Future of NHS Patient Safety Investigations Consultation

NHS Improvement is consulting on changes to its Serious Incident Framework

Tue 8th May 2018 The PDA

NHS Improvement is consulting on changes to its Serious Incident Framework.


The consultation documents can be found here https://improvement.nhs.uk/resources/future-of-patient-safety-investigation/ It closes at 5pm on 12 June 2018.

An excerpt from the consultation document reads:

Decades of learning in healthcare and other industries has shown that individuals are rarely to blame when things go wrong. It is not true that if people simply try hard enough they will not make errors, or that punishment when they make errors leads to them making fewer of them. The safest organisations and industries recognise that people make mistakes and that the best approach to ensuring safety is to create systems, processes, practices, environments and equipment that support people to do their jobs as safely as possible. This systems approach to safety recognises that incidents are linked to the system in which individuals are working. Looking at what is wrong in the system helps organisations identify and address the root cause of a particular incident and therefore prevent it from happening again.

The PDA finds much to agree with in the overall systems approach to patient safety described in the document.

In December 2017, the PDA launched its Safer Pharmacies Charter in parliament. This sets out seven basic commitments for pharmacy owners which would underpin and improve patient safety in pharmacy, using a systems approach. Each commitment details a basic fundamental safety requirement, such as safe staffing and the ability to raise concerns. Unfortunately, members tell us that the systems standards described in the charter are often not met or enforced, and our view is that there are shortcomings in pharmacy premises regulation in Great Britain. A Freedom of Information request in November 2017 revealed that the General Pharmaceutical Council (GPhC), which is the statutory pharmacy regulator in Great Britain, has issued over 3,500 sanctions against individual registrants since 2010, but has never issued a single sanction for a failure to comply with its Standards for Registered Pharmacies. The systems approach to patient safety described in this consultation would be a considerable improvement on the current situation.

Notwithstanding that the Serious Incident Framework needs improvement, we are of the view that it would be of great value in community pharmacy and GP practice-based pharmacy. We understand it is intended to be broadly applicable to all providers of NHS care, but in reality it is not being used widely, if at all, in community pharmacy and we have no evidence of it being used in GP practices by pharmacists. More needs to be done to ensure that serious incidents can be properly investigated, with the rigour described in the framework, in community pharmacies and in GP practices.

The PDA will be responding as an organisation, but members may also wish to respond as individuals. The consultation documents can be found here:

If you would like to provide your views as to how the PDA should respond, please email consultations@the-pda.org

The Pharmacists' Defence Association is a company limited by guarantee. Registered in England; Company No 4746656.

The Pharmacists' Defence Association is an appointed representative in respect of insurance mediation activities only of
The Pharmacy Insurance Agency Limited which is registered in England and Wales under company number 2591975
and is authorised and regulated by the Financial Conduct Authority (Register No 307063)

The PDA Union is recognised by the Certification Officer as an independent trade union.

Cookie Use

This website uses cookies to help us provide the best user experience. If you continue browsing you are giving your consent to our use of cookies.