Response to PHSO report – Broken trust: making patient safety more than just a promise

  • 4th July 2023

In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report.

In the report Broken trust: making patient safety more than just a promise, PHSO examines 22 NHS complaints cases where patents died due to avoidable errors.[1] After analysing these cases, they have identified four broad themes of clinical failing leading to avoidable deaths: failure to make the right diagnosis, delays in providing treatment, poor handovers between clinicians and failure to listen to the concerns of patients or their families.

The report also considers the issue of compounded harm, the additional harm that people experience when interactions following patient safety incidents feel closed and defensive. From their findings, they identify the following scenarios that are likely to contribute to compounded harm:

  • failure to be honest when things go wrong
  • a lack of support to navigate systems after an incident
  • poor-quality investigations
  • a failure to respond to complaints in a timely and compassionate way
  • inadequate apologies
  • unsatisfactory learning responses.

Considering these findings, the PHSO make several recommendations at the end of their report aimed at tackling these issues.

Patient Safety Learning’s reflections

We welcome this new report from the PHSO.

Sadly, the patient safety themes that it raises are all too familiar. Avoidable harm resulting from delays in providing treatment and failing to listen to patient concerns come up time and time again in reports into patient safety incidents. As do failures to respond appropriately after harm occurs, such as poor-quality investigations that do not result in learning or improvement. We see many of the issues that this report raises also feature prominently in recent reports into major patient safety scandals, such as those in East Kent and Shrewsbury and Telford.[2] [3]

Below we share our thoughts specifically on the report’s recommendations for change.

Investigations and PSIRF

The report highlights that while there have been some positive developments in seeking to improve investigations in the NHS, and welcomes the introduction of the new Patient Safety Incident Response Framework (PSIRF), there remains “a gap between the welcome rhetoric in PSIRF guidance documents and the defensive behaviours from some NHS leaders we still see in our casework”.[4]

PHSO note concerns about the additional flexibility that PSIRF offers, suggesting that this may present a risk at Trusts with poor cultures who do not carry out investigations when they should. In response to these concerns, it makes recommendations around the need for close monitoring of the rollout of PSIRF by Integrated Care Boards and Board members who lead on PSIRF in their organisations.

Patient Safety Learning agrees with these recommendations. Although there are many welcomed elements to PSIRF, its success to a large part will depend on having the right organisational leadership and resources to support the transition to this new approach to investigations. We believe that this initiative should be judged on its implementation in supporting culture change and in translating learning from investigations into reduction of avoidable harm.

Duty of candour and support for patients

Duty of candour is intended to ensure that healthcare providers are open and transparent with the public. In legislative terms, it sets specific requirements for organisations to follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.[5]

PHSO state that from evidence gathered through their casework that they find that this duty is not always implemented as it should be and state they think this requires more attention and monitoring. The report recommends that:

“The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.”[6]

We agree with this recommendation. As part of this reviewing problems with compliance, we believe that there are also broader questions that also need to be addressed concerning how the implementation of this is monitored and what remediation and redress is available to patients and the families when these obligations are not met.

The report also notes that despite a statutory duty for local authorities to commission NHS complaints advocacy, these services can be limited and are often restricted to helping people navigate the NHS complaints process. It recommends that:

“The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident.”[7]

At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. Access to advocacy services is an essential part of this, helping address the power imbalance between patients and the healthcare system when things go wrong. We fully support this recommendation.

Complex and fragmented patient safety landscape

Discussing the national patient safety picture, the report points to the confusing landscape of patient safety roles and responsibilities that currently exist. It highlights how organisational functions can often overlap, creating confusion over who does what and undermining patient safety leadership. It recommends that:

“The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families”[8]

This is not a new concern. Five years ago, in its report Opening the door to change, the Care Quality Commission (CQC) raised similar issues, noting the lack of clear understanding of how patient safety is organised nationally and who is responsible for what tasks.[9] The Professional Standards Authority for Health and Social Care also pointed this out in their report last year, Safer care for all, stating:

“For too long, individual organisations with different and specific remits have been expected to work together to address workforce and patient and service user safety issues. This approach is structurally flawed as there is generally no accountability for joint working and collaboration; bystander apathy and differing organisational priorities also present significant barriers. Everyone understandably looks at the problem through the lens of their own remit, but no one has the overview.”[10]

Patient Safety Learning agrees with the PHSO’s assessment of this problem. We also highlighted this issue in our report last year, Mind the implementation gap. As stated then, we believe that with the current fragmented approach to patient safety leadership, the Secretary of State for Health and Social Care lacks the levers and means to fundamentally improve our national approach to patient safety.[11]

Workforce strategy

The report also makes a recommendation around the Government producing its long-term workforce strategy and sets out what the PHSO think this document must include, which was subsequently published the day after the report.

Workforce shortages and pressures in the NHS and social care have serious implications for patient safety. We will be looking closely detail of the new NHS Long Term Workforce Plan, in the coming days and weeks from this perspective.[12]

Patient safety as a core purpose of health and social care

In this report PHSO make the case that patient safety must be a consistent priority over the long term. It recommends that the Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority.

We agree with this recommendation. Patient Safety Learning believes that the persistence of avoidable harm is the result of our failure to address the complex systemic causes that underpin it. In our report A Blueprint for Action we set out the need for a transformation in approach to patient safety. This sets out how too often patient safety is typically seen a strategic priority, which in practice will be weighed (and inevitably traded-off) against other priorities.[13] To transform our approach to this it is important patient safety is not just seen as another priority, but as a core purpose of health and care.

This applies to all parts of the system. We need everyone - politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders - involved in this effort.


[1] PHSO, Broken trust: making patient safety more than just a promise, 29 June 2023.

[2] Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022.

[3] 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.

[4] PHSO, Broken trust: making patient safety more than just a promise, 29 June 2023.

[5] Public Health England, Duty of candour, Last updated 5 October 2020.

[6] PHSO, Broken trust: making patient safety more than just a promise, 29 June 2023.

[7] Ibid.

[8] Ibid.

[9] CQC, Opening the door to change: NHS safety culture and the need for transformation, December 2018.

[10] Professional Standards Authority for Health and Social Care, Safer Care for All: Solutions from professional regulation and beyond, 6 September 2022.

[11] Patient Safety Learning, Mind the implementation gap: the persistence of avoidable harm in the NHS, 7 April 2022.

[12] NHS England, NHS Long Term Workforce Plan, 30 June 2023.

[13] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.

PHSO Broken Trust Report website image2


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