Safety, openness and culture

In 2025, we made significant progress towards improving safety across the sector. This included in-depth activity across inter-related themes:

• Building a culture of greater transparency and openness – listening to patients and staff
• Fostering a learning environment both within and across organisations, including embedding patient safety principles
• Providing robust governance and oversight
• Addressing specific clinical priorities.

Building a culture of greater transparency and openness – listening to patients and staff

We have been ensuring that people are supported to speak out, and that when things feel wrong, there are mechanisms available that result in action. This has included work on the following areas:

• Freedom to Speak Up: encouraging staff to raise concerns
• Martha’s Rule: supporting patients and families to escalate concerns when they feel their clinical condition is deteriorating or concerns are not being adequately addressed
• Jess’s Rule: asking GPs to ‘reflect, review and rethink’ if a patient presents three times with the same or escalating symptoms
• Supporting sexual safety: ensuring a basic environment of respect and physical security for all – a vital component of a modern safety culture
• Patient Safety Partners (PSPs): working with patients to actively co-design systems, ensuring that their voices are integrated into the learning process.

Fostering a learning environment both within and across organisations

We have been building rigorous systems to identify and quantify systemic failures, supporting the shift from ‘blame’ to ‘improvement’, and facilitating action across the sector. This has included work on the following areas:

• Learning from Patient Safety Events (LFPSE): sharing information with the national data-sharing platform so we can all learn from each other’s errors
• Share and Learn: developing a community of practice to bring organisations together to share learning
• The Patient Safety Incident Response Framework (PSIRF): utilising the framework developed by NHS England to shift the focus from individual accountability towards a systemic understanding of how and why incidents occur
• Patient Safety Specialists: establishing professional leadership roles in individual organisations responsible for bridging national policy with local frontline practice.

Providing robust governance and oversight

We have been leveraging independent bodies and transparent data to scrutinise performance, maintain public trust and lead improvement. This has included work on the following areas:

• HSSIB (Health Services Safety Investigations Body): engaging with the central body that leads investigations, aiming at improving care at a national level
• PHIN adverse event data: ensuring the sector has sight of meaningful data to inform learning across privately-funded activity.

Addressing specific clinical priorities

While the themes above address systemic and cultural factors, some safety challenges require direct, targeted intervention at the clinical level:

• Never events: reviewing sentinel events that indicate a fundamental failure of safety systems and are therefore a key marker of overall system performance
• Preventing blood clots (VTE): ensuring processes are in place to address a high-volume clinical priority that remains a leading cause of preventable hospital deaths
• Transfers out: managing the specific safety risks inherent in the interfaces between teams and care settings.

The progress made in 2025 continues our move away from viewing patient safety as a series of isolated clinical checks. Rather, by interlinking culture, learning, governance and clinical priorities, we have moved closer to an approach that looks at the whole system.