Recommendation BRIS-106: Establish independent National Patient Safety Agency for healthcare safety and quality
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
We support and endorse the broad framework of recommendations advocated in the report ‘An Organisation with a Memory’ by the Chief Medical Officer’s expert group on learning from adverse events in the NHS. The National Patient Safety Agency proposed as a consequence of that report should, like all other such bodies which contribute to the regulation of the safety and quality of healthcare, be independent of the NHS and the DoH.
Government response
No government response to this recommendation is on the record yet.
Delivery
DHSC and NHS England state no delivery position (27 February 2026)
The NHS Patient Safety Agency was disbanded in 2012, and its functions transferred to the NHS Commissioning Board (now NHS England)
The NHS Patient Safety Strategy, published in July 2019 and updated in 2021, sets out how NHS England will support staff and providers to share safety insight and empower people – patients and staff – with the skills, confidence and mechanisms to improve safety. An update on progress in June 2023 set out that much progress has been made across the strategy’s main programmes of work.
It describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems and highlights the importance of a just culture. It states that there are many aspects to a good safety culture and that leaders need to play a key role in championing its development.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Superseded”. Table row: section 6.2 No. 106, PDF page 118-119.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
The Government rejected the recommendation that the National Patient Safety Agency be outwith the NHS.
In its January 2002 response, the Department of Health said the organisation had been established in 2001 as a special health authority, ensuring it had the confidence of healthcare staff and was able to work closely with the NHS.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 6.2 No. 106, PDF page 106-107.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding