Final Report > Recommendations > The safety of care
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The safety of care
- We support and endorse the broad framework of recommendations advocated in the report `An Organisation with a Memory' by the Chief Medical Officer's expert group on learning from adverse events in the NHS. The National Patient Safety Agency proposed as a consequence of that report should, like all other such bodies which contribute to the regulation of the safety and quality of healthcare, be independent of the NHS and the DoH.
- Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events. 
- Major studies should, as a matter of priority, be carried out to investigate the extent and type of sentinel events in the NHS to establish a baseline against which improvements can be made and measured.
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