HSSIB's latest report found there are no overarching principles that all health and care providers and ICBs can use which enable a consistent and collaborative approach to safety management.

Sian Blanchard, head of patient safety insights at HSSIB, said: ‘We were told by those working in Integrated Care Boards about the challenges faced in delivering cross-organisational care and in how they monitor, escalate and respond to safety risks.

‘It is crucial that lines of responsibility and accountability are defined including at a national level, and those we spoke to welcomed any further work on establishing approaches that would help them to manage recurring or emerging risks more proactively.'

The report found ICBs do not have visibility of some patient safety risks, which impacts on their ability to effectively deal with those risks to keep patients safe. The investigation also found variation in how risks are escalated to a regional and national level, and how responses to escalations are fed back, meaning patient safety across multiple service providers is not adequately managed.

The HSSIB recommends the 10-Year Health Plan and the NHS Quality Strategy further explore of how safety management principles could be applied in health and care settings.

It contains safety suggestions for ICBs which focus on visibility and management of patient safety risks and also the development of patient safety capability and expertise.

An NHS spokesperson said: ‘As HSSIB themselves acknowledge, the Patient Safety Incident Response Framework represents a significant step forward for the investigation of incidents, moving towards a more comprehensive, supportive and evidence-based approach in line with the latest advances in safety science.

‘As this framework continues to be embedded, having been made mandatory in April 2024, NHS England is continuing to support ICBs in their complex role of overseeing safety across healthcare systems.'