A tired surgeon sits on the floor of a hospital corridor with their head hanging down.

The impact of staff fatigue on patient safety: how do we manage the risk

17 March 2023

We facilitated a half-day event on 17 March 2023 to ask how healthcare can understand and start to manage the risk of staff fatigue.

This event was held by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Watch the event video

This event brought together clinical, NHS patient safety representatives and professionals from other safety critical industries. The collaboration of these professionals was intended to share insights around the risk of fatigue, how to consider fatigue in the context of investigations and provide some pragmatic resources and plans for the NHS to introduce the concept and tools for fatigue management.


9.30: Welcome and introductions

9.35 - 9.45 How HSIB has started to consider fatigue in investigations - Dr Laura Pickup, Senior Investigation Science Educator (HSIB).

9.45 - 10.10 Background and scale of fatigue challenge in healthcare - Dr Mike Farquhar, Consultant in Paediatric Sleep Medicine, Guys and St Thomas.

10.10 - 10.35 How does it feel in healthcare - Dr Emma Plunkett, Consultant Anaesthetist in Birmingham and co-chair of the Joint Association of Anaesthetists, Royal College of Anaesthetists and Faculty of Intensive Care Medicine Fatigue Working Group.

10.35 - 10.50 What can we do about fatigue in hospitals - Dr Nancy Redfern, Consultant Anaesthetist Newcastle and co-chair of the Joint Association of Anaesthetists, Royal College of Anaesthetists and Faculty of Intensive Care Medicine Fatigue Working Group

10.50 - 11.05 Coffee Break

11.05 - 11.35 Humans are humans: learning about fatigue investigation and management from two contrasting industries - Mark Young (Railway Safety Investigator RAIB) and Will Tutton (Marine Safety Investigator MAIB).

11.35 - 12.00 Fatigue risk management in practice - Phil Barton, Head of FRMS at EasyJet (please note that presentation slides are not available for this talk and it's not included in the event video).

12.00 - 12.25 Designing a fatigue risk management system for the NHS: a case study from the UK ambulance sector - Professor Kristy Sanderson (University of East Anglia).

12.25 - 12.30 Closing remarks - Dr Rosie Benneyworth, Chief Investigator, HSIB.


Phil Barton

Phil is the Head of the Fatigue Risk Management (FRM) System for EasyJet. He has forty-five years’ experience in crew work and rest regulation, operational rostering, and fatigue risk management with over thirty-five years in supervisory and management roles. Phil has a post graduate qualification in education and lecturer in FRM principles and contributes to various industry and regulatory advisory bodies and is presently a member of the EASA IFTSS panel, the CAA Fatigue FOLG, and an A4E representative on the EU FTL Effectiveness Research Project Mirror Group.

Dr Michael Farquhar

Mike joined the Evelina London sleep medicine team as a consultant in 2012. He is involved in educating healthcare professionals on the importance of sleep and the impact of fatigue on healthcare, with a focus on sleep for staff working night shifts. His work led to the introduction of the “HALT: Take A Break” campaign for Guy's and St Thomas' staff in 2017, and he has worked with organisations including the Royal College of Paediatrics and Child Health, Association of Anaesthetists of Great Britain and Ireland, the Royal College of Anaesthetists, the Royal College of Nursing and the British Medical Association in this area. He has been recognised with the Association of Anaesthetists Association Award and the Royal College of Anaesthetics Humphry Davy Award for his contributions to the #FightFatigue campaign, as well as the 2020 BMJ Award for Workforce and Wellbeing Team.

Dr Emma Plunkett

Emma is a consultant anaesthetist at University Hospitals Birmingham and Birmingham Women’s Hospital. Her clinical interests are obstetric anaesthesia and peri-operative medicine. Her non-clinical interests are around ways we can support staff wellbeing and help them to perform at their best. She currently co-chairs the Joint Fatigue Group - a partnership between the Association of Anaesthetists, RCoA and FICM to improve the culture around fatigue – and co-authored the national surveys on fatigue in anaesthetists and the #FightFatigue resources. She is a trained mentor, leads the wellbeing group in her department and has introduced positive reporting systems (Learning from Excellence) where she works.

Dr Nancy Redfern

Nancy is a Consultant Anaesthetist in Newcastle and co-chair of the joint working group on fatigue. She was Hon. Membership Secretary at the Association of Anaesthetists when a trainee died driving home tired after a night shift. This spurred her on to try and improve fatigue risk management, both locally where Newcastle now has fatigue on the risk register, and more widely with talks and workshops for hospitals, Royal Colleges, Health Boards, Heath Education and in Europe. She advises the European Patient Safety Foundation and is a member of the European Board of Anaesthesia. Her research on fatigue is practically based, investigating ways to manage fatigue in busy clinical environments.

Professor Kristy Sanderson

Kristy is Chair in Applied Health Research, School of Health Sciences, University of East Anglia, and Mental Health Theme Lead for the NIHR Applied Research Collaboration East of England. With a background in psychology, epidemiology and public health, her research programme is exploring the health and wellbeing of health and social care staff. She is Chief Investigator of the NIHR-funded CATNAPS study, where she is working with the NHS ambulance sector to design a fatigue risk management system to improve both patient and staff safety.

Dr Will Tutton

Will joined as an Inspector with the Marine Accident Investigation Branch (MAIB) in 2019 as its first specialist human factors Inspector. Prior to this Will worked in the defence sector for 20 years working on tanks to fast jets as a Senior Principal Human Factors Engineer. He is a Chartered Fellow of the Institute of Ergonomics and Human Factors (CIEHF). He is also a member of the Institute of Marine Engineering, Science and Technology’s Human Element Working Group, the Human Element Industry Group, as well as representing MAIB on the Lloyds Register human element rules panel and was recently on the Advisory Research Board for the SAFEMODE research project. He has also been a Visiting Professor at Loughborough University supporting research to translate human factors practices from defence into healthcare and is a past Trustee of the CIEHF. Will holds a PhD in human factors and design from Loughborough University.

Dr Mark Young

Mark is an Inspector with the Rail Accident Investigation Branch (RAIB) and leads the Branch’s work on human factors. Before joining the RAIB in 2012, he worked in academia, researching and teaching in human factors, with a particular focus on transport safety and vehicle automation. Mark has around 25 years’ experience working in human factors, and holds a degree in Psychology and a PhD in Human Factors, both from the University of Southampton. He is also a Visiting Professor at Loughborough University’s Design School, a Trustee of the Chartered Institute of Ergonomics and Human Factors (CIEHF) and a Chartered Fellow of CIEHF.

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