Patient safety governance
Lack of well-protected and defined resources for national patient safety agencies and insufficient awareness among healthcare professionals of the Duty of Candour.
1,161 items
12 sources
10 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
91match
#2 - Establish a national framework for patient safety with clear targets and improved complaints system.
The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England’s approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing and unresponsive complaints system. Neither the Department nor NHS England know how 3 much cost the NHS incurs...
Matched on
terms: patient, safety
Inquiry recommendation
87match
F41 - Use of information about compliance by regulator from: Patient safety alerts
The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety alerts should continue following the transfer of the National Patient Safety Agency's functions in June 2012 to the...
Matched on
terms: patient, safety
Committee recommendation
87match
#15 - Lack of centralised learning causes repeated patient safety incidents across trusts.
Written evidence submitted to us raised concerns about a lack of centralised learning leading to incidents being repeated across multiple trusts.31 When asked what it was doing to improve systemic learning from patient safety incidents, NHS England told us it had a “variety of mechanisms” but did not provide any detail on what these were.32
Matched on
terms: patient, safety
Committee recommendation
87match
#13 - Health system overwhelmed by patient safety recommendations, hindering affirmative action.
In 2024, the Health Services Safety Investigations Body reported that the broader health system was drowning in patient safety recommendations rather than taking affirmative actions to improve it.26 NHS England told us that there are over 1,500 recommendations in the system and that managing those centrally is a huge task. NHS England told us that the new National...
Matched on
terms: patient, safety
Inquiry recommendation
86match
BRIS-106 - Establish independent National Patient Safety Agency for healthcare safety and quality
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...
Matched on
terms: patient, safety
PHSO recommendation
86match
Broken trust: making patient safety more than just a promise
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.
Matched on
terms: patient, safety
Committee recommendation
83match
#17 - Department fails to outline specific actions for reducing patient harm and improving safety.
The previous Committee were concerned that the Department was spending billions of pounds of taxpayers’ money without an effective plan to minimise future costs of the clinical negligence scheme.25 In April 2024, the Committee recommended that, by summer 2024, “the Department should set out the key reasons for patient harm and the actions it will take to address...
Matched on
terms: patient, safety
Committee recommendation
83match
#10 - Patient safety system suffers from duplication and minimal improvement amidst reforms.
The NHS reports around 2.4 million patient safety incidents annually, most of which (70%) cause no harm to patients, but around 0.5% of patient safety incidents result in severe harm or death. The 2025 Dash review identified considerable overlap and duplication in the current patient safety landscape with relatively little improvement over the last five to 10 years.12...
Matched on
terms: patient, safety
Inquiry recommendation
82match
BRIS-110 - National Patient Safety Agency to manage national sentinel events database
The national database of sentinel events should be managed by the National Patient Safety Agency, so as to ensure that a high degree of confidence is placed in the system by the public.
Matched on
terms: patient, safety
Inquiry recommendation
78match
IHRD-55 - Board Member Training on Patient Safety
Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.
Matched on
terms: patient, safety
Committee recommendation
74match
#4 - Develop a plan to reduce patient harm and manage escalating clinical negligence costs.
It is unacceptable that the Department is yet to develop a plan to deal with the cost of clinical negligence claims, and so much taxpayers’ money is being spent on legal fees. The Department has set aside an astounding £58.2 billion to cover the potential costs of clinical negligence events occurring prior to 1 April 2024, the second...
Matched on
terms: patient, safety
PFD report
73match
Rosalind Baird
There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
Matched on
terms: patient, safety
PFD report
73match
Alwyn Head
Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Matched on
terms: patient, safety
PFD report
69match
Barry Dillion
Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
Matched on
terms: patient
PFD report
69match
Annette Krasinsky-Lloyd
Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.
Matched on
terms: governance, patient
Committee recommendation
69match
#2 - Acknowledge general practice crisis and detail short-term steps to improve patient safety and access.
In response to this Report the Government and NHS England should be clear in acknowledging that there is a crisis in general practice and set out in more detail the steps they are taking in response to this crisis in the short term, to protect patient safety, strengthen continuity, improve access and reduce GP workloads.
Matched on
terms: patient, safety
Committee recommendation
69match
#1 - General practice in crisis due to poor patient access and safety risks, unacknowledged by government.
The first step to solving a problem is to acknowledge it and we believe that general practice is in crisis. It is clear from the latest GP Patient survey results that despite the best efforts of GPs, the elastic has snapped after many years of pressure. Patients are facing unacceptably poor access to, and experiences of, general practice...
Matched on
terms: patient, safety
PFD report
65match
Kirabo Kiwanuka
Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.
Matched on
terms: patient
PFD report
65match
Lea Hunsley
The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Matched on
terms: patient
PFD report
65match
Hubert Kelly
Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.
Matched on
terms: patient
Inquiry recommendation
65match
F32 - Interim measures
Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary measures to ensure such protection while any investigation required to make a final determination is undertaken.
Matched on
terms: patient, safety
CQC action
65match
Stepping Out
Governance systems were not sufficiently robust to identify where quality and safety was being compromised.
Matched on
terms: governance, safety
Inquiry recommendation
62match
F62 - Improved patient focus
For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.
Matched on
terms: patient
PFD report
61match
Stephen Ellis
A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Matched on
terms: patient
PFD report
61match
Natasha Raghoo
The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Matched on
terms: patient
PFD report
61match
Mary James
Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
Matched on
terms: patient
PFD report
61match
Sharon Henshall
The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.
Matched on
terms: patient
PFD report
61match
Stephen Taylor
Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.
Matched on
terms: patient
Inquiry recommendation
61match
F59 - Care Quality Commission independence strategy and culture
Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.
Matched on
terms: patient
CQC action
61match
Serenity House
The provider had failed to ensure the safe careand treatment of people. Quality assurance systems were fragmented and ineffective. There was a lack of oversight of people's care, safety and the quality of service. Risk management process was not robust and people were not protected from harm or potential harm. The system to maintain adequate staffing and provide...
Matched on
terms: safety
Inquiry recommendation
60match
F143 - Clear metrics on quality
Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms to be established so that outliers or progression to poor performance can be identified and accepted as needing to be fixed.
Matched on
terms: patient, safety
Inquiry recommendation
60match
F141 - Taking responsibility for quality
Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its retained individual responsibility to take whatever action within its power is necessary in the interests of patient safety.
Matched on
terms: patient, safety
LGO / SPSO decision
60match
NIPSO-improving-healthcare-through-better-patient-engagement - Various
Shared decision making in a healthcare setting is about involving patients and their families in decisions about their clinical care. Not only does this foster a more compassionate, effective healthcare service, it is vital for patient safety. By listening to and working with patients, a service is more likely to understand and meet their needs, and be responsive...
Matched on
terms: patient, safety
PFD report
57match
John Fox
Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
Matched on
terms: patient
PFD report
57match
Lana-Liza Chervonenko
High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Matched on
terms: patient
PFD report
57match
Eileen Smith
The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based on external appearance, stressing the need for better communication with carers.
Matched on
terms: patient
PFD report
57match
Frederick Sutton
Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic care failures.
Matched on
terms: patient
PFD report
57match
Darren Jones
The report identifies a need for review of protocols regarding when renal advice should be sought, especially for transplant patients, along with the education of staff and availability of immunosuppressant drugs.
Matched on
terms: patient
PFD report
57match
Bryan Catanach
Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted in a fall, and essential traction equipment was unavailable.
Matched on
terms: patient
PFD report
57match
Dorothy Imisson
The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
Matched on
terms: patient
PFD report
57match
Milly Zemmel
There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.
Matched on
terms: patient
PFD report
57match
Marian Grant
Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients on non-trauma wards, coupled with ineffective EPR alerts, increased the risk of avoidable death.
Matched on
terms: patient
PFD report
57match
Mary Ryder
Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not followed.
Matched on
terms: patient
PFD report
57match
Joseph Page
Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
Matched on
terms: patient
Inquiry recommendation
57match
BRIS-121 - Assign executive and non-executive board members responsibility for clinical safety strategy.
At the level of individual trusts, an executive member of the board should have the responsibility for putting into operation the trust’s strategy and policy on safety in clinical care. Further, a non-executive director should be given specific responsibility for providing leadership to the strategy and policy aimed at securing safety in clinical care.
Matched on
terms: safety
PHSO recommendation
57match
Ignoring the alarms: How NHS eating disorder services are failing patients
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Matched on
terms: patient
Inquiry recommendation
57match
F67 - Focus on compliance with fundamental standards
The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as a priority focus a review of the standard of service delivered to patients, and the sustainability of a service at the required standard.
Matched on
terms: patient
Inquiry recommendation
57match
F60 - Consolidation of regulatory functions
The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.
Matched on
terms: governance
Inquiry recommendation
57match
F37 - Use of information about compliance by regulator from: Quality accounts
Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent that it is not practical in a written report to set out detail, this should be made available via each trust's website. Reports should no longer be confined...
Matched on
terms: safety
CQC action
57match
Heritage Healthcare-Middlesbrough
The provider must ensure good governance, including accurate record-keeping, effective audits, and appropriate monitoring of service quality.
Matched on
terms: governance