Abstract

Get full access to this article
View all access options for this article.
References
1.
Vincent
C
Carthey
J
Oikonomou
E
Macrae
C.
Redesigning safety regulation in the NHS . Br Med J 2020 ;
368 : m760.
2.
Oikonomou
E
Carthey
J
Macrae
C
Vincent
C.
Patient safety regulation in the NHS: mapping the regulatory landscape in healthcare . BMJ Open 2019 ;
9 : e028663.
3.
Dash
P.
Review of Patient Safety across the Health and Care Landscape .
London :
Department of Health and Social Care , 2025 .
4.
Walshe
K.
The Care Quality Commission has lost its way . BMJ 2024 ;
386 : q1832.
5.
Dash
P.
Review into the Operational Effectiveness of the Care Quality Commission: Full Report .
London :
Department of Health and Social Care , 2024 .
6.
Wiig
S
Macrae
C.
Introducing national healthcare safety investigation bodies . Br J Surg 2018 ;
105 : 1710 –1712 .
7.
Tiirinki
H.
Consolidating safety investigation: Finland’s journey and the influence of the HSSIB. Poole: Health Services Safety Investigation Body. See www.hssib.org.uk/news-events-blog/consolidating-safety-investigation-finlands-journey-and-the-influence-of-the-hssib/ (last checked 16 July 2025).
8.
Macrae
C.
Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety . J R Soc Med 2019 ;
112 : 365 –369 .
9.HSSIB . Investigation report: the impact of staff fatigue on patient safety. Poole: Health Services Safety Investigation Body. See www.hssib.org.uk/patient-safety-investigations/the-impact-of-staff-fatigue-on-patient-safety/investigation-report (last checked 16 July 2025).
10.HSSIB . Workforce and patient safety: summary of investigations. Poole: Health Services Safety Investigation Body. See www.hssib.org.uk/patient-safety-investigations/workforce-and-patient-safety/ (last checked 16 July 2025).
11.HSSIB . Investigation report: safety management systems: an introduction for healthcare. Poole: Health Services Safety Investigation Body. See www.hssib.org.uk/patient-safety-investigations/safety-management-systems/investigation-report/ (last checked 16 July 2025).
12.
Macrae
C
Vincent
C.
Learning from failure: the need for independent safety investigation in healthcare . J R Soc Med 2014 ;
107 : 439 –443 .
13.
Macrae
C.
Healthcare safety investigations must offer a safe space for learning. BMJ Opinion . See https://blogs.bmj.com/bmj/2018/07/23/carl-macrae-healthcare-safety-investigations-must-offer-a-safe-space-for-learning/ (last checked 16 July 2025).
14.
Macrae
C
Vincent
C.
A new national safety investigator for healthcare: the road ahead . J R Soc Med 2017 ;
110 : 90 –92 .
15.
Macrae
C.
Inquiries alone will not tackle failures of care. Health Service Journal 10 April 2013. See www.hsj.co.uk/technology-and-innovation/inquiries-alone-will-not-tackle-failures-of-care/5056561.article (last checked 16 July 2025).
16.House of Commons Public Administration Select Committee . Investigating Clinical Incidents in the NHS: Sixth Report of the Session 2014–15 .
London :
UK Parliament , 2015 .
17.Joint Committee on the Draft Health Service Safety Investigations Bill . Draft Health Service Safety Investigations Bill: A New Capability for Investigating Patient Safety Incidents .
London :
UK Parliament , 2018 .
18.
Edwards
N.
The Triumph of Hope Over Experience: Lessons from the History of Reorganisation .
London :
NHS Confederation , 2010 .
19.Hansard . NHS 10-Year Plan. Vol. 770, debated Thursday, 3 July 2025 .
London :
UK Parliament , 2025 .
