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.
345 items
1 source
17 inquiries
Source spread
Where this theme appears
Patient safety governance has been flagged across 1 independent accountability source:
345 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (345) — showing 50 strongest matches
40 — Independent specialist advice if in doubt
Recommendation: While hospital managers will usually seek medical advice from the medical director or clinical directors in the first instance, if any substantial doubt remains they shall seek advice from independent specialist medical advisers or the Royal Colleges, whether directly or …
Unknown
39 — Non-medical managers seek medical advice
Recommendation: Hospital managers without medical qualification shall seek medical advice on matters requiring it. If there is doubt as to the need for advice on any matter relating to patient care, the doubt shall be resolved by seeking advice.
Unknown
34 — Report unresolved problems to regional office
Recommendation: If no solution is found after all diligent attempts, the parties should keep records of their attempts and the reasons why they have failed, such records to be lodged by way of report to the relevant NHS Executive Regional Office.
Unknown
33 — Plan to resolve identified problems
Recommendation: Where problems are identified a plan, jointly where necessary, shall be drawn up to resolve them as soon as possible.
Unknown
32 — Investigate failing individuals or departments
Recommendation: Where there is good reason to believe that an individual or department may be failing and affecting patient care, it shall be the duty of the Trust with the co-operation of the university, and if appropriate on a joint basis, …
Unknown
31 — Treat substantial alterations as new
Recommendation: Any substantial alteration in an existing venture shall be treated as if a new venture.
Unknown
29 — Business plan for new ventures
Recommendation: Where a new venture, such as the establishment of a Chair or department, is contemplated, both parties where appropriate shall consider in detail the aims and resources available and draw up a realistic business plan before any final commitment is …
Unknown
27 — Disagreement and patient care
Recommendation: Where there is disagreement each party shall reconsider bearing in mind that patient care is of paramount importance. In the event of continued disagreement an arbitrator may be appointed, but in any case the Trust shall take immediate steps to …
Unknown
20 — Duty to disclose substantial matters
Recommendation: The duty of utmost good faith shall require either party to disclose to the other any substantial matter relating to the performance of the individual or department, whether clinical or academic.
Unknown
16 — Verify container before release
Recommendation: every authorisation for release of organs for burial or cremation must not be completed until the content of the container is confirmed and the form counter-signed;
Unknown
4 — Consider independent incident team
Recommendation: In devising a Serious Incident Procedure the Chief Executive and Trust Board shall consider the need for a serious incident team independent of the hospital.
Unknown
2 — Trust devises incident procedure
Recommendation: In the event of a serious incident the Chief Executive and Trust Board shall devise a suitable Serious Incident Procedure similar to those already in place for major disasters and review it from time to time making any necessary alterations.
Unknown
1 — Develop serious incident procedures
Recommendation: Serious Incident Procedures should be developed and put in place.
Unknown
37 — Permits and isolations remain in force
Recommendation: A permit to work and its consequent isolations, both mechanical and electrical, should remain in force until the work is sufficiently complete for the permit to be signed off and the equipment returned to operation (para 18.8).
Unknown
36 — Mechanical isolation procedure
Recommendation: All permit to work systems should incorporate a mechanical isolation procedure which involves the physical locking off and tagging of isolation valves (para 18.29).
Unknown
34 — Harmonisation of permit to work systems
Recommendation: Standardisation of the permit to work system throughout the industry is neither necessary nor practicable. However, in view of the fact that there is much in common between the systems of different operators, the industry should seek to increase harmonisation, …
Unknown
32 — Permit to work part of the SMS
Recommendation: The operator’s permit to work system should form part of its SMS (para 21.56).
Unknown
28 — Workforce involvement part of the SMS
Recommendation: The operator’s procedures included in line management of operations which are aimed at involving the workforce in safety should form part of its SMS (para 21.56).
Unknown
3 — Safety management system content
Recommendation: The SMS should be in respect of (a) the design (both conceptual and detailed) of the operator’s installations; and (b) the procedures (both operational and emergency) of those installations. In the case of existing installations the SMS in respect of …
Unknown
2 — Objectives the Safety Case must demonstrate
Recommendation: The Safety Case should demonstrate that certain objectives have been met, including the following:- (i) that the safety management system of the company (SMS) and that of the installation are adequate to ensure that (a) the design and (b) the …
Unknown
6 — Monitoring deaths in hospitals
Recommendation: i. By 31 March 2027, all hospital Trusts must have in place effective mechanisms for Board- level monitoring of all deaths of children and babies. ii. By 31 March 2027, all hospital Trusts must have in place a clear and …
Gov response: No formal government response published. The Secretary of State for Health and Social Care's oral statement of 15 September 2026, made on the day the Inquiry's report was published, names neither this recommendation nor board-level …
Unknown
AFA-4 — Governance
Recommendation: The Inquiry recommends a programme of work by the Trust to: • Consolidate governance improvements into a clear, prioritised programme overseen by the Board. This will ensure that the large number of improvement plans do not become overwhelming or get …
Words of: Dr Stephen Austin, Southern Trust Medical Director, in a Southern Health and Social Care Trust news release, 24 June 2026
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
AFA-2 — Organisational development and cultural reform
Recommendation: The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. …
Words of: Dr Stephen Austin, Southern Trust Medical Director, in a Southern Health and Social Care Trust news release, 24 June 2026
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
R81 — Expert clinical governance advisory function
Recommendation: The DoH should establish an expert clinical/social governance advisory function to support providers.
No response yet
R79 — Board member learning framework
Recommendation: The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in governance (including both financial and clinical/social care governance, including patient …
No response yet
R77 — Triennial Board governance reviews
Recommendation: The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.
No response yet
R76 — NED with clinical governance expertise
Recommendation: NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as a senior independent director with that responsibility. The DoH should …
No response yet
R75 — Executive Director of Clinical and Social Care Governance
Recommendation: There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance for complex systems requires specialist skills. While this is largely recognised within finance governance, only superficial consideration is …
No response yet
F68 — Focus on compliance with fundamental standards
Recommendation: No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Board of the NHS Trust Development Authority will only approve a Trust’s application to be passed to Monitor, when it is satisfied that the Trust has clearly demonstrated that it is able to …
Accepted
F67 — Focus on compliance with fundamental standards
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The focus of the NHS Trust Development Authority is to enable NHS Trusts to provide high quality, sustainable services for their local communities. It does this by overseeing all aspects of a Trust Board’s …
Accepted
F66 — Improving contribution of stakeholder opinions
Recommendation: The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is sought on the fitness of a potential applicant NHS trust …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The NHS Trust Development Authority will test Trusts’ Patient and Public Involvement strategies to ensure they are engaging with their patients and local community throughout the Foundation Trust application process, particularly on the quality …
Accepted
F65 — Quality of care as a pre-condition for foundation trust applications
Recommendation: The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support for a foundation trust application.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The NHS Trust Development Authority has published its Accountability Framework which sets out how Trusts will be held to account for delivering the appropriate quality of care. Trusts which are failing to meet these …
Accepted
F64 — Authorisation of foundation trusts
Recommendation: The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Not accepted, although we agree with the principle of better regulation of the authorisation process. As outlined in relation to recommendation 19, we agree with the principle of better regulation of the authorisation process, but …
Not accepted
F63 — Improved transparency
Recommendation: Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. Monitor has published all side letters since 2011 and risk ratings are published on a quarterly basis. Side letters are issued in certain circumstances where an applicant meets the statutory requirements for authorisation but …
Accepted
F62 — Improved patient focus
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. A central theme of Monitor’s Quality Governance Framework is whether the Boards of NHS organisations actively engage patients, staff and other key stakeholders on quality. From April 2013 it is also a licence condition …
Accepted
F61 — Consolidation of regulatory functions
Recommendation: A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a justification for reduction of the resources allocated to this area …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Not accepted, although we agee with the principle regarding changes to the regulatory system. While we do not accept this recommendation in the light of the response to recommendation 19, we agree with the principles …
Not accepted
F60 — Consolidation of regulatory functions
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. However, we believe that the best way to achieve the desired outcome is through closer co- operation between Monitor and the Care Quality Commission rather than through the transfer of functions. The …
Accepted in part
F59 — Care Quality Commission independence strategy and culture
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle Steps have already been taken by Care Quality Commission to establish a series of sector specific advisory groups, which include senior representatives from Royal Colleges and patient groups. These groups support the …
Accepted in part
F58 — Care Quality Commission independence strategy and culture
Recommendation: Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a patient …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Care Quality Commission uses a wide range of means to engage people who use services in its work. It is holding a number of events and activities to ask people how they it …
Accepted
In progress
F57 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Care Quality Commission has carried out a significant review of how it uses information to identify potential failures in the quality of care in hospitals. Taking each of five key questions – is …
Accepted
F56 — Care Quality Commission independence strategy and culture
Recommendation: The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. In April 2013 the Care Quality Commission published its new three year strategy, Raising Standards, putting people first – our strategy 2013–16.54 This document sets out how the Care Quality Commission will make major …
Accepted
F55 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined in this report.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Care Quality Commission has begun implementing a new approach to inspection and enforcement that is fundamentally different. It has appointed chief inspectors to lead this new approach in each sector. Key means of …
Accepted
F54 — Care Quality Commission independence strategy and culture
Recommendation: Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission's statutory role.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Care Quality Commission is implementing this recommendation by means of partnership agreements and operational protocols which include criteria to make and store a formal record of meetings. So far, these cover the Care …
Accepted
In progress
F53 — Care Quality Commission independence strategy and culture
Recommendation: Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. There are no plans to abolish the Care Quality Commission. The Care Quality Commission has set out a new strategy for the next three years, and has a new Board in place, with five …
Accepted
In progress
F52 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Care Quality Commission is developing Memoranda of Understanding with medical, nursing and midwifery Royal Colleges. These will ensure that peer review and accreditation schemes are taken fully into account as new methods of …
Accepted
In progress
F51 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by such inspectors who should have the support of a team, …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Chief Inspector of Hospitals has begun inspecting in this way. Useful lessons were learnt from the Care Quality Commission’s targeted inspections of 150 learning disability in-patient units following events at Winterbourne View hospital; …
Accepted
In progress
F50 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Care Quality Commission has introduced a fundamentally different and strengthened approach to inspection as the centrepiece of how it assures standards of care. The Care Quality Commission’s new approach to inspection involves large …
Accepted
F49 — Enhancement of monitoring and the importance of inspection
Recommendation: Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained from: The Quality and Risk Profile; Quality Accounts; Reports from …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Care Quality Commission is fundamentally changing the way it monitors providers on the quality of their services. Through its Chief Inspector of Hospitals, it has introduced a new system in the hospital sector. …
Accepted
F48 — Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
Recommendation: The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. Professor Sir Mike Richards, the Chief Inspector of Hospitals, has already written to Foundation Trust Councils of Governors about the first wave of his new NHS Trust inspections, setting out how Councils …
Accepted in part
In progress
F47 — Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
Recommendation: The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current 'sounding board events'.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Care Quality Commission has taken steps to engage Overview and Scrutiny Committees and Foundation Trust Governors, to increase their input to its new approach to inspection and monitoring. All Overview and Scrutiny Committees …
Accepted
In progress