References

The national state of patient safety: what we know about avoidable harm in England. 2022. https://tinyurl.com/5dar5ewd (accessed 15 December 2022)

The report of the Morecambe Bay investigation. 2015. https://tinyurl.com/ycmajuhd (accessed 15 December 2022)

Reading the signals: maternity and neonatal services in East Kent – the report of the independent investigation. 2022. https://tinyurl.com/4ks6vdc6 (accessed 15 December 2022)

Findings, conclusions, and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust (Ockenden report – final). 2022. https://tinyurl.com/4s4sz7rj (accessed 15 December 2022)

Shrewsbury maternity scandal: Key findings from damning Ockenden inquiry report. 2022a. https://tinyurl.com/bdd9w3dk (accessed 15 December 2022)

NHS could face biggest maternity scandal ever as Nottingham probe expected to exceed 1,500 cases. 2022b. https://tinyurl.com/5bye5wed

Reflecting on patient safety in 2022

12 January 2023
Volume 32 · Issue 1

Abstract

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some major patient safety reports published in 2022, and considers the lessons to take away from them

All in all, 2022 was a bumper year for the publication of seminal patient safety reports. These reports were highly significant, with major implications for patients and the NHS. Patient safety as a topic is a major one and relentless efforts are needed by all in the NHS to bring about a proper patient safety culture.

This need for relentless action is reflected in the publication cycle of reports. There is a danger that, with the frequency of reports, vital patient safety messages can get lost. In a sense, the adage about ‘yesterday's news’ applies. Key recommendations are made in one patient safety crisis report. There is then a flurry of media attention and soul-searching by trusts and then another crisis report breaks. The previous report is soon forgotten, consigned to the pile dating back well over 20 years. These reports make excellent recommendations but seemingly many get lost and important changes do not take root.

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