Patient Safety Commissioner Publishes Impact Report
I am delighted to announce the publication of the Patient Safety Commissioner Impact Report, which sets out the impact that the Patient Safety Commissioner has made over the first three years of the role. This report can be found here.
Updates
Secretary of State and Social Care reaffirms commitment to respond to the Hughes report within this parliament
The Patient Safety Commissioner has continued to seek clarity from the Department of Health and Social Care on financial redress for the thousands of patients harmed by valproate and pelvic mesh. On 2 March 2026, the Commissioner wrote to the Secretary of State requesting an update on timelines for a compensation scheme and highlighting the […]
Patient Safety Commissioner calls for urgent compensation for pelvic mesh and valproate patients
More than two years after the Hughes Report was published, the Government has yet to provide a clear timeline for implementing a compensation scheme for the thousands of patients harmed by pelvic mesh and valproate. Professor Hughes has described the delay as unacceptable, given the severity and scale of harm involved, and has written directly […]
Patient Safety Commissioner to approach Number 10 directly over redress delays
Patient Safety Commissioner Professor Henrietta Hughes has today announced she will approach Number 10 directly to secure financial redress for those harmed by pelvic mesh and the medicine valproate, following a Government update that provides no timetable for decisions on financial compensation. The announcement comes nearly two years after the publication of the Hughes Report in February 2024, which […]
Responding to the National Voices report
Responding to the publication of the Department of Health and Social Care (DHSC) and National Voices report – ‘Patient views on medical devices prescribed to them outside of hospital in England’ Patient Safety Commissioner Professor Henrietta Hughes said: “Hearing the patient voice is paramount if we are to make important progress in the way we […]
Patient Safety Commissioner publishes letter to Minister Ahmed
On Friday 31 October 2025, marking the second anniversary of the Ministerial Advice to the DHSC, I wrote to Minister Ahmed formally to exercise the powers under the Medicines and Medical Devices Act 2021 (Sch 1, para 3), to request information for the purposes of carrying out my core duties. I have requested a clear timeline of […]
PSC and MHRA welcome Dash review of patient safety organisations
Following the publication of the government’s 10 Year Plan on the 3rd of July 2025, which confirmed that the hosting of the Patient Safety Commissioner will be transitioning from the Department of Health and Social Care to the Medicines and Healthcare products Regulatory Agency (MHRA), Patient Safety Commissioner Professor Henrietta Hughes and MHRA Chief Executive […]
Patient Safety Commissioner welcomes 10 Year Health Plan
I welcome the 10-Year Health Plan, specifically the focus on patient voice, transparency and accountability. Working in partnership with patients and listening to what they say leads to more improvement and less harm. I look forward to supporting patients and the healthcare system to make this a reality for all.
PSC Annual Report laid before Parliament
My annual report for 2024-25 has been laid before Parliament. It highlights the policy work and activities over the year. It is available on my website here
RNID and SignHealth publish report on accessibility of healthcare for people with hearing loss
The RNID and SignHealth have published a report on accessible healthcare for people who are deaf or have hearing loss. The report shows that the NHS does not have the systems in place to fulfil the right to accessible healthcare for people who are deaf or have hearing loss, and the NHS often fails to […]
‘The Safety Gap must be closed’
People with sensory impairment face challenges and no more so then when it comes to managing health conditions with devices that are not designed for them and medicines they have difficulty using. I have been contacted by many patients with vision or hearing loss who experience…
HSSIB report highlights challenges to managing safety systems
The Health Services Safety Investigations Body (HSSIB) has published a new report, Safety Management: Accountability Across Organisational Boundaries, highlighting significant challenges in managing patient safety risks across multiple healthcare providers. This report highlights that there exist no overarching safety management principles to ensure a consistent collaborative report across healthcare providers and ICBs. The investigation examines […]
One year on from the Hughes Report
It is one year since I published the Hughes Report on the options for redress for those harmed by pelvic mesh and valproate. When I launched the report in Parliament on 7th February 2024, I never imagined that a year later I would…
’How the National Joint Registry supports patients undergoing surgery’
At the heart of the National Joint Registry is an organisation that looks after the best interest of patients undergoing joint surgery. It does this by recording, monitoring, analysing, and reporting on the…
New analysis reveals reduction in valproate prescribing
Prescribing of valproate has reduced significantly following the introduction of a quality improvement programme that promotes safety and patient choice. New analysis presented to the National Patient Safety Committee shows: a 53% reduction in initiation in girls aged 0-12 a 60% reduction in 13-54 women started on valproate a 65% reduction in women re-starting valproate […]
Using the Patient Safety Principles to improve culture
All healthcare work sometimes includes making truly difficult decisions, decisions that can have serious consequences for patients and their families, now, or in the future. This stretches from wards to Boards and into every part of the healthcare system. You only need…
’Striking the right balance with antidepressant prescribing’
Antidepressant prescribing is at record levels in England, with around one in five adults receiving these medicines for a range of mental health conditions and chronic pain. Prescriptions have…
’Ask for something that is actionable’
I am the chief executive of Demos, a cross-party think tank that works to put people at the heart of policy making to improve how policy is developed as well as trust in politics. Think tanks sit outside government and are…
The New Zealand Experience
In 2016 the Health Quality Safety Commission (HQSC) in NZ launched a five-year programme that improved and standardised the way health care systems recognised and responded to deterioration. There were three main work streams…
‘New principles will help us make the right choices’
Every day we have to make tough choices, balancing benefits and risks. Those choices impact on patient safety, right now or far into the future, with effects that we might have never intended or anticipated. There are too many tragedies where people…
Introducing Ryan’s Rule, the forerunner of Martha’s Rule
Ryan’s Rule was developed in response to the tragic death of Ryan Saunders in 2007. Sadly, Ryan died from an undiagnosed streptococcal infection that led to toxic shock syndrome. Worried that Ryan’s condition was worsening, his parents…
‘It is up to us to seize the opportunities from Darzi’
To celebrate World Patient Safety Day, I have spoken with and learned from global patient safety leaders at the Patient Safety Movement Foundation, the World Health Organisation, the Women in Medicine International Network, and…
‘It is up to us to create a new and safer system for the future’
To celebrate World Patient Safety Day 2024, which this year focused on improving diagnostics for patient safety, I spoke with and learned from global patient safety leaders at the Patient Safety Movement Foundation, the World Health Organisation, the Women in Medicine International Network, and the HSJ Patient Safety Congress.
Review finds safety recommendations system ‘untenable’
The current situation on recommendations for safety and quality in healthcare is untenable according to a new review. The DHSC-commissioned review was published by HSSIB on behalf of a group of ALBs. It concludes that the substantial number of recommendations made to the healthcare system means providers struggle to prioritise and implement recommendations. It found […]
PSC welcomes new guidance on valproate usage by men
Men taking valproate and their partners are being advised to use effective contraception according to new guidance from the MHRA. It recommends that male patients and their partners use effective contraception during valproate treatment and for at least three months after stopping the medication. It follows a study which reports a possible association between valproate […]
‘Leaders must be empowered not infantilised’
There is a fragility at the top of the health system, a lack of individual accountability. There is infantilisation of people who have been selected to be expert and dysfunction in the relationships between…
New summary of key patient safety surveys
The 2024 edition of Patient Experience in England is now available from Care Opinion. As well as summarising the key findings from last year’s large scale patient surveys, the report looks at wider research covering issues such as equity and accessibility as well as studies on patient voice and safety. It is available at Patient Experience […]
NHS England launches new primary care patient safety strategy
NHS England has released a new primary care patient safety strategy. Although the National Patient Strategy pertains to all sectors, this new strategy provides specific focus on primary care and sets out national and local commitments. View it at NHS England » The NHS Patient Safety Strategy
Learning for Martha’s Rule in Wales
Eirian Edwards and Chris Subbe explain how they have implemented the new initiative in Wales. In April 2023 we officially launched the Call 4Concern service for all adult patients admitted to our hospital in Bangor, as the first site in Wales to…
‘Patients and families can be agents of improvement’
More than 20 years ago, my husband and I took our 15-year-old son Lewis to an American children’s hospital for elective thoracic surgery. Our 10-year-old daughter accompanied us. Four days later we made the lonely trip home with only our daughter. Our son left the hospital via another route: the morgue…
‘Principles provide the opportunity to do things differently’
Enormous emphasis has been placed on patient safety in the NHS in recent years and good progress has been made, for example, through the NHS Patient Safety Strategy, which at its core seeks to improve the way…
‘Patients inspired me to create a new service’
The national implementation of Martha’s Rule is a major step forward in the commitment to improve patient safety. It is a shame that it has come about following the unnecessary tragic death of 13-year-old Martha Mills. Unfortunately, Martha and her family are not the only ones to suffer…
‘A quiet revolution in patient safety’
Patient safety is at the heart of everything we do – how often have we heard this being stated by leaders of healthcare organisations? And yet, report after report on scandals which have happened in the…
Making change happen at scale
How do we make change happen at scale across a complex health system? It has been said that the best way to understand something is to try to change it. Through the sprint policy development meetings to devise the plan to make Martha’s Rule a success in England, we heard from…
‘How the Patient Experience Library is helping to embed patient voice’
The Patient Safety Commissioner’s strategy aims to ‘embed patient safety and patient voice throughout the healthcare system’. This really matters. Time and again, it is patients and families who are sounding the alarm on healthcare safety…
‘Getting it right for the most vulnerable means it is better for everyone.’
Getting it right for the most vulnerable means it is better for everyone. This applies as much to improving patient safety as anywhere else. We need to identify harmful events and put controls and systems in place to prevent them…
‘We need the political will to see patients as partners’
The 6th Global Ministerial Health Summit in Santiago, Chile, was a great opportunity to hear from global partners about progress in patient safety and innovations to embed patient voice…
‘My plans for this year will benefit patients’
The updated Patient Safety Commissioner strategy, which I published in January, sets out 3 main aims…
‘Top patient safety priority must be to transform the culture of the NHS’
Retiring NHS Ombudsman Rob Behrens calls for a cultural transformation in the NHS so it becomes collegiate, respectful, and well-led, prioritises patient safety, and listens to patients and all who speak up for them.
Why insight from patients and families is crucial to every safety investigation
HSSIB exists to investigate patient safety concerns so we can improve healthcare care at a national level. At the heart of this is a professional patient safety investigation that helps us to understand how…
Revolutionising diabetes management
For me, the principles of Type 1 diabetes and good outcomes has always based itself on three planks: self-management, peer support and access to trained professionals…
Universal provision of pre-filled syringes
We have asked leading experts what works to improve patient safety and this is what they told us…
Collaborating with patients, clinicians and manufacturers to deliver better outcomes
We have asked leading experts what works to improve patient safety and this is what they told us…
Restorative responses to adverse events
On 7th February the PSC will launch the Hughes report on redress options for those harmed by pelvic mesh and valproate. In the lead up the launch we hear from Jo Wailling about how restorative practice can heal harm.
‘New research demonstrates the life-changing impact of sodium valproate exposure’
Dr Sonia Khanom and Dr Rebecca Bromley outline new research into the impact of valproate.
‘We must combat epistemic injustice’
Organisations who are genuinely interested in the views and experiences of patients, families, carers and the workforce can learn from these experiences. I was very encouraged by the new Secretary of State for health and social care Victoria Atkins MP who recently spoke…
Delivering Meaningful Patient Involvement in ICSs
Recognising good practice and seizing the opportunities to change how the NHS delivers care has the potential to make a huge impact on patient experiences and outcomes. This does not have to mean wholesale reorganisation but the NHS should embrace best practice…
‘Hospital leaders need to embed a safety culture across their organisations’
It is just over a year after we appointed Dr Henrietta Hughes as our first ever Patient Safety Commissioner. She is a champion for patients and promoting their views in relation to the safety of medicines and medical devices…
‘Mandatory Yellow Card reporting is essential to prevent harm’
In the report First Do No Harm, Baroness Cumberlege described the health system as disjointed, siloed and unresponsive. Many changes have taken place since the publication of her report in 2020, not least the establishment of my role as the Patient Safety Commissioner…
‘Why we need a Sunshine Payments Act’
How would you feel if your doctor offered you a treatment your health condition with good results and very little risk? You might snap it up. But what if you subsequently found out your doctor took thousands of pounds from the treatment makers to write a scientific paper promoting it…
‘Monitoring the safe use of the most potent teratogenic medications’
I have recommended that NHS England set up a system for monitoring the safe use of the most potent teratogenic medications, starting with the safe use of sodium valproate in patients on a pregnancy prevention programme…
‘Clear guidance and transparency are needed’
In the 16 years of my career as a medic in the pharmaceutical industry, there is one experience that has become all too familiar. I sit in an auditorium. A doctor or other healthcare professional takes the stage to present on behalf of a pharmaceutical company…
‘Informed consent is central to medical innovation’
The advances in medical science are inspiring and continuing to develop at pace from the latest cancer treatments to cutting-edge surgery. We owe so much to the clinical pioneers and brave patients willing to be the ‘first’.
‘Patient safety and surgical innovation – why new isn’t always better’
We often assume that new is better but when things don’t work out as hoped, it’s a different story. This is the culture of surgical innovation. Robots, gadgets, and other novel ways of operating are exciting and they generate attention. Surgeon enthusiasm for improving outcomes sweeps patients along.
Moving patient experiences at WHO
My abiding memory from the WHO Global Conference ‘Engaging Patients for Patient Safety’ was the shocking experiences outlined by patients and families from across the world who had been bereaved or suffered appalling and life-changing harm.
World Patient Safety Day series 3: Active partners in patient safety
The third in our series of blogs in the lead up to World Patient Safety Day is from Rachel Power, chief executive of the Patients Association. She reflects on progress on patient engagement and what needs to happen next.
World Patient Safety Day series 2: Co-design of strategies
As part of our series leading up to World Patient Safety Day, David Lawson, who leads the DHSC’s medical technology directorate, discusses how patients are influencing the strategy development.
World Patient Safety Day series 1: Engaging patients in policy formation
In the lead up to World Patient Safety Day on 17 September, we are running a series of blogs from a range of experts considering different aspects of patient engagement and participation. The first is from Sue Strudwick, a Patient Safety Partner at Kingston Hospital, on involving patients in policy-writing.
‘What stops us listening to patients’
I’m a medical educator and for many years I have trained doctors and other health professionals to become better listeners. Nearly all the people I have taught have thought they were good at listening but then found how to do so better.
‘How predictive analytics and AI can prevent patient harm’
Over the past few years, technology has been a driver for better patient care, from the proliferation of electronic medical records, continuous monitoring on general floors, to data analytics turning output from multiple inputs into useful information that can improve health, wellbeing, and patient outcomes.
‘Positivity and abundance – shadowing the PSC’
As a patient, it is often hard to find patience during changes of regulation for a chronic condition. Whether it is changing medicines, doctors, time zones, or even diagnoses, finding trust in the process is inevitably challenging.
‘We need to improve the end-to-end process of decision-making and consent’
There is a consensus that improving consent will help patients understand the benefits and risks of the procedure they are considering, as well as the benefits and risks of the alternatives, including doing nothing…
‘The value of submitting a Yellow Card report cannot be overstated’
Established in 1964 to protect and improve patient safety, the Yellow Card scheme is the Medicines and Healthcare products Regulatory Agency’s (MHRA) system for collecting suspected side effects or adverse incidents involving medicines, vaccines, and medical devices.
‘We will only improve patient safety by the collaboration of and respect for healthcare workers’
At the World Patient Safety Movement Summit at the beginning of June I had the pleasure to meet with and hear from Don Berwick, the leading authority on healthcare improvement.
‘The importance of patient partnerships’
‘First Do no harm’ should be the golden thread that is woven throughout all healthcare systems. Sadly, the reality is that despite the implementation of significant initiatives designed to improve systems and processes, many instances of avoidable harm still occur on a regular basis…
‘The PSC is the golden thread tying the system together’
‘In my foreword to the report of the Independent Medicines and Medical Devices Safety Review, I did not attempt to summarise all our nine recommendations or other aspects of our review…’
‘When the conversation is only about money, risk to patients increases’
‘If we listen to patients, they will give us the route map to success. We will have better patient safety, improved staff retention and better finances…’
‘Engaging patients is key’
Imagine a world where we get the information about medicines and medical devised that we need to make the right choices about our healthcare. And those that deliver care to us get the right information to share with us so that we give truly informed consent.
‘I will be a champion for patients’
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‘Leaders need to open up their mindset’
My role as Patient Safety Commissioner is to promote the safety of patients in relation to medicines and medical devices and to promote the importance of listening to the views and experience of patients and the public. But we shouldn’t need a new statutory role to tell us this – the whole system should be listening continuously to patients and acting on their feedback.
‘Unless we listen to patients and act, we are heading straight back to the days of Mid Staffs’
The Cumberlege report, First Do No Harm, revealed that patients did not feel heard, did not have the information needed to make the right decision about their care, could not trust the answers or that the system prioritised their and their families safety.
‘We must listen to all patients’
First Do No Harm, the independent review of the safety of medicines and medical devices led by Baroness Julia Cumberlege, found that patients’ voices were ignored, and that the health system did not listen and act, but was defensive, dismissive, and disjointed. As the first ever Patient Safety Commissioner I have been listening to patients and patient safety experts to understand what needs to improve.
The latest blog from the PSC:
Secretary of State and Social Care reaffirms commitment to respond to the Hughes report within this parliament
The Patient Safety Commissioner has continued to seek clarity from the Department of Health and Social Care on financial redress for the thousands of patients harmed by valproate and pelvic mesh. On 2 March 2026, the Commissioner wrote to the Secretary of State requesting an update on timelines for a compensation scheme and highlighting the […]
The latest guest blog:
Secretary of State and Social Care reaffirms commitment to respond to the Hughes report within this parliament
The Patient Safety Commissioner has continued to seek clarity from the Department of Health and Social Care on financial redress for the thousands of patients harmed by valproate and pelvic mesh. On 2 March 2026, the Commissioner wrote to the Secretary of State requesting an update on timelines for a compensation scheme and highlighting the […]
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