Patient Safety
Do we need to review our approach to patient safety?
Dr. Penny Dash’s review of patient safety has concluded that there has been: “a shift towards safety over the last 5 to 10 years, with considerable resources deployed, but relatively small improvements have been seen”. CSJ provides an overview of the key findings of the review and the wider response to the report.
Dr. Penny Dash’s Review of patient safety across the health and care landscape was first commissioned by the Secretary of State for Health and Social Care, following a review into the operational effectiveness of the Care Quality Commission (CQC) in the summer of 2024. Finally published on 7 July 2025, her patient safety review opens with some key statistics: of around 600 million patient interactions with the NHS a year, around 3,000 (1 in 200,000) result in a safety investigation. She points out that if the UK had performed
at the level of the top decile of Organisation for Economic Co-operation and Development (OECD) countries in 2022, there could have been 780 fewer deaths per year due to unsafe care. Furthermore, of the avoidable deaths in 2022
in England and Wales, around 65% could be attributed to conditions considered preventable (around 82,000 deaths). While many of the underpinning drivers of ill health are beyond the scope of the NHS, there remains “considerable opportunity to ensure more consistent delivery
of high-quality care”, she concludes. She points out that 4.4 million people have diabetes, but less than two-thirds receive recognised best practice care. In the worst-performing GP practice, the figure was under 2%. In financial year 2022 to 2023, complications
from diabetes included approximately: l 9,500 limb amputations l 48,000 strokes l 34,000 heart attacks l 155,000 cases of heart failure
The review points out that inequity and inequalities are evident across all dimensions of quality - people living in some of the poorest parts of the country die on average 10 years earlier than those in more affluent areas, and satisfaction with services differs by age, gender, race and socioeconomic status. Unsafe and ineffective care disproportionately impacts those from disadvantaged groups and those same groups report higher levels of dissatisfaction in care delivery.
The review points out that over the last 10 years, there has been an increasing focus on the safety of care with a number of high-profile failures, such as the Mid Staffordshire NHS Foundation Trust scandal. Dr. Dash explains that the reaction to these failures has typically been to set up a public inquiry into what went wrong, with recommendations for changes that often establish new organisations and bodies external to the mainstream work of the commissioners and providers of care. In her review, she comments that while this is “understandable”, it has led to a growth in the number of organisations considering safety and the wider quality of care, with the resulting impact of “even more recommendations and a cluttered landscape”. Therefore, her review aims to consider where appropriate changes can be made.
Key findings In the review, she observes that the focus on safety has been “at the expense of other aspects of quality of care”. In addition, various new organisations and bodies have cost “at least £60 million per year”, while DHSC-sponsored reviews and inquiries into safety are estimated to have cost at least £100 million. Commissioned by the Department of Health
and Social Care, the review was asked to look at six specific organisations that were established to either assure - or contribute to improving - the safety of care, while also making reference to the wider landscape of organisations influencing quality of care. The six organisations included: l CQC l Health Services Safety Investigations Body (HSSIB)
l Patient Safety Commissioner l National Guardian’s Office l Healthwatch England and Local Healthwatch l patient safety learning aspects of NHS Resolution
September 2025 I
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