NHS patient safety strategy – progress update – April 2025

The NHS Patient Safety Strategy is now realising the impact we anticipated when we launched it in 2019: saving 1,000 additional lives and £100 million annually.

This update highlights the significant achievements across the strategy’s national patient safety programmes.

Martha’s Rule

  • Martha’s Rule gives patients, families and staff a way to request a rapid review if they are worried that deterioration is not being addressed
  • Piloted across 143 acute hospital sites and launched in May 2024
  • Between September 2024 and February 2025:
    • 2,389 calls made to escalate concerns; 73% from families seeking help and 47% relating to acute deterioration
    • 129 potentially life-saving interventions triggered, including:
      • 57 urgent admissions to high dependency or intensive care units
      • 60 transfers to specialist services (coronary care, respiratory care, return to theatre)
    • Changes in care for a further 336 cases, for example the introduction of a new medication such as an antibiotic
    • Calls unrelated to acute deterioration are also improving patient care, including:
      • 340 calls led to clinical concerns such as medication delays being addressed
      • 448 calls resolved communication issues

Maternity and neonatal care

Medicines safety

  • 1,900 deaths prevented through medicines safety initiatives
  • £9 million saved in admission costs
  • Better management of long-term opioid use has significantly contributed to this. Against the 2021 baseline, data to November 2024 shows:
    • 596 lives saved over 2 years
    • a projected 1,802 lives saved from reversing the rising trend in opioid use
    • 3% reduction in high-dose opioid prescribing
    • 12,657 fewer patients a month on high-dose opioids, halving their risk of death from opioids
    • 5% sustained reduction in rate of opioid prescribing for chronic use
  • Safer use of valproate and oral anticoagulants, fewer incidents of gastric bleeding, methotrexate overdose and drug-induced acute kidney injury

Early identification of deterioration (in addition to Martha’s Rule)

Transforming how we learn and respond to patient safety events

Patient Safety Incident Response Framework (PSIRF)

  • Patient Safety Incident Response Framework (PSIRF), a revolutionary new approach to incident response that centres on maximising learning and patient safety improvement now implemented in every NHS secondary care provider and being piloted in 50+ GP practices
  • Embeds systems thinking and improved engagement with patients, families and staff, promoting a patient safety culture
  • Providers report they are better able to identify safety priorities and act quickly

Learn from Patient Safety Events (LFPSE) service

  • Learn from Patient Safety Events (LFPSE) service: full implementation by November 2024 across all NHS trusts of new national system for recording and learning from patient safety events
  • Real-time incident reporting across the NHS, with over 3 million patient safety events recorded each year

National medical examiner system

  • National medical examiner system developed: local medical examiner offices cover the whole of England and Wales
  • Requirement for medical examiners to provide independent review of all deaths became statutory in September 2024
  • This system also provides enhanced support for bereaved families to ask questions and raise concerns about care, helping to identify hundreds of patient safety incidents that can then be responded to

Identifying and responding to patient safety risks

Building capability and capacity to address safety challenges

Patient safety leadership

  • Network of over 800 patient safety specialists created; they provide expert patient safety leadership, guidance and support at NHS organisations across England
  • All patient safety specialists offered in-depth training in patient safety (see below)

Patient safety training and education

Involving patients and the public in patient safety

Strengthening national patient safety systems