the default position. This transparency should support a model of continuous improvement, which learns from both successes and events, and ensures that patients, workers and communities do not face avoidable harm due to a cover up culture. Use information and data to drive improved care and outcomes for patients and help others to do the same Leaders should enable patients to have access to their personal and other data to help them improve their own care. They should ensure that good quality data is collected and meets the needs of all patients, including those from underrepresented and inclusion health groups. Workers should be supported to use and share information and data to drive improved care and outcomes for patients, in accordance with the Caldicott Principles. Shared principles These principles were subject to a publication consultation, which we responded to on the 5 September 2024. You can find our full comments on each principle here. We welcome the principles that the Patient Safety Commissioner has set out today. There is significant overlap between these seven principles and the six foundations of safer care we identify in our report, A Blueprint for Action.[2] For example: “Put patients at the heart of everything” aligns with our foundation on “Patient engagement”. 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. “Use information and data to drive improved care and outcomes for patients and help others to do the same” aligns with our foundation on “Data and insight for patient safety”. We would also consider that these principles, when taken together, align with our view set out in A Blueprint for Action about the need for a transformation in our approach to patient safety placing this as a core purpose of health and care. The Patient Safety Commissioner’s proposed principles also share much in common with the World Health Organization’s (WHO) Global Patient Safety Action Plan.[3] This sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. There is again significant overlap between the points included in its seven strategic objectives and these principles. The principle “Put patients at the heart of everything” also reflects a wider international initiative in patient safety, the WHO Patient safety rights charter that was published earlier this year.[4] The Charter aims to outline patients’ rights in the context of safety and promotes the upholding of these rights, as established by international human rights standards, for everyone, everywhere, at all times. Areas not covered by the principles In our consultation response we also highlighted several areas not included in these principles. We would suggest these should also be considered when creating guidance for senior leaders on how to deliver safer care for patients and reduce avoidable harm. Shared learning This is one of the six core foundations of safer care we identify in A Blueprint for Action. Healthcare is systematically poor at learning from harm. If patients are to be safer, we need people and organisations to share learning when they respond to incidents of avoidable harm, and when they develop good practice for making care safer. It is vital that patients, clinicians, managers, and health and social care system leaders share learning about safety practice and performance to make care safer. This was the key driving force behind the creation of the hub, our platform to share learning for patient safety. Patient safety standards One of the primary reasons for the persistence of avoidable harm is that healthcare does not have or apply standards of good practice for patient safety in the way that it does for other issues. Standards that do exist are insufficient and inconsistent. At Patient Safety Learning, we believe that health and social care organisations need to have standards for patient safety. These can inform 'what good looks like' and enable organisations to self-assess against them.[5] Designing for safety and safety in use Treating patient safety as a core purpose of health and care requires us not just to respond to and mitigate the risk of harm, but also to design healthcare to be safe for patients and the staff who work within it. This would include greater use of human factors expertise and systems thinking to inform the safe design, safety management and approaches to investigating unsafe care. This is also covered in depth as part of the Global Patient Safety Action Plan’s second strategic objective, ‘High-reliability systems’. Challenge of implementation Publishing these principles, the Patient Safety Commissioner said that: “The Patient Safety Principles act as a guide for leaders at all levels on how to design and deliver safer care for patients and reduce avoidable harm, in a just and learning culture. They are relevant to healthcare providers as well as commissioners, regulators, manufacturers, and the broader supply chain. The principles provide a clear framework for planning, decision-making, and working collaboratively with patients as partners.”[1] While we welcome this aspiration, how these are used in practice will determine their success. 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. All too often when it comes to patient safety, there exists an implementation gap between what we know improves patient safety and what is said about this compared to what is done in practice.[6] An example of this can be seen concerning the first of these principles, “Create a culture of safety”. This emphasises the role of leaders having a responsibility to lead by example to inspire a just and learning culture of patient safety. A similar aspiration is also identified in the NHS Patient Safety Strategy, which includes patient safety culture as one of the two foundations required in working towards its safety vision “to continuously improve patient safety”.[7] However, despite this commitment in the NHS, blame cultures and a fear of speaking up continue to persist. As highlighted in our recent report analysing the NHS staff survey results, there often exists a significant gap in this respect between what organisations say about their approach to safety culture and how staff feel.[8] If these principles are to be realised, they will need not just to be accompanied by a endorsement from the Department of Health and Social Care and the NHS, but also clear action. References Patient Safety Commissioner for England, Patient Safety Principles, 23 October 2024. Patient Safety Learning. The Patient Safe Future: A Blueprint for Action, 2018. WHO. Global Patient Safety Action Plan 2021-2030, 3 August 2021. WHO. Patient safety rights charter, 18 April 2024. Patient Safety Learning. Standards, Last accessed 4 September 2024. Patient Safety Learning. Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022. NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024.

Speak Up For Safety is a Just Culture training workshop that aims to help staff at all levels, understand the importance of creating an environment that encourages people to share concerns and feedback. It was developed by Bella Knaapen, Surgical Support Governance & Risk Management Facilitator and Sarah Leeks, Senior Health & Wellbeing Practitioner at Norfolk and Norwich University Hospitals NHS Foundation Trust. This presentation has been shared by the authors and is designed to be used in Speak Up for Safety training workshops. Bella has also written a blog for the hub about how Speak Up for Safety was developed and how it is helping staff feel safe and empowered to speak up.

In Celebration of International Women’s Week, join Bevan Brittan and Howden for an inspiring conversation with a panel of leading women in healthcare. Our expert panel will explore 'Just Culture' and its impact on healthcare professionals and medical malpractice claims. Our expert speakers will share their insights and experiences, examining how both the independent and public sectors can learn from mistakes to avoid future adverse outcomes for both the workforce and their patients: Julie Charlton, Partner at Bevan Brittan Oonagh Sharma, Partner at Bevan Brittan Sabrina Meetaroo, Solicitor and Head of Risk and Claims Advocacy at Howden Dr Cathy Cale, Group Medical Director at Spire Healthcare Claire Damen, CEO at Independent Health Group and Chair of IHPNs Women Leader’s Network Register

This one-day masterclass focuses on the Principles and Practice of a Restorative, Just, and Learning Culture, emphasising how empathy is crucial to fostering a fair and psychologically safe environment. Through experiential learning using a true story, participants will have the opportunity to see things differently; examining how empathy and compassionate leadership underpin a Just Culture, helping organisations move from blame to learning, accountability, and system improvement. The session will bring empathic thinking into real-life practice, guiding attendees to understand the emotional complexities of patient safety incidents, staff fears and wellbeing and working with human reactions. It will highlight the difference between retributive and restorative practices and how adopting restorative approaches can enhance both patient and staff outcomes. In a safe, supportive environment, participants will reflect on how personal biases affect communication, and explore how culture change can be achieved and the challenges. The session will integrate self-reflection activities to strengthen personal well-being, emotional resilience, and inclusive leadership skills, which are vital for creating a compassionate, high-performing team. Using emotive and thought provoking material, balanced with the science of emotional intelligence, the real impact of a restorative, just and learning culture principles are felt, ensuring attendees leave with actionable insights, combined with emotional understanding to drive systemic change in their teams and wider organisations. KEY LEARNING OBJECTIVES Understanding of Restorative vs. Retributive Practices: Dig deeper into a thought-provoking journey through a patient safety incident, understanding some of the complex emotional component, demystifying some of the myths. What is a Just Culture and Empathy in Practice: Participants will explore develop the ability to apply and promote empathetic practice and the psychological benefits of restorative practices that foster trust and transparency. Seeing Perspectives for Culture and Change: Understand emotional motivations within behaviour and how easily we all see things differently and come from a place of fear. Unpacking the ‘Funnel of Life’: Enhancing Compassionate and Inclusive Leadership while Cultivating Self-awareness of Our Own Funnel Restorative Care - Emotions at the Heart of Stakeholder Support: Explore how a restorative culture nurtures patients, carers, and staff by addressing emotional challenges and managing difficult incidents. Psychological Safety for Team Health: Understand how a lack of civility, empathy and emotional awareness has the potential to cause psychological harm, negatively impacting on being a just, fair and learning culture Shifting Perspectives: From Surface Critique to Systemic Restorative Thinking: Explore how psychological safety influences professional communication, and is all empathy useful for a restorative, just and learning culture? Register hub members get a 20% discount. Email [email protected] for discount code.

Restorative practice - learning culture, how do you create a culture where people feel able to speak up and be listened to. Freedom to speak up, enabling a culture where people feel able to speak up, governance, board assurance, Culture and Good Governance - OFLOG dept launched in July which will look at governance in local authorities. There’s been an incident in your organization. People are impacted. You need to do something. How do you avoid blame, and how do you start learning and improving? This session will explore the principles and theory behind a just and learning culture and give you some insights into how this can be implemented. Alongside an international thought leader on this subject we will hear from an NHS organisation’s experience of developing and sustaining their approach to this. This session will help you understand how your teams/services/organisations can create cultures that foster learning when things don't go as expected. People will leave with an understanding of a just and learning culture alongside insights around implementation in their own organisations. Register

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

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Stephen talks to us about his time as turnaround Chair of Mid Staffordshire NHS Foundation Trust, how NHS boards can ensure they live their values and why creating a safe space to share concerns improves patient safety.