Patient Safety Review

Debate between Bernard Jenkin and Jeremy Hunt

Monday 6th July 2026 Commons Chamber

[Sir Bernard Jenkin (Harwich and North Essex) (Con)]

I am grateful for this opportunity to evaluate the Dash review of patient safety, and I thank the Minister for the meeting with her this afternoon.

I hope that the House and Penny Dash will forgive me, but in the interests of brevity and clarity, I shall be direct. Whenever asked to justify the abolition of the Health Services Safety Investigations Body, Ministers refer to Dash, but Dash fails to make the case for what it recommends. This new clinical incident investigator was established less than three years ago. HSSIB is a new concept in healthcare, conceived to challenge the culture of denial and blame in the NHS. It is proving itself, even with its very limited budget. One early report on aortic dissection led to 300 more people receiving lifesaving treatment. The Minister now has a list of key recommendation impacts produced by HSSIB. A lot of them may seem small or piecemeal, but so far it is only a small body.

After a boy suffered an avoidable death from cancer, HSSIB recommended to NHS England a new community language translation and interpreting services framework so that non-English speaking patients would get appointment letters for their children that they could read and understand. HSSIB recommended a protocol between prisons and ambulance services to avoid wasting ambulance time and new guidance for non-accidental injury of babies in emergency departments where no specific guidance had existed before.

The Dash review shows no understanding of HSSIB’s purpose and no comprehension of coherent safety systems management. Dash gets facts wrong and misinterprets the law, either through a failure of understanding or because the recommendation to abolish HSSIB somehow reflected the desired outcome of the review, regardless of the facts.

I will set out some specific questions, most of which the Minister has had in advance. If she does not have enough time to respond, I look forward to discussing them at a future meeting that we discussed having.

[Sir Jeremy Hunt (Godalming and Ash) (Con)]

My hon. Friend is making a powerful case. Does he agree that one of the common themes in all the maternity scandals that we have been discussing in recent weeks, sadly, has been how a blame culture in the NHS makes it hard for NHS staff to speak openly about why tragedies have happened, and that that is why they welcome HSSIB, with its safe space protections? Is he worried that that could be undermined by putting HSSIB into the Care Quality Commission, which has a legal duty to act on information it receives, therefore creating the worry for people talking to HSSIB that the information that they give to it may no longer be protected in the same way?

[Sir Bernard Jenkin]

I 100% agree with my right hon. Friend. He will note that I will pick up on those points during my remarks.

I come back to the questions that I want to put to the Secretary of State. First, if HSSIB’s investigations are intended to continue unaffected by the transfer to the CQC, why bother with the expense of the transfer? Are Ministers simply using Dash as the pretext for what people in the Department or elsewhere in the NHS would like to have?

HSSIB was deliberately started very small, but the intention was that over time it would take over more investigations in health and replace the need for wasteful, lengthy, inexpert ad hoc public inquiries. Over the years, inquiries have proved to be a chaotic means of investigation, assembling expertise from scratch, which is then lost after the inquiry, and failing to command public confidence or to fix the system. That is why, after the 1999 Paddington rail crash, the Ladbroke Grove inquiry in 2001 established the rail accident investigation branch. Since then, despite many fatal rail accidents, there has been no public inquiry into a rail crash—nor has the public felt the need to demand one—and rail safety has improved.

Given that HSSIB is expert, full time, and can conduct much cheaper and quicker investigations than public inquiries, how can Ministers accept the Dash recommendation to abolish it? Why not consider expanding HSSIB to avoid the need for so many costly public inquiries?

Dash complains about there being far too many recommendations—yes, there are—but, as Dash itself enumerates, it is the 30 public inquiries that, in its language, have “cluttered” the “landscape” with some 1,400 recommendations over recent years. HSSIB is therefore not the source of those recommendations. In HSSIB’s first 34 months of operation, it has produced only 56 recommendations. How can Ministers use that reason to justify HSSIB’s abolition?

Dash refers more than once to

“quality (including safety) of care”.

That elides quality of care with safety. In any other safety-critical industry, safety is seen as a distinct, separate and overriding priority. It is telling that in the report, the words “including safety” are added merely in parentheses, as though safety is ancillary to quality, but that becomes justification for rationalisation while actually compromising safety.

Safety system management is intrinsic to safety and public confidence in other safety-critical activities, such as aviation, but this is alien to NHS culture. I therefore ask the Minister again: without HSSIB, which independent body will promote a coherent understanding of safety system management in health, and who is to hold the NHS and Government to account for safety failures?