Clinical negligence: Government and NHS fail to act despite repeated warnings over patient safety, says PAC report

- Department of Health and Social Care's (DHSC) failure to address problems with maternity care has led to avoidable harm, PAC report finds 

Government has failed to tackle the issue of clinical negligence – despite repeated warnings from the Public Accounts Committee (PAC) for over two decades. In a new report, the PAC finds that, as government's liability for clinical negligence quadrupled over 20 years (£60bn in '24-'25), the DHSC is unable to show any meaningful action taken to address this, and that the NHS has not done enough to tackle the underlying causes of patient harm.

The report paints a picture of a system overwhelmed by safety recommendations that it cannot action, with evidence that, despite the NHS in England keeping a plethora of data on patient harm, its fragmented nature does not amount to good information which could identify and address clinical negligence's underlying causes.

The PAC is further highlighting the problem of disproportionate legal costs in clinical negligence claims. Claimant legal fees more than tripled to £538m in 2024-25, while claims with damages of £25k or less cost far more in fees than victims receive, with a cost-to-damages ratio of 3.7 to 1. Government's previous plans to limit the amount paid to lawyers in lower-value cases were not implemented as planned two years ago, and the DHSC should develop an alternative mechanism to speed up decisions and reduce costs for these cases.

Recent increases in settlement costs (tripling to £3.6bn in '24-'25) are likely to rise significantly to over £4bn/yr by the end of the decade, with these costs representing many tragic incidences of patient harm. However, despite warnings from the PAC dating back to 2002, the DHSC would not commit to acting to make improvements to the fundamental issues of clinical negligence until the completion of a review announced last year, for which it did not have an expected date. The PAC is seeking, within two months of this report:

• an operational plan from government to tackle clinical negligence;
• a national framework for improving patient safety with clear annual improvement targets, and
• a national system for sharing data between NHS trusts.

The report calls in particular for the DHSC to learn lessons from its failure to improve maternity care in England, and set out how it plans to reduce the incidence of harm and the costs of claims in this area. The report shows settled claims involving infants and children increasing significantly, reaching £325m in claims for paediatric failings in 2024-25. The inquiry heard that 120-130 brain injury cases involving children are settled every year, but it can take an average of 11-12 years to resolve each claim, at a high cost both for the victim's experience and financially.

Evidence to the PAC's inquiry from the Royal College of Obstetricians and Gynaecologists suggested that the maternity workforce is struggling under the pressure of delivering increasingly complex care, with more than half of births involving medical intervention, such as a caesarean section or the use of instruments such as forceps. Further evidence raised concerns that inadequate training, poor workforce planning and failure to adhere to staffing requirements have created the conditions for clinical negligence claims to occur. The PAC asks that DHSC and NHS find and fix systemic failings in care, and for the publication of the Amos review into maternity and neonatal care in England within two months alongside its response to the report.

Finally, the report notes that claims being settled on the basis of how much a victim's care would cost in the private sector, rather than in the NHS, stem from a law from 1948. The inquiry heard that this is a major contributory factor to the increasing cost of very high-value cases of £1m+. It is not clear how far the taxpayer is paying twice for clinical negligence – once when a victim is compensated, and then again if the victim uses the NHS for their subsequent care rather than the private sector. The DHSC should set out how it will guard against the risk of paying twice for the care of those it has harmed.

Sir Geoffrey Clifton-Brown, Chair of the Public Accounts Committee, said: “Clinical negligence is the second-largest financial liability across government, but represents to our Committee a different matter entirely from other large items like nuclear decommissioning or pensions. This is a swelling accounting of profound suffering. Each case can represent unspeakable devastation for the victims involved, and the overall picture is of a system struggling to keep its patients safe from avoidable harm. Indeed, the rising costs of such claims are diverting resources away from frontline care badly in need of them. That is why it feels impossible to accept that, despite two decades' worth of warnings, we still appear to be worlds away from government or NHS engaging with the underlying causes of this issue.

“Tragic failings in maternity care are one driver of this trend, and one of many problems within this system which we can see government has failed to address. Indeed, patients often pursue such costly legal action due to the lack of a complaints system worthy of the name, and disgracefully for lower-value claims, the legal costs can be over three-and-a-half times what victims can expect to receive in damages. Government must move at pace towards a less adversarial system, reducing costs and ensuring that claims are paid more quickly for the benefit of families involved. Whatever happens next, government has been in unacceptable stasis on the issue of clinical negligence for the majority of my political life, as numbers have continued to creep up. For those harmed by the outcomes of this system, the time for change has long since come and gone. We hope our recommendations, and those of other forthcoming reviews, help government and NHS carry out their duties to prevent future harm.

“We would like to sincerely thank everyone who contributed evidence to our inquiry on this topic, in particular to those submitters who are victims of clinical negligence.”

Notes to editors

The PAC's 2002 report on handling clinical negligence claims in England can be found here.

The PAC's 2017 report on managing the costs of clinical negligence in hospital trusts can be found here.

The PAC's report on the DHSC Annual Report and Accounts 2022-23 called on government to urgently reduce clinical harm to ensure better patient outcomes and free up

taxpayer money.

The PAC's report on the DHSC Annual Report and Accounts 2023-24 called on government to reduce tragic incidences of patient harm, with jaw-dropping amounts paid out on clinical negligence claims.

PAC report conclusions and recommendations 

The Department has failed to tackle the rising costs of clinical negligence despite repeated warnings. The government's liability for clinical negligence has quadrupled in real terms since 2006-07, reaching £60 billion in 2024-25. Annual settlement costs have tripled to £3.6 billion in 2024-25 with forecasts suggesting the cost of clinical negligence will continue to rise significantly in coming years. Recent increases have been driven mainly by rising damages, particularly for a small number of very-high-value cases in obstetrics with an average cost of £11.2 million per claim. Our predecessor committees reported on clinical negligence in 2002 and 2017, and both this Committee and our immediate predecessor raised further concerns about progress in its 2024 and 2025 reviews of the Department's accounts. Despite these repeated warnings, the Department cannot provide reassurance that it has taken any meaningful action to address clinical negligence to date. Furthermore, the Department would not commit to any new improvement activity until David Lock KC finishes his ongoing review of clinical negligence. The Department could not provide an expected completion date for this review but did assure the Committee that it would cover all aspects of clinical negligence.

Recommendation 1.

1. a) Alongside its Treasury Minute response to this report the Department should write to the Committee explain its operational plan to tackle clinical negligence, including key milestones for achieving reductions in claim costs and volumes. 
2. b) The Department should also publish David Lock KC's review of clinical negligence within six months of it being completed. This should include all supporting analysis and the Department's response to any recommendations made by the review.

The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England's approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing and unresponsive complaints system. Neither the Department nor NHS England know how much cost the NHS incurs treating patients it has harmed each year, but research suggests it could be significant. There is also evidence to suggest that a better initial response to harm, such as timely apologies or explanations, could reduce both the number of claims and cost of clinical negligence. We were also told during our informal private roundtable that effective compassionate, local resolution is both ethically right and fiscally responsible. Recent reviews have found that the NHS is overwhelmed by safety recommendations that it cannot action and one person we spoke to as part of our roundtable referred to the NAO's findings on this as the NHS drowning in recommendations. Despite the Department's stated commitment to improve patient safety and reduce harm, it has yet to outline any of the specific measures it will take to achieve this. It is also not clear how the abolition of NHS England will impact future patient safety arrangements and the little progress made to date.

Recommendation 2.

1. a) The Department must set a national framework for improving patient safety with clear targets for annual improvement.
2. b) The Department must review the NHS complaints system and improve the number of cases that are resolved without recourse to litigation.
3. c) The Department should estimate and track the costs to the NHS of treating avoidable harm.
4. d) The Department should write to the Committee to set out progress in implementing the Dash Review and its assessment of the impact of abolishing the Health Services Safety Investigations Body (HSSIB) on patient safety.
5. e) The Department and NHS England should have a clear system of accountability for patient safety, learning from mistakes and sharing what works, implementing best practice across the NHS streamlining patient safety alerts and recommendations from national bodies.

We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people's lives and NHS finances. Behind every clinical negligence claim is a tragic incident of patient harm. We were disappointed that neither the Department nor NHS England could adequately explain how the NHS uses its extensive data on patient harm to identify and address the underlying causes of clinical negligence. Data is not routinely reviewed at a national level as NHS England claim there is no direct connection between data on patient harm and clinical negligence claims. NHS Resolution has committed to making better use of its extensive claims database and to explore options to extract more detailed insight on the causes of harm to prevent the same things happening again. However, we remain concerned that poor investment in data analytics will leave the NHS lagging behind the private sector, where legal firms are now using artificial intelligence to triage clinical negligence claims on an industrial scale. One person we spoke to at our private roundtable described the English NHS having a plethora of data and no information, adding that we need more NHS data in one place.

Recommendation 3.  

1. a) The Department should establish a national system for sharing data between trusts and analysing trends. If there are barriers to sharing protected data, it should develop analysis on an anonymised basis to pull out lessons and provide early warning alerts to trusts.
2. b) The Department, NHS England and NHS Resolution should explore the use of artificial intelligence to analyse live data, detect discrepancies and outliers quickly, and improve the speed of early warning systems.

The Department's failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. Over the last 20 years the cost of settling claims involving infants and children has increased significantly. In 2024-25, costs for claims involving brain injury at birth were £1,554 million, with the total cost of claims for paediatric failings reaching £325 million. Damages awarded in these cases are higher than most clinical negligence claims as they typically include compensation for lifelong health and social care, future lost earnings and any necessary adaptations to accommodation. Court rulings on the eligibility of innovative or novel treatment options have also increased the value of damages awarded in recent years.  NHS Resolution settles around 120 to 130 brain injury cases involving children every year but it can take an average of 11-12 years to resolve each claim. In response, NHS Resolution has developed an innovative early notification scheme to provide more timely support to families and improve the speed at which lessons are learned. NHS England told us that it expects the final part of the Amos Review into England's maternity and neonatal services in 2026, but this does not mean it is waiting to act on its recommendations. 

Recommendation 4.  

1. a) The Department and the organisations it funds need to learn lessons from its failure to improve maternity care in England. Where problems arise the Department and the wider NHS should look for systemic failings in care and tackle these problems at their cause.
2. b) The Department should publish the Amos Review within two months alongside its response and set out how it plans to reduce the incidence of harm and the costs of claims in maternity care.

Legal costs in clinical negligence claims are disproportionate for medium and low volume claims. Legal costs in clinical negligence claims have risen sharply, with claimant legal fees increasing in real terms from £148 million in 2006-07 (in 2024-25 prices) to £538 million in 2024-25. At 19% of total settled claim costs it is unacceptable that so much taxpayers' money continues to be spent on legal fees. NHS Resolution has worked hard to increase the number of claims resolved without litigation (83% in 2024-25, up from 66% in 2006-07). It has also expanded its use of alternative dispute resolution and mediation. There are considerable financial benefits to these approaches which have been well received by the legal sector. However, we are extremely concerned that low-value clinical negligence claims (damages of £25,000 or less) cost far more in legal fees than victims receive in damages, with a 3.7:1 cost-to-damages ratio. The Department's previous plans to limit the amount paid to lawyers in lower-value cases were not implemented as planned in April 2024 and remain under review.

Recommendation 5.  

The Department should a) develop alternative dispute mechanisms to speed up decisions and reduce costs for less complex cases. As part of this, the Department should look at international examples (such as in New Zealand and Sweden) of non-adversarial and ombudsman models and assess how our ombudsman system could be improved; and

1. b) clarify its position on a fixed recoverable costs scheme for lower-value clinical negligence cases at the earliest opportunity.

Clinical negligence claims are settled on the basis of costs of care in the private sector and yet there is nothing to stop the claimant using the NHS or publicly funded social care in the future, potentially inflating the costs of claims. It is not clear the extent to which the taxpayer is paying twice for clinical negligence - once through compensation for injury and then again by providing subsequent health and social care. A law from 1948 states that damages must be calculated on the presumption that care will be provided by the private sector and not the NHS or local government. NHS Resolution identified this as a major contributory factor to the increasing cost of very high-value cases (£1 million or more), where about 60% of the damages relate to future care. Although claimants can be asked to declare in court if they plan to use the NHS for treatment, this rarely happens in practice and cannot be mandated. NHS Resolution is unable to ask successful claimants for information on how they spend their award or whether they subsequently access state funded services to manage their condition. Local authorities are also not able to consider clinical negligence compensation awards when assessing eligibility for publicly funded social care.

Recommendation 6. The Department should develop, within six months, proper estimates of the impact of assuming health and social care for clinical negligence victims will be provided exclusively by the private sector. It should by the same deadline set out additional measures - including any requiring changes to legislation - which it judges would effectively guard against the risk of paying twice for the care of those it has harmed and an indicative timeline for their potential implementation.