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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.

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].

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 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.

In a review shared on the hub, Roger Kline, Research Fellow at Middlesex University Business School, explored the literature on patient safety and speaking up, arguing that staff being able to raise concerns safely and effectively is essential for patient safety, but the NHS continues to struggle with creating a culture where this happens reliably. In this blog, Roger reflects on some of the findings of his review. A critical characteristic of effective teams is whether every member is willing to speak up to share thoughts and ideas to improve processes, to raise concerns and admit mistakes. In healthcare, the failure of those to whom concerns are raised to listen and act on them decisively is a major factor in unsafe and suboptimal care delivery. NHS inquiry findings and recommendations are remarkably consistent on this issue. The Ely Inquiry (and other inquiries in the 1970s),[1] the Bristol Inquiry (2001),[2] the Mid-Staffordshire Hospital inquiries in 2010 and 2013,[3][4] and more recently Ockenden (2022),[5] all highlighted the failure to listen to staff who raised concerns and, worse, the victimisation of some of those who did raise concerns. Yet when the voices of healthcare staff are listened to and acted upon they can improve the safety and quality of services—as well as staff wellbeing.[6] Following the Francis Reports,[7] there was some limited improvement in NHS staff survey responses on whether NHS staff felt willing to raise concerns, whether they would be treated fairly if they did, and whether they felt their managers and employers would listen and act on those concerns. After Covid-19 that limited improvement stopped. Despite the raft of legislation, NHS regulation and exhortation, the 2023 National Guardian Office report entitled 'Fear and Futility' noted a “sharp decline in Freedom to Speak Up Guardians’ perception of the improvements in the Speak Up culture of the healthcare sector…” It noted that: “there is a growing feeling that speaking up in the NHS is futile – that nothing changes as a result.”[8] Staff safety is key to patient safety, so the fact that the majority of concerns raised are about staff safety is not a separate issue from patient safety but intimately linked.[9] So, when staff ought to—and often do—raise concerns what goes wrong? First, it has been repeatedly found by Francis (2015),[7] Kline and Warming (2024)[10] and others, that NHS staff are sceptical that raising concerns is effective and believe that by doing so it makes things worse for them personally due to victimisation.[11] Second, some staff groups are particularly sceptical of the effectiveness and/or safety of raising concerns. Kline and Warmington found that of Black and Minority Ethnic (BME) staff who did raise concerns, only 5.4% said they were taken seriously and that their problem was dealt with satisfactorily.[10] The most common outcome, in 42.7% of cases, to a race discrimination concern was nothing happening.[12] Begeny et al. (2023) revealed that within the UK surgical workforce, two-thirds of women medics (63.3%) had been subjected to sexual harassment, sexual assault and rape from colleagues, but only 16% of those impacted by sexual misconduct made a formal report.[13] Surviving in Scrubs (2023) noted a serious resulting risk to patient care from the silencing of female staff voicing concerns about such behaviours, as female staff reported that their clinical judgements were questioned, decisions were not taken seriously, clinical requests were ignored and referrals were refused.[14] Third, Mannion emphasises the importance of hierarchy in shaping behaviours: "Effective voicing of concerns is but the first stage in reshaping better safer healthcare: those with influence have to hear, and they have to act… In an intensely hierarchical organisation such as the NHS, entrenched status and power differences between professional groups can harm the development of open reporting cultures. Any attempt to address speaking up in the NHS must deal with the challenging organisational dynamic of resistance to bad news."[15] Reitz and Higgins (2020) suggest: "...power imbalance in organisational roles (as) perhaps the most important factor that makes employee silence such a common experience." They conclude that: “...instigating whistleblowing lines and training employees to be braver or insisting that they speak up out of duty, will achieve little therefore, without leaders owning their status and hierarchy, stepping out of their internal monologue and engaging with the reality of others."[16] Fourth, reputation continues to trump candour. Francis (2013) concluded that: “There lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism’; and an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern”.[4] Finally, alongside the refusal to adopt evidenced-based proactive interventions goes a lack of accountability for those whose power creates silence. Ministers have spoken strong words: “NHS managers who silence whistleblowers could be barred from working in the NHS, under proposals being announced this week.” [17] But such statements will only be effective if they are part of a wider evidence-driven strategy. In the meantime, victimisation of those raising concerns remains widespread, as recent reviews of the treatment of whistleblowers by both employers and the largest professional regulators have found.[18][19] Moreover, advice from professional regulators, as with NHS England, is very focused on individual professional accountability rather than system abuse of power.[20] Unfortunately, despite the best efforts of some NHS organisations, the conclusion Pope and Burnes reached a decade ago still stands: “The NHS exhibits too high a level of collective ego defences and protection of its image and self-esteem, which distorts its ability to address problems and to learn. Organisations and the individuals within them can hide and retreat from reality and exhibit denial; there is a resistance to voice and to “knowing.”[21] References Ely Hospital, Cardiff: Inquiry findings, Hansard, 27 March 1969. Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984 -1995. The National Archives, 2021. Mid Staffordshire NHS Foundation Trust Public Inquiry 2010. 24 February 2010. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Vol. 1: Analysis of evidence and lessons learned (part 1) HC 898, Session 2012-2013. Donna Ockenden. Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust. 30 March 2024. Mannion R, Davies H. Understanding organisational culture for healthcare quality improvement. BMJ  2018;363:k4907. Freedom to speak up Review, February 2015. National Guardian Freedom to Speak Up. Fear and futility: what does the staff survey tell us about speaking up in the NHS? June 2023. Patient Safety Learning. Why is staff safety a patient safety issue? 3 September 2020. Written evidence submitted by Roger Kline and Professor Joy Warmington (NHL0074). March 2024. Correspondence. Sir Robert Francis’ Freedom to Speak Up review. 11 February 2015. Kline R, Warmington J. To hot to handle? Why concerns about racism are not heard... or acted on. January 2024. Begeny CT, Arshad H, Cuming T, et al. Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights. BJS, 2023; 110(11): 1518–26. https://doi.org/10.1093/bjs/znad242. Cox B, Jewitt C, MacIver E. Surviving healthcare: sexism and sexual violence in the healthcare workforce. Surviving in Scrubs. November 2023. Mannion R, Blenkinsopp J, Powell M, et al. Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews. NIHR 2018; 6(30). Reitz R, Higgins J. Speaking truth to power: why leaders cannot hear what they need to hear. BMJ Leader 2020; 10.1136/leader-2020-000394. DHSC. Press release. New protections for whistleblowers under NHS manager proposals. 24 November 2024. Patient Safety Learning. The whistleblower playbook. the hub. 26 June 2025. Nursing & Midwifery Council. Independent Culture Review. July 2024. General Medical Council. Speaking up. Pope R, Burnes B. A model of organisational dysfunction in the NHS. 2013. Journal of Health Organisation and Management, 2013; 27(6): 76-697. https://doi.org/10.1108/JHOM-10-2012-0207. Further reading on the hub: Patient safety and speaking up—learning from the literature (Roger Kline) Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Top picks for staff psychological safety