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The Independent Medicines and Medical Safety Devices Review: Shining a spotlight on patient safety

14 Jul 2020

Jacqueline Ladds

Executive Director of Policy & External Relations

‘First Do No Harm’, the report of the Independent Medicines and Medical Safety Devices Review, published this week, is a powerful and harrowing read. It details avoidable harm suffered by many thousands of patients and families over decades. It is a report that the whole healthcare system must reflect on and learn from.  

HCPC is not named in the Review’s report, but we welcome and support what it has to say about patient safety. Nothing matters more than ensuring that the care and treatment patients and service users receive is safe. The test of a good healthcare system is that problems are spotted early, addressed swiftly, and lessons are learned. As a regulator our aim is to provide a framework through our Standards to help professionals prevent patient safety issues from arising in the first place.

In this blog, we explore three themes from the Review which will be of interest and importance to our registrants.

Listening to patients

‘First Do No Harm’ rightly focuses on the importance of acting in the best interests of patients and service users. This is something we know professionals on our Register take seriously, and is clearly articulated in our Standards of conduct, performance and ethics – working in partnership with them to promote and protect their interests.

The report recommends the appointment of a Patient Safety Commissioner; a port of call for patients, a listener and advocate. A person who is independent and outside the healthcare system but has the power to hold it to account and require it to act in patients’ interests.   

At HCPC, we encourage patients and service users who have any concerns to follow our step by step guide – this will help them to understand how and with whom they should raise their concerns.   

Open and Honest

The report focuses on the Duty of Candour, which is the legal requirement for healthcare professionals to be open and honest with patients and service users when something goes wrong. The report found that this statutory duty has not always been adhered to, and a culture of blame and fear has existed across the healthcare system which makes staff reluctant to speak out or to admit mistakes. 

Professionals registered with HCPC are encouraged to be open and honest with patients and service users. Our Standards of conduct, performance and ethics, set out our expectations. We specifically strengthened our standards, to incorporate this need to be open and honest, following the report of the Francis Inquiry into failings at Mid Staffordshire NHS Trust in 2013. That report called for openness, transparency and candour throughout the healthcare system.

Our registrants commit to informing service users when things go wrong, apologising, learning lessons and taking action to put matters right, and dealing promptly and openly with concerns and complaints.

MHRA reform

The report also encouraged reform of the Medicines and Healthcare products Regulatory Agency (MHRA), the regulator of medicines and medical devices, to ensure it works both for patients and with them. Some of the professions we regulate use and supply to patients products which are regulated by the MHRA and an overhaul of the way the MHRA functions will be of direct interest and relevance to them. It may have implications for the way they work with patients and service users. More information is available in this section of our website.


The Government has pledged to consider carefully the Review’s recommendations and to set out its response to the recommendations as soon as possible. We will monitor the Government’s approach closely, and provide guidance and advice to registrants on changes that could have an impact on the way they work in future. We are all committed to making sure that patient safety is paramount in healthcare.  

At HCPC, we are reviewing the report’s recommendations and will be reflecting on them over the coming weeks and months. In particular, this will include:

  • Data and intelligence; ensuring we improve our ability to hold, access, analyse and share (where appropriate) data and intelligence.
  • Patient-centred care and our role in ensuring patient voices are heard.
  • The role of regulation in advanced practice; the report recommends the GMC register doctors’ clinical interests with supporting accreditation.
Page updated on: 14/07/2020