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More must be done to learn from tragedies, says the PSA

The Professional Standards Authority for Health and Social Care (PSA) comments on the evaluation by an Expert Panel of the House of Commons Health and Social Care Committee 

We welcome an important review of the implementation of key inquiry recommendations for patient safety, which shows that some of them have not been fully implemented by the Government.

Actions on the accountability of NHS managers and improving organisational culture in the NHS were found to ‘require improvement’. This echoes what we said in our evidence to the Expert Panel.

The report shows the importance of following-up on government promises in the wake of inquiries into major healthcare failings. We are calling for this to happen, for the next government to put in place a system to make sure that this happens every time, and for actions to help make inquiries more effective. This could become part of the role of the Patient Safety Commissioner.

Alan Clamp, Chief Executive, said:

‘Our report Safer care for all showed how efforts to improve safety in healthcare are sometimes falling short, and inquiries are a big part of this – the same problems of dysfunctional cultures and not learning lessons are identified over and over. Something needs to change.

We want to see systematic monitoring of government action on inquiry recommendations, as part of a broader change to make inquiries work better for patients and families.’



Note to Editors

  1. Making care safer for all - a manifesto for change 2024 outlines the PSA’s recommendations to government to help tackle some of the big challenges within health and social care. 
  2. The PSA oversees 10 statutory bodies that regulate health and social care professionals in the UK.
  3. We assess their performance and report to Parliament. We also conduct audits and investigations and can appeal fitness to practise cases to the courts if we consider that sanctions are insufficient to protect the public and it is in the public interest.
  4. We also set standards for organisations holding voluntary registers for health and social care occupations and accredit those that meet them.
  5. We share good practice and knowledge, conduct research and introduce new ideas to our sector. We monitor policy developments in the UK and internationally and provide advice on issues relating to professional standards in health and social care.
  6. We do this to promote the health, safety and wellbeing of users of health and social care services and the public. We are an independent body, accountable to the UK Parliament.
  7. Our values are – integrity, transparency, respect, fairness and teamwork – and we strive to ensure that they are at the core of our work.
  8. More information about our work and the approach we take is available at