Systemic Investigation
Partially Accepted
Partially Complied
Broken trust: making patient safety more than just a promise
Systemic investigation into patient safety failings across the NHS, examining how the patient safety system fails to learn from mistakes. Draws on PHSO casework to identify failures in local investigations, duty of candour, patient advocacy, and oversight. Makes 7 recommendations to DHSC, NHS England, ICBs and government.
7 recommendations
5 with response
Recommendations
Integrated Care Boards / NHS England
Rec 1
Pending
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is needed. This should include paying special attention to the balance of patient safety investigations versus other learning responses in Trusts (or service areas of a Trust) where there are poor CQC ratings for safety and leadership, or where other national bodies have raised concerns.
NHS Trust Boards
Rec 2
Pending
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local investigations did not take place, or did not find that things went wrong, but PHSO or another independent oversight body later identified failings.
Department of Health and Social Care / NHS England
Rec 3
Partially Accepted
The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.
Partially accepted:
DHSC launched a call for evidence on the statutory duty of candour in April 2024. Findings published 26 November 2024 (261 responses received). DHSC stated it will 'carefully consider' responses before developing future policy. No final policy recommendations yet published.
26 November 2024
Department of Health and Social Care
Rec 4
Pending
The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident.
Response:
No formal government response published.
Department of Health and Social Care
Rec 5
Accepted
The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.
Government accepted:
Government commissioned the Dash Review, an independent review of patient safety organisations led by Dr Penny Dash. Published July 2025. Government accepted all 9 Dash recommendations via Written Ministerial Statement HCWS785, 7 July 2025.
7 July 2025
HM Government
Rec 6
Pending
The Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority.
Response:
No formal government response published.
HM Government
Rec 7
Accepted
The Government should urgently produce its long-awaited long-term workforce strategy, with cross-party support, to increase the numbers entering and staying in the workforce across clinical and non-clinical roles. This strategy must: include independent, evidence-based and fully costed projections of future workforce requirements; include detailed plans for training and recruiting new staff, retaining staff already working in the NHS and attracting those who have left to return; take account of the mix of different professional skills required, rather than just total numbers in the workforce, and how existing professional skills can be deployed where they are most needed.
Government accepted:
The NHS Long Term Workforce Plan was published on 30 June 2023. Backed by over £2.4 billion in government investment. Sets out plans to train, retain and reform the workforce over 15 years.
30 June 2023