Yesterday’s report, ordered by Prime Minister David Cameron, stopped short of recommending minimum staffing levels in the NHS.
But it called for a review so wards were never too short of staff to care for patients.
Ministers welcomed the recommendations although critics demanded urgent action to tackle problems already identified by the Francis review into the Mid Staffordshire scandal.
The report by US expert Prof Don Berwick set out measures including criminal sanctions for staff who wilfully neglect patients.
It called for supervisory regimes and regulation in the NHS to be made simpler to “avoid diffusion of responsibility”, raising the prospect of another in a series of shake-ups in the field. It said continually improving patient safety should “permeate every action and level in the NHS”.
Prof Berwick said criminal sanctions should only be used rarely for a “very small number of cases”. Accidental errors would not be subject to prosecution but organisations that misled regulators or hid evidence would face the courts.
He added: “Most staff are trying to do their best. When things go wrong generally in a healthcare system, what’s going on is that staff are trying to do the right thing but the system is not supporting them to do that.”
He said “nothing will be more important than the voice of parents and carers”, urging the NHS to end any “tokenism” over listening to patients’ views.
In a key message, he reiterated calls for a review of staffing, including measures to allow NHS leaders to check they have the right numbers on their wards.
But Prof Berwick, who described the NHS as the envy of countries around the world, said staff ratios should not become enshrined in law as they would change over time.
His report said hospital bosses should take responsibility for ensuring clinical areas were adequately staffed to take account of varying levels of patient illness. It made no recommendations but pointed to research which suggested safety risks increased significantly on wards with fewer than one nurse per eight patients.
Health Secretary Jeremy Hunt welcomed the findings and said: “I want to get to a point where every patient has confidence that their care will be safe and where every member of NHS staff feels supported to make safe, high quality care the priority.”
Mr Hunt said the Government wanted to “act very quickly” but more work was needed on staff- to-patient ratios.
“If you set a target, everyone focuses on achieving that target and then once they’ve achieved it they heave a sigh of relief.
“But my worry is that if you start mandating things from the centre, you create an artificial target and hospitals and trusts say ‘well if we meet that national minimum we’ve done our job as far as staffing’s concerned’ when actually they haven’t because you’ll find there are places that need a lot more help and a lot more care.”
The Royal College of Physicians said an emphasis on staffing would “help the NHS cope with the increasing strain it is under due to the inexorable rise in emergency admissions, the increasing proportion of inpatients with dementia and comorbidities, poor continuity of care, out-of-hours care breakdown and a looming medical workforce crisis”.
But shadow health secretary Andy Burnham demanded urgent action. “All the experts are now telling the Government to get a grip on staffing levels,” he said. “The time for excuses is over. While Ministers dragged their feet, over 800 nursing jobs were lost last month alone – now totalling almost 5,000 since the election.”
Katherine Murphy, of the Patients’ Association, said the latest report into the NHS fell “far short of what is needed”.
“The endless number of reviews, and the constant navel gazing they inspire, has deflected attention from the key questions that should be dominating the mind of everyone that cares about the NHS,” she said.
“When will healthcare assistants be regulated? When will the complaints system be comprehensively overhauled? What practical action will be taken to ensure that the NHS, including primary care, is an open and transparent system in which individuals, as well as organisations, are held to account for their actions? Above all, when will all 290 recommendations made by Francis be implemented in full?”