The sloth like approach to NHS patient safety culture development

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In this post, John Tingle discusses patient safety culture in NHS.

John Tingle

John Tingle

We will all need medical help at some time in our lives and if you live in England this will most probably take place within the publicly funded National Health Service (NHS). Most people will receive safe care but unfortunately some will not. From April to June 2022, a total of 652,246 patient safety incidents were reported to the NHS patient safety incident reporting system. The World Health Organisation (WHO) state that in high income countries it is estimated that on average one in ten patients is subject to an adverse event while receiving hospital care. In any health care system, some degree of error is going to be inevitable.

Nobody is infallible.

Nobody is infallible and health care can be complex, dependent on human beings treating other human beings with often complicated equipment and processes. The best we can hope to do is to successfully manage risk. This is where patient safety policies and practices come in and it is a controversial, worrying topic in the NHS in England and globally. There have been several high-profile NHS patient safety failures over the years, and these continue. Patient safety and NHS maternity care in England is a particular pressing issue of concern. The Care Quality Commission (CQC)  states:

“This year, we continue to have concerns around the quality of maternity services. Ten per cent of maternity services are rated as inadequate overall, while 39% are rated as requires improvement. Safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for their safety and 12% rated as inadequate for being well-led.”

There are other long standing patient safety concerns in England which have been detailed over the years and have received wide national media coverage. What is clear is that the NHS needs to take more active steps to develop a proper NHS patient safety culture. Steps have been taken to do this, but progress is regarded by many as being too slow. There is also an implementation gap between what we know about the causes of patient safety issues and what we do about it.

Putting our knowledge and research into effect for safer care.

The NHS is palpable poor in some quarters of learning lessons from past health care adverse events and of changing practices. Patient safety investigation reports often show the same errors being repeated. The Parliamentary and Health Service Ombudsman (PHSO) has noted this along with others. The PHSO, Rob Behrens, stated in the foreword to his report,” Broken trust: making patient safety more than just a promise”:

“In this report, we consider the reasons for the continued failures to accept mistakes and take accountability for turning learning into action and improvement. (p.7).”

Two recent reports

Two recent reports have been published calling for more, quicker action on developing a proper NHS patient safety culture. The charity, Patient Safety Learning have published a report, “We are not getting safer: Patient safety and the NHS staff survey results.” This report analyses the results of NHS staff responses to several questions relating patient safety in the NHS Staff Survey 2023 and finds major issues, failings with NHS patient safety progress. Lamenting on the lack of progress in developing a proper NHS patient safety culture.

In the section of the NHS staff survey on reporting of errors, near misses and patient safety incidents, Patient Safety Learning express concern over several survey responses including the following:

-59.45% of staff said their organisation treats staff who are involved in an error, near miss or incident fairly. (q19a) (2022:58.17%.

Patient Safety Learning state on this finding:

“It is a deeply concerning finding that over 40% of staff cannot say with confidence that their organisation treats them fairly if they are involved in an error, near miss or incident. (p.5).”

The report is a hard hitting one and makes some excellent observations and recommendations on how to improve NHS patient safety matters.

A second report

A second report recently published is by The House of Commons Health and Social Care Committee Expert Panel,” Expert Panel: Evaluation of the Government’s progress on meeting patient safety recommendations”. The panel has reported on the government’s progress on meeting patient safety recommendations and have found that this requires improvement:

“Overall, despite good performance in some areas, the evidence we received has led us to rate.

the Government’s overall progress in the area of patient safety as ‘requires improvement’.

Our rating partly reflects the length of time it has taken for the Government to make.

progress on fully implementing four of the recommendations which were accepted nine.

years ago, or longer. (pp15-16).”

The report does a deep dive into several past patient safety crises and investigation report recommendations. Several NHS patient safety stakeholders submitted written evidence to the panel, and these also provide valuable perspectives on the current state of NHS patient safety culture development.


NHS patient safety efforts need to step up a pace and improve, particularly in the area of maternity care. Reports by regulators, CQC and others have shown that NHS lesson learning from past adverse health care event crises do not always take place. NHS care practices do not change sufficiently with often the same errors being repeated. Both reports discussed shine a powerful light on what needs to change for a proper NHS patient safety culture to become a reality rather than a well-meaning aspiration.

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