For NHS Enterprise Architects and Digital Leadership

This strategic review examines LFPSE not just as a compliance requirement, but as an opportunity to rebuild reporting culture and strengthen clinical governance through better technical architecture.

Executive Summary

The Learn from Patient Safety Events (LFPSE) service is not just another IT system upgrade. With the decommissioning of the National Reporting and Learning System (NRLS) in June 2024, LFPSE is now the single, mandated platform for recording patient safety events across the NHS. That makes compliance non-negotiable.

But compliance is only half the story. If implemented well, LFPSE also offers the chance to rebuild staff confidence in reporting, strengthen governance, and create the conditions for a culture of proactive learning. The real challenge for Trusts lies not in the technology itself, but in overcoming reporting fatigue and the legacy of a blame culture. The strategic task for CTOs is to make sure the technical design and organisational change programme come together to close the loop — showing staff that reporting leads to real improvement.

Part 1: From NRLS to LFPSE — What Has Changed

The contrast with NRLS is stark. NRLS functioned largely as a one-way repository: reports went in, national statistics came out, and little filtered back to frontline teams. LFPSE introduces a richer taxonomy, distinguishing psychological from physical harm and even allowing staff to record examples of "good care." That last feature may sound minor, but it represents a profound shift. Instead of only documenting what went wrong, staff can now share what went right. This is a deliberate counterweight to the culture of blame that discouraged reporting in the past, and an early step towards what NHS England calls a "just culture."

Technically, the difference is equally significant. LFPSE has been built on an API-first design, replacing batch uploads with real-time submissions. Machine learning is already being used to anonymise free-text reports, reducing the burden on local teams and enabling safer sharing of data.

Early Results Are Encouraging

Between January and March 2025, LFPSE recorded 833,136 events, a 7% increase on the previous quarter. Of those incidents, 64% resulted in no harm. Growth has been particularly strong in community and mental health services, which suggests staff are increasingly confident about logging near misses and low-harm events.

That shift matters: a healthy reporting culture is measured not just by the serious incidents captured, but by the willingness to report problems before they escalate.

Part 2: Technical and Operational Realities

From a CTO's perspective, the promise of LFPSE is its technical architecture. NRLS relied on manual, batch-based reporting. LFPSE offers real-time, API-driven integration. Success now depends on how well it is embedded into Local Risk Management Systems (LRMS). Vendors are rolling out accredited LFPSE-compliant systems — Radar Healthcare is one early mover — but the role of the Trust CTO is to hold suppliers to account. An LRMS should not just "submit" to LFPSE, but also pull feedback back in, enriching local dashboards and governance packs.

Interoperability is another crucial point. While LFPSE's specification is not formally FHIR, it follows similar principles of structured, machine-readable data. That alignment matters. If treated simply as a silo, LFPSE risks being another reporting obligation. But if treated as a data service, it can be linked with rostering, prescribing, and even workforce systems. Imagine connecting incident data about fatigue with e-rostering patterns, or linking medication safety events with prescribing workflows. That is how LFPSE moves from compliance to real system learning.

Part 3: The Human Factor

The biggest barrier, however, is cultural. Staff often describe reporting as long-winded and unrewarding — "a faff," as one clinician put it. Without better user experience, we risk perpetuating that perception.

More damaging still is the "black hole" problem: staff submit reports but never hear what happened next. Unless Trust leadership actively demonstrates how LFPSE reports are used — through dashboards, governance meetings, and transparent feedback — staff engagement will plateau. The technology provides the tools, but it is leadership that must close the loop.

This is where CTOs need to work in lockstep with Chief Medical Officers and governance teams. Simply implementing the feed is not enough; staff need to see visible impact. That requires investment in training, change management, and communication.

Part 4: Strategic and Financial Implications

LFPSE is more than an IT programme. It is a central plank of the NHS Patient Safety Strategy. National estimates suggest the service could help:

For a large Trust, the value lies not only in improved safety but in reduced exposure to clinical risk and litigation.

Conclusion: What Good Looks Like

For boards and executive teams, the message is clear. LFPSE is mandatory, but it also represents a foundation for something larger.

Key Recommendations

Handled poorly, LFPSE will be just another reporting obligation. Handled well, it will become the backbone of a culture of learning that makes patient care safer and more sustainable.

Further Reading