Patient Safety Timeline

While the institutional development of patient safety in the NHS is a recent phenomenon (since 2000), it is the product of developments over the previous seventy years. This chronology places patient safety in wider historical context, showing its relationship with developments such as general management, public/patient participation in the NHS, clinical risk management (litigation), clinical governance, and concerns about health care quality.

The focus is on historical developments in the British NHS since 1948. Inevitably, as with much historical interest in the NHS, the timeline is England-centric, although in time it will be broadened to include developments in other parts of the UK too.

It should be noted also that medical harm and the acknowledgement of it has a much longer history. It is encoded in medical ethics (in the phrase ‘first, do no harm’), the development of professional self-regulation, as well attempts by health practitioners and scientists in previous centuries to reduce mortality rates. In this sense, the history of patient safety is nothing less than the history of medicine in its entirety.

This chronology builds upon others, on the policy history of the NHS, by organisations such as the Socialist Health Association, the Health Foundation, and the Nuffield Trust.

NB: The following timeline is a work in progress and is by no means comprehensive. While efforts have been made to ensure accuracy, please note that some inaccuracies and/or omissions may remain. As the Hazardous Hospitals project develops, this timeline will be updated. If you have any comments or suggestions, please feel free to add them below, or contact me directly.

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

Year	UK patient safety events	Other events
1948		Establishment of the NHS.
1952	Establishment of national Confidential Enquiry into Maternal Deaths
1967	The campaigner Barbara Robb’s Sans Everything: A Case to Answer 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. Further reading: Claire Hilton, Improving Psychiatric Care for Older People: Barbara Robb’s Campaign 1965-1975, Mental Health in Historical Perspective (Basingstoke: Palgrave Macmillan, 2017).
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).
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 Service to inspect hospitals and make recommendations. However, the Service is not empowered to investigate individual complaints, or intervene in matters of clinical judgement.
1973	Report of the Davies Committee into hospital complaints procedures (Report of the Committee on Hospital Complaint Procedure).	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.
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 UCL.	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).	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 NHS Trusts (as opposed to medical insurers). Launch of International Journal of Risk and Safety in Medicine Launch of AVMA Medical and Legal Journal	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 management.
1994	Royal Society of Medicine conference on clinical risk management. Establishment of Association of Litigation and Risk Management (ALARM)	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 Resolution). 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 UCL. 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.	Department of Health report, A First Class Service: Quality in the New NHS. Public Interest Disclosure Act 1998.
1999	US Institute of Medicine report To Err is Human: Building a Safer Health System. Department of Health commissions Expert Committee on Patient Safety 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 incidents	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) Publication of consultation paper Supporting Doctors, Protecting Patients.
2000	Department of Health report, An Organisation With A Memory 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 Reform 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 Agency (NPSA). Establishment of Commission for Health Improvement (CHI). Publication of Kennedy Report into children’s heart surgery at Bristol Royal Infirmary. 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. 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. Publication of NPSA patient safety guidance, Seven Steps to Patient Safety.	Abolition of Community Health Councils (CHCs)
2004	Health Foundation launches the Safer Patients Initiative. Department of Health report Building a Safer NHS for Patients: Improving Medication Safety Formation of the World Alliance for Patient Safety.	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 Safety	Establishment of NHS Institute for Innovation and Improvement.
2006	Department of Health report Safety First Department of Health report Good Doctors, Safer Patients NHS Redress Act passed by Labour government, providing mechanisms for financial redress in lieu of litigation, but subsequently left to languish on statute book
2007	Concerns raised about mortality rate at Mid Staffordshire General Hospitals NHS Trust
2008	Publication of Lord Darzi’s review, High Quality Care for All. Corporate Manslaughter and Corporate Homicide Act. Launch of Patient Safety First Campaign 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).
2009	Establishment of the Care Quality Commission (CQC), replacing the Healthcare Commission. Establishment of the National Quality Board. NHS providers publish annual quality accounts, including patient safety. The NHS Constitution 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).
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).
2011	Journal Quality and Safety in Health Care becomes BMJ Quality and Safety
2012	National Patient Safety Agency abolished. Functions transferred to NHS England.	Health and Social Care Act: NHS reorganisation.
2013	Full Francis Report on healthcare failures at Mid Staffordshire NHS Foundation Trust. Berwick Review into patient safety: A Promise to Act–A Commitment to Learn. Designation of Academic Health Science Networks (AHSNs)	Establishment of Healthwatch and NHS England Replacement of NHS Institute with NHS Improving Quality.
2014	Establishment of Patient Safety Collaboratives. Launch of Sign Up to Safety campaign Health and Social Care Act 2008 Health Regulations 2014. Regulation 20 providing for the first time, a statutory duty of candour for health professionals.
2015	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)
2016	Establishment of NHS Improvement, merging functions of Monitor and NHS Trust Development Agency.
2017	Establishment of Healthcare Safety Investigation Branch (HSIB).
2018	Report of Gosport Independent Panel into mortality at Gosport War Memorial Hospital. 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	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.	NHS England and NHS Improvement merge. Creation of ministerial role for patient safety (along with mental health and suicide prevention): Nadine Dorries MP originally appointed as Parliamentary Under-Secretary of State (now Minister).
2020	Report of the Independent Inquiry into the Issues Raised by Paterson First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review (Cumberlege report). Interim Ockenden report into maternity services at Shrewsbury and Telford Hospital NHS Trust