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This blog reflects on a patient safety concern arising from the death of my late best friend. It argues that discharge decisions should not rely too heavily on point-in-time observations, early warning scores or apparent mobility when serious unresolved pathology may still exist in the background. The aim is not to assign blame, but to highlight a wider safety learning point about the need to assess the full clinical picture when deciding whether a patient is safe to leave hospital. One of the most troubling lessons I have learned from healthcare harm is that a patient can appear “well enough” for discharge on paper while, in reality, still being at grave risk. My late best friend died after a final illness in which I believe the bigger clinical picture was not given enough weight. I have already been through the formal NHS complaints route and the Parliamentary and Health Service Ombudsman. Those processes did not uphold my concerns. But what remains with me, and what I believe has wider patient safety relevance, is the reasoning pattern that I think his case illustrates. My concern is not simply that the outcome was tragic. Poor outcomes alone do not prove poor care. My concern is that short-term signs of improvement appeared, in my view, to carry more weight than serious unresolved pathology in the background. This is the patient safety issue I want to highlight: discharge decisions can become too heavily influenced by a snapshot of how a patient looks on one day, rather than by the full trajectory and unresolved seriousness of their illness. A patient may have acceptable observations, a relatively low National Early Warning Score (NEWS), the ability to mobilise and an understandable wish to go home. But none of that necessarily means the underlying risk has gone away. That distinction matters. Observations tell us whether certain physiological measurements are abnormal at a particular moment. They do not, on their own, tell us whether infection has truly been brought under control, whether worrying imaging findings have been resolved, whether organ dysfunction is still evolving or whether a fragile improvement is likely to collapse after discharge. The danger, in my view, is that “safe for discharge” can slide into meaning “not obviously unstable right now.” Those are not the same thing. This case has left me with a lasting concern that healthcare systems may sometimes over-value point-in-time indicators of stability and under-value the wider pattern of serious disease. If that happens, discharge may be judged through too narrow a lens. The patient may look acceptable in the moment, but the unresolved pathology may still be severe enough to make discharge unsafe. This is not an argument against NEWS, against discharge or against trying to help people leave hospital promptly when it is appropriate. It is an argument for clinical reasoning that looks beyond the snapshot. When clinicians are considering discharge, especially in complex patients, I believe there should be a more explicit safety question: does this patient merely look stable today or is the overall clinical picture genuinely safe for discharge? That question requires more than observations. It requires attention to imaging, unresolved infection, organ function, co-morbidities, recent deterioration and the likely direction of travel once the patient leaves the ward. For families, the distinction can be life-changing. For patient safety, it may be system-changing. My hope in sharing this is not to assign blame, but to support learning. If one lesson can come from this death, I hope it is this: the bigger picture should never be overshadowed simply because a patient appears acceptable on observations on a particular day.

In healthcare, we often talk about 'never events'—serious incidents that should not occur if appropriate systems are in place. But what happens when they do occur? I recently had the great pleasure of working with a group of anaesthetic resident doctor colleagues on a patient safety project that began with exactly that question. Within a short period in 2025, our large UK teaching hospital experienced two wrong-sided peripheral nerve blocks after six years without a single reported incident. We wanted to understand why. Looking beyond individual error Both incidents occurred during a major transition: we were moving anaesthetic records, consent forms and safety checklists from paper to digital. At first glance, the timing felt more than coincidental. After initial governance processes were completed, our team used the Patient Safety Incident Response Framework (PSIRF)[1] to explore what had happened. Introduced in the NHS in 2022, PSIRF promotes a systems-based approach rather than searching for a single 'root cause'. It examines how elements such as people, tasks, tools and technology, environment and organisational factors interact to increase risk. For us, this shift in perspective proved crucial. Instead of asking “who made this mistake?”, we were able to consider “what conditions made this error more likely?”. What we found: small gaps in a complex system We brought together a multidisciplinary 'learning MDT', combining insights from staff interviews and systems analysis. A clear pattern emerged: no single failure caused these incidents. Instead, multiple small vulnerabilities aligned. One issue stood out. In our previous paper-based system, clinicians used a 'Stop Before You Block' (SBYB) sticker—a simple but effective visual cue prompting a final safety pause before performing a nerve block. During the digital transition, this physical prompt disappeared. Other contributing factors reinforced the problem: Staff worked under cognitive overload, juggling interruptions, changing plans and high-acuity patients. Digital consent processes made SBYB checks feel more cumbersome, drawing attention away from the patient and towards the computer. Poor visibility of surgical site markings increased the barriers to performing SBYB. Ergonomic challenges in anaesthetic rooms made equipment setup frustrating. Time pressure on theatre lists encouraged task compression. In both cases, clinicians skipped the SBYB pause entirely—not out of negligence, but because the system no longer reliably supported it. These events didn’t reflect individual failure. They reflected a system under strain during organisational change. From insight to action: designing safer systems We knew we couldn’t eliminate complexity from clinical environments, but we could design systems that make the safe action the easy action. We developed a multi-faceted improvement plan. 1. Strengthening standards and education We updated our local guidance, aligning it with national recommendations from the Safe Anaesthesia Liaison Group and Regional Anaesthesia UK.[2] We rebranded it as the 'Prep Stop Block LocSSIP' (Local Safety Standard for Invasive Procedures). We promoted this through clinical governance meetings and delivered targeted teaching to consultants, trainees and anaesthetic practitioners. To support sustainability, we embedded a training video into the anaesthetic resident doctor induction programme and uploaded it to our intranet. 2. Fixing friction in the system We addressed practical barriers: Improved access to longer ultrasound cables. Standardised surgical site markings to improve visibility. Explored integrating anaesthetic complexity into theatre scheduling. Trialled LED signs to indicate when the anaesthetic room is in use; thus creating a 'sterile cockpit' by discouraging interruptions during anaesthetic procedures. Introduced electronic tablets so consent forms could be viewed alongside the patient and checklist. Each of these changes aimed to reduce cognitive load and create space for safer practice. 3. Introducing a physical safety barrier Our most impactful intervention was the 'Prep Stop Block Lid'. We designed a lidded box displaying a safety infographic. Clinicians place prepared local anaesthetic inside and cannot access it until they complete the SBYB pause. This shifts safety from memory to physical design, creating a clear pause point in the workflow. We refined the intervention through Plan–Do–Study–Act (PDSA) cycles with frontline feedback before wider rollout. What we’ve learned so far Early data show improvements in process measures, including increased visibility of the SBYB step. Audits of Prep-Stop-Block compliance suggest an improvement from 34% during digital transition to 100% at most recent review. However, we remain cautious. We are still in a 'zone of vulnerability', where changes are ongoing and their full impact is unclear. Because never events are (fortunately) rare, it will take time to determine whether these interventions reduce harm. That said, several key lessons have already emerged: Never events are rarely about individuals. They arise from system conditions that make errors more likely. Digital transformation can unintentionally remove safety cues. We must actively design these back into new systems. Education and policy are necessary but insufficient. The most reliable safety interventions are embedded into workflow, especially physical or procedural 'forcing functions'. A call to action If your department is undergoing digital transformation, take a moment to ask: “What safety cues might we be losing—and how will we replace them?” We need to move beyond simply digitalising existing processes. Instead, we should use these transitions as opportunities to design safer, more resilient systems from the ground up. Because when it comes to patient safety, 'never' is not a guarantee, it’s a goal we must actively work towards. References https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/ https://www.salg.ac.uk/salg-publications/stop-before-you-block/

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].

Training to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools. Who should attend? Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries. Who should attend? Executives, commissioning, & service managers supporting service lead investigator roles The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting Register hub members receive a 20% discount. Email [email protected] for discount code.

Sharon Weldon is the Transformative Simulation topic lead for the hub. In this blog, Sharon introduces Transformative Simulation, explains how it can be applied to patient safety, how teams might use it to test and refine safer ways of working, and signpost you to where you can find further information and resources on Transformative Simulation. Transformative Simulation is a structured framework for using simulation not to educate, but to illuminate, test and improve complex health and care systems. While simulation has traditionally focused on clinical skill development, Transformative Simulation positions simulation as a vehicle for collective inquiry, shared sense-making and system redesign. Patient safety is one of the core domains in which this approach is actively applied. Why Transformative Simulation matters for patient safety Healthcare harm rarely arises from a single error; it emerges from interactions between people, processes, cultures, technologies and organisational pressures. Transformative Simulation addresses this complexity directly. It enables organisations to move beyond retrospective incident review toward embodied system inquiry and practical redesign. Through Transformative Simulation, organisations can: Explore how governance, hierarchy and context influence safety behaviours. Test potential changes in a psychologically safe environment before implementation. Engage patients, families and staff in co-produced learning. Translate investigation findings into system-level reform. What makes Transformative Simulation distinct Transformative Simulation is structured around seven simulation-based intentions (SBIs), which clarify the purpose of each simulation activity, and the 4D process: Design, Delivery, Data and Debrief. Each stage is deliberately aligned with the chosen intention, ensuring learning is architected rather than incidental. Central to the framework is the principle of reciprocal illumination: simulation informs practice, and practice reshapes simulation design. This creates an adaptive learning loop that supports system-level change. Transformative Simulation in patient safety contexts Transformative Simulation has been applied in safety-critical settings, including Never Events prevention, organisational learning after serious incidents, leadership and governance review, and human factors integration. The aim is not performance rehearsal alone, but structured exploration of system conditions that shape safety outcomes. Working with the hub community Through collaboration with Patient Safety Learning, in this topic area we will share case examples, host structured discussions and explore how simulation can strengthen shared learning and system redesign. The intention is to complement existing safety approaches by offering a structured method for working with complexity in practice. Invitation hub members are invited to share experiences, questions and case examples. Where do patient safety investigations most often stop short of system redesign? How might simulation help teams test and refine safer ways of working? The Transformative Simulation Special Interest Group (ASPiH) The Transformative Simulation Special Interest Group (TfS SIG), hosted by ASPiH (Association for Simulated Practice in Healthcare), brings together clinicians, patient safety professionals, human factors experts, patients and system leaders committed to advancing simulation as a vehicle for system-wide change. The SIG works across sectors and national contexts to develop theory, practice and evidence in Transformative Simulation, including applications in patient safety, human factors, leadership and digital innovation. Further resources, publications and events can be found via ASPiH and the TfS SIG: https://aspih.org.uk

‘Neo’, an Allied Health Professional working on the frontline, reflects on the role of Royal College reviews in the NHS, why they matter and the unintentional consequences that can occur when shared in the public domain. Patient safety sits at the heart of the NHS’s founding principles. Every policy, pathway and performance metric ultimately exists to serve one core purpose: to deliver safe, effective care to patients. Yet ensuring patient safety in a complex, high-pressure healthcare system is not a static achievement. It requires continual reflection, learning and the courage to confront uncomfortable truths. One of the most important—and often misunderstood—mechanisms for doing this within NHS Trusts is the commissioning of Royal College reviews. These reviews offer expert, independent insight into clinical services, workforce challenges, governance arrangements and patient pathways. At their best, they are a powerful method for organisations to speak up, surface risk and identify areas for improvement before harm occurs. However, when these reviews enter the public domain, the resulting media scrutiny and public reaction can create unintended consequences that threaten their future use. What are Royal College reviews and why do they matter? Royal College reviews are typically commissioned by NHS Trusts, Integrated Care Boards or national bodies when there are concerns about service delivery, staffing, outcomes or sustainability. They are conducted by experienced clinicians and system leaders with deep specialty expertise, bringing an external and credible perspective. Crucially, these reviews are not disciplinary processes. They are diagnostic tools. They aim to identify systemic issues—such as workforce shortages, governance gaps, training pressures or service configuration challenges—rather than assign individual blame. In this way, they align closely with the NHS’s stated commitment to a “just culture”, where learning and improvement are prioritised over punishment. For many Trusts, commissioning a Royal College review is an act of organisational maturity. It signals a willingness to ask difficult questions, to listen to expert advice and to address risks proactively. Often, the issues identified will already be known internally but require external validation to unlock support, resources or system-wide change. Transparency versus trust: when reviews go public The challenge arises when Royal College reviews are published or leaked into the public sphere. Transparency is a core NHS value, and patients and the public have a legitimate interest in understanding how services are performing. However, the way these reports are reported and received can significantly distort their purpose. Media coverage frequently focuses on the most alarming language within a report—phrases such as "unsafe”, “not sustainable” or “significant risk”. Stripped of context, these terms can understandably cause public concern and distress. Headlines may imply negligence or crisis, even where a service continues to deliver care safely under immense pressure. For staff working within those services, this can feel deeply demoralising. Clinicians and managers who have actively sought external review in the interests of patient safety may find themselves portrayed as presiding over failure. In some cases, public narratives overlook the structural factors underpinning the findings—national workforce shortages, funding constraints or system-wide demand—and, instead, focus on perceived local shortcomings. The chilling effect on commissioning and publishing reviews Perhaps the most worrying consequence of this dynamic is its potential to deter Trusts from commissioning or publishing reviews at all. If seeking external advice is consistently followed by reputational damage, regulatory escalation or hostile media scrutiny, organisations may understandably become more risk averse. This creates a paradox. The very tools designed to surface risk early and prevent harm can become perceived as liabilities. In extreme cases, this may encourage a culture of silence, where concerns are managed internally or issues are allowed to persist unexamined for fear of public outcry. History has shown the cost of such silence. Major patient safety failures across the NHS have repeatedly been associated with ignored warnings, suppressed concerns and a reluctance to challenge the status quo. Reviews and inspections only become 'bad news stories' when systems fail to listen and act early. Reframing reviews as a sign of strength, not failure If Royal College reviews are to continue playing a meaningful role in patient safety, a shift in narrative is needed—not only within the NHS, but across media, regulators and public discourse. Commissioning a review should be understood as a sign of organisational openness and responsibility. Publishing a review, even when its findings are uncomfortable, should be seen as an act of transparency and commitment to improvement. Reports should be read as starting points for action, not verdicts on competence or care quality. There is also a role for NHS leaders to provide clearer context when reviews are released. This includes explaining why the review was commissioned, what immediate actions have already been taken and how recommendations will be supported at system and national level. Without this framing, reports risk being interpreted in isolation, detached from the wider pressures facing the service. Supporting staff while protecting patients At the centre of this issue are NHS staff—clinicians, nurses, allied health professionals and managers—who are often working at or beyond capacity. Reviews frequently highlight risks arising from workforce shortages or unsustainable rotas, yet public reactions can inadvertently place blame on the very people raising those concerns. Protecting patient safety and supporting staff are not competing priorities. In fact, they are inseparable. A system that punishes honesty, discourages speaking up or treats external review as failure, ultimately undermines both. Royal College reviews offer a rare opportunity: expert insight combined with professional credibility, focused on learning rather than blame. To lose or weaken that mechanism because of fear would be a significant setback for patient safety. Moving forward The NHS is at a critical juncture. Demand continues to rise, resources remain constrained and the margin for error is slim. In this context, the ability to speak openly about risk, invite external challenge and learn from expert review has never been more important. Rather than asking whether Royal College reviews are damaging to public confidence, we should ask a different question: what does it say about a system if organisations are afraid to look honestly at themselves? Patient safety is not protected by silence. It is protected by courage, transparency and a shared commitment to improvement—even when that improvement begins with uncomfortable truths. What are your thoughts and experiences of Royal College Reviews? We'd be interested to hear your views. Add your comments below—you'll need to be a hub member and signed in (sign up here). Further reading on the hub: Read more blogs from staff on the frontline in our Florence in the Machine series.

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 FACILIATOR 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. Register hub members receive a 20% discount. Email [email protected] for discount code.