Patient Safety Watch: NHS plan sets out bold new patient safety agenda

Good afternoon and welcome to this fortnight’s edition of the Patient Safety Watch newsletter. It’s a jam-packed edition, so let’s get stuck in.

New 10-Year Health Plan for the NHS published

The big news this week is, of course, the publication of the government’s new 10-Year Health Plan for the NHS. The “three big shifts” at the heart of the plan have been widely covered in HSJ, the Guardian, the Independent and elsewhere. Instead of repeating those summaries, here’s a look at what the plan says specifically about patient safety:

Regulation and leadership

• New powers to disbar senior leaders who cover up unsafe practices, silence whistleblowers or behave dishonestly – long-called-for regulation of senior NHS managers is finally on the way;
• A new Management and Leadership Framework to set clear standards and expectations;
• Creation of a College of Executive and Clinical Leadership to define and promote excellence; and
• New performance-related pay arrangements for senior managers, with pay withheld where care or financial standards are not met.

Complaints and patient voice

• Comprehensive reform of the NHS complaints process: clear standards, quicker responses, and handling by dedicated patient experience teams rather than PALS or external advocates – overdue and welcome;
• Appointment of a national director of patient experience to embed patient voice within the system, replacing Healthwatch England’s role; and
• Use of AI to analyse complaints data to speed up learning and response.

Investigations, oversight and maternity safety

• The functions of the Health Services Safety Investigations Body (HSSIB) will transfer to the Care Quality Commission, remaining a distinct, independent unit;
• The Patient Safety Commissioner will move under the Medicines and Healthcare Products Regulatory Agency for clearer oversight of medicines and devices safety; and 
• As announced last week, the government has launched a rapid national investigation into maternity and neonatal safety and the creation of a National Maternity and Neonatal Taskforce, chaired by the health and social care secretary, to co-produce an action plan with bereaved families. This marks a major intervention by Wes Streeting – some further thoughts from me here.

CQC

• Transition to an intelligence-led inspection model using real-time data and AI to spot emerging risks;
• Extending the time limit for the CQC to bring legal action – reflecting concerns raised by harmed families; and
• Peer-led inspection teams, including people with lived experience, and immediate feedback after inspections to enable faster improvement.

Data, transparency and incentives

• Quarterly league tables ranking providers on safety and quality; 
• More use of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs), shared publicly via the NHS App to help patients choose providers;
• “Patient Power Payments” pilot: patients can choose to withhold payments if care isn’t safe or good enough; and
• Persistently poor performance to trigger decommissioning or contract termination.

Culture and accountability

• Freedom to Speak Up Guardians to become part of core oversight, with the CQC assessing whether organisations truly listen to staff; and
• Boards made explicitly accountable for care quality day-to-day and after safety incidents.

My thoughts?

In the coming months, there’ll be plenty of analysis, but my first reaction from a patient safety perspective is cautious optimism.

Nobody designed today’s NHS landscape; it evolved over many years of successive governments with new initiatives, often in response to past inquiries and scandals. While often well intentioned, this patchwork has created unnecessary complexity. Against that backdrop, many of the plan’s commitments feel welcome yet overdue: reforming the complaints system, finally regulating senior NHS managers, strengthening patient voice and giving the CQC more bite (crucially, Mr Streeting has confirmed CQC’s easy-to-understand ratings system will remain).

I was also relieved to see confirmation that HSSIB’s function will continue – albeit as a discrete unit within the CQC – after alarming media reports last week that HSSIB was to be scrapped. HSSIB has had a bumpy journey, but it has changed the game in delivering high-quality, systems-focused investigations of patient safety issues – focused on learning, not blame. In addition, its education team has helped spread systems thinking, patient safety science, and investigation expertise across the NHS.

The original case for keeping safety investigation separate from regulation (best set out in the paper that led to HSSIB’s creation, McCrea & Vincent, 2014) still holds. Rosie Benneyworth’s blog in response to the changes makes important points: retaining HSSIB’s independence, systems focus and “safe space” powers is crucial and must not be diminished in the transfer.

One disappointment: there’s no full commitment to review or reform the litigation system – something myself and others feel is desperately needed. Still, the government has asked David Lock KC to advise on improving patients’ experience of clinical negligence claims: a small step forward.

And what about delivery? It’s worth noting a chapter titled “Change begins” – which HSJ reported was listed on the draft plan’s index page – did not appear in the final version. Hopefully, we’ll see more details on how the plan will be delivered soon!

In other news this edition…

Watchdog warns families not listened to in fatal sepsis cases

HSSIB has raised renewed concerns that patients continue to die from sepsis because early warning signs are missed, and families raising concerns about deterioration are too often ignored.

Investigation reports highlight gaps in recognising sepsis promptly, despite years of national focus. HSSIB’s latest report urges a culture change to ensure families’ voices are heard as vital safety alerts.

Senior managers arrested amid Lucy Letby investigation

Three former senior leaders from the Countess of Chester Hospital Foundation Trust – where babies were murdered by Lucy Letby – have been arrested on suspicion of gross negligence manslaughter.

Cheshire Constabulary began its investigation into possible corporate manslaughter at the trust in October 2023. In March 2025, the investigation’s scope was widened to include potential gross negligence manslaughter – a separate offence which is focused on individuals’ grossly negligent action or inaction.

First patient death linked to cyber attack confirmed

The first patient death directly linked to the recent cyber attack on pathology supplier Synnovis has been confirmed.

The attack, which severely disrupted blood tests and pathology services across London hospitals, contributed to delays that HSJ reports resulted in a patient’s death.

This marks a significant and deeply concerning escalation in cyber threats’ impact on patient safety.

Pharmacists warn medicine shortages are risking patient safety

A new survey by the Pharmaceutical Journal has found that three-quarters of pharmacy staff believe medicine supply chain delays are now putting patient safety at risk.

Respondents reported increased stress, treatment delays, and patient harm linked to shortages, highlighting the urgent need for a more resilient medicines supply system.

Review highlights safety caveats in physician associates’ use 

A new rapid evidence review, led by Nottingham University’s Nicola Cooper, has found that physician associates (PAs) can improve access to care and support clinical teams, but only when working under direct supervision or in clearly defined post-diagnostic roles.

Published in BMJ Open, the review analysed 40 comparative studies. While it found no major safety concerns in supervised settings, the current evidence to support using PAs in undifferentiated or unsupervised roles is insufficient.

The findings come amid growing debate over expanding the NHS’s PA workforce. The authors urge health systems to ensure robust supervision, governance, and clear role boundaries to safeguard patients and maintain quality of care.

Sharing some good stuff…

One in five escalation calls under ‘Martha’s rule’ result in action

A recent BMJ report highlights that approximately 20 per cent of escalation calls made under Martha’s rule lead to escalation or adjustments in care. NHS leaders are describing the policy as “having a significant impact”, with early evidence suggesting it is helping identify at-risk patients sooner.

Martha’s rule was born from the deeply tragic loss of Martha Mills and her parents’ incredible campaigning. It is heartening to know that lives are already being saved as a result.

Help us improve patient safety across NHS hospitals – share your experiences!

Patient Safety Watch is working with THIScovery to gather real examples of patient safety initiatives that have improved patient safety. We want to find out more about what has been done, how it was developed, and how well it worked. The aim is to reduce duplication, share what is working, and explore the potential for building a shared library of interventions.

A short video about the project and how to get involved is available here.

National Maternity Safety Conference – full programme published

Following the success of the five previous events, this year’s National Maternity Safety Conference, hosted by Baby Lifeline, takes place at the Hilton Metropole in Birmingham on 25 September. This conference will bring together NHS professionals, families, researchers and stakeholders to discuss this year’s theme: Shaping the Future of Maternity Care Together.

The full programme is now available here. Previous events have sold out quickly so please do book early to avoid disappointment.

That’s nearly all for this edition. Before signing off, a quick congratulations to friend and colleague Mahendra G Patel, who has become the first pharmacist in England to receive an honorary fellowship from the Royal College of General Practitioners. A well-deserved recognition of his trailblazing work in research, patient safety, equity, and cross-professional collaboration.

And finally…

Remembering Lucian Leape, founder of the modern patient safety movement

The Institute for Healthcare Improvement has honoured the legacy of Lucian Leape, who passed away on 30 June 2025, aged 94. Widely regarded as the founder of the modern patient safety movement, his work revealed the true scale of avoidable harm in hospitals.

Dr Leape championed systems-based solutions over individual blame. Across more than four decades, he fought to elevate patient and clinician safety, foster transparency, and refocus medical culture around error prevention rather than condemnation.

I’ll finish this newsletter with one of Dr Leape’s most well-known quotes:-

“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”

That feels like an important note to end on, especially in these times of rapid and significant change.

Thanks for reading, and please look out for our next newsletter from Jeremy in two weeks’ time.

James