With the abolition of NHS England announced (Streeting, 2025), the NHS patient safety landscape will hopefully change and be reformed, rationalised. Change will not happen overnight and there will be a period of transition as services move or become absorbed. This will also be a period of uncertainty. Organisational change is not new to the NHS – in my view, it has always appeared to be in a constant state of flux. This is one of the endemic patient safety problems of the NHS that inhibits proper development of a safety culture.
The NHS is one of the largest employers in the world with a vast range of activities, so some degree of change is going to be inevitable as it adjusts to new circumstances. This seems even more likely given the comments from the Health Secretary, Wes Streeting, who has spoken recently about the forthcoming Dash Review report:
‘Penny Dash, the new Chair of NHS England, has identified hundreds of bodies cluttering the patient safety and regulatory landscape, leaving patients and staff alike lost in a labyrinth of paperwork and frustration.’
For BBC News, Buchanan (2025) reflected on the abolition of NHS England and what it might mean for patient safety:
‘At the heart of many of the patient safety scandals uncovered in recent years has been a poor culture, an unwillingness to openly engage with patients. At the root of those problems has been poor behaviour in particular trusts, but repeatedly, families have complained that [NHS England]'s own secrecy has added to the problem.
He highlighted the uncertainty about the future and pointed to the abolition of the National Patient Safety Agency in 2012, which in his view was ‘a world-leading organisation’, one that ‘wasn't perfect but was admired globally for its sole focus on improving patient outcomes’. I would fully support this view. The organisation created a valuable NHS focal point for patient safety and produced some excellent education and training reports, which are still in use today. Buchanan (2025) had some interesting quotes from patient safety stakeholders, including Paul Whiteing, Chief Executive of the charity Action against Medical Accidents, who believes that ‘in the short term, the reorganisation could set back patient safety’.
Corridor care
The patient safety problems created by corridor care have been frequently highlighted in the media. The harrowing report by the Royal College of Nursing (RCN) (2025) on nurses' experiences of corridor care revealed chronic patient safety issues and captured well the enormity of the problem: 90.8% of those surveyed for the report said that patient safety is being compromised by care in ‘temporary escalation places’ (the term used by NHS England (2024)). RCN (2025) gives the stark, unabridged reality of ‘corridor care’.
The Royal College of Physicians (RCP) conducted a snapshot survey of members, over 3-16 February 2025 on UK doctors and corridor care, termed ‘temporary care environments’ in the report (RCP, 2025a; 2025b). The survey received responses from 961 physicians across the UK, from a range of specialties. Of the respondents, 77.9% said that they had delivered care in a temporary environment in the past month; 889 respondents provided further detail on the last temporary location where they delivered care, which included (RCP, 2025a):
The survey also asked members about the impact on patient care and responses included (RCP, 2025b):
Other impacts are outlined such as increased stress for patients, doctors and relatives:
‘I have had more than one patient die directly because of not being in an appropriate clinical area, ie on a trolley in the corridor rather than resus as there is no room for them.’
The survey provides valuable insights into the acute patient safety problems caused by corridor care, adding to the picture painted by the RCN.
CQC reports: patient safety and staff issues
Hospital assessment reports from the Care Quality Commission (CQC) are a rich source of NHS patient safety information. They show the practical reality of how well patient safety policies and practices are working in an everyday, clinical care context. In reading these reports it is important to remember that when it comes to NHS patient safety culture development some trusts will be more mature than others. Also, looking at patient safety holistically across the NHS you do not see a one-size-fits-all patient safety approach. Care quality and patient safety standards vary between trusts and across their clinical units. One clinical unit within a trust may demonstrate better patient safety standards than another.
Many factors can contribute to this variation, such as poor leadership, teams ‘working in silos’, or poor working relationships between professional groups. These and other factors are vividly illustrated in reports of independent investigations into patient safety incidents. One example of the serious patient safety problems that can be brought about by corridor care can be seen in the CQC (2024) report on Medway Maritime Hospital.
Both good and poor findings are relayed in the report, which must be read as a whole to get a full, fair and balanced picture of the patient safety issues involved. The good practices identified often seem to be eclipsed by the poor ones. There are mixed views reported, and different conclusions reached on some issues:
‘Staff reported that frail, bed-bound patients had been told to soil themselves because there were not enough staff to take them to the toilet. Patients were stranded in ED [the emergency department] for 50 hours or more, with no access to wash facilities. There was a lack of pillows and blankets for patients, including those located on trolleys close to the ambulance entrance and patients were left in their soiled clothing, and medications not given. However, during the on-site assessment staff described how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.’
The report further states that ambulance crews worked with emergency department staff to highlight safeguarding concerns to the staff and safeguarding team when they were handing over the care of patients.
There were mixed views from patients about their involvement in managing their conditions and risks. It was stated that staff did not always complete patient risk assessments and observations at the correct frequency.
In the ‘safe and effective staffing’ section there is a detailed discussion of patient safety problems reported by carers, patients and relatives. Some patients did not experience a shortage of staff whereas others did. The report relays feedback from patients, staff and others, including:
‘They said, “Staff were crying on the phone for help, no one seemed to turn up”. “No staff responsible for corridor patients”. Other comments included, “Quick to be seen”, “I was treated promptly and efficiently”.’
In terms of the ‘safe’ descriptor there is an ‘inadequate’ rating and the CQC states that this service scored 38 (out of 100) for this area. What is clear from the report and rating is that there are significant patient safety concerns identified. CQC (2024) provides an important insight into the patient safety problems that this Trust faced at the time of inspection and what must be done to improve matters.
Improving communication processes: trauma cards
Communication between health professionals and patients is an area that the NHS has struggled with for many years, and it continues to do so. There is a direct correlation between failures in communication and healthcare complaints and litigation. Often, if professionals had communicated properly with the patient in the first place, then the complaint or litigation case might never have occurred. All efforts to improve communication processes are valuable and are to be welcomed.
Healthwatch (2025) has recently produced a report on ‘trauma cards’. People who have experienced trauma can be reluctant to access healthcare services and the report discusses how these cards can assist them. There is information on the card saying that the holder has experience of trauma with a link to helpful resources. This eases the communication process and empowers the individual patient.
‘Trauma refers to the way that some distressing events are so extreme or intense that they overwhelm a person's ability to cope, resulting in lasting negative impact.’
Healthwatch Essex piloted the cards in 2022 and Healthwatch later commissioned research to further understand the potential use of them. The report presents findings from that research and several recommendations are made. It is clear that trauma cards can help people and that there is a need for them, with Healthwatch stating that 59% of respondents had experienced trauma at some point in their lives, and over two in five (43%) of those currently experiencing trauma said they would be likely to use a trauma card if these were available for free (Healthwatch, 2025: 3). Recommendations include the roll-out of a national pilot of a trauma card along the lines of Healthwatch Essex's local pilot.
Conclusion
Change is on the horizon for the NHS organisations with a patient safety remit. Regardless of what any new NHS patient safety framework may look like in the future, serious endemic patient safety issues remain to be dealt with. The patient challenges of corridor care and the harrowing impact that this is having on some nurses, doctors, patients and others is acutely worrying. In terms of enhancing patient–professional communication, trauma cards are a novel and interesting way forward.