Patient safety: what lessons can be learned?

Delayed by Covid-19, the Government recently published their response to the recommendations of the Public Administration and Constitutional Affairs Committee’s Inquiry on Follow up on the PHSO report: Missed opportunities: What Lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust – a snappy title if ever there was one!

In the introduction, they reiterate that patient safety must remain a top priority for the NHS in England and that they remain committed to creating an NHS that learns from incidents and puts that learning into practice.

High quality investigations are central to their vision and they flag the new Patient Safety Incident Response Framework which was trialled in 2020. The Healthcare Safety Investigation Branch are described as leading the way and the focus on leadership in the NHS People Plan is stated as something that will help prevent the unacceptable failures identified in the Parliamentary and Health Service Ombudsman report where safety incidents did not result in the required learning and improvement.

In their conclusion they confirm:

• The cases highlighted by the PSHO report are unacceptable
• They want to ensure the highest qualify safety and care for mental health patients
• They expect the Mental Health Act Code of Practice to be adhered to

We summarise the rest of the response document in a table which you can read here.