Introduction
The “Review of patient safety across the health and care landscape”, published on 7 July 2025 and authored by Dr Penny Dash, presents a comprehensive assessment of how patient safety is managed across England’s health and care system and offers a critical lens on the current state of safety governance in England.
The review was asked to look at six national bodies, CQC, HSSIB, Patient Safety Commissioner, National Guardian’s Healthwatch England and NHS Resolution, and determine how they work within the wider health and care landscape. Nine strategic recommendations were made for improving the patient safety health and care system across England.
Key points arising from the review are:
1. Fragmentation and Complexity
The current patient safety system is cluttered and fragmented, with overlapping responsibilities across six national bodies. The growth in new bodies, along with multiple reviews and inquiries, has resulted in an overwhelming number of recommendations. This complexity hinders clarity, accountability, and effective learning. Streamlining is necessary.
2. Limited Investigations vs Scale of Care
Out of 600 million NHS interactions annually, only around 3,000 results in safety investigations – highlighting a major gap in learning from harm. The review recommends that most investigations into safety incidents should continue to be managed within provider and commissioner organisations. HSSIB should operate as a dedicated, expertise-led investigation facility that can be used in a responsive way, with HSSIB’s functions being transferred to CQC.
3. Reactive vs Proactive Safety Culture
The system is largely reactive, shaped by responses to past failures. The review calls for a proactive, learning-focused approach to safety governance. A revamped National Quality Board should be responsible for developing a comprehensive strategy to improve quality of care which is in line with the aims of DHSC and the NHS in England. There should also be a clear safety strategy for Social Care.
4. Leadership and Accountability
There is a need for stronger leadership at both national and provider levels to drive safety improvements. There is a variation in the effectiveness and accountability of Boards and standardisation of core processes/practices is lacking within and across providers. Providers and Commissioners must focus on clear lines of accountability and streamlined governance structures and CQC should focus on the role of board as part of its assessment framework.
5. Data Collection and Technology
Improvement in how data is collected, analysed, and used to identify risks and drive improvement is needed. This includes better integration of data sources and more timely use of intelligence. Technology, in particular the use of AI, has the potential to significantly improve safety and wider quality of care.
6. Amplifying the voice of the Patient and Staff
Strengthening how patient and public feedback is gathered is critical. Very few NHS Boards have an executive director for user or customer experiences, the norm in other customer-focused industries. Similarly, there is a need to strengthen the role of Freedom to Speak up Guardians, placing the responsibility for the role firmly with providers and Commissioners.
Conclusion
This review highlights the critical need for clarity, coordination, and accountability in the complex landscape of patient safety.
At ibex gale, our Governance and Assurance team has deep expertise in governance, patient safety, and healthcare investigations, supporting healthcare providers to navigate these changes and embed robust, effective systems. We welcome this report as a first step in looking at where change is most needed, and hope it leads to a more efficient system that improves patient safety outcomes.
Author: Siwan Griffiths, Governance Specialist
