Chapter 40. Freedom to Speak Up Guardians

Background

Sir Robert Francis explained in evidence that the reason for the 2015 Freedom to Speak Up Review, which he chaired, was:
“[T]here were … cases of about 20 healthcare staff who one way or the other … raised concerns of a wide variety of things … most were about patient safety, but some were about fraud or other issues, and all of these people having raised the concern had found themselves the subject of an investigation or adverse action of some shape or form.”¹

He considered that “the remedies available by way of employment law didn’t seem to protect anybody”.² In response to his report, the appointment of Freedom to Speak Up Guardians (FTSU Guardians) became part of the standard NHS contract in 2017.³ Whilst whistleblowing legal protections had been in place for some time, there was not a developed system of speaking up.

The National Guardian’s Office (NGO) came into being in 2016; it was a small organisation, with limited resources (16 staff) and limited powers. In a helpful written statement, Mr Charlie Cassell, Director of Operations and Strategy for the NGO, pointed out that it had neither the power nor resources to hold hospitals or other healthcare settings to account in respect of the raising of concerns/FTSU. He explained the ways in which the NGO might be expanded to good effect.⁴

The FTSU Guardian role and its challenges

In her written statement, Dr Jayne Chidgey-Clark, National Guardian for the NHS (September 2021 to December 2021), summarised the FTSU Guardian role thus:
“Freedom to Speak Up guardians work alongside trust leadership teams to ensure all staff have the capability to speak up effectively and are supported appropriately. They work to ensure that speaking up processes are effective, continuously improved and that safety and quality are assured as a result. They also engage their Boards in all freedom to speak up matters and issues that are raised so that a culture of speaking up, listening up and following up, is instilled throughout the organisation and the NHS.”
According to the most recent annual data report from the NGO – published in May 2026 and reporting on the period 1 April 2025 to 31 March 2026 – the number of FTSU Guardians serving in various organisations had risen to 1,519.⁵
Until very recently, all FTSU Guardians were appointed by hospital Trusts from within their existing staff. There was no central funding, and the role was in addition to their existing role (which could be anywhere in the hospital, clinical or otherwise). Trusts also appoint executive and non-executive leads for Speaking Up. The NGO’s website (as of June 2026) said that some Trusts are now appointing full-time FTSU Guardians;⁶ but no numbers are given, and I infer that this has happened in a small minority of large Trusts. Ms Helené Donnelly OBE, Ambassador for Cultural Change and Lead Freedom to Speak Up Guardian for the Midlands Partnership Foundation NHS Trust from 2013 to 2022, said that FTSU Guardians were busy members of mid-level management. She thought the amount of time they had ring-fenced for their FTSU duties was unclear.⁷ Mr Cassell’s evidence mirrors that of Ms Donnelly, Ms Raphael (Director of Protect) and Mr Stuart Lythgoe (Director of Operations for the Hospital Consultants and Specialists Association): “Unfortunately, there is variation in how the guardian role is implemented with evidence that many guardians do not have enough protected/ring fenced time to carry out their roles effectively.”⁸
The NGO did not investigate individual cases, nor did it audit the work of individual Guardians. Rather, it provided well-regarded mandatory training;⁹ offered support calls to guardians; collected anonymised data from guardians, every quarter, about the cases dealt with; and offered board/trustee development sessions for leaders. Ms Donnelly explained that there are three tiers of FTSU training – the first for all workers, the second for those with any leadership and management responsibility, and the third for senior leaders, including executives at board level and non-executives. Her experience was that most Trusts had mandated the first tier, some the second tier, but none all three.¹⁰ She was aware that some senior leaders asked their assistants to click through the FTSU e-learning materials.¹¹ I assume this is a small minority of senior leaders. Its effect is to undermine the importance of the FTSU system.
Professor Dixon-Woods said in evidence that there was significant variability in how well Trusts operated their FTSU Guardian system. She explained that in an organisation lacking the right culture at senior level, the introduction of a FTSU Guardian is treated as a box-ticking exercise, the thinking being: “We need to ensure we’ve got one, we need to send in a report every year.”¹² In other hospitals with a “highly open, learning committed culture, they would have put a lot of effort into finding the right person, briefing them and … providing them with the resources that they need and encouraging staff to come forward rather than treating it as literally yet another duty”.¹³ Evidence from Ms Donnelly¹⁴ and Mr Lythgoe confirmed the reality on the ground. Mr Lythgoe said that the Hospital Consultants and Specialists Association’s advice to a doctor with a concern would depend on which hospital they worked for.¹⁵ The move towards less national oversight, with the abolition of the NGO, is worrying in this context (see below).
Professor Bowers KC had a similar impression:
“I think there is a feeling that some Trusts have excellent Speak Up Guardians who are dedicated to the role and are sympathetic and have sufficient time to devote to it. But in some it’s really just another role on top of busy, busy roles that they are conducting anyway and there’s no, as I understand it, job description or standardisation of what they should do.
So I think the answer is that in some Trusts it works well, with some dedicated people. In others, it works less well.”¹⁶
Ms Donnelly’s view, from her wide experience, was that many FTSU Guardians, and others, still do not feel able to speak up because there is often a culture of “toxic negativity” towards somebody who speaks up. She explained that with “an absolutely overstretched National Health Service where everybody is firefighting, everybody is under pressure”, and therefore executives do not look kindly on members of staff bringing additional problems to them.¹⁷ She pointed to the problem of a “ripple effect” – when a concern is known not to have been dealt with, others, who would otherwise have raised a concern themselves, stay silent.¹⁸
The 2025 NHS Staff Survey showed a concerning decline in workers’ confidence in speaking up, with the FTSU sub-score falling to a five-year low of 6.37 (down from 6.45 in 2024).¹⁹ It was the view of Mr Lythgoe that the majority of hospital doctors did not feel it was possible to raise patient safety concerns without experiencing a detrimental effect on their careers. He pointed to the results of a survey carried out by the Hospital Consultants and Specialists Association in 2023, where 70% of the 526 respondents expressed that view.²⁰ The detriments reported included the threat of referral to a regulator and the threat of disciplinary proceedings.²¹ This occurred at the Countess.
The experience of the Hospital Consultants and Specialists Association is that the GMC referrals lead to lengthy delays, and the GMC does not often investigate a complaint that a referral was made vexatiously. The disciplinary proceedings often take the form of action under the Maintaining High Professional Standards framework, but the process is slow, leading to “inordinate delay” and loss of skills.²² Investigations against doctors often themselves create problems of isolation or division within departments, and such divisions can then be a pretext for dismissal under the “some other substantial reason” provision in the Employment Rights Act 1996 (section 98(1)(b)).²³
Ms Raphael’s view was that whilst policies were all very good, there was a lack of accountability for dealing with whistleblowing at senior management level.²⁴ I addressed this question when dealing with the duty of candour (see Chapter 38). Ms Raphael also pointed to the absence of accountability at regulator level: “[A]lthough there are a plethora of regulators in the health sector, there doesn’t seem to be a single regulator that’s actually focused on punishing those who silence whistleblowers.”²⁵ The number of regulators was commented on by a number of Inquiry witnesses, and I have dealt with this elsewhere. As to accountability for punishing whistleblowers, I return to this below.
Ms Donnelly’s view was that a wish to protect the reputation of the organisation often led to concerns not being addressed. She was critical of the lack of transparency around the outcomes of investigations – for example, that even where a finding of bullying was made, this was often not disclosed. Similarly, where an allegation of bullying was dismissed, this outcome was often not shared.²⁶
Ms Raphael gave powerful evidence of active victimisation of whistleblowers by the malicious overuse of the Datix system.²⁷
On 30 June 2025, as a result of Dr Dash’s Review of Patient Safety Across the Health and Care Landscape (the Dash Review), for DHSC, it was announced that the NGO would be closed at the end of June 2026 and its functions transferred to NHS England – whose own abolition had been announced three months earlier.²⁸ A letter dated 13 August 2025 was published on the NGO’s website and signed on behalf of NHS England, DHSC and the interim Director of Operations at the NGO. It sought to give reassurance that FTSU and the role of FTSU Guardians would be incorporated into the NHS Standard Contract for 2026/27; and expressed a commitment to the national support of, and guidance for, FTSU Guardians.²⁹
In April 2026, NHS England updated their website to confirm that, from 1 July 2026, NHS England would take over delivering “some activities previously undertaken by the National Guardian’s Office” and “trusts, primary care organisations, ICBs and independent providers will be taking on greater responsibility and accountability for embedding effective Freedom to Speak Up arrangements”.³⁰ There is no comment on what will happen when NHS England is abolished.
FTSU Guardians should be properly supported and trained. The NGO provided confidential one-to-one support and access to a national employee assistance programme specifically for Guardians. From abolition, Trusts and other organisations are to ensure there is independent psychological support available locally to their Guardian. Guardians can contact the NHS England Contact Centre with general enquiries and request specialist one-to-one support. This contact centre is the same “whistleblowing hotline” that only one Trust mentioned in response to the questionnaire that the Inquiry conducted (see Appendix 2), suggesting limitations in its efficacy.³¹
A key change is training. Refresher training will no longer be mandatory, and the future of board-level training is unclear. The NGO previously monitored compliance with training; this will now be done locally. In 2025/26, the NGO “stepped down 304 guardians who informed us they are no longer in the guardian role or who were non-compliant with training requirements”.³² Without an organisation to oversee national compliance, upholding standards may not happen. It could add to local variation, which I discuss below.³³
Guardian networks and Guardian mentors have been a feature of the FTSU system. Ms Donnelly told the Inquiry: “[T]he national and regional Freedom to Speak Up Guardian networks provide a safe space for Guardians to gain peer support and advice, to learn and share best practice.”³⁴ The NGO said these networks are “a cornerstone of professional connection, offering trusted and confidential spaces for guardians to share experiences, seek advice, and navigate complex or sensitive cases. They play a critical role in upholding guardian well-being, reducing isolation, and promoting reassurance, reflective practice and mutual learning.”³⁵ The NGO helped to coordinate these networks and the mentoring scheme.
Mentors were introduced in the summer of 2022. They are “experienced guardians who help newly appointed Freedom to Speak Up guardians reflect on their experience, helping them to identify any learning and support needs through discussion and guidance as they progress in their role”.³⁶ Quarterly mentor meetings were facilitated by the NGO. NHS England’s FTSU team and regional teams are now to take over network support. Any loss of national support needs is not acceptable. NHS England’s position is that “[n]ew guardians will be able to access mentors through the NHS England training platform”.³⁷ These new arrangements do not provide reassurance that Guardians will be adequately trained and supported.
With the abolition of the NGO, quarterly data collections are being handled through NHS England’s national data process, and only cover NHS Trusts, Foundation Trusts and ICBs – not primary care and independent healthcare organisations.
As recommended in the Dash Review, under the new arrangements: “The CQC will now verify guardian arrangements in NHS trusts through their Well-led inspections.”³⁸ However, the plans for this are still to be confirmed, with NHS England stating it will “continue to liaise with the CQC on how compliance will be assessed within the Well-led inspection regime”.³⁹ That this is not already determined is concerning. See below.

Investigations

Ms Donnelly informed the Inquiry that HR departments, which should investigate concerns raised with, and then by, FTSU Guardians, frequently make poor decisions, such as appointing investigators who are “known to be good friends with the person they are investigating or have worked very closely with them”.⁴⁰ What happened at the Countess was an example of an analogous situation, where neither investigator nor chair of the panel should have been appointed to deal with Letby’s grievance. Ms Donnelly also pointed out the problem of busy managers being tasked with undertaking complex investigations when they lacked the training to do so. This leads to poor-quality investigations and detriment of the core role of the FTSU Guardian. Ms Donnelly suggested creating a central pool of investigators to deal with anything above low-level matters.⁴¹ This echoed the evidence and views of Dr Benneyworth (see Chapter 43).

Scotland

Scotland has a different system for whistleblowing. There is a central body – the Independent National Whistleblowing Officer (INWO) – which has the power to investigate whistleblowing concerns in healthcare. Ms Rosemary Agnew is the current Scottish Public Services Ombudsman, which office, since 2021, includes the INWO. The INWO sets standards that NHS Scotland healthcare providers are expected to follow in handling whistleblowing concerns.⁴²
Importantly, the INWO has the following power:
“As the final stage of the whistleblowing process, I can consider all action taken in the NHS organisation’s investigation and their response to the concern. This includes any decisions made about the substantive matter [emphasis added] (not just the handling of the concern), and can consider any clinical judgement made or relied upon. The INWO is given explicit powers to comment on (speak up) culture and whether there has been any detriment to any individual.”⁴³

In other words, the role of the INWO is not just about process; it can also be about substance.

The INWO also runs “monitored referrals”. As Ms Agnew explained:
“A monitored referral is where the INWO, with the whistleblower’s consent, refers the concern [raised] to the NHS organisation on their behalf …
…
The benefits of this approach are that it gives whistleblowers the reassurance that the INWO is aware of the issue; and it puts the NHS organisation on notice that the INWO is aware of the issue. It also highlights for both parties that advice and support is available.
I have made about 19 monitored referrals in total. With such small numbers, it is difficult to draw definitive conclusions, but one indicator of effectiveness is that, so [far], only a small proportion of these have come back to the INWO for further investigation.”⁴⁴
The INWO has a statutory power to disclose information to appropriate bodies, including to the police and regulators, if there is a threat to the health or safety of a person or persons.⁴⁵

Effectiveness of the INWO

Ms Donnelly said that she had spoken to individuals who had worked within the INWO system and escalated concerns to it, and that, while this system was not perfect, it had “real bonuses to it”.⁴⁶ Mr Lythgoe’s experience was that it had led to an improvement of the situation in Scotland.⁴⁷ Ms Raphael said that Protect was involved in drafting the INWO’s standards, and her view was that the INWO was a good system because (a) it had the power to tell hospital boards to investigate concerns, and (b) its standards, in terms of expectations about how concerns should be addressed, were more specific than the standards that applied in England.⁴⁸
Ms Agnew felt that “significant and genuine progress has been made across Scotland”.⁴⁹ She noted that survey data showed that 79% of NHS Scotland staff said they were confident to speak up, and that 74% were confident that concerns would be followed up.⁵⁰ She reflected that placing whistleblowing within the remit of the Scottish Ombudsman has had distinct benefits, and that: “The underlying learning from this, is that there may be benefit to leveraging impact by strengthening what exists and building on experience already gained.”⁵¹

Externally employed FTSU Guardians?

Mr Cassell’s view echoed that of Sir Robert Francis: “Guardians who work within the organisation they support are close to where care is delivered and the people who deliver it. They understand local culture and can build trust. However, managing confidentiality and real or perceived conflicts of interest can be challenging.”⁵²
I accept the argument against making Guardians external to Trusts. When part of the hospital or other healthcare setting, Guardians are easier to contact, know the local conditions, and are able easily to contact those who need to be aware of the concerns. Hospitals and other settings ought to be encouraging of, and responsible for, the effectiveness of FTSU Guardians. Outsourcing effectiveness and responsibility for such an important function would be unwise.

An INWO for England?

Sir Rob Behrens, who was the Parliamentary and Health Service Ombudsman between April 2017 and March 2024, persuasively argued for the inclusion of an equivalent to the INWO within England’s Ombudsman:
“[O]ne of the great ironies, lamentable ironies, is that the UK Ombudsman does not have the powers of the devolved Ombudsman that were created in the United Kingdom fairly recently.
So the Northern Irish and the Welsh public service Ombudsman have the power of own initiative but we don’t.
And in Scotland, the law has been changed so that the Ombudsman is the body to which people who want to blow the whistle can go and get advice about what to do in these difficult circumstances. And … that’s not perfect, but it means there is a public body that people can go to to raise their concerns and feel supported.”⁵³
Sir Robert Francis agreed that there should be a central body to which people could turn, in addition to local Guardians:
“I would use it as something alongside your Freedom to Speak Up policy. We have talked about guardians and I am very keen on everywhere having guardians. But there is also a place for having an external agency to which people can go entirely confidentially.
One would like to think that the regulator would be sufficient but it may not be … and if one is talking about sensitive issues whether they be crime as in harm to patients or sexual misconduct and harassment and bullying, all of that would benefit from having an external place that you can go to, either anonymously or not[,] to record your issue.
I would like to think that it needs to be an outsourced place which has a clinical and professional understanding and expertise within it.”⁵⁴
As I have set out, Sir Rob Behrens gave evidence that the integration of the INWO within the Scottish Public Services Ombudsman seems to work very well, and he cautioned against a further flourishing of regulatory bodies in healthcare.⁵⁵
Acknowledging that the NGO has been abolished I recommend that its functions to support FTSU Guardians should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman’s powers must be increased to include (a) investigating complaints that whistleblowing in the NHS has not been dealt with adequately, and (b) assisting whistleblowers by referring their concerns to the relevant NHS bodies and overseeing the response.
This will increase the degree of independent oversight over the handling of whistleblowing in the NHS, whilst simplifying (or, at least, not further complicating), the regulatory matrix in the health service.

The Dash Review

As set out above, Dr Dash, in her review, in recommending the abolition of the NGO pointed out that its role is partly to build a network of FTSU Guardians and partly to provide a national voice and leadership. The first part had broadly been achieved (see above). It is not clear where the national voice and leadership is to come from. Dr Dash says that “clear routes for staff to escalate concerns have been set out by government” and so it “is not clear that there is a need for an independent oversight body”.⁵⁶ What seems to have been overlooked is that whatever issues are raised by the FTSU Guardian there is no requirement on hospitals to act upon concerns. Some do take action, and do so effectively. Many of them do not. I have dealt with this issue in Chapter 38.
Dr Dash considered that placing the responsibility for FTSU Guardians firmly within the responsibilities of commissioners and providers would raise the profile and importance of staff voices and allow for a more rapid response. This system is now in place. This seems to me rather optimistic, given that, even after ten years, Ms Donnelly was still pointing to failings within the system.⁵⁷
Dr Dash acknowledges that there will still be a need to ensure a level of independence to support FTSU functions. In many organisations, this role is played by a senior non-executive director, and these arrangements should continue, according to Dr Dash. She recommends that ensuring that these functions are happening in all commissioners and providers should be a core function of CQC as the independent regulator of health and care. This is also being acted upon.
Two things arise from this. First, I am confident that the level of competence of the CQC teams would need significant strengthening before CQC can be given another core function, particularly one of such sensitivity. Second, ensuring that the functions are happening amounts to no more than checking there is a process. It is likely that this will be another box-ticking exercise, as seen at the time of the inspection of the Countess in February 2016. It does not grapple with the substance of the concerns.
Dr Dash points to other industries’ mechanisms that encourage and enable employees to raise concerns, which are of a wholly different order from those I have described in this Report so far. The Civil Aviation Authority and the maritime industry fund the Confidential Human Factors Incident Reporting Programme (CHIRP), where anyone working in these industries can raise safety concerns in confidence.⁵⁸ A similar organisation, CIRAS (Confidential Incident Reporting and Analysis Service), operates a ‘Confidential Safety Hotline’ that serves the transport sector, including rail, buses, highways, ports and transport supply chains.⁵⁹ These examples support the view that an external body is necessary to allow the effective escalation of concerns and to enable action being taken. An important point is that these examples are properly funded by their respective industries and are acknowledged to be essential.

Conclusions

Like Sir Robert Francis and several other witnesses at the Inquiry (Ms Donnelly, Sir Rob Behrens, Mr Cassell), and notwithstanding the abolition of the NGO, I am quite sure that an external structure with national reach is still necessary. The Parliamentary and Health Service Ombudsman is ideally placed to carry out this work. It would require appropriate funding. Another, probably more expensive, approach would be to set up a structure along the lines of the successful Scottish INWO model.
I firmly recommend that FTSU Guardians remain in place; that their work – and the responses to it by the hospitals/other healthcare settings – is properly monitored and reported upon; and, importantly, that there is an external body with powers to act, to whom FTSU Guardians and others may go when they have serious concerns that are not being dealt with by the hospital or healthcare organisation. It is to be expected that the number of such referrals will be small, as all hospitals develop a positive approach to raising concerns and acting upon them. But an external, independent body of the type I have described is essential.