An independent Patient Safety Commissioner is vital for patient protection: lessons from the Cumberlege Review

The Medicines and Medical Devices Safety Review (or the Cumberlege Review) was published last week into the harmful impacts of pregnancy test Primodos, epilepsy drug sodium valproate and pelvic mesh implants. The widely publicised review has shown why the establishment of an independent Patient Safety Commissioner is an absolute priority in giving patients and families a voice to prevent avoidable harm in future.

The Department of Health and Social Care would do well to look to the role of the Children’s Commissioner role, currently held by Anne Longfield. The position was established in 2004 as the independent voice of children and young people, championing their interests and bringing their concerns to the national arena. The independent nature of the Children’s Commissioner gives them the freedom to monitor, promote and protect the human rights of children successfully.

The Cumberlege Review shows that NHS leaders and doctors need to effectively be held to account for their own operations to ensure that the patient’s interests are put first. Sir Cyril Chantler, one of the review panel members, said that if such a Commissioner post had existed before, there would have been no need for this latest inquiry because the Primodos, Valproate and mesh scandals would have been dealt with at an early stage, preventing the high number of patient incidents that were allowed to occur.

This sentiment was echoed by Chief Executive of the Epilepsy Society, Clare Pelham, who highlights the need for radical change in the regulation of the Healthcare System. She said that the culture of ‘doctors know best’ must end now, and the appointment of a Patient Safety Commissioner “is imperative to listen to patients and enable their voices to influence improvements to patient safety”. Pelham emphasises that the commissioner must be “one of us” – that is not a doctor, a nurse, a scientist, or someone with years of experience within the NHS. Pelham says, “They must be a patient, like any of us who goes to see their doctor in their hour of need full of trust and confidence and deserves openness and a willingness to learn from mistakes, as well as care and understanding.”

In 2010 the then Children’s Commissioner for England Maggie Atkinson called for dialogue between government and stakeholders over concerns for the welfare of children held in detention for immigration purposes. The case is an example of how the Children’s Commissioner intervened on behalf of children and young people in areas of policy that were not designed to encompass children’s rights. An independent Patient Safety Commissioner can provide a similar voice to patients and their families, to ensure that the key decisionmakers are held to account.

At a time when we are particularly grateful to NHS staff, it is essential that the government looks to best practice within other departments to ensure that patients are no longer let down by the nation’s most loved institution, which was set up to protect each and every one of us.  If Matt Hancock is serious about focusing on prevention and early detection, then the government should look to replicate the success of the independent Children’s Commissioner Role. An independent commissioner can be free from government agendas to hold the system to account effectively, monitor trends, and encourage and require the system to act. They would press the system to take timely action where action is called for to minimise harm.

The Whitehouse team are experts in providing public affairs advice and political analysis to a wide range of clients engaging with health and social care providers and policy makers, not only in the United Kingdom, but also across the member states of the European Union and beyond. For more information, please contact our Chair, Chris Whitehouse, at