Patient Safety Review
House of Commons · Commons Chamber · 6 Jul 2026 · 20 speeches · Official Report
Motion made, and Question proposed , That this House do now adjourn. -( Mark Ferguson. )
I am grateful for this opportunity to evaluate the Dash review of patient safety, and I thank the Minister for the meeting with her this afternoon. I hope that the House and Penny Dash will forgive me, but in the interests of brevity and clarity, I shall be direct. Whenever asked to justify the abolition of the Health Services Safety Investigations Body, Ministers refer to Dash, but Dash fails to make the case for what it recommends. This new clinical incident investigator was established less than three years ago. HSSIB is a new concept in healthcare, conceived to challenge the culture of denial and blame in the NHS. It is proving itself, even with its very limited budget. One early report on aortic dissection led to 300 more people receiving lifesaving treatment. The Minister now has a list of key recommendation impacts produced by HSSIB. A lot of them may seem small or piecemeal, but so far it is only a small body. After a boy suffered an avoidable death from cancer, HSSIB recommended to NHS England a new community language translation and interpreting services framework so that non-English speaking patients would get appointment letters for their children that they could read and understand. HSSIB recommended a protocol between prisons and ambulance services to avoid wasting ambulance time and new guidance for non-accidental injury of babies in emergency departments where no specific guidance had existed before. The Dash review shows no understanding of HSSIB’s purpose...
My hon. Friend is making a powerful case. Does he agree that one of the common themes in all the maternity scandals that we have been discussing in recent weeks, sadly, has been how a blame culture in the NHS makes it hard for NHS staff to speak openly about why tragedies have happened, and that that is why they welcome HSSIB, with its safe space protections? Is he worried that that could be undermined by putting HSSIB into the Care Quality Commission, which has a legal duty to act on information it receives, therefore creating the worry for people talking to HSSIB that the information that they give to it may no longer be protected in the same way?
I 100% agree with my right hon. Friend. He will note that I will pick up on those points during my remarks. I come back to the questions that I want to put to the Secretary of State. First, if HSSIB’s investigations are intended to continue unaffected by the transfer to the CQC, why bother with the expense of the transfer? Are Ministers simply using Dash as the pretext for what people in the Department or elsewhere in the NHS would like to have? HSSIB was deliberately started very small, but the intention was that over time it would take over more investigations in health and replace the need for wasteful, lengthy, inexpert ad hoc public inquiries. Over the years, inquiries have proved to be a chaotic means of investigation, assembling expertise from scratch, which is then lost after the inquiry, and failing to command public confidence or to fix the system. That is why, after the 1999 Paddington rail crash, the Ladbroke Grove inquiry in 2001 established the rail accident investigation branch. Since then, despite many fatal rail accidents, there has been no public inquiry into a rail crash-nor has the public felt the need to demand one-and rail safety has improved. Given that HSSIB is expert, full time, and can conduct much cheaper and quicker investigations than public inquiries, how can Ministers accept the Dash recommendation to abolish it? Why not consider expanding HSSIB to avoid the need for so many costly public inquiries? Dash complains about there being far too many...
Will the hon. Member give way?
Very briefly-I have a lot to say.
In that case, carry on.
I thank the hon. Gentleman. Recommendation 1 in the Dash review says that the new National Quality Board should “avoid unfunded mandates being imposed on the system without due consideration”. Public inquiries have certainly made well meaning but unaffordable recommendations-I think of the Francis inquiry recommendation on blanket standards for minimum staffing-but it is wrong to see safety as a cost in opposition to other benefits. The cost of safety failures is astronomic, with NHS clinical negligence costing £3.6 billion a year, despite all the public inquiries. Effective safety management is about the cost-effective management of risk, not risk elimination at any cost. If the air accidents investigation branch did not balance costs with effective risk management, aeroplanes would not fly. Can the Minister therefore point out which of HSSIB’s recommendations have been too expensive to implement? If not, where is the justification for abolishing HSSIB? Neither the NQB nor the CQC should control investigations. The AAIB cannot be prevented from making independent recommendations by the Civil Aviation Authority, the Transport Secretary or airlines themselves. Why should the NQB, which will be subject to political direction, be allowed to decide what safety recommendations should be made and what should be investigated, as Dash recommends? On page 31, Dash incorrectly states: “HSSIB was not able to retain the maternity programme because the Health and Care Act 2022 does not...
I commend the hon. Gentleman for speaking so clearly about why having an independent HSSIB-independent of those providers-to investigate is so important. Time and again, we hear about devastating failings in the NHS. He alludes to maternity services, but we could add to the list infected blood and pelvic mesh. Does he agree that professionals and those working inside the NHS must be able to speak freely when things go wrong in order to learn lessons, and that that is only possible with an independent investigating organisation?
I thank the hon. Lady for that intervention. Only an independent investigator can find the causes of the incident that may be part of the culture or practice of that provider, or of the system as a whole. It is like suggesting that airlines or aircraft manufacturers can protect passenger safety without the independent accountability provided by the AAIB. Of course, providers should have the capacity and capability of conducting patient safety investigations, but they must know that HSSIB can and will look at that work and will hold them to account. Recommendation 3 also says that HSSIB should continue as what it calls “a centre of excellence for investigations” in the CQC, but I am afraid that this is just a sop. The CQC, as was pointed out by my right hon. Friend the Member for Godalming and Ash, is a regulator and compliance enforcer, not an investigator. How can the CQC also be an independent investigator? Dash also says that the CQC internal successor should collaborate through the NQB to agree the scope of any investigations it carries out and agree the recommendations. Dash is effectively saying that CQC investigations will be overseen by the NQB. That is a direct attack on the independence of investigations. Can the Minister explain who in future will conduct independent and unconflicted investigations into safety incidents in the NHS? For example, how would an investigation under the CQC be free to find that the CQC inspections themselves were causing unintended harm...
I thank the hon. Member for Harwich and North Essex (Sir Bernard Jenkin) for securing this important debate. He has long taken a serious interest in patient safety, including in the importance of independent investigation. I recognise the strength and sincerity of the points that he has raised and will try to answer all of his questions. At the heart of this debate is a simple question: when patients and families tell us something has gone wrong, does the system listen and learn, and, most importantly, does it change? Patients do not judge the system by the number of reports published, the number of organisations involved, or the number of recommendations written; they judge it by whether care becomes safer. For too long, across too many parts of the system, we have seen the same pattern: harm happens; a review follows; lessons are identified; but the change patients were promised does not always follow quickly enough. This Government are determined to change that. Dr Penny Dash’s review was commissioned to consider whether the current landscape of organisations provides effective leadership, listening and regulation on patient safety and wider quality of care, and whether a different approach could deliver better outcomes for patients.
I rise to intervene before the Minister goes down the HSSIB route, which I completely understand is the focus of the debate today. I want to put on record once more the concerns about Healthwatch and its abolition. I know there is a strong desire to see independent patient voice maintained outside the system; of course, Healthwatch was established due to issues within health structures, including, notably, the Mid Staffordshire scandal.
I thank my hon. Friend for putting that on the record. He will know that we are in Committee stage of the Health Bill and there will later be the opportunity to debate this issue on the Floor of the House.
I thank the Minister for outlining the case incredibly well. I have a request in relation to the vital lessons learned on data collection, streamlined complaints and patient safety culture. It is important for us all that those lessons are shared with the Northern Ireland Assembly Minister, Mike Nesbitt, as health is a devolved matter; we need to ensure that there is safety for all across this United Kingdom of Great Britain and Northern Ireland.
Absolutely. I am very privileged to have patient safety in my brief. I know everybody across this House really cares about it, and I will make sure that officials do as the hon. Gentleman requests.
I want to concur with all of the remarks by the hon. Member for Harwich and North Essex (Sir Bernard Jenkin), who has made a crucial point. But there is a wider issue, which the Health Bill completely misses and which I urge Ministers to look at, around the accountability systems within the NHS. The reforms are not going to deliver accountability. They are going to weaken it, and as a result we will see more requests for investigations into patient safety. I want the Minister to take that point away, because I am really worried that we are going to see a system that is more unsafe as a result of these reforms.
I thank my hon. Friend for her contribution-she is absolutely right. I take accountability very seriously and am going to talk about it in my remarks in this debate. Far too often, we see so many inquiries and so many recommendations but nobody taking responsibility for implementing the change. In the end, patients have to feel that things have changed, not that we are just having further reports and recommendations. The Penny Dash review examined six organisations that are overseen by the Department: the Care Quality Commission; the National Guardian’s Office; Healthwatch England and the local Healthwatch network; the Patient Safety Commissioner; the Health Services Safety Investigations Body; and the patient safety learning functions of NHS Resolution. The review’s conclusion was clear. The problem is not that people working in patient safety lack commitment-we all know that there are dedicated people across the system doing important work every day-but that the system around them has become too cluttered, complex and difficult for patients, staff and leaders to navigate. We inherited a landscape with more than 70 routes for patients and service users to raise concerns or provide feedback, and around 40 public bodies with a formal role in quality and safety. That complexity does not automatically make patients safer. It can make responsibility unclear, create duplication and make it harder to ensure that learning leads to improvement. A cluttered landscape, as we would all...
I am listening very carefully to what the Minister is saying. She has engaged positively with the questions I have asked, but she has actually made the case for keeping HSSIB separate. Will she reflect on that? If the only thing she wants is for the CQC to own the recommendations, she should amend HSSIB and say, “The CQC must ensure that the recommendations are implemented.” In fact, the recommendations are directed at Ministers and bits of the health service that are answerable to her and to the Secretary of State. We should keep HSSIB separate, but by all means let us discuss how to ensure that the recommendations are implemented properly.
I am grateful to the hon. Member for his comments. I did recognise the reason for keeping the functions separate, but just because they are part of the CQC does not mean to say that they do not have their independence. I have pretty much set out the powers that they current have and what they will be able to do, but they do not prioritise investigating the situations that we spoke about, such as “never events”. It is not simply about the investigation; it is about how we get those “never events” to lead to learning and change in the system. How do we hold the system to account to ensure that the very thing that the regulator recommends is implemented? What that journey looks like for patients will be far more significant, as opposed to those bodies simply doing investigations that lead to further recommendations.
House adjourned without Question put (Standing Order No. 9(7)).