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NHS Patient Safety Timeline

Year UK patient safety events   Other events
1948     Establishment of the NHS.
1952 Establishment of national Confidential Enquiry into Maternal DeathsLink opens in a new window    
1955 First guidance from the Ministry of Health to NHS hospitals on the reporting of accidents and untoward occurrences (HM(55)66).  
1960 Guidance from the Ministry of Health on 'Prevention of Harm to Patients Resulting from Physical or Mental Disability of Hospital Medical or Dental Staff' (HM(60)45).  
1961 Joint Memorandum by the Medical Defence Union, Royal College of Nursing, and National Council of Nursing, 'Safeguards against wrong operations'.  
1963 Joint Memorandum by the Medical Defence Union, Royal College of Nursing, and National Council of Nurses, 'Safeguards against failure to remove swabs, etc., from patients'.  
1966 First guidance to NHS hospitals from Ministry of Health on the handling of patient complaints, containing provisions for the holding of inquiries. (HM(66)15).  
1967 The campaigner Barbara Robb’s Sans Everything: A Case to AnswerLink opens in a new window draws attention to the care of the elderly on long-stay hospital wards in psychiatric hospitals. While several of her recommendations, such as a hospital inspectorate, were subsequently adopted by the government following the Ely Scandal, her allegations were dismissed, and Robb was discredited by the Minister of Health, Kenneth Robinson.    
1968 Ministry of Health report Allegations Concerning the Care of Elderly Patients in Certain Hospitals (Cmnd. 3687). Creation of Department of Health and Social Security (DHSS)Link opens in a new window.
1969 Ely Hospital report: Report of the Committee of Inquiry into Allegations of Ill – Treatment of Patients and other irregularities at the Ely Hospital, Cardiff (Cmnd. 3975).  
1970     Establishment of the Hospital Advisory ServiceLink opens in a new window to inspect hospitals and make recommendations. However, the Service is not empowered to investigate individual complaints, or intervene in matters of clinical judgement.
1972

Guidance to hospitals on the prevention of surgical accidents (HM(72)37)

 
1973

Report of the Davies Committee into hospital complaints procedures (Report of the Committee on Hospital Complaint Procedure).

Guidance to hospitals on the reporting of accidents associated with defects in medicinal products, supplies and equipment (HM(73)9).

Establishment of the Health Service Commissioner (Ombudsman). Patient complaints can be referred to the Ombudsman, but it is not empowered to investigate clinical complaints, or the actions of GPs.

   
1974     NHS reorganisation: creation of Regional Health Authorities (RHAs), Area Health Authorities (AHAs), and district management teams

Establishment of Community Health Councils (CHCs), which act as the voice of patients in the NHS, but cannot deal with complaints arising from clinical procedures.
1975 Merrison Committee report into the regulation of the medical profession.    
1976 Hospital Advisory Service expanded to include community health services, becoming NHS Health Advisory Service.    
1978 Report of the Pearson Commission recommends that the experiences of New Zealand and Sweden in relation to the institution of no-fault compensation for medical injuries should be examined.    
1980 Airing of BBC ‘Play for Today’ Minor Complications, by the playwright Peter Ransley, focusing on medical injuries. Black Report on health inequalities published, but buried.Link opens in a new window
1981 First guidance to NHS hospitals on the handling of clinical complaints (e.g. relating to patient safety incidents).    
1982 Establishment of Action for the Victims of Medical Accidents (AvMA), later Action Against Medical Accidents   NHS reforms: abolition of Area Health Authorities (AHAs) and creation of District Health Authorities (DHAs).
1983     Griffths Report: NHS general management introduced.
1984     Establishment of Anesthesia Patient Safety Foundation (USA)
1985 Hospital Complaints Procedure Act requires that all NHS hospitals have a complaints procedure in place.

Avoidable Mishaps in Medicine study at UCLLink opens in a new window.
  Establishment of NHS Management Executive.
1986 Establishment of Datix, developer of incident reporting and risk management software    
1987     White paper, Promoting Better Health: The Government’s Programme for Improving Primary Health Care
1988 Establishment of National Confidential Enquiry into Perioperative Deaths (NCEPOD) (later National Confidential Enquiry into Patient Outcomes and Death).Link opens in a new window   Department of Health and Social Security (DHSS) splits into Department of Health and Department of Social Security.
1989 Brighton Health Authority initiates pilot clinical risk management programme.

First AVMA annual conference held in Harrogate.
  White paper, Working for Patients formalises process of clinical audit in the NHS
1990 Crown indemnity for medical negligence introduced, placing the onus of financial responsibility for managing clinical risks onto regional and district health authorities and new NHS trusts (as opposed to medical insurers).

Launch of International Journal of Risk and Safety in Medicine

Launch of AVMA Medical and Legal Journal
Department of Health brochure 'Medical Negligence: New NHS Arrangements' National Health Service and Community Care Act
1991     Implementation of NHS reforms. Introduction of internal market and GP fundholding. Establishment of NHS Trusts with boards composed of Executive and Non-Executive Directors.

Establishment of Institute for Healthcare Improvement (USA)
1992 Launch of journal Quality in Health Care

Establishment of Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI)
  Session on ‘Human Error in Medicine’ at American Association for Advancement of Science meeting
1993

Report of Audit Commission finding continuing problems with NHS complaints procedure.

Directorate of Public Health in North Thames (West) Region funding programme of research into complaints, claims and risk managementLink opens in a new window.

Publication of Risk Management in the NHS by the NHS Management Executive. This manual, aimed at managers within the NHS, covered direct and indirect risks to patient care, health and safety risks, and organisational risks such as data security. Sir Duncan Nichol, the Chief Executive of the NHS Management Executive, warned health care providers that 'risk management ... is no longer an optional extra'. Amongst its many recommendations was the need for NHS providers to establish standardised incident reporting systems, and the need for training of staff in risk management.

Risk Management in the NHS, NHS Management Executive, 1993  
1994 Royal Society of Medicine conference on clinical risk management.Link opens in a new window

Establishment of Association of Litigation and Risk Management (ALARM)Link opens in a new window
  NHS Management Executive renamed NHS Executive.
1995 Medical (Professional Performance) Act empowers the General Medical Council to consider the clinical performance of doctors.

Establishment of NHS Litigation Authority (now NHS ResolutionLink opens in a new window).

Establishment of Clinical Negligence Scheme for Trusts (CNST) whereby Trusts self-insure by pooling financial risks for clinical negligence claims.

Establishment of Clinical Risk Unit at UCLLink opens in a new window.

Launch of journal Clinical Risk, incorporating AVMA Medical and Legal Journal
   
1996 Health Service Commissioner (Ombudsman) required to consider clinical complaints and actions of GPs   Regional Health Authorities (RHAs) abolished, replaced by regional offices of the NHS Executive; District Health Authorities replaced by Health Authorities.

Annenberg I conference on patient safety (‘Examining Error in Medicine’) at the Annenberg Center
1997     Department of Health white paper The New NHS: Modern. Dependable, introducing concept of clinical governance.

Establishment of National Patient Safety Foundation (USA)
1998

NHS Trusts begin to publish death rates from surgery

(October) Opening of the public inquiry into the events at Bristol Royal Infirmary (Kennedy Inquiry)

  Department of Health report, A First Class Service: Quality in the New NHS.

Public Interest Disclosure Act 1998.
1999

Health Select Committee considers the handling of adverse incidents and occurrences in the NHS.

Department of Health commissions Expert Committee on Learning from Experience under the chairmanship of Chief Medical Officer, Liam Donaldson.

Trusts required to publish annual reports on clinical governance.

Development of the London Protocol – a framework for the investigation of clinical incidentsLink opens in a new window

US Institute of Medicine report To Err is Human: Building a Safer Health SystemLink opens in a new window.

Health Act: Creation of Primacy Care Trusts (PCTs); statutory duty on PCTs, Health Authorities and NHS Trusts to monitor and improve quality; Commission for Health Improvement.

Establishment of National Institute of Clinical Excellence (NICE)Link opens in a new window

Publication of consultation paper Supporting Doctors, Protecting Patients.

2000 Department of Health report, An Organisation With A MemoryLink opens in a new window estimates that 850,000 patients (around 1 in 10) admitted to NHS hospitals encounter an adverse health event. However, these figures are very broad extrapolations based on previous studies in the US, Australia, and UK. The NHS Plan: A Plan for Investment. A Plan for ReformLink opens in a new window outlines the Labour Government’s reform plans for the NHS. The Government commits to sending the Commission for Health Improvement into Trusts where there are serious concerns about patient safety. It further commits to the establishment of a mandatory reporting system for adverse health events.
2001 Establishment of National Patient Safety AgencyLink opens in a new window (NPSA).

Establishment of Commission for Health Improvement (CHI).

Publication of Kennedy Report into children’s heart surgery at Bristol Royal InfirmaryLink opens in a new window.

Department of Health report Building a Safer NHS for Patients: Implementing An Organisation With A Memory

Establishment of the Shipman Inquiry.
 
2002 Journal Quality in Health Care becomes Quality and Safety in Health Care

World Health Organisation resolution on patient safety

Establishment of Commission for Patient and Public Involvement in Health

Establishment of Council for Healthcare Regulatory Excellence (CHRE)

Establishment of Patient Advisory and Liaison Services (PALS)

NPSA Conference, Building a Patient Safety Culture.

NPSA releases first patient safety alert, on preventing accidental overdose of intravenous potassium.
National Health Service Reform and Health Care Professionals Act; renaming and replacement of Health Authorities with Strategic Health Authorities (initially 28, later reduced to 10); abolition of NHS Executive and its regional offices.
2003

Consultation paper Making Amends, setting out proposals to reform system of clinical governance and recommending a legal duty of candour.

Establishment of National Reporting and Learning System (NRLS)

Establishment of Medicines and Healthcare Products Regulatory Agency (MHRA), merging the Medicines Control Agency and Medical Devices Agency.
.
Design Council/Department of Health report, Design for Patient Safety: A System-Wide Design-Led Approach to Tackling Patient Safety in the NHS.Link opens in a new window

Creation of Council for Healthcare Regulatory Excellence (CHRE).


Publication of NPSA patient safety guidance, Seven Steps to Patient SafetyLink opens in a new window.

Abolition of Community Health Councils (CHCs)
2004

Health Foundation launches the Safer Patients InitiativeLink opens in a new window (ran until 2008).

Department of Health report Building a Safer NHS for Patients: Improving Medication Safety

Formation of the World Alliance for Patient SafetyLink opens in a new window.

Health and Social Care (Community Health and Standards) Act. Establishment of Healthcare Commission, legally known as Commission for Healthcare Audit and Inspection (CHAI). The CHAI incorporates the functions of the previous Commission for Health Improvement.
2005

National Audit Office report: A Safer Place for Patients: Leaning to Improve Patient SafetyLink opens in a new window

NPSA alert and guidance on Being Open: Communicating Patient Safety Incidents with Patients and their Carers

Establishment of NHS Institute for Innovation and ImprovementLink opens in a new window.
2006 Department of Health report Safety First

Creation of National Patient Safety Forum

Department of Health report Good Doctors, Safer Patients

NHS Redress ActLink opens in a new window passed by Labour government, providing mechanisms for financial redress in lieu of litigation, but subsequently left to languish on statute book
 
2007

Publication of Healthcare Risk Assessment Made Easy by NPSA

Concerns raised about mortality rate at Mid Staffordshire General Hospitals NHS Trust

 
2008

Publication of Lord Darzi’s review, High Quality Care for AllLink opens in a new window.

Corporate Manslaughter and Corporate Homicide Act.

Launch of Patient Safety First CampaignLink opens in a new window by NPSA, NHS Institute for Innovation and Improvement, and the Health Foundation.

UK trials, and a year later fully implements, WHO surgical checklists.

Mid Staffordshire General Hospitals NHS Trust attains Foundation Trust status (January). Healthcare Commission launches investigation into Mid Stafforshire NHS Foundation Trust (April).

Formation of Safe Anaesthesia Liaison GroupLink opens in a new window. A collaboration between the Royal College of Anaesthetists, Association of Anaesthetists and NHS England

 
2009

Establishment of the Care Quality Commission (CQC)Link opens in a new window, replacing the Healthcare Commission.

Establishment of the National Quality BoardLink opens in a new window.

NHS providers publish annual quality accounts, including patient safety.

The NHS ConstitutionLink opens in a new window published, embodying a commitment to patient safety as both an underlying principle and a right.

Non-statutory inquiry into the events at Mid Staffordshire NHS Foundation Trust commissioned by Secretary of State for Health, Andy Burnham. Chaired by Robert Francis QC (published in 2010).

WHO Surgical Safety ChecklistLink opens in a new window mandated for use in NHS

NPSA revised guidance on Being Open

NPSA publishes first iteration of its Never Events Policy Framework. 'Never events' are defined as 'serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.' Initially, eight never events are listed including wrong-site surgery and retained instrument post-operation. The term 'Never Event' was first introduced in 2001 by Ken Kizer, the former CEO of the National Quality Forum in the USA.

NPSA Never Events Framework 2009-10

 
2010

Publication of initial Francis Report into healthcare failures at Mid Staffordshire NHS Foundation Trust.

Public inquiry into events at Mid Staffordshire NHS Foundation Trust announced by Secretary of State for Health, Andrew Lansley. Again chaired by Robert Francis QC (Final report published in 2013).

NPSA publishes National Framework for Reporting and Learning from Serious Incidents Requiring Investigation (the Serious Incident Framework). The SIF was revised by the NHS Commissioning Board in 2013, and again by NHS England in 2015.

 
2011 Journal Quality and Safety in Health Care becomes BMJ Quality and Safety

NHS Wales launches NHS redress scheme (Putting Things Right)
   
2012

NPSA. Functions transferred to NHS England.

CHRE becomes Professional Standards Authority for Health and Social Care (PSA).

  Health and Social Care Act: NHS reorganisation.
2013

Full Francis Report on healthcare failures at Mid Staffordshire NHS Foundation TrustLink opens in a new window.

Berwick Review into patient safety: A Promise to Act—A Commitment to LearnLink opens in a new window.

Designation of Academic Health Science Networks (AHSNs)

Establishment of HealthwatchLink opens in a new window and NHS EnglandLink opens in a new window

Replacement of NHS Institute with NHS Improving Quality.
2014

Establishment of Patient Safety Collaboratives.

Launch of Sign Up to Safety campaignLink opens in a new window

Health and Social Care Act 2008 Health Regulations 2014. Regulation 20 providing for the first time, a statutory duty of candour for health institutions.

NICE publishes first guideline on safe staffing for nursing in adult inpatient wards in acute hospitalsLink opens in a new window.

   
2015

The Report of the Morecambe Bay Investigation (Kirkup ReportLink opens in a new window).

Publication of the Freedom to Speak Up Review by Robert Francis QCLink opens in a new window

Public Administration Select Committee report on clinical incidents in the NHS. Recommendation that a new independent patient safety investigation body should be established.

First meeting of Independent Patient Safety Investigation Service (IPSIS) Expert Advisory Group. The IPSIS was later renamed the Healthcare Safety Investigation Branch (HSIB)

Health and Social Care (Safety and Quality) ActLink opens in a new window

 
2016

Establishment of NHS ImprovementLink opens in a new window, merging functions of Monitor and NHS Trust Development Agency.

Creation of the National Guardian's OfficeLink opens in a new window, and Freedom to Speak Up Guardians in NHS.

   
2017 Establishment of Healthcare Safety Investigation Branch (HSIB)Link opens in a new window.    
2018

Report of Gosport Independent Panel into mortality at Gosport War Memorial HospitalLink opens in a new window. The report showed that concerns had been raised by nurses as early as 1991 about the inappropriate prescription and administration of drugs such as diamorphine, and that the lives of over 450 people had been shortened between 1987 and 2001. However, the scandal only came to public attention following the death of Gladys Richards in 1998, who had been admitted following a hip operation.

CQC Report Opening the Door to Change: NHS safety culture and the need for transformation

Journal Clinical Risk becomes Journal of Patient Safety and Risk Management

Publication of A Just Culture GuideLink opens in a new window by NHSEI

Department of Health becomes Department of Health and Social Care (DHSC).
2019 Publication of NHS Patient Safety Strategy by NHS England and NHS Improvement: Safer Culture, Safer Systems, Safer Patients.Link opens in a new window NHS England and NHS Improvement merge.

Creation of ministerial role for patient safety(along with mental health and suicide prevention): Nadine Dorries MPLink opens in a new window originally appointed as Parliamentary Under-Secretary of State (now Minister).
2020

Report of the Independent Inquiry into the Issues Raised by PatersonLink opens in a new window

First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety ReviewLink opens in a new window (Cumberlege report).

Interim Ockenden report into maternity services at Shrewsbury and Telford Hospital NHS TrustLink opens in a new window

Publication of introductory version of Patient Safety Incident Response Framework (PSIRF)Link opens in a new window by NHSEI

 
2021 Rollout of the Learn From Patient Safety Events (LFPSE) serviceLink opens in a new window, replacement of the National Reporting and Learning System (NRLS). The new service promises, amongst other things, to cut through the 'information overload' of the previous incident management system by leveraging new technology, such as machine learning, to create more useful outputs, and making it easier for NHS staff to upload, access and analyse patient safety event data.    
2022

Appointment of the first Patient Safety Commissioner, an outcome of the Ockenden Report (2020)

Publication of full Ockenden Report into failures in maternity care at Shrewsbury and Telford Hospital NHS TrustLink opens in a new window

   

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Patient Safety Timeline by Dr Christopher Sirrs is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.