Sexual safety: the implications for patient safety

We would like to thank the stakeholders who supported this exploratory work and those with lived experience who shared their experiences with us.

This report is intended for healthcare organisations, policymakers and the public to help improve patient safety in relation to sexual safety.

Please note that due to the subject matter of this report it contains details which some readers may find distressing.

Between May and September 2024, the Health Services Safety Investigations Body (HSSIB) carried out exploratory work to consider the potential of conducting an investigation into patient safety risks associated with sexual safety.

Certain elements of sexual safety, such as those that are within regulatory or criminal liability remits, were not considered in scope of HSSIB’s exploratory work as they fall outside of HSSIB’s directions, as set out in the Health and Care Act 2022. Many staff on patient and patient on patient sexual safety concerns were considered to fall into regulator or criminal liability remits. The exploratory work therefore focused on incidents involving staff on staff sexual behaviours and the wider impact these behaviours may have on patient safety.

HSSIB engaged with 20 different stakeholder organisations including national organisations, regulators, universities, royal colleges and professional associations, national patient advocacy organisations, and independent activist groups. A full list of stakeholders can be seen in the appendix to this report. Many of the stakeholders engaged with were leads on sexual safety in their respective organisations.

HSSIB found there were many ongoing and new initiatives, such as the NHS sexual safety in healthcare organisational charter, that would take time to develop, embed and reach a mature state to allow evaluation. An HSSIB investigation would therefore offer limited value at this time. However, HSSIB felt that publishing a summary of the ongoing work could be helpful to the health and care system.

Sexual safety means ‘feeling safe from any behaviours, circumstances or environments that a person might perceive to be a sexual harm to themselves. Feelings of sexual safety are individualised and each person will have different situations that may cause them to feel greater or lesser safety from sexual harm’ (National Collaborating Centre for Mental Health, 2020). Sexual behaviours can range from making sexual or sexist comments, jokes and/or innuendos to rape, sexual assault and sexual harassment (General Medical Council, 2023). HSSIB considered all types of sexual behaviours when exploring the potential for conducting an investigation about sexual safety.

In recent years, a number of high-profile reports have demonstrated evidence that there is widespread sexism, sexual misconduct and harassment in healthcare. In particular, several reports have highlighted these issues in the ambulance services, mental health services and in surgical settings. For example:

• ‘Breaking the silence’, which explored sexual misconduct by colleagues in the surgical workforce
• ‘Surviving healthcare: sexism and sexual violence in the healthcare workforce’, which analysed 150 stories and details 174 incidents of sexism, sexual harassment and sexual assault occurring between colleagues within the healthcare workforce
• ‘Reducing misogyny and improving sexual safety in the ambulance service’, which highlights sexual safety issues among ambulance staff
• ‘Promoting sexual safety through empowerment’, which reviewed sexual safety and the support of people’s sexuality in adult social care
• ‘Sexism in medicine’, a report based on a survey of nearly 2,500 doctors which highlights an issue with sexism in the medical profession.

The latest NHS staff survey in 2023 included questions on unwanted sexual behaviour for the first time. It asked: “In the last 12 months, how many times have you been the target of unwanted behaviour of a sexual nature in the workplace? This may include offensive or inappropriate sexualised conversation (including jokes), touching or assault.” The survey found that more than 50,000 NHS staff (8.67% of those surveyed) said they had been the target of at least one incident of unwanted behaviour of a sexual nature from patients/service users, their relatives or other members of the public and almost 26,000 (3.84%) had been the target of such behaviour from colleagues.

In September 2023, NHS England launched the ‘Sexual safety in healthcare – organisational charter’. Health and care organisations were asked to commit to a zero-tolerance approach to any unwanted, inappropriate and/or harmful sexual behaviours within the workplace, and to 10 core principles and actions.

This section of the report summarises the findings from HSSIB’s exploratory work.

Impact on patient safety

HSSIB considered the evidence gathered during stakeholder discussions and relevant literature against HSSIB’s investigation criteria and found there was not sufficient evidence to make an assessment. Stakeholders felt there was potentially a link between sexual safety and patient safety; however, they had limited data or information to evidence this link.

HSSIB considered the issue of bullying and harassment more broadly and found there was a range of international research which indicated that threats to worker safety through bullying and harassment was associated with poor clinical outcomes (Walker et al, 2018).

HSSIB makes the following safety observation

Current and ongoing initiatives

HSSIB was told about sexual safety improvement initiatives that each of the different stakeholders were undertaking. HSSIB noted that the improvement work focused on organisational culture and behaviour and not on understanding the impact of sexual safety on the delivery of safe care.

Several stakeholders, including NHS England, ambulance services and the Royal College of Surgeons, discussed developing appropriate reporting systems for sexual safety concerns. These reporting mechanisms would provide an anonymous space for incidents to be reported and investigated, and enable organisations to identify “hotspots” that required action.

In October 2024, the NHS published the ‘National people sexual misconduct policy framework’ and the ‘Sexual safety charter assurance framework’ to support integrated care boards and trusts in ensuring staff:

• understand their rights and responsibilities
• recognise and report sexual misconduct at work
• get advice and support.

New NHS e-learning resources are also available to equip healthcare staff with the knowledge and skills to recognise and respond to sexual misconduct.

Several stakeholders had either developed or were developing education materials and courses for staff on sexual safety to raise awareness and aid recognition of inappropriate sexual behaviour. In addition, stakeholders had updated their policies and professional/organisational standards to set clearer expectations for staff around sexual safety.

A growing number of healthcare organisations were signing up to the NHS sexual safety in healthcare organisational charter. When HSSIB started exploring sexual safety (in May 2024) 343 organisations had signed up to the charter; this had risen to 420 at the time of writing (October 2024). The NHS England website gives details of the organisations that have signed up to the charter. The charter allows organisations to show their commitment to tackling sexual safety and offers an opportunity for shared learning in how organisations are applying the charter’s 10 principles.

Recent reports that explore sexual safety in healthcare, such as ‘Breaking the silence’ and ‘Surviving healthcare: sexism and sexual violence in the healthcare workforce’, have also made numerous recommendations. The recommendations include having a national implementation and investment strategy, policies and codes of conduct, education of workforces, improving support, an independent anonymous reporting system, data collection, an improved communication system between healthcare employers, regulators and the police, and a call for an independent inquiry into the culture of sexism and sexual misconduct in healthcare. Time will be needed for these recommendations to be actioned and embedded.

HSSIB found that there was duplication of effort in some of the improvement work being undertaken and there was limited evidence of an overall strategy. HSSIB saw that there is potential for increased co-ordination and collaboration to mitigate duplication of effort and increase the impact of the different streams of improvement work.

On 26 October 2024, the Worker Protection (Amendment of Equality Act 2010) Act introduced a new legal duty on employers to take reasonable steps to prevent the sexual harassment of staff. The Equality and Human Rights Commission (EHRC) has published updated workplace sexual harassment guidance to support organisations in the actions they need to take. The change to law and EHRC guidance aims to raise awareness of what constitutes sexual harassment with training and risk assessments being advised. The topic of sexual safety will have a higher priority in the workplace, and hopefully empower and encourage concerns of sexual harassment to be reported.

HSSIB makes the following safety observations

HSSIB has shared the findings of this exploratory work with NHS England to support its work to encourage alignment of sexual safety improvement work and investment in sexual safety.

While HSSIB will not be conducting an investigation specifically into sexual safety at this time, sexual safety is being considered in HSSIB’s mental health inpatient settings investigations. HSSIB remains committed to improving sexual safety in healthcare and will consider the issue in its ongoing work. HSSIB has signed up to the NHS sexual safety in healthcare organisational charter and encourages other organisations to do so.

Association of Ambulance Chief Executives (2024) Reducing misogyny and improving sexual safety in the ambulance service. Available at https://aacesite.s3.eu-west-2.amazonaws.com/wp-content/uploads/2024/05/13151959/AACE-REDUCING-MISOGYNY-WHAT-WE-KNOW-V3A-BB-revised-May24.pdf (Accessed 4 September 2024).

British Medical Association (2021) Sexism in medicine. Available at https://www.bma.org.uk/media/4488/sexism-in-medicine-bma-report-august-2021.pdf (Accessed 4 September 2024).

Care Quality Commission (2020) Promoting sexual safety through empowerment. Available at https://www.cqc.org.uk/sites/default/files/20200225_sexual_safety_sexuality.pdf (Accessed 4 September 2024).

Equality and Human Rights Commission (2024) Sexual harassment and harassment at work: technical guidance. Available at https://www.equalityhumanrights.com/guidance/sexual-harassment-and-harassment-work-technical-guidance (Accessed 22 October 2024).

General Medical Council (2023) Professional standards. Maintaining personal and professional boundaries. Available at https://www.gmc-uk.org/-/media/gmc-site/ethical-guidance/mdg-2023/maintaining-personal-and-professional-boundaries-english.pdf (Accessed 2 September 2024).

Health and Care Act (2022) (UK Public General Acts). Part 4, Investigations. Available at https://www.legislation.gov.uk/ukpga/2022/31/section/110/enacted (Accessed 4 September 2024).

Health Services Safety Investigations Body (n.d.) Mental health inpatient settings. Available at https://www.hssib.org.uk/patient-safety-investigations/mental-health-inpatient-settings/ (Accessed 17 October 2024).

House of Commons Library (2023) Worker protection (Amendment of Equality Act 2010) – Lords stages and amendments. Available at https://researchbriefings.files.parliament.uk/documents/CBP-9867/CBP-9867.pdf (Accessed 4 September 2024).

National Collaborating Centre for Mental Health (2020) Sexual safety collaborative. Standards and guidance to improve sexual safety on mental health and learning disabilities inpatient pathways. Available at https://www.rcpsych.ac.uk/docs/default-source/improving-care/nccmh/sexual-safety-collaborative/sexual-safety-collaborative---standards-and-guidance.pdf?sfvrsn=1eb6a5b7_2 (Accessed 2 September 2024).

NHS England (2023) Sexual safety in healthcare – organisational charter. Available at https://www.england.nhs.uk/long-read/sexual-safety-in-healthcare-organisational-charter/ (Accessed 10 October 2024).

NHS England (2024a) National people sexual misconduct policy framework. Available at https://www.england.nhs.uk/publication/national-people-sexual-misconduct-policy-framework/ (Accessed 22 October 2024).

NHS England (2024b) Sexual safety charter assurance framework. Available at https://www.england.nhs.uk/publication/sexual-safety-charter-assurance-framework/ (Accessed 22 October 2024).

NHS Learning Hub (n.d.) Understanding sexual misconduct in the workplace. Available at https://learninghub.nhs.uk/Resource/57103 (Accessed 22 October 2024).

NHS Staff Survey (n.d.) National results. Available at https://www.nhsstaffsurveys.com/results/national-results/ (Accessed 4 September 2024).

Surviving in Scrubs (2023) Surviving healthcare: sexism and sexual violence in the healthcare workforce. Available at https://www.survivinginscrubs.co.uk/app/uploads/2023/11/Surviving-in-Scrubs-Surviving-Healthcare-Report.pdf (Accessed 4 September 2024).

The Working Party on Sexual Misconduct in Surgery (2023) Breaking the silence. Addressing sexual misconduct in healthcare. Available at https://www.wpsms.org.uk/_files/ugd/db2313_6246937816244a589b4519284026586a.pdf (Accessed 4 September 2024).

Walker, J. (2018) A theoretical study on workplace bullying and sexual harassment amongst first responders. Available at https://www.proquest.com/docview/2185999972?%20Theses&fromopenview=true&pq-origsite=gscholar&sourcetype=Dissertations%20&parentSessionId=MaJocnTkhaqbt0SzsdpQqGL96jjP50KI%2F5DxE%2Fy2Llw%3D (Accessed 2 September 2024).

HSSIB contacted stakeholders across the healthcare landscape to explore the potential for a patient safety investigation. The stakeholders who responded and engaged with this exploratory work are listed below.

• Association of Ambulance Chief Executives
• Care Quality Commission
• College of Paramedics
• General Optical Council
• Health and Care Professions Council
• Independent Healthcare Providers Network
• National Guardian’s Office
• NHS England
• NHS Professionals
• NHS Providers
• Nursing and Midwifery Council
• Parliamentary and Health Service Ombudsman
• Patient Safety Commissioner
• Royal College of Anaesthetists
• Royal College of Nursing
• Royal College of Psychiatrists
• Royal College of Surgeons
• Surviving in Scrubs
• University of Glasgow
• Working Party on Sexual Misconduct in Surgery’s
• 1 mental health trust.