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

In manufacturing a missed signal can cost a product, but in healthcare it can cost a life.  In this blog, Annette Cairns, a leadership development specialist, asks how we can adapt the system-level thinking seen in manufacturing for the unique human complexity, variability and vulnerability that patient care brings. In manufacturing, there was a moment—and you can trace it back through aviation, oil and gas and automotive—when the conversation about safety changed fundamentally. It stopped being about finding the person who made the mistake, and started being about understanding the system that allowed the mistake to happen. That change didn’t come easily or by any means quickly. It required organisations to accept an uncomfortable truth: that in complex, high-pressure environments, human error isn’t primarily a sign of individual failing. It’s a predictable consequence of how systems are designed, how cultures are shaped and how leadership behaves in the moments that really count. The results, where that change has genuinely taken root, have been significant. Aviation is the most cited example—an industry that rebuilt its entire safety culture around the principle that hierarchy, in a cockpit or control tower, cannot be allowed to silence a concern. Crew Resource Management gave co-pilots not just permission but a structured obligation to speak up, regardless of seniority. Near-miss reporting removed the threat of punishment from honesty. Safety culture became something designed into the system, not dependent on the courage of individuals. In manufacturing, parallel principles emerged. James Reason’s Swiss Cheese model gave organisations a language for understanding that failures are almost never caused by one person, but instead they happen when holes in multiple defensive layers happen to align. Toyota’s production system gave every worker on the line the ability to stop everything the moment something didn’t look right. The message was clear and consistent: the system is designed to receive your concern. You don’t need to be brave to raise it. Speaking up is what we do here. Healthcare has borrowed much of this thinking, and rightly so. Just Culture principles, incident reporting frameworks, the language of human factors, all have roots in what manufacturing and aviation learned the hard way over decades. And yet a significant gap remains. It sits not within the clinical team, but between the clinical team and the patient. This is where healthcare faces a layer of complexity that manufacturing simply does not. In manufacturing, the subject of a safety concern, whether it’s the process, the component or the output, has no psychological state. It isn’t frightened. It doesn’t defer to the expertise of the people responsible for it. It has no uncertainty about what ‘normal’ feels like, no anxiety that raising a concern might result in worse treatment, no cultural background or language barrier that makes speaking up feel impossible or unsafe. A patient has all of these things. And they have them at the precise moment they are most vulnerable, most dependent on others and are least certain of their own ground. They are, in the truest sense, inside the system they are being asked to influence. That is a profoundly different position from a worker who can step back from a production line and raise a concern from a position of relative stability. When a patient stays silent about something that concerns them, they are rarely choosing silence because they lack information or awareness. They are making a calculation (often unconsciously) based on the culture they are experiencing: the responsiveness of the people around them, the signals they have received about whether their voice is genuinely welcome, and the very human fear that being perceived as ‘difficult’ might affect the quality of their care. In a system where patients feel they must be compliant to be safe, we have already failed at the most fundamental level. Traditionally, healthcare has tried the route of patient education, but you cannot close this gap just by training patients to be more assertive or by producing better information leaflets about how to raise concerns. It is an organisational and leadership problem—and I believe one that requires the same system-level thinking that transformed safety culture in manufacturing. It requires leaders who understand that psychological safety for patients is not a clinical add-on. It is a core organisational competency. Leaders who ask not just "did we give the patient an opportunity to speak?" but "have we genuinely designed a system in which speaking up is the path of least resistance—and in which our teams have the skills and the capacity to hear what patients say, and act on it?" My extensive work on health and safety behaviour change in manufacturing and technical organisations has consistently shown that the leadership behaviours which create safety: active listening, psychological safety, the reward of raising concerns rather than resolving them quietly, are not industry-specific. They are human. What is industry-specific is the stakes when those behaviours are absent. In manufacturing, a missed signal can cost a product. In healthcare, it can cost a life. The framework for getting this right already exists. Manufacturing and aviation built it over decades of hard-won experience. The question for healthcare is not whether to adopt this system-level thinking, but how to adapt it for the unique human complexity, variability and vulnerability that patient care brings. That work starts with leadership. It always does.

In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Helen and Peter speak to Rebecca Wight, a nurse consultant practitioner. Rebecca talks about her time at the The Christie, a cancer treatment centre in Manchester, and what happened to her when she tried to raise patient safety concerns about a colleague. Despite escalating these concerns to management and clinical leadership, Rebecca reported being ignored, having her concerns dismissed as a personal attack, and facing a "brick wall" from leadership. Rebecca reflects on the toll the process took on her and her family, her experience of going through an employment tribunal and why there needs to be more support for people who raise concerns within their organisation. Subscribe to our YouTube podcast to keep up to date with the latest episodes. Transcript of the interview Read a blog from Peter and Helen about the interview series

The 2025 review of patient safety in England, chaired by Dr Penny Dash, proposed changes intended to coordinate and rationalise patient safety roles and responsibilities. In this long-read article Patient Safety Learning reflects on NHS England’s proposals to implement one of these changes, the abolition of the National Guardian’s Office, which was introduced following Sir Robert Francis‘s 2015 review Freedom to Speak Up.[1] Last year’s Review of patient safety across the health and care landscape proposed a number of structural changes to the roles of existing national healthcare organisations. Among these was a recommendation to “streamline functions relating to staff voice”, suggesting there could be greater alignment between responsibilities that are currently divided between the National Guardian’s Office and NHS England. It also suggested there should be a greater role for healthcare providers in delivering Freedom to Speak Up (FTSU) functions. The review recommended that: “Now that guardians have been established across providers, the responsibilities of the National Guardian for Freedom to Speak Up in the NHS and National Guardian’s Office should be incorporated into providers. This means that the distinct role of National Guardian is no longer required. As part of its wider inspection responsibilities, a core function of CQC should be to assess whether every commissioner and provider has effective Freedom to Speak Up functions, with the right skills and training.”[2] NHS England have subsequently held a short consultation on proposals for putting these changes into practice.[3] This month they published the outcome, setting out new details for revised responsibilities for FTSU across the NHS.[4] In this article we reflect on these proposals. Policy and guidance It appears that while NHS England will seek to incorporate the National Guardian’s Office’s guidance functions into its existing FTSU team, the policy function may largely cease. It states that these changes present an “opportunity to integrate Freedom to Speak Up insights into wider staff experience and patient safety policy development”. Patient Safety Learning believes that in practice this will result in a notable loss of the analysis and research by the National Guardian’s Office from recent years. NHS England are unlikely to be able to replicate some areas of this work credibly, without being seen as marking their own homework, for example analysing staff survey results.[5] There is also likely to be less capacity to look at how experiences of speaking up can vary amongst different groups of NHS staff. Previous research commissioned by the National Guardian’s Office has, for example, been able to highlight specific issues relating to speaking up and ethnicity and the experience of oversees-trained healthcare workers.[6] [7] NHS England itself is currently undergoing a reorganisation that will end in its functions being transferred to the Department of Health and Social Care. It is not clear how this may impact FTSU functions in the longer term. Or whether any arrangements will be put in place to ensure that high-level NHS oversight on speaking up policy and driving changes in safety culture is retained. It is plausible we could see a further reduction in national resources and capability in FTSU functions in the near future. Moving responsibilities to providers A central focus of these changes is to move more FTSU functions under the remit of individual NHS organisations, aligned with recommendations of Penny Dash’s patient safety review last year. This includes placing greater responsibility on them for ensuring local FTSU guardians are trained and supported. NHS England state that: “NHS healthcare providers and commissioners will be solely responsible for ensuring their guardians are appropriately trained, including ensuring all new guardians complete the foundation guardian training, which will be available through the e-Learning for Health platform. As part of trust-level Well-led assessments, the CQC will consider how effectively trust leadership ensures that guardians are appropriately trained.” Evidence indicates that there is wide variability in how the FTSU Guardian role operates across the NHS, being resourced and deployed differently by NHS Trusts.[8] [9] There is prospect of further divergence as more aspects of FTSU functions are delegated to individual organisations as part of these new arrangements. Increased oversight responsibilities for individual providers and commissioners may create further problems. Such a model may work well where organisations show a strong commitment to ‘speaking up’, but not for those with existing poor practices. As proposed, it appears CQC inspections would be the primary avenue to identify these issues going forwards. Inspections are by their nature infrequent. This may lead to a failure to identify, and respond to, problematic cultures and where there is a lack of support for listening to staff. We believe the NHS needs oversight arrangements to ensure that protections are in place for staff who want to raise concerns. The removal of the National Guardian’s Office is one less mechanism of independent accountability. National points of contact Currently the National Guardian’s Office maintains a central, public registry of FTSU Guardians. As part of NHS England’s proposed changes, this registry will close. Instead, all organisations will be required to list their guardian(s) on their website, with the CQC verifying this through inspections. This change will clearly simplify processes at a national level. However, it may have the potentially unintended consequence of making it more difficult for NHS staff to find information about their local FTSU Guardian. Given the variable layout and quality of NHS organisation websites, the accessibility of this information could differ significantly from Trust to Trust. We believe it is important that these changes do not increase barriers to staff accessing information about speaking up routes. We also note that requirements from NHS England to publish information on a providers websites are not always fulfilled. We highlighted an example of this last year, noting that a significant number of Trusts who have not published their Patient Safety Incident Response Plans, contrary to national guidance.[10] Closure of the public registry will be coupled with a closure of the separate FTSU contact point for enquiries, which currently receives approximately 4,000 enquiries a year, hosted by the National Guardian’s Office. Instead, queries will be re-directed to NHS England’s contact centre and escalated to its FTSU team if required. With access to the right information and guidance, this transition could be relatively smooth. The NHS England proposals note that most existing queries relate to training, guardian contacts, and data submissions and reporting. However, there may be an issue that on sensitive FTSU issues, staff may feel less able or willing to go through this route, as opposed to an enquiry line hosted by a body separate from NHS England. This applies all concerns that are raised, not just patient safety issues, with the majority of FTSU queries focused on staff behaviours (though these may also have implications for patient safety). With NHS England functions being moved into the Department of Health and Social Care, it is not yet clear how such queries will be addressed and support provided in future years. Data and insights Turning to data collection, NHS England states that its objective in making changes in this area is to: “Improve national data collection so it is more consistent and supports system learning and improvement, reduces administrative burden, and integrates more effectively with existing NHS systems to generate meaningful insights.” The National Guardian’s Office currently collects quantitative and qualitative FTSU data from all guardians every quarter and publishes the quantitative data. When it has closed, NHS England states that it will continue to collect quantitative data from NHS Trusts and Integrated Care Boards through the NHS national data collection process. However, it will pause national data collection for primary care and independent health providers. It is hard to envision how ceasing to collect FTSU data in relation to primary care and independent health providers is an improvement on the current arrangements. The proposals note that NHS England will “review” FTSU arrangements for these sectors, with no indication on whether this will re-start. We hope they will re-consider this decision in the long term. Looking ahead The National Guardian’s Office and FTSU Guardians were introduced following Sir Robert Francis‘s 2015 review Freedom to Speak Up.[1] Over ten years later many of the problems it highlighted around speaking up and the presence of blame cultures in the NHS continue to persist, presenting barriers to improving patient safety. The existing FTSU structures are seen to have made improvements in some areas, but have not addressed, and would not be able to address solely, the underlying systemic causes of these culture problems. As the most recent results of the NHS Staff Survey have shown, there has been no significant improvement in responses to questions on reporting, speaking up and acting on patient safety concerns in recent years.[11] These issues form a recurring theme across inquiries into major patient safety scandals. They are also reflected in the shocking experiences and testimonies of whistleblowers, such as those highlighted in our Speaking up for patient safety interview series.[12] It is notable that in this new document outlining changes to FTSU functions, there is no significant mention of the importance of protecting staff (including FTSU Guardians themselves) who raise concerns. Tackling these problems needs a greater focus, on creating a culture in healthcare that supports raising, discussing and addressing the risks of unsafe care. This needs to happen at both a national and organisational level. As part of this there should be at least the maintenance of support, if not improvement on the current arrangements, for local FTSU Guardians. This includes the ability to coordinate and to develop evaluation and impact frameworks that enable learning and good practice to be shared and consistently implemented. It remains to be seen if these new arrangements provide this, or if the loss of a separate National Guardian’s Office ultimately has a negative impact on patient safety. References Robert Francis QC. Freedom to speak up: An independent review into creating an open and honest reporting culture in the NHS. February 2015. Department of Health and Social Care. Review of patient safety across the heath and care landscape. 7 July 2025. NHS England. Future of Freedom to Speak Up: engagement pack. 28 January 2026. NHS England. The future of Freedom to Speak Up. 16 April 2026. National Guardian’s Office. Listening to the silence: What does the Staff Survey tell us about speaking up in the NHS? 24 July 2024. Roger Kline and Ghiyas Somra. Difference Matters: The impact of ethnicity on speaking up. September 2021. National Guardian’s Office. Listening and Learning: Amplifying the voices of overseas-trained workers. May 2025. Aled Jones et al. Implementation of ‘Freedom to Speak Up Guardians’ in NHS acute and mental health trusts in England: the FTSUG mixed-methods study. 1 August 2022. Roger Kline. Patient safety and speaking up—learning from the literature. 11 March 2026. Patient Safety Learning. What do Patient Safety Incident Response Plans tell us about how the NHS is approaching safety investigations? 7 May 2025. Patient Safety Learning. Patient Safety Learning’s response to the NHS Staff Survey Results 2025. 13 March 2026. Patient Safety Learning. Key themes emerging from our ‘Speaking up for patient safety’ interview series. 14 May 2025.

In healthcare, developing a culture of psychological safety is essential to ensuring patient safety; a priority identified in the NHS Patient Safety Strategy. In the context of 10 Year Health Plan for England and healthcare leaders' commitments to psychological safety across all developed nations, it is essential that the safety of patients and staff is at the core of its design and delivery to avoid harm and reduce incidents. If the healthcare system is to truly be transformed over the next decade, matters of culture need to be addressed. At this event, attendees will: Meet experts in culture, clinicians, patient safety who will be highlighting why changes need to be made and how individual healthcare professionals can apply good practice to address the challenges. Gain a deep understanding of what psychological safety is and why it is essential to promote and deliver a safety culture in healthcare. Comprehend the actions needed to improve psychological safety in healthcare - what does good look like? Be provided with an opportunity to make personal commitments for better patient safety. Opportunity to engage with key note presentations, panel session discussions, and listen to personal experience of those than have been damaged by poor culture. Learning outcomes will include: Attendees will be able to identify what psychological safety is, how it shows up in team behavior, and how it differs from trust, comfort, or simply being “nice. Be able to apply practical strategies to build psychologically safe environments by learning specific behaviors - such as framing work as learning, modeling vulnerability, and responding productively to patient safety incidents and risk. Identify, evaluate, and address barriers to psychological safety. Attendees will be able to spot common organizational, cultural, and interpersonal obstacles and use structured approaches to reduce fear, friction, and silence. Find out more and register here.

In this article, Patient Safety Learning reflects on the results of the NHS Staff Survey 2025, focusing on responses relating to reporting, speaking up and acting on patient safety concerns. On 12 March 2026 the NHS published the results of its 2025 staff survey.[1] 729,423 staff from 238 organisations took part in this survey, which provides a snapshot of their experiences of working in the health service. The survey includes several questions on reporting patient safety incidents and near misses, concerns about clinical safety and views on speaking up more broadly. As we set out in this analysis, unfortunately the Staff Survey results suggest there are little signs of positive progress across many of these areas. Reporting of errors, near misses and incidents A high number of survey respondents, 86.16%, answered that their organisation encourages staff to report errors, near misses and incidents. However, 40.71% of respondents (over 290,000 staff) subsequently answered that they were unable to say with confidence that their organisation treats them fairly if they are involved in an error, near miss or incident. Answers to both these questions in the Staff Survey have remained fairly consistent across the past four years, as illustrated by the table and graph below. These results suggest there persists a significant disconnect between what organisations tell staff about reporting patient safety issues, and how staff feel they will be treated if they actually raise concerns. 67.3% of staff said that when errors, near misses or incidents are reported, their organisation takes action to ensure that they do not happen again. Responses to this question have also remained fairly static for the past four years (within a range of 67-69%), with nearly a third of staff consistently feeling unable to answer this question with a positive response. Responses to this question also vary significantly according to Trust type, with Community Trusts scoring highest on average (75.91%) and Ambulance Trusts scoring lowest (54.79%). Connected to this, nearly two-fifths of respondents, 38.98%, did not agree that they are given feedback about changes made in response to reported errors, near misses and incidents. When staff are unable to clearly see that their organisation acts on their safety concerns, it is understandable that they may be less motivated to report these. Concerns about clinical safety When asked about whether they would feel secure raising concerns about unsafe clinical practice, 71.1% of respondents answered this positively. Although this is quite a high percentage, the response rate in 2025 means that over 200,000 NHS employees, 28.9% of survey respondents, could not say that they would feel secure raising such concerns. When asked if they were confident that their organisation would address these concerns, 55.49% of staff responded positively. As illustrated by the table and graph below, responses to both these questions have remained fairly consistent across the last five years. Speaking up about concerns Turning to speaking up about concerns more broadly, 39.71% of survey respondents (over 280,000 staff) could not say that they felt safe to speak up about anything that concerns them in their organisation. As with the questions on reporting incidents, errors and near misses, again the average response varies significantly according to Trust type. When looking at Community Trusts, this figure drops to 30.2% but is significantly higher in Acute and Acute & Community Trusts (41.03%) and Ambulance Trusts (45.53%). When asked about their confidence in their organisation addressing their concern, just over half of all respondents did not express confidence that this would happen. As illustrated by the table and graph below, responses to both these questions have remained more or less consistent over the past five years, with a small decline this year. Safety culture in the NHS The 2025 staff survey results show no significant change in responses to questions on reporting, speaking up and acting on patient safety concerns in recent years. While the survey only provides an annual snapshot of experiences of working in the NHS, its findings suggest that a fear of speaking up and a lack of confidence that concerns will be acted on still persists in too many NHS organisations. These issues form a recurring theme across inquiries into major patient safety scandals.[2] [3] [4] They also can be seen reflected in the shocking experiences and testimonies of whistleblowers, such as those highlighted in our Speaking up for patient safety interview series.[5] Staff being able to raise concerns safely and effectively is essential for patient safety. However, as highlighted in a recent review shared by Roger Kline on the hub, the NHS continues to struggle with creating a culture where this happens reliably.[6] [7] Need for action It was notable that the need to tackle problems relating to safety culture was absent in the 10 Year Health Plan for the NHS, as highlighted in our response to this last year.[8] If the healthcare system is to truly be transformed over the next decade, then we cannot simply proceed by ignoring these issues or assuming they will resolve themselves. At Patient Safety Learning, we believe it is vital that we create a culture in healthcare that supports raising, discussing and addressing the risks of unsafe care. Year on year we highlight the stagnant set of staff survey results in this area because we do not believe the lack of improvement in this area is acceptable. Too often, at a national level, it appears that the extent and persistence of blame cultures in healthcare, and the need to tackle this, are acknowledged but action is not taken to address these significant challenges. It is difficult to imagine that the scale evidence of an unsafe culture in other safety critical industries would be tolerated—where the consequences of not addressing the risk in incidents may also be serious injury or loss of life. We hope that the soon to be published new NHS Quality Strategy will reflect on the importance of this issue and that health system leadership will recognise this issue as an urgent priority.[9] References NHS Staff Survey. NHS Staff Survey National Results. 12 March 2026. The Mid Staffordshire NHS Foundation Trust Public Inquiry. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 6 February 2013. 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. Independent Investigation into East Kent Maternity Services. Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. Helen Hughes and Peter Duffy. Key themes emerging from our ‘Speaking up for patient safety’ interview series. Patient Safety Learning, 14 May 2025. Roger Kline. Power and the sound of silence. Patient Safety Learning, 11 March 2026. Roger Kline. Patient safety and speaking up – learning from the literature. Patient Safety Learning, 11 March 2026. Patient Safety Learning. 10 Year Health Plan: Patient Safety Learning’s response. 14 August 2025. Patient Safety Learning and Aqua. Patient safety and the new NHS Quality Strategy. 25 February 2026.