Patient safety


Commenting on the report, Patient Safety Learning’s Chief Executive, Helen Hughes, said: “It is vital that we create a culture in healthcare that supports raising, discussing and addressing the risks of unsafe care. Results of this year’s and previous years’ staff surveys, coupled with evidence from patient safety scandals and whistleblower testimonies, show that in too many parts of the NHS this is simply not the case. “It is difficult to imagine that the evidence


of an unsafe culture in other safety critical industries, where the consequences of incidents may also be serious injury or loss of life, would be deemed acceptable. Surely it must be unacceptable in healthcare. “We are calling on NHS England to


acknowledge the scale of this problem and respond to this as part of its expected update on the implementation of the Patient Safety Strategy this year. If there is to be any positive movement on scores on safety issues in coming years, now is the time to act.”


References 1. Francis, R, Freedom to Speak up – A review of whistleblowing in the NHS, February 2015


2. NHS Patient Safety Strategy, Accessed at: https://www.england.nhs.uk/patient-safety/ the-nhs-patient-safety-strategy/


3. Patient Safety Learning, We are not getting safer: Patient safety and the NHS staff survey results, March 2024. Accessed at: https://d2z1laakrytay6.cloudfront. net/Report_Wearenotgettingsafer_ PatientsafetyandtheNHSstaffsurveyresults_ Issued_2024-03-25-170020_djqc.pdf


4. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. https://www.gov.uk/government/ publications/final-report-of-the-ockenden- review


5. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. https://www.gov.uk/government/ publications/maternity-and-neonatal- services-in-east-kent-reading-the-signals- report


6. The Mid Staffordshire NHS Foundation Trust Public Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 6 February 2013. https://www.gov.uk/government/ publications/report-of-the-mid-staffordshire- nhs-foundation-trust-public-inquiry


7. Peter Duffy, Whistle in the Wind: Life, death, 22 www.clinicalservicesjournal.com I August 2024


detriment and dismissal in the NHS. A whistleblowers story, 2019.


8. Peter Duffy, Smoke and Mirrors: An NHS whistleblower witch-hunt, 2021.


9. Peter Duffy, NHS whistleblowing: the long and winding road, Trends in Urology & Men’s Health, 19 December 2023. https://wchh. onlinelibrary.wiley.com/doi/10.1002/tre.952


10. Patient Safety Learning, Lucy Letby verdict, a future inquiry and patient safety, 23 August 2023. https://www.patientsafetylearning.org/ blog/lucy-letby-verdict-a-future-inquiry-and- patient-safety


CSJ


11. Health Service Journal, Revealed: How trust execs resisted concerns over Letby, 18 August 2023. https://www.hsj.co.uk/countess-of- chester-hospital-nhs-foundation-trust/ revealed-how-trust-execs-resisted- concerns-over-letby/7035170.article?mkt_ tok=OTM2LUZSWi03MTkAAAGNp7piJih6pX66etu Z3oFhTcHb_rNei_OoF3GUzXCeSkEeFZxFGke-w_ YP-g9vQBWDGMzhYKJR5eRq0Q4QMGOicsJ9i7P UcwuNF4mgqKpAw2hGC48


12. Thirlwall Inquiry, Terms of reference, 19 October 2023. https://thirlwall.public-inquiry. uk/document/terms-of-reference/


13. NHS England, Safety culture programme group (SCPG) report: Overview of safety culture discovery and discussions 2021, Last Accessed 16 March 2023. https://www.pslhub.org/ learn/culture/safety-culture-programmes/ safety-culture-programme-group-scpg- report-overview-of-safety-culture-discovery- and-discussions-2021-r7693/


14. NHS England, Safety culture: learning from best practice, 15 November 2022. https:// www.england.nhs.uk/long-read/safety- culture-learning-from-best-practice/


15. NHS England, Improving patient safety culture – a practical guide, 10 July 2023. https://www. england.nhs.uk/long-read/improving-patient- safety-culture-a-practical-guide/


16. NHS England, A just culture guide, Last accessed 3 January 2024. https://www. england.nhs.uk/patient-safety/patient- safety-culture/a-just-culture-guide/#about- our-guide


17. Mersey Care NHS Foundation Trust, Restorative Just and Learning Culture, Last accessed 3 January 2023. https://www. merseycare.nhs.uk/restorative-just-learning- culture


18. NHS England, Safety culture: learning from best practice, November 2022, accessed at: https://www.england.nhs.uk/publication/ safety-culture-learning-from-best-practice/


19. Northumbria University, Participants wanted: New study to explore implementing Restorative Just Culture in NHS Trusts, Patient Safety Learning’s the hub, 23 January 2024.


https://www.pslhub.org/learn/research- data-and-insight/research/participants- wanted-new-study-to-explore-implementing- restorative-just-culture-in-nhs-trusts-r10834/


20. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. https:// s3-eu-west-1.amazonaws.com/ddme-psl/ content/A-Blueprint-for-Action-240619.pdf


21. Patient Safety Learning, Standards, Last accessed 7 March 2024. https://www. patientsafetylearning.org/standards


About Patient Safety Learning


Patient Safety Learning is a charity and independent voice for improving patient safety. It aims to harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of harm. It believes that patient safety should not be negotiable. Through its work, it supports safety improvement through policy, influencing and campaigning, and the development of ‘how to’ resources such as the hub (https://www. pslhub.org/), a free award-winning platform to share learning for patient safety, as well as Patient Safety Standards and support tools (https://www.patientsafetylearning.org/ standards).


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