Fundamental standards of behaviour
Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report they make, including information about any action taken or reasons for not acting.
- The Patient Safety Incident Response Framework (PSIRF), published by NHS England in August 2022 and mandatory from autumn 2023, replaced the Serious Incident Framework. PSIRF requires organisations to support staff in reporting patient safety events and to provide feedback on reports (Patient Safety Incident Response Framework, NHS England, August 2022).
- The Learn from Patient Safety Events (LFPSE) service, launched by NHS England in 2023-24 to replace the National Reporting and Learning System, provides a national platform for recording patient safety events (LFPSE, NHS England, 2023-24).
- The Freedom to Speak Up framework, established following the Sir Robert Francis "Freedom to Speak Up" review (February 2015), requires all NHS trusts to have a Freedom to Speak Up Guardian. NHS England reports that all trusts have appointed guardians (Freedom to Speak Up Review, Sir Robert Francis, February 2015; Freedom to Speak Up National Guardian's Office).
How was this evidence gathered?
Response
Accepted
Response
AcceptedThe government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
Francis recommended insisting on incident reporting with feedback to reporters. The Freedom to Speak Up Review (February 2015) led by Francis himself resulted in Freedom to Speak Up Guardians in all NHS trusts (over 800 Guardians by 2024). The National Guardian's Office was established in 2016. By 2024-25, over 38,000 cases were raised with Guardians annually (up from zero before 2016). 80% of workers who spoke up would do so again. However, 12% of cases were anonymous (suggesting some feel unsafe) and the Lucy Letby case showed that even with FTSU mechanisms, concerns can be ignored by management.
View detailed findings
Freedom to Speak Up infrastructure is well-established and heavily used but the Letby case at Countess of Chester demonstrated that concerns raised by clinicians can still be systematically ignored.
Over 1,400 Freedom to Speak Up Guardians across healthcare organisations in England. 38,000+ cases raised in 2024-25, cumulative total exceeds 142,000 since inception. However, NHS Staff Survey 2024 shows only 71.5% of staff feel secure raising concerns about unsafe practice (stagnant for years), and only 57% are confident their organisation would address concerns.
Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS). NRLS fully decommissioned 30 June 2024. LFPSE has broader coverage including primary care, uses machine learning for analysis and improved trend identification.
HSSIB formally launched 1 October 2023 as independent statutory body under Health and Care Act 2022. Replaced HSIB (non-statutory, established 2016). Has statutory "safe space" protections, powers of entry, inspection and seizure. Conducts system-focused patient safety investigations.
Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework from Autumn 2023. Shifts from individual blame to system-based learning approaches. Mandatory for all NHS-funded secondary care providers. Part of NHS Patient Safety Strategy (July 2019).
Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS.
First Patient Safety Commissioner Dr Henrietta Hughes OBE appointed 12 September 2022 under Medicines and Medical Devices Act 2021. Independent champion for patient safety regarding medicines and medical devices.
Sir Robert Francis published Freedom to Speak Up Review on 11 February 2015 with 20 principles and actions. Led to: Freedom to Speak Up Guardians mandatory in all NHS trusts from October 2016; National Guardian's Office established January 2016.
Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year.
Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted.