Asking the fundamental questions

It is important that we all try to find time to reflect on what we do, to see where we are going and where we have been. In a busy NHS this is difficult, but it is nevertheless important to try – all professionals need to do this as change happens and we must properly prepare for it. Several recent publications discussed here have caused us to reflect on some fundamental issues in patient safety and clinical negligence.

Henrietta Hughes, the Patient Safety Commissioner, has shared her ideas on several patient safety matters (Hughes, 2023). These include the need to hear more of the views of patients at trust board meetings and at other occasions where patient safety is discussed. She called for a ‘seismic shift’ in the way patients' and their families' voices are heard (Hughes, 2023). There is also a need, she stated, to improve how health professionals communicate with patients – to address dismissive and defensive behaviour of clinicians, which is still a continuing problem. Putting patient safety first is a key underpinning premise of the report.