Care Quality Commission -
This review was carried out at the request of the Secretary of State for Health and Social Care and sought to help understand the barriers to delivering safe care and to identify learning that can be applied to improve patient safety. It examines the issues that contribute to the occurrence of never events and wider patient safety incidents in NHS trusts in England. The report found that too many people are being injured or suffering unnecessary harm because NHS staff are not supported by sufficient training, and because the complexity of the current patient safety system makes it difficult for staff to ensure that safety is an integral part of everything they do.