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New patient safety research by Northumbria University achieves global accolades

Looking to improve practice through learning

Errors, mishaps and misunderstandings are surprisingly common in medicine and around one in 10 patients suffer avoidable harm, impacting on patients, their families, health care organisations, staff and students. However a research project seeking to improve patient safety across Europe, led by Newcastle-based Northumbria University, has received international acclaim as it looks to improve practice through learning.

The SLIPPS (Shared Learning from Practice to improve Patient Safety) project is Co-funded by the Erasmus+ Programme of the European Union, and is led by Professor Alison Steven, a Reader in Health Professions Education at Northumbria University.  Professor Steven has a longstanding interest in the use of education to raise standards of care and ensure patient safety. Considering the rapid spread of Covid 19, she says improving patient safety and standards of care across Europe and beyond, has never been more important.

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New patient safety chief revealed

A management coach and adviser to the Care Quality Commission has been appointed as the new ‘national guardian’ for the ’freedom to speak up’ programme.

Jayne Chidgey-Clark will take up her new role on 1 December. The national guardian’s office leads, trains and supports the network of over 700 freedom to speak up guardians in England, as well as providing “challenge and learning to the healthcare system”.

Ms Chidgey-Clark, a registered nurse, has served as a specialist adviser to the CQC since 2017. She has run her own coaching, consultancy and interim management business since 2009. She was a clincial adviser to NHS England’s new care models programme for three years until 2018 and the director of the end of life care modernisation project at Guy’s and St Thomas’ Foundation Trust between 2008 and 2011.

Her appointment comes after Henrietta Hughes announced in June she was stepping down from the role after five years.

Ms Chidgey-Clark, who is the third appointee to the position, said: “I feel excited and privileged to have been appointed as the new National Guardian for the NHS. I am passionate about, and committed to, making a real difference in people’s lives through the planning and delivery of the highest quality, effective care with excellent outcomes for people who use our health services, and their families.”

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Source: HSJ, 11 November 2021

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New partnership to improve patient safety in South East London ICS

Guy’s and St Thomas’ NHS Foundation Trust will work with Omnicell to develop a European technology-enabled inventory optimisation and intelligence service which will be initially implemented across South East London Integrated Care System (ICS). This partnership will encompass all six acute hospital sites within the South East London ICS, including Guy’s & St Thomas’, Kings College Hospital NHS Foundation Trust and Lewisham & Greenwich NHS Trust.

The project will have the following goals:

  • Develop analytics and reporting tools with a goal of improving patient safety, achieving increased operational efficiency and cost efficiencies
  • Utilize the analytics and reporting tools with a goal of achieving agreed efficiencies and cost reductions
  • Demonstrate the impact of managing clinical supplies and medicine spend together at scale
  • Build a service model for the ICS which can be scaled up and adopted by other hospital groups in the UK

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New panel will oversee NHS competition regime, DHSC decides

The government will set up an independent panel to oversee disputes arising from decisions made under a new provider selection regime, it said today.

The new panel should “help ensure that… procurement processes are transparent, fair and propionate, enabling all providers to compete for contracts” and “are not unfairly excluded from offering services to patients and service users”, the Department of Health and Social Care said in a response to its consultation on the new rules governing the commissioning of healthcare services.

The intent is to move the NHS away from always putting new contracts out to competitive tender and “towards collaboration across the health and care system”, the document says. 

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Source: HSJ, 14 July 2023

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New online GP access rules already risking patient harm, practices warn

New rules that force general practices in England to accept online queries from patients during core working hours are already risking harm to patients and increasing GPs’ workload and stress, a survey indicates.

More than half (55%) of general practices polled in a BMA survey said online consultations were having a negative effect on patient care.

Some 1341 practices responded to the survey, around 22% of England’s total number. Together, those practices represent almost 14 million registered patients.

The Department of Health and Social Care dismissed the data, saying the survey involved a “small minority of GP practices” and did not reflect the national picture.

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Source: BMJ (20 November 2025)

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New observatory will set out actions to tackle racism “within months,” say campaigners

The architects behind the new NHS Race and Health Observatory have vowed that it will deliver actionable recommendations within months to tackle the structural racism that exists throughout healthcare.

Victor Adebowale and Mala Rao called for an observatory to tackle the ethnic health inequalities in the UK in a special issue of The BMJ that they co-edited in February (bmj.com/racism-in-medicine) and NHS England confirmed at the end of the May that the centre would go ahead.

Speaking at a meeting to discuss the aims of the observatory on 12 June, Adebowlae told more than 20 assembled stakeholders that he wanted the new centre “to fire on all cylinders,” making recommendations for changes to services that are likely to affect the health outcomes of people from black and ethnic minority backgrounds “within a couple of months.”

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Source: BMJ, 15 June 2020

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New NHSE chair seeks ‘clear accountability and responsibility’

The author of a major report into quality and governance in the NHS has stressed the responsibility of local boards – and hinted at a rebalancing from regulators to providers.

Penny Dash – who on Monday was confirmed as the new chair of NHS England – told a patient safety conference that accountability and responsibility for delivery were much clearer in many other industries.

“It is not like this in other industries,” she said. “They have very clear lines of accountability and responsibility, particularly through boards. It is usually much clearer who is responsible for delivering and who is responsible for regulating. That does not just stop at the board but throughout the organisation. It’s very clear what people’s jobs are.”

Dr Dash completed a review of the Care Quality Commission last year, and a second review covering wider quality and safety oversight is expected within the next three weeks.

Dr Dash told the HSJ podcast last month that her review would emphasise the role of boards, and that quality should encompass productivity and efficiency as well as safety and effectiveness, messages she also addressed at the Patient Safety Forum conference, organised by Public Policy Projects with Patient Safety Learning.

She said: “We know that well-managed services lead to more efficient use of resources – that in itself is a big quality opportunity. We can actually do things for less that frees up money for more care.”

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Source: HSJ, 4 March 2025

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New NHS training launched as dementia rates increase among Asian and Black people

Healthcare leaders are rolling out new NHS training to help speed up dementia diagnoses among Black and Asian people following criticism about a lack of support for patients from minoritised communities, The Independent has revealed.

An awareness campaign is being launched in England to help those from ethnic minority communities receive a prompt diagnosis and get the support they need at the earliest opportunity.

The announcement follows a critical report which found that thousands of south Asian people with dementia are being failed by “outdated health services designed for white British patients”.

Dr Bola Owolabi, director of the Healthcare Inequalities Improvement programme at NHS England, said: “The pandemic put a greater spotlight on longstanding health inequalities experienced by different groups across the country.

“While there are many factors involved, the NHS is playing its part in narrowing the gap and ensuring equitable access to services through taking targeted action where needed to improve outcomes."

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Source: The Independent, 21 May 2023

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New NHS programme to reduce brain injury in childbirth 

Expectant mothers will receive safer maternity care as a new NHS programme to help prevent brain injury during childbirth is rolled out across the country. 

The Avoiding Brain Injury in Childbirth (ABC) programme will help maternity staff to better identify signs that the baby is in distress during labour so they can act quickly.

It will also help staff respond more effectively to obstetric emergencies, such as where the baby’s head becomes lodged deep in the mother’s pelvis during a caesarean birth.

The government programme, which will begin from September and follows an extensive development phase and pilot scheme, will reduce the number of avoidable brain injuries during childbirth – helping to prevent lifelong conditions like cerebral palsy.

The national rollout is only one step the government is taking to improve maternity services under its Plan for Change to fix the health service, as it reforms the NHS to ensure all women receive safe, personalised and compassionate care.   

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Source: Department of Health and Social Care, 12 May 2025

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New NHS probe into spinal surgeon's care

Hundreds of patients treated by a spinal surgeon who was found to have caused them serious harm could have their cases reviewed.

NHS England has confirmed it will look back into two hospital reviews into John Bradley Williamson, who worked at Salford Royal Hospital and the Royal Manchester Children's Hospital from 1991 to 2015.

It comes after former patients, who said they had experienced problems linked to his surgery, said they believed the previous reviews were too limited.

Mr Williamson said he has "always strived to provide the very best care for patients" and would cooperate with any patient care investigation.

A report into the surgeon's care between 2009 and 2014 found he had caused "severe harm" to seven patients at Salford Royal Hospital. Some screws were poorly placed, and some patients suffered heavy blood loss, the report found.

One former patient, treated by Mr Williamson when she was 11, said she had been living in "agony" after the surgery at the former Pendlebury Children's Hospital, now Royal Manchester Children's Hospital.

Campaigners, including the sister of a teenager who died during spinal surgery by Mr Williamson, have called for a full recall of all patients on whom the surgeon operated.

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Source: BBC News, 24 April 2025

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New NHS plan to help patients avoid long hospital stays

Action to help tens of thousands more people avoid lengthy spells in hospital is being rolled out nationwide as part of the NHS Long Term Plan.

NHS doctors, nurses and other staff are being encouraged to ask themselves ‘Why not home? Why not today?’ when planning care for patients recovering from an operation or illness, as part of a campaign – called ‘Where Best Next?’ – which aims to see around 140,000 people every year spared a hospital stay of three weeks or more.

The campaign will see posters and other information placed in hospitals aimed at different staff groups, encouraging them to take practical steps every day to help get patients closer to a safe discharge – whether to their own home or a more suitable alternative in the community.

Dr Taj Hassan, President of the Royal College of Emergency Medicine, said: “The ‘Why not home? Why not today?’ campaign is really important in helping staff to make sure patients are discharged promptly if it is medically appropriate... A greater length of stay increases the risk of hospital acquired infections and further illness. We know that extended stays in a hospital bed can lead to significant muscle loss, particularly in older people, so ensuring that patients do not stay any longer than they need really is vital."

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Source: NHS England, 19 August 2019

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New NHS online hospital to focus on eyes, menopause and prostates

The new NHS online hospital service being launched in England next year will initially focus on menopause, prostate and eye conditions.

The NHS has selected nine different conditions in total for the service which will be available through the NHS app in 2027.

The service, which was first announced in September, will allow patients to have assessments, check-ups and follow-up appointments online and will have its own dedicated team of doctors.

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Source: BBC News, 6 January 2026

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New NHS model needed for adoption of innovative medical devices

The system for introducing new medical technologies into the NHS remains complex, crowded, and difficult to manage, according to a new report by the Medical Technology Group (MTG).

The paper also calls for innovative treatments with medical devices to be given the same support as new pharmaceutical medicines.

Current NHS mechanisms to support the uptake and use of innovative technology are severely limited in scope and are focused on ‘picking winners’ rather than the broad system-wide adoption of new technology, the report states.

It points to the Accelerated Access Pathway, for instance, which supports fewer than 10 technologies each year; and the lack of a clear mechanism to support the widespread uptake of innovative products across the NHS.

And the absence of a broad, national commissioning policy means patients sometimes miss out on the benefits of established technology due to a regional variation in access.

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Source: BBH, 24 March 2021

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New NHS long COVID service for children

NHS England are set to launch a new service for children suffering from long COVID.

Although data has suggested that children are less likely to suffer from severe disease, there have been an increasing number of reports of continued symptoms. 

The new service will consist of 15 new paediatric hubs with experts to treat young people and advise their families and carers or refer them to specialist services. 

The NHS has invested £100m in specialist services to help meet the needs of the possible hundreds of thousands who are expected to experience long COVID with symptoms ranging from breathing difficulties to fatigue.

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Source: Sky News, 15 June 2021

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New NHS genetic testing service ‘could save thousands of children’ in England

Very sick babies and children will be diagnosed and start treatment more quickly thanks to a “revolutionary” new genetic testing service being launched by the NHS.

Doctors will gain vital insights within as little as two days into what illnesses more than 1,000 newborns and infants a year in England have from the rapid analysis of blood tests.

Until now, when doctors suspected a genetic disorder, such tests have sometimes taken weeks as they had to be done in a sequential order to rule out other possible diagnoses, delaying treatment.

NHS England bosses say the service could save the lives of thousands of seriously ill children over time and will usher in “a new era of genomic medicine”.

The clinical scientists, genetic technologists and bioinformaticians will carry out much faster processing of DNA samples, including saliva and other tissue samples as well as blood. They will share their findings with medical teams and patients’ families.

“This global first is an incredible moment for the NHS and will be revolutionary in helping us to rapidly diagnose the illnesses of thousands of seriously ill children and babies, saving countless lives in the years to come,” said Amanda Pritchard, NHS England’s chief executive.

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Source: The Guardian, 12 October 2022

Further hub reading

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New national investigation looks at outpatient appointments after hospital stays

The Healthcare and Safety Investigation Branch (HSIB) started a new national investigation looking into a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient hospital stay.

If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment.

The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.

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Source: HSIB, 20 December 2019

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New national incident reporting system delayed amid fears of patient safety ‘disaster’

The deadline for the NHS to move to a new system for safety incident reporting has been delayed after widespread concerns the rollout could be a ‘disaster’.

A memo from NHS England to local teams yesterday, seen by HSJ, says the deadline to transition to the new “learning from patient safety events” database has been pushed back by six months to September 2023.

The creation of LFPSE is a key strand of NHSE’s safety strategy, along with the overhaul of how serious incidents are investigated. It aims to make it easier for staff across all healthcare settings to record safety events, as the service will be expanded to include primary care.

It will replace the current national reporting and learning system, a central database created in 2003 to help identify trends and maximise learning from mistakes. The new system is part of a national strategy that pledges to save 1,000 extra lives and £100m in care costs each year from 2023-24.

Multiple patient safety managers at local trusts had raised concerns to HSJ about the previous March deadline, with one patient safety lead saying it would have been a “disaster” if enforced.

Helen Hughes, chief executive of charity Patient Safety Learning, said NHSE also needs to change its way of working, as well as the deadline extension. She said:

“We believe that NHS England needs to seriously reconsider their approach to engaging with trust leaders and staff on this issue, so that improvements can be made to the new LFPSE service to ensure it has the best possible chance of success, and to enable patient safety improvement.”

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Source: HSJ, 20 October 2022

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New national deadline to eliminate two-year waiters

NHS England has issued a new deadline to treat patients who have been waiting more than two years for treatment, a month after saying it had ‘virtually eliminated’ the longest waits, it has emerged.

The goal of no-one waiting more than 104 weeks for treatment by July this year was one of the first milestones in the elective recovery plan hammered out between NHSE and ministers.

They were not eliminated by the end of July, but the number was reduced to 3,000, having stood at 22,000 in January.

The remaining group consisted of nearly 1,600 patients who had been offered faster treatment elsewhere but did not want to travel, 1,000 who required complex treatment and could not be transferred to another provider and 168 who were not treated by the deadline, according to information issued in the summer by NHSE.

Now integrated care systems have been told there is a new “national expectation” to treat the remaining, final two-year waiters by the end of September. HSJ was told the goal has been framed as an ambition rather than a target because it includes patients who have chosen to wait longer.

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Source: HSJ, 21 September 2022

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New Naloxone campaign tries to reduce deaths from drug overdoses

A new campaign to increase awareness of life-saving treatment that can reverse drug overdoses has been launched in Scotland.

The Scottish government and Scottish Drugs Forum (SDF) have joined together to help improve information about naloxone which can prevent deaths in the case of opioids overdoses.

Drugs policy minister Angela Constance said: “Firstly, on International Overdose Awareness Day I want to pass on my sincere condolences to all those who have been affected by a drug-related death. That is why I am pleased to launch this joint campaign with Scottish Drugs Forum to encourage the public to get involved in our national mission and equip themselves to save a life."

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Source: The Independent, 31 August 2021

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New mum says maternity treatment was 'humiliating'

More than 250 people have come together in a Facebook group to share stories of issues they have experienced with maternity care.

All of the women were treated at Oxford's John Radcliffe (JR) Hospital, which is run by Oxford University Hospitals NHS Foundation Trust (OUH).

Among them is Oria Malik, who told the BBC that following a "tough" labour her aftercare was "humiliating" and left her feeling "very vulnerable".

Ms Malik gave birth at the JR seven months ago, and said what began as a positive experience "quickly turned" after her pain levels were ignored.

"I just felt really isolated because I couldn't communicate to anyone how much pain I was in," Ms Malik said.

"I told the midwife that I felt the need to push at 7am, and she said 'oh no, you're not in labour, you're fine' - but my body needed to push a baby out at that point."

While inserting a cannula into Ms Malik's arm following the birth, one nurse was "so rough" with her hand that she "ended up with a blood clot" in her vein that has "still not really healed".

Separately, Ms Malik said a maternity support worker consistently left the curtain open to her space on the ward.

She said: "There were people and families in the bed's opposite who could see me laying in a bed - I didn't have any clothes on."

"There was no privacy - I found it really humiliating and [it made me feel] very vulnerable."

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Source: BBC News, 24 February 2025

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New mothers more likely to die in UK than Scandinavia

Women are four times as likely to die after childbirth in Britain as in Scandinavian countries, a study published in the BMJ has found.

Researchers analysed data on the number of women who die because of complications during pregnancy in eight high-income European countries.

They found that Britain had the second-highest death rate, with one in 10,000 mothers dying within six weeks of giving birth, only slightly less than in Slovakia, the worst performing.

The study found that rates of “late” maternal death — when women die between six weeks and a year after giving birth — were nearly twice as high in Britain as in France, the only other country for which data was available. Heart problems and suicide were the main causes of death.

Professor Andrew Shennan, an obstetrician at King’s College London, said: “Any death relating to pregnancy is devastating. Equally shocking are the avoidable discrepancies in worldwide maternal mortality.

“Causes of [maternal] death are relatively consistent across the world, and largely avoidable. Most deaths are due to haemorrhage, sepsis and hypertensive disorders of pregnancy.

“In Europe, non-obstetric causes of death have become proportionately more common than obstetric causes, including deaths from cardiovascular disease (23%) and suicide (13%); these should be prioritised.”

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Source: The Times. 17 November 2022

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New mothers left alone and in pain as maternity crisis worsens

Unable to move and with her newborn baby crying out of reach, Neya Joshi was left alone for hours on an understaffed maternity ward and had to beg for a glass of water.

“It was awful, I was so helpless and so desperate, and no one was interested in helping me. I have never felt fear like it,” she said.

The medical copywriter, 30, was diagnosed with post-traumatic stress disorder months after giving birth to her son Arjun at Croydon University Hospital in May 2020 and had therapy for a year to recover from the trauma.

She is one of thousands of mothers across the country experiencing poorer care because maternity units lack enough staff.

Data from 122 NHS trusts in England shows maternity units were forced to shut their doors to women in labour more than 323 times in 2020-21, with units shut for a total of 16,294 hours, the equivalent of 679 days. When this happens women are forced to go to an alternative hospital to give birth. Staffing shortages were given as a reason in more than two-fifths of the closures.

Joshi saw first hand the impact of a lack of midwives when she was admitted to hospital to be induced after her waters broke at the height of the pandemic. Visiting restrictions meant she was alone on a ward for 24 hours and, despite being told she was a high priority, there were no free beds.

“After they had started the induction I was told someone would come and check me within six hours but no one came and I was just left on my own for hours,” she said. Eventually, after concerns over her baby’s heart rate, she had an emergency caesarean section but her husband was then made to leave an hour later.

“I was taken to the postnatal ward and that’s where it all really went downhill,” she said. “It was awful. I was just lying there. I couldn’t move because I had the epidural and my baby was crying."

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Source: The Times, 6 February 2022

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New mothers being driven to suicide, senior midwife warns

The senior midwife tasked by the government and NHS to investigate serious maternity scandals has warned that new mothers are being driven to suicide and backed an MP’s review into birth trauma.

Donna Ockenden said it was “appalling” that women who should be in the “happiest times of their lives” were taking their own lives, after it was found suicide was the leading direct cause of deaths up to 12 months after giving birth.

Ockenden, who has exposed poor maternity care across the country, is preparing to give evidence to an inquiry launched by Theo Clarke, the Conservative MP for Stafford, on birth trauma.

Clarke thought she was going to die after giving birth to her daughter Arabella last year, having suffered a third-degree tear.

But it was the lack of help available that opened her eyes to the estimated 200,000 women a year who experience birth trauma.

Ockenden told The Times she had “huge respect” for Clarke’s inquiry and said: “I think that this whole issue of maternal trauma, sometimes long-term psychological trauma for families as well post a difficult maternity experience, is not necessarily given enough air time.”

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Source: The Times, 8 January 2023

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New migraine drug on NHS could help thousands of patients in England

Thousands of people in England who get migraines could benefit from a drug that has been approved on the NHS.

The National Institute for Health and Care Excellence (Nice), the drugs regulator, said it was recommending rimegepant for preventing migraines in the approximately 145,000 adults where at least three previous preventive treatments had failed.

The drug, also called Vydura and made by Pfizer, is taken as a wafer which dissolves under the tongue. It is the first time Nice has recommended an oral treatment for preventing migraines.

“Each year the lives of millions of people in England are blighted by migraine attacks,” said Helen Knight, the director of medicines evaluation at Nice. “They can be extremely debilitating and can significantly affect a person’s quality of life.

“Rimegepant is the first oral treatment for migraine to be recommended by Nice and for many thousands of people it is likely to be a welcome and more convenient addition to existing options for a condition that is often overlooked and undertreated.”

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Source: The Guardian, 31 March 2023

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