Patient Safety Watch: Dash Review opens a crucial door

Good afternoon and welcome to the latest edition of the Patient Safety Watch Newsletter, this time from me, Jeremy. It’s been a huge month for patient safety, so let’s get stuck right in.

Patient safety reforms

The Dash Review, commissioned by the Department of Health and Social Care, was published last week. In the end we had to wait until after the 10-Year Health Plan.

Although many of the patient safety organisations impacted were set up by me, I do recognise the need to simplify the patient safety landscape.

Two concerns have surfaced in particular: first whether the Health Services Safety Investigations Body (HSSIB) will have the statutory independence it needs as part of the Care Quality Commission (what happens, for example, if the regulator itself is found to be at fault?) and second, whether the abolition of the National Guardian role will compromise the generally appreciated role of local Freedom to Speak Up guardians.

Penny Dash has been engaging with the All Party Patient Safety Group, which I chair, to get to the bottom of these issues, and we have already had one meeting. The biggest opportunity will be if, as the report recommends, the NHS now sets up a system to monitor and implement the hundreds of patient safety recommendations made every year by inquiries, regulators and coroners.

This is due to happen through a revamped National Quality Board. If it is co-chaired by Ms Dash as chair of NHS England and Sir Mike Richards as chair of the CQC, I think it could have a real chance of success because the decisions on what to implement and by when would be made by people with a responsibility to implement them. It is going to be a busy autumn.

PA role reform in the Leng Review

The government has accepted all 18 recommendations from the independent review led by Gillian Leng into physician associates and anaesthesia associates. Professor Leng is a well respected and independent figure, and her reforms include:

• Clearer titles: PAs will be renamed “physician assistants,” and AAs as “physician assistants in anaesthesia” to reduce confusion and reinforce that these roles support – not replace – doctors.
• Stronger oversight: New professional faculties will set standards, and PAs/AAs must work under the supervision of a designated doctor.
• Tighter boundaries: PAs/AAs will no longer treat undiagnosed patients unless clearly defined and appropriately supported. Improved training and regulatory frameworks will be introduced.

Maternity failures at Swansea Bay

An independent review has confirmed widespread failings in Swansea Bay University Health Board’s maternity and neonatal services, highlighting poor staffing, leadership, communication, pain management, postnatal support, and complaints handling. Many families described feeling unheard or unsafe.

A family-led report, published one day earlier, included the voices of over 50 affected families, detailing similar concerns around trauma, exclusion and safety.

Key recommendations from an independent review include formalising governance induction processes for medical staff and improving the use of incident data by introducing run charts to monitor trends over time. The review also calls for clearer delineation of responsibilities for incident reporting between obstetric and neonatal teams, and for the existing maternity performance dashboard to be expanded to incorporate patient experience, complaints, incident data, and staff feedback.

It also called for the introduction of the Harmed Patient Pathway across the whole of Wales to ensure that responses to patient harm are “swift, decisive and non-defensive.” Can we have that in England too, please?

LeDeR report delays spark criticism

The government has come under fire for delays to the 2024 Learning from Lives and Deaths (LeDeR) report, which examines the deaths of adults with learning disabilities and autism in England.

According to ITV, the report was submitted to the government in December 2024 and marked as complete in June 2025, yet has still not been published. The delay has caused alarm among campaigners and policymakers, who are calling for either immediate publication or at least an official explanation for the delay. NHSE attributed the hold-up to “practical data issues.”

Communication breakdowns at hospital discharge

A new report from the HSSIB highlights an ongoing risk to patients at the point of discharge from hospital. The investigation found that electronic discharge summaries are frequently not reaching community or primary care teams in a usable form, if at all – leading to medication errors, missed follow-up, and in some cases, avoidable harm.

This is not a new issue. Communication failures during discharge have been raised in numerous reviews over the past decade. Yet, despite widespread adoption of electronic records, interoperability and information governance barriers continue to undermine safe handovers.

Safeguarding under strain

Doctors and child protection charities have raised concerns that NHS budget cuts are undermining statutory safeguarding duties, including multi-agency support for vulnerable children. In an open letter to the health and social care secretary, signatories warn that cuts to designated safeguarding leads, training budgets, and child protection teams risk “creating the conditions” for another tragedy on the scale of Baby P or Victoria Climbié.

Safety concerns force suspension of children’s hearing services

Blackpool Teaching Hospitals Foundation Trust has suspended its children’s audiology service following concerns about the safety and reliability of assessments. According to local reports, the decision was made after a number of children were found to have been incorrectly diagnosed or not followed up, potentially delaying vital interventions for speech, language and cognitive development.

Sepsis investigation

HSSIB has published three in-depth investigation reports, each modelling a patient safety incident investigation (PSII) under the Patient Safety Incident Response Framework (PSIRF). Despite ongoing national efforts, the investigations highlight that early recognition of sepsis remains a significant challenge. Common themes include rapid patient deterioration, missed early warning signs like confusion, and family concerns that were raised but not always acted upon.

The reports recommend strengthening systems and training to support earlier detection, ensuring family input is actively listened to, and standardising sepsis-response pathways across care settings. They also emphasise the importance of sharing learning across NHS trusts to improve timeliness and responsiveness. The three reports will also be a useful reference for NHS trusts as examples of exemplar PSIIs under PSIRF.

And finally for this edition — a plug for a brilliant podcast episode featuring Bill Kirkup CBE

In a recent FabStuff podcast episode, Dr Kirkup speaks to Roy Lilley and Niall Dickson, with candid reflections on the limits of high-profile healthcare inquiries.

Despite good intentions, he argues that familiar failings like poor communication and weak leadership continue to resurface. Too often, recommendations fade without follow-up or accountability. Real progress, he suggests, requires cultural change – not just more reports – and embedding inquiry lessons into everyday practice through leadership, governance, and staff engagement. It’s a timely and important listen.

That’s all for now. James and I will be back in September. Wishing you a very pleasant summer…