NHS England pledges further action to protect patient safety following Berwick Report publication

NHS England today welcomes the Berwick Report into NHS patient safety, and pledges further action to help make the NHS the safest healthcare system in the world.

Professor Don Berwick, renowned international expert in patient safety, was asked by the Prime Minister to carry out the review following the publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals which has now been presented to NHS England and the Department of Health.

His report makes recommendations for the NHS, its regulators and the government in building a robust nationwide system for patient safety rooted in a culture of transparency, openness and continual learning with patients firmly at its heart.

Jane Cummings, Chief Nursing Officer, is NHS England’s national director responsible for patient safety. She said:

“Don Berwick’s report is landing at exactly the right time for the NHS. He has highlighted many of the key areas that the NHS is actively addressing to give our patients quality care every time and support our staff to work with the right conditions for success.

“NHS England welcomes the focus on growing a culture which puts patients first, engages and empowers patients and carers, supports transparency and learning and takes responsibility for poor care. This is all underpinned by having the right staff with the rights skills and knowledge. We are already tackling this through the actions set out in Compassion in Practice and by working with NICE and other key partners such as Health Education England.

“This report demonstrates the passion for patient safety that so many in the NHS have and will be a touchstone for patient safety in the NHS for the next decade or more. NHS England accepts the challenges set in this report and will lead the way in responding.”

In response to the recommendations in the report, NHS England will work with its national partners across the health and social care system to assess and implement the recommendations. We will examine the recommendations in detail to establish how they can be implemented across the NHS, in the context of existing projects and other key recent reports about the safety and quality of patient care.

NHS England’s Director of Patient Safety, Dr Mike Durkin, said: “As part of the restructure of the NHS system, patient safety is now firmly embedded where it should be, at the heart of our health service. At NHS England, we are working with leading clinicians right across the NHS to assess and understand what can go wrong in healthcare using analysis of hard and soft data and then develop new ways of working to make their patients safer.

“More and more NHS clinicians are reporting incidents and “near-misses”, however minor they may at first seem, to our national systems. Reporting these incidents is not about punishment – it’s about making sure all parts of the NHS learn from one another, gaining a full understanding of what can go wrong and how it can be prevented in future. As Don Berwick makes clear in his report, an open, supportive culture where it is understood that humans make genuine mistakes, is key to this.

“Don Berwick’s report contains a number of actions that everyone in the NHS can implement immediately – building on the improvements we have already started to make to improve how we listen to patients and working even harder to seek out and address risks to patient safety. Other elements which cut across the NHS and its regulatory system will need to be considered in detail, and I look forward to working with colleagues throughout the healthcare system to fully consider them as a top priority.

“We are very grateful for the time and effort that Don and the whole Advisory Group have put into this report. Their integrity and passion for patient safety have resulted in a landmark set of findings.”

The report also includes three letters written by Professor Berwick to senior government officials and senior executives in the NHS; clinicians, managers and all NHS staff, and the people of England (documents available via our archived website).


  1. S.RAVI says:

    Prof Berwick in his letter to us clinicians has hit the nail on the head with his recommendations in terms of guiding priniciples.
    I would like to state however, my extreme frustration at the fact the changes that are needed urgently are slow in coming in the NHS.
    What has been laudable is the fact that hospital acquired infections have been controlled remarkably well due to investment in cleansing agents and education of the public.Antibiotics save less lives than good hygiene!
    Loss of the team structure and the lack of continuity of care have been lost in the re structuring process. I am now in an invidious position of introducing members of ‘my team’ on Monday morning to patients after a long weekend only to find that the team disappears the next day and is replaced by a ‘new team’. They then have to ‘re-know’ their patients. One can argue that if every one works as they should it must not be a problem and good hand overs will suffice. That is utopian. When I was a junior doctor in the early 80’s in the NHS I got to know my patients because I clerked them, talked to them daily and related to the same team and shared an active doctor’s mess where much was discussed. We had the best days of the NHS BUT that is not to say that things are not better. Undeniably much progress has been made and we should all be proud that we are delivering better care and more accurate diagnosis because of advances in radiology,basic biochemistry,endoscopy, chemotherapy, hand hygiene and laparoscopy.
    There is however a point that I always make and that is this – ‘ if one gets to know one’s patients well then one is likely to go the extra mile in case of an adverse turn of events’. Trainee and junior doctors must be indoctrinated in the value of listening to patients and getting to know them. Care will then be better and complaints and dis satisfaction less as compassionate care prevails. Attitude of the individual clinicians vary but determines the altitude to which they can fly.

  2. Nic Hart says:

    My Daughter died in recent months at the age of nineteen whilst attending the University of East Anglia, after neglect and negligence by a number of NHS agencies including the UEA medical centre, the Norfolk community eating disorder service (NCEDS) and the Norfolk and Norwich hospital.

    Even the cleaner at University knew that my daughter urgently needed medical intervention and called 999 before the NCEDS and the UEA Medical service acted.

    My daughter died of a curable illness because of the lack of care provided by the NHS.

    I have raised numerous questions of these agencies, and they have refused to answer even basic questions, running to their medical defence unions rather than provide open and honest answers to our questions.

    In so doing they do a great disservice to my daughter and to their professions.

    I will never stop fighting to get to the root of this tragedy and the truth will and must be heard so that improvements can be made.

    Day to day my daughter’s family and friends struggle with her loss, we miss her terribly.

    Nic Hart
    Her father

    Professor Berwick suggests a more open and honest NHS in the future. It is certainly not here at the moment (August 2013).

    Place the quality and safety of patient care above all other aims for the NHS

    Insist upon, and model in your own work, thorough and unequivocal transparency, in the service of accountability, trust, and the growth of knowledge

  3. Robin Kenworthy says:

    For attention Dr. Mike Durkin
    I have read the Berwick documents with interest, while much of it is re-affirmation of previous papers it pulls many strands together and importantly defines Patient Involvement at all levels. Before the dissolution of CHC I had the impression that this was happening. We are now in the development stage of the third innovation of patient active engagement in the NHS the big difference being that Social Services are now seen as an element of comprehensive healthcare.
    That having been said I find there are several component parts missing from the documents:-
    1.) The requirement to record and report is of little use if the learning is not only implemented, but the subsequent changes must be monitored and continually reviewed to ensure that they are the right changes producing the desired result.
    2.) Little attention is given to the need for a patient education programme, advances in care delivery and survival techniques mean that a link must be made with the Education Curriculum to introduce basic first aid, life support and CPR to Year 6 pupils upwards and teaching them how to take responsibility for their own health. At the same time an adult programme of information on the changing face of healthcare in the community should be instigated, perhaps the PPG’s have a Health promotion role here?
    3.) Much of the DH estate is dilapidated and well past its suitability date particularly GPs, Dentists Opticians and Pharmacies this increases infection risk, lowers staff moral and reduces respect from patients and public. If the environment is good and right for the purpose there are improvements in wellbeing for both staff and patients. If personal responsibility for minor ailments and care for continuing stabilized conditions is to be encouraged in the community adequate facilities must be provided as promised in the 1948 leaflet.
    I must also add my two pennyworth, before retirement I was in H&S Facility Management, I am now an FT Elected Public Governor, and the Patient member of the HLP initiative but also I am LCT complex needs (diabetic, heart, eyes and neuropathy) in recent years besides several minor prescribing errors I have recorded the following:-
    1.) Cannula inserted badly caused internal bleeding in back of hand, had to go to A&E the day after discharge.
    2.) When being moved from a trolley to theatre table I was dropped between the two.
    3.) A tablet (not mine) found on the floor when locker moved was just dropped into the dregs of a tea cup and no report made.
    4.) Transcript of my notes between clinicians attributed the Nova Rapid dosage to Levemir, and omitted Nova Rapid.
    5.) Blood test in December showed Vit. D unmeasureable no action taken till April
    So far as I can determine 1,2 & 3 were not recorded as incidents, four would not have been if I had not written, an apology for a transcription error was received with nearly a dozen typos in it. Five is an ongoing PALs enquiry. OK I am probably more alert to these issues than others but this is not an acceptable state of affairs.

    Robin Kenworrthy

    • NHS England says:

      Dear Robin

      Many thanks for taking the time to provide this feedback.

      The Berwick report was fully independent and the group that wrote it no longer exists, however we and many others will help implement it.

      We absolutely agree about implementation of learning – a key theme of the report is learning and that involves monitoring and continual review of the implementation of learning – continuous improvement should then result.

      There are recommendations for patient education (page 19) but childhood education is a little beyond our remit. Have you contacted Dept of Education?

      Equally we don’t do estates but agree with the basic point you may about premises being safe and fit for purpose

      Finally agree that we should never accept mistakes and your raising of them with the providers involved is important – highlighting concerns as part of a constructive dialogue is a key part of improving safety. I hope and trust the issues are resolved satisfactorily and if you’re concerned about lack of reporting and responding to incidents, ensure this is flagged with the Trust. You can also report incidents yourself at

      Best wishes

      Mike Durkin
      Director of Patient Safety, NHS England