Taking a reading on NHS patient safety: views from the ombudsman

It is difficult to get an accurate reading on where we are with patient safety in the NHS in England – is it making steady progress towards developing a proper patient safety culture, or is this only an aspirational pipe dream?

The Parliamentary and Health Service Ombudsman (PHSO), Rob Behrens, has expressed concern on several NHS patient safety matters in recent publications. The PHSO occupies a unique vantage point in the NHS from which to view NHS patient safety matters as his office makes the final decisions on complaints that have not been resolved. His jurisdiction also extends to other government departments and public organisations.

In his Broken Trust report from June 2023, the PHSO reviewed the most serious NHS complaints received by his office where avoidable death has resulted. The review highlighted an implementation gap, noting that there has been a lot of patient safety activity over the last 10 years but when the complaint cases are analysed: