Safety recommendation
HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention.
Response:
DHSC is taking forward work to design an oversight mechanism that supports the effective implementation and learning from safety recommendations. The mechanism will enable the tracking, prioritisation and oversight of safety recommendations to implementation. This work builds on the work of the HSSIB-led Recommendations to Impact Group and wider Government plans for the oversight of government-led inquiries. It also aligns with the outcome of the Dash Review published on 7 July and its findings and recommendations relating to the oversight and prioritisation of recommendations.
As part of this work, DHSC is working with the cross-organisational Recommendations Working Group (DHSC, HSSIB and NHS England) to review a cohort of recommendations made by national organisations specific to mental health services, including mental health inpatient settings. A project will be established in partnership with NHS England leads for mental health policy and patient safety policy to conduct the review and identify what actions if any have been taken in response to the cohort of recommendations. The review will allow us to pilot the proposed approach for a recommendations hub, which is intended to form part of the national oversight mechanism and provide useful learning about the barriers and enablers to implementation. The National Quality Board (NQB) will be responsible for reviewing, analysing and taking forward recommendations as outlined in the 10 year health plan and the Dash review of patient safety across the health and care landscape.
Action planned to deliver safety recommendation:
Undertake a review of a cohort of mental health recommendations to understand what actions have been taken in response and identify any barriers or enablers to their implementation, by November 2025. Other dependencies identified: Work programme to implement Dash recommendation that the National Quality Board takes responsibility for the oversight of implementation of recommendations and that it builds and maintains a repository of recommendations from multiple sources.
Response received on 28 August 2025.