"The report paints a troubling picture of the current state of patient safety in England, emphasising that in many areas of care, safety has deteriorated rather than improved over the past two years. We agree that urgent action needs to be taken and that healthcare organisations should not be working in a disjointed way. We support the view that a more focused and coherent approach to safety will drive learning and improvement.
“It is worrying that there continues to be a worsening of poor outcomes in maternity care. It is also disheartening that the report shows that there are significant divides and disparities overall, with the impact of unsafe care felt more acutely in some parts of the country than others. Our investigations often highlight where gaps and inequalities create a significant risk of harm to patients and will continue to examine and address this issue through our work. One of our key priorities is ensuring that our investigations include the voices and experiences of all people affected by patient safety incidents.
“We also agree with the NSPS assessment that there are too many recommendations flooding the system, with many not being implemented or acted upon. HSSIB has been working with a range of national organisations to look at this and we published a focused report on this in September. It is crucial that recommendations with the greatest impact are prioritised and that there is better visibility to help us identify themes, coordinate change programmes, share best practices and prevent duplication.
“ As the report says, in order for patient safety ambitions to be realised and for change to be implemented, honest conversations are vital and a genuine culture of collaboration is needed. This report is another reminder that we all have our part to play to reduce harm to patients. HSSIB is committed to working with colleagues across the healthcare system to help deliver meaningful change that improves the safety and quality of care patients receive.”
