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John Tingle

Different stakeholder perspectives on NHS safety

An independent expert panel commissioned by the House of Commons Health and Social Care Committee (HSCC) has issued the report of its findings on the Government's progress on meeting patient safety...

A palpable sense of frustration with NHS patient safety culture development

Patient Safety Learning (2024) is a charity for improving patient safety that provides excellent resources to share learning. It has recently produced a report analysing the results of questions...

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

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,...

The challenges facing the NHS in implementing Martha's Rule

The call for Martha's Rule arose out of the tragic death of 13-year-old Martha Mills, who died from sepsis in 2021 at King's College Hospital, London. There was a failure to recognise that she...

Be careful about what you wish for in NHS patient safety reform

‘Patients struggle to navigate the complaints system and it may take some time to find the correct organisation to complain to.’ .

Clinical negligence: should the NHS consider a no-fault system?

‘… costs … have continued to grow at an eye-watering rate. Ten years ago, the NHS paid £900 million in damages; last year it was £2.17 billion – equivalent to the annual running costs of the biggest...

The enormity of the NHS patient safety culture development challenge

Improvement recommendations are made after a patient safety crisis, often repeated ones, but the system does not change much or at all. Errors are repeated, lessons go unlearnt. This might seem a...

Patient engagement, patient empowerment and patient safety

‘I have discovered that we need a seismic shift in the way that patients' and families' voices are heard. This requires changes in legislation, regulation, policy, commissioning, education,...

Back to patient safety basics: improving communication with patients

‘Trusts receive too many safety-related messages from too many different sources. The trusts we spoke to said there needed to be better communication and coordination between national bodies, and...

Patient safety: why does the NHS always seem to get a bad press?

Rob Behrens, the Parliamentary and Health Service Ombudsman (PHSO), gave evidence to the Times Health Commission (Sylvester, 2023a; 2023b). This was a controversial session during which the PHSO...

The importance of NHS patient safety lesson learning

‘SO1: Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere.’ .

Developing perspectives in NHS patient safety

In terms of patient safety improvement practices and culture development, a recent report published by Healthcare Excellence Canada (Gilbert et al, 2023) provides some interesting and valuable...

Patient empowerment: the need to go beyond buzzwords

When we use concepts such as patient empowerment, we need to be as specific as we can about what we mean and understand about the term. We don't want the words to be just seen as a convenient ‘clarion...

Martha's Rule and NHS patient safety

One issue she discusses are the professional silos and hierarchies, for example:.

Determining what good looks like in patient safety

In a clinical negligence case, for example, the court must carefully unpack and analyse the level of care given to determine whether there was any negligence. Lawyers discuss with clinical experts the...

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