Bar Council. Written evidence submitted by The Bar Council (NLR0069). 2021. (accessed 13 April 2023)

Care Quality Commission. Opening the door to change. NHS safety culture and the need for transformation. 2018. (accessed 12 April 2023)

Care Quality Commission. The state of health care and adult social care in England 2021/22. 2022. (accessed 12 April 2023)

Department of Health. An organisation with a memory. Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. 2000. (accessed 12 April 2023)

The Mid Staffordshire NHS Foundation Trust Public Inquiry. Final report. 2013. (accessed 15 April 2023)

Hempsons Solicitors. Written evidence submitted by Hempsons Solicitors (NLR0014). 2021. (accessed 13 April 2023)

House of Commons Health and Social Care Committee. NHS litigation reform. Thirteenth Report of Session 2021–22. 2022. (accessed 13 April 2023)

Patient Safety Commissioner. 100 Days Report. 2023. (accessed 12 April 2023)

Reading the signals. Maternity and neonatal services in East Kent – the Report of the independent investigation. 2022. (13 April 2023)

A decade after Francis: is the NHS safer and more open?. 2023.

NHS Staff Survey. 2022 NHS staff survey. National results. 2023. (accessed 15 April 2023)

Findings, conclusions, and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust (Ockenden Report – Final). 2022. (accessed 25 May 2022)

Patient Safety Learning. Mind the implementation gap: The persistence of avoidable harm in the NHS. 2022. (accessed 13 April 2023)

NHS Patient Safety Timeline. 2023. (accessed 12 April 2023)

Patient safety in the NHS: after Francis

20 April 2023
Volume 32 · Issue 8


John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses several recently published patient safety reports

As the adage goes, to know where you are going, you need to know where you have been. This is true of any professional endeavour. A period of appraisal and reflection is periodically needed on past efforts and events to assess progress. A reset, or recalibration, may be called for, either because there has been failure or, conversely, because everything is tracking towards expectations.

The key point in developing any policy is to be forward thinking and not to be rooted in the past. I have said this in previous columns, and it is worth repeating again, because it is particularly relevant to the efforts of the NHS in developing a patient safety culture: too much of a backward-looking perspective can hamper the development of a safety culture, and there are concerns that such a focus is hampering the NHS to deal with patient safety issues. Such sentiments were recently expressed by the patient safety commissioner, Dr Henrietta Hughes. In her First 100 Days Report, she stated:

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