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  1. Past hour
  2. Event
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    Dr Zoe Brummell will summarise her research into the Learning from Deaths programme and explore the obstacles to organisational learning as well as the ways it should happen. The session will explore How the Learning from Deaths programme failed to learn. What gets in the way of learning. What learning that leads to improvements looks like. Why partnership with families for organisational learning matters and what it looks like. Register
  3. Event
    Families are contacted by a Family Liaison Officer from the NHS at one of the most vulnerable moments people are likely to experience – following an unexpected and traumatic death. Families, often overwhelmed by grief, face arranging the funeral, an NHS investigation, a Coroner’s Inquest – processes that are unfamiliar, confusing and often alarming. Families describing these processes talk about feeling lost, frightened, confused, faced with trying to ask questions to systems they don’t understand. The Family Liaison Officer can offer support, information, understanding, signposting and consensual referrals to other sources of help. But not all Trusts employ them and it is not always clear how their insights help Trusts learn and improve. The session will explore: The role of Family Liaison Officers? – A national perspective The difference between a Family Liaison Officer working in the NHS and in the Police How families experience Family Liaison Officers How we hope this role will develop Register
  4. Event
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    Mental health services have developed Experts by Experience work to involve patients/service users in services, but the engagement of family and friends carers has progressed much more slowly. It’s complicated by complex family relationships and potential disagreements and estrangements, yet family and friends know their loved one best of all and hold information that can assist with safety planning, understanding risk and supporting recovery. This session will explore: What co-production is – and what it is not. How co-production with patients/service users can work well. How can we improve co-production with family and friends carers. What best practice looks like. Register
  5. Today
  6. Community Post
    Digital health technologies have transformed many aspects of healthcare, from electronic health records and telemedicine to remote patient monitoring and AI-assisted decision support. While these innovations have the potential to improve patient outcomes, many healthcare professionals also report challenges such as alert fatigue, increased documentation, and workflow disruptions. I'm interested in hearing from others working in healthcare: Which digital health tools have had the biggest positive impact on patient safety in your organisation? Have you experienced situations where technology created new risks or made clinical workflows more complicated? What strategies have helped balance innovation with usability for frontline staff? How can healthcare providers ensure that digital transformation genuinely supports clinicians rather than adding administrative burden? It would be great to hear real-world experiences, lessons learned, and examples of digital solutions that have successfully improved both patient safety and efficiency.
  7. Content Article
    The 2026 National Model for Clinical Governance (national model) aims to drive high-quality care and better outcomes for patients in Australian hospitals. The national model is a short, simple, principles-based document that describes key actions and clarifies roles within health services to achieve high-quality care. It signals a strategic shift in how clinical governance is understood, led and embedded in all health services. The model:  elevates clinical governance to the highest level of organisational leadership and oversight, highlighting the crucial role of boards and executives in governing for high-quality care reshapes Australia’s approach to clinical governance, shifting the main focus from complying with accreditation requirements to building the culture of the organisation to one in which delivery of high-quality care is the core focus of everyone in a health service, every day. The national model is accompanied by a practical guide to implementation and tools.
  8. News Article
    Women in England are at their highest risk of suffering a serious injury while giving birth since records began in 2020, NHS figures show. The rate of women sustaining the most serious type of tear during childbirth rose to 31.1 in every 1,000 in January, February and March – the highest since monitoring started in 2020. Similarly, the rate of women having a postpartum haemorrhage increased during 2025 to 31.2 in every 1,000 births – the highest annual rate over the five years data has been collected. Helen Morgan, the Liberal Democrat health spokesperson, who obtained the figures from NHS England, said: “Behind these statistics are women going through unimaginable trauma, requiring surgery and in many cases months or even years of recovery. Some will never fully recover. “This news … shows that we need to treat maternity services as a national crisis. The truth is that we will not reverse this dangerous, unacceptable trend – of rising blood loss and record severe tears – until we make safety a priority.” NHS bosses and ministers are preparing for the publication on Tuesday of Lady Amos’s government-commissioned report into the state of childbirth care. It will add to the increasingly urgent clamour for a major transformation of often-inadequate childbirth care in order to make it safe. The government intends to publish an action plan to transform maternity services by the end of the year. But pressure is intensifying for it to spell out its plans sooner. The rate of third- and fourth-degree perineal tears has risen to 31.1 in 1,000, from 25 in 1,000 when figures were first published in June 2020. The rate of postpartum haemorrhage – which involves the loss of 1.5 litres of blood – has increased similarly over that time, from 25.6 in 1,000 to last year’s 31.65 in 1,000. It was slightly lower – 31.2 in 1,000 – in early 2026. The Department of Health and Social Care voiced unease at the birth injury trends. “These are concerning findings, and as last week’s shocking report into maternity services at Nottingham university hospitals [trust] underlined, too many women are being failed by poor quality maternity care,” a spokesperson said. Read full story Source: The Guardian, 28 June 2026
  9. News Article
    One person a week dies with undiagnosed and therefore untreated tuberculosis in England, a study has found. British-born, older men were among those most likely to have TB diagnosed only after death, researchers said, suggesting healthcare workers could be overlooking the possibility of the disease in these patients. Being diagnosed with TB postmortem should be considered a “never event” that prompts urgent investigations, they said, describing it as “the ultimate diagnostic delay”. Tuberculosis rates in England are at a 10-year high, with 9.4 cases per 100,000 people in 2024. The rate is only just below the World Health Organization’s “low incidence country” threshold of 10 cases per 100,000 – a level expected to be breached when 2025 figures are published. Most TB cases are diagnosed in people born outside the UK, with an average age of 36. But research published in the journal Thorax found that was not the case in those diagnosed after death, who tended to be older and British-born. “As TB rates continue to rise, we need to keep asking: ‘Could this be TB?’, even in people who do not fit the usual risk profiles,” said Dr Eleanor Morgan, the study’s co-author and a resident doctor at Liverpool University hospitals NHS foundation trust. “If England is to eliminate TB, reducing delays in diagnosis will be essential so that fewer people miss the opportunity to receive effective treatment.” The researchers also found children aged under four were at higher risk, which they said could be linked to underdeveloped immune systems, non-specific symptoms, and challenges in getting samples from very young children for testing. Read full story Source: The Guardian, 29 June 2026
  10. News Article
    More than a million children in England are currently engaged with mental health services, a figure described as revealing the "sheer scale of distress young people are facing today". The Children’s Commissioner, Dame Rachel de Souza, has declared that the nation is "in no doubt that we are facing a crisis in young people’s mental health". Her annual report, published on Monday, revealed that 1,048,965 children had active referrals to children and young people’s mental health services in the 12 months leading up to March 2025. This figure encompasses children who were referred for, awaiting, or receiving treatment during that period, though it excludes those already undergoing treatment at the start of the year. The number of active referrals has almost doubled from 563,639 in 2018-19, with a 9.5% increase in the last year alone. While Dame Rachel noted there appeared to be "no straightforward answers" to the surge, data obtained from NHS England by her office indicates anxiety as the primary reason for referrals. The report also exposed concerning waiting times, with a weighted average of 128 days for all children in the year ending March 2025. Of those still awaiting treatment at that point, 60,041 (16%) had been waiting for over two years, an increase from 14% the previous year, with waits exceeding a year described as "common". Dame Rachel branded the figures "stark", stating: "Roughly one in 10 children have an active referral to mental health services in England, which clearly demonstrates the sheer scale of distress young people are facing today. These are not just numbers, but children whose lives have been put on hold for months and, in some cases, years waiting for support they urgently need." Read full story (paywalled) Source: The Independent, 29 June 2026
  11. News Article
    Nearly all the first wave of “neighbourhood health centres” (NHC) – currently being developed for launch by next year – were already doing the job required of the model, government documents reveal. Ministers – who have used the centres as a high-profile symbol of delivering their 10-Year Health Plan – announced in March that 27 would be opened by 2027. The Department of Health and Social Care said at the time that the centres would mean “tens of thousands of patients… will benefit from improved healthcare on their doorstep”. Government has previously accepted that many NHCs will be created from “upgrading, repurposing, or extending” existing NHS buildings. However, documents obtained by HSJ reveal for the first time that, for 22 of the 27, officials recorded they “could already be considered an NHC” when they were considered for acceptance to the programme. An industry source, who wished to remain anonymous, told HSJ: “It’s an open secret in the sector that lots of these sites are already performing the function required of NHCs.” They said most were community centres built under a national private finance scheme in the 2000s and “were designed to do exactly the same thing” at that time. The source added that: “Labour seems to have taken a leaf out of the Tories’ [new hospital programme] playbook on a more modest scale.” This meant, they said, finding out “what projects were underway already” and then to “badge them up as a programme”. Read full story (paywalled) Source: HSJ, 29 June 2026
  12. News Article
    An NHS manager died after an urgent referral was “recategorised” and a triage time of six weeks was arranged instead. Mr Paul Harries was scheduled to undergo a scan in July 2022 as the result of a 2020 test showing an abdominal aortic aneurysm (AAA) was increasing in size. However, he did not attend and was then “lost to follow-up”, according to a coroner’s report into his death. In February 2023, Mr Harries attended accident and emergency department for an unrelated reason. A scan showed the AAA had grown even larger. However, his GP was not informed of this finding until April 2024. The GP made an urgent referral to the vascular surgery team at the Royal Sussex County Hospital in Brighton. However, the surgeon who was sent the referral rated Mr Harries as “amber”, meaning he would be triaged within six weeks and be seen within 40. A scan in May 2024 showed the AAA was “difficult to measure”, and Mr Harries was given an outpatient appointment in October of that year. However, he died at his home in Brighton two weeks before the appointment. His family contacted the hospital in February 2025, raising concerns that he had not been followed up appropriately, and an inquest opened in September last year after a patient safety incident investigation was concluded. West Sussex, Brighton and Hove coroner Joseph Turner said that the changes made by the hospital since his death “do not appear to fully resolve the observed weaknesses” that saw an urgent GP referral not resulting in appropriate action by the hospital. He said that the hospital remained reliant on three separate referral systems, and the emergency department had an inconsistent approach to reporting incidental findings in existing conditions to GPs. Read full story (paywalled) Source: HSJ, 29 June 2026
  13. Content Article
    Mental health inequalities are systematic, avoidable and unfair differences in mental health outcomes between groups. Disadvantage is not evenly distributed in UK society, but follows clear patterns across geography, age, gender and socio-economic position. These differences are shaped by the social determinants of mental health – the social, physical and economic conditions that impact us across our lifespan. The Foundation Reports research series provides recommendations for decision-makers to tackle mental health inequalities in each nation, to target preventative action for the people and communities in greatest need.
  14. Content Article
    More information about "Aligning patient safety with productivity: Reflections from the Patient Safety Forum 2026"
    In February, Public Policy Projects (PPP) hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients. In this article, Patient Safety Learning reflects on one of the panels discussions—Aligning patient safety with productivity. Against a backdrop of long waiting lists and increasing financial pressures, improving productivity is a priority for healthcare leaders, commissioners and providers. The 10 Year Health Plan for England identifies this as a key issue of the NHS, setting a target to deliver a 2% year on year gain in productivity over the next three years. Productivity gains can sometimes be seen as running contrary to patient safety—a push to deliver more activity while cutting resources. However, at Patient Safety Learning we believe that creating a safer health system can be a key driver of productivity. Unsafe care and its consequences are inherently inefficient: it leads to longer stays, readmissions, litigation, staff turnover and reputational damage. At the Patient Safety Forum 2026 an expert panel was convened to discuss this topic, with the following members: Andi Orlowski, Director, NHS Health Economics Unit Professor Sanjiv Sharma, Group Medical Officer, Barts Health NHS Trust Stephen Rocks, Head of Secretariat for NHS Productivity Commission, The Health Foundation Gayathri Kumar, Lead Health Economist, NHS Health Economics Unit Panellists had a thought-provoking discussion about this topic. In this blog we reflect on the key takeaways from this panel. Scale of the challenge Andi Orlowski noted that while there had been many positive discussions at the Forum about improving patient safety, outcomes and experiences, the financial backdrop faced by the health service remains stark. He pointed to wider pressures on the Government to increase expenditure in areas outside of healthcare, such as defence, and the likely need for the NHS to do more work with the same money or less going forward. Panellists reflected on the scale of the productivity challenge faced by the health system. It was noted that since the onset of the Covid-19 pandemic, the NHS has grown in terms of staffing but productivity has fallen considerably in official measures. This is obviously not in itself a direct relationship, with the latter being associated with a range of issues varying from higher waiting list burdens to increased patient complexity. Stephen Rocks spoke about the work of The Health Foundation’s NHS Productivity Commission. This was established to provide evidence and solutions to boost productivity over the next decade. He was clear that patient safety should be seen as being aligned to productivity, with reductions in avoidable harm ultimately improving patient outcomes and by definition improving productivity. As part of its work, the NHS Productivity Commission held a public call for evidence this year. This invited a wide range of stakeholders to share their insights, ideas and expertise on the productivity challenge and how it could be tackled. Since the Patient Safety Forum took place a summary of its activities to date has now been published. Keeping sight of value A recurring discussion theme was that in looking to improve productivity in healthcare, we should not lose sight of value. By value, we mean whether patients achieve outcomes that matter to them, relative to the resources that have been used. What is meant by value in this context, however, can differ depending on perspective. Reflecting on this point, an audience member noted the importance of ensuring productivity discussions included the views of patients and frontline staff members. Gayathri Kumar concurred with this view, emphasising the importance of having deliberative conversations that include everybody who has a stake in decision making. Speaking about a practical example of this, she referred to the Health Economics Unit using the STAR (Socio-Technical Allocation of Resources) method to support Integrated Care Boards (ICBs). Taught through the Smarter Spending in Population Health programme, this is intended to help decision-makers to effectively assess their resources to see how they can create more value. This involves: Bringing together key stakeholders at decision conferences. Asking them to identify the criteria that matters to them and map the different interventions in a pathway. Subsequently working out what the value for money is, on both the financial side of things and in value terms. By coming together in this way, the aim is that decisions are not simply making assessments based on statistics divorced from patient and healthcare professional experience. It provides a way of identifying higher value interventions and services, crucial when there are only finite budgets available. Not just a financial focus Not simply focusing on financial improvements when thinking about productivity was also a key topic of discussion amongst the panel. Sanjiv Sharma from Barts Health Trust spoke about the importance of recognising the interrelationship of finance, quality and safety in healthcare, rather than framing them in oppositional terms. Avoidable harm in healthcare is not just a tragedy for those involved but comes at a huge financial cost. Sanjiv noted the Organisation for Economic Co-operation and Development (OECD) estimate that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending. Reflecting on their work at Barts Health Trust, Sanjiv said that when they spoke about productivity they used a simple definition: using their resources to treat the highest number of patients in the safety way through the delivery of high-quality care. This moves slightly beyond a pure definition of productivity, also bringing in issues of quality, safety and access. Considering an example of an improvement made without a pure financial focus, he cited the introduction of digital push notifications at Barts Health Trust to improve attendance at outpatient appointments. He said that by using these over a 12-month period they had managed to reduce non-attendance from 12.3% to 10.3%. While this may sound like quite a small percentage, the gain from this was not simply an improvement in attendance. Fewer wasted appointments had enabled them to create a significant number of new appointments, effectively delivering more care while expending a similar resources. This activity links to national proposals around improvements to the NHS App, with plans to use push notifications more widely to remind patients about upcoming appointments and relay important messages. Sanjiv also shared an example from a clinical productivity programme at Barts Health Trust looking at how outpatient clinics operate in the context of breaking down long waiting lists. In particular, looking at how the clinics can be organised more efficiently to better use the time of the most highly remunerated part of the workforce (consultants) so that more patients can be seen in normal working time. He noted this not only can save money on additional working hours, but also reduces the risk of consultants becoming overworked or burned out. More broadly, Sanjiv noted that when considering how healthcare can increase productivity, it is also important to recognise that there are limits to this. He spoke about the need for more honest conversations in wider society about what we can expect from healthcare, with our ageing population in the UK driving ever increasing demand on the system. 10 Year Health Plan As noted earlier, the 10 Year Health Plan for England sets specific goals for productivity improvements in the NHS. But how will this be measured and assessed? Gayathri noted that the answer to this was complex, as it depends on the perspective you take. She noted that if you were planning to take a societal perspective or NHS and broader perspective, you would consider the system impacts. Wider than this, she emphasised the importance of bringing together stakeholders from across different parts of care pathways so they can make things better—delivering both cost savings and improved patient outcomes. Andi reflected positively on the work Gayatri and her colleagues had done in this area. He noted that their work around the three shifts in the 10 Year Health Plan had involved reviewing over 6,000 papers to find which were cash-releasing by seeking the evidence base in the published literature and the grey literature. He noted that in many cases, performing these interventions would not achieve savings as often it results in moving pressures around the system. For example, increasing activity in an acute organisation saves money there, but transfers in activity in primary care which increases costs there. The importance of looking at the system as a whole was emphasised. Digital developments Panellists also discussed how digital advances can unlock productivity gains in the NHS. An example provided was switching to digital communications in full; for instance, stopping the use of paper letters. It was noted that this is quite a simple change, but can potentially unlock huge cost savings, while in turn reducing or enabling the re-direction of administrative resources in other areas. However, how this is delivered in practice requires considerably effort to change how healthcare organisations work, with far more complexity sitting behind such proposals than may first be apparent. The example of using artificial intelligence (AI) more was also highlighted, which is another key element of the 10 Year Health Plan. It was noted that while currently our approach to the application of AI in the NHS is a little uneven, it could potentially unlock significant improvements in processes if applied correctly in future. Role of Integrated Care Boards Whether ICBs could play an important role in improving productivity was also discussed by the panel. With a renewed focus on their strategic commissioning role, there is significant potential for ICBs to drive forward NHS productivity. Stephen Rocks suggested that they could potentially help look at improving productivity through the lens of their role in maximising population health management. He said he would welcome seeing more work at an ICB level that could help us to understand how well their areas are doing in terms of outcomes, and considering going forward if there is potentially more of a role for outcomes-based contracting rather than paying through block contracts or for activity targets. Importance of leadership One final key area of reflection from panellists was how leadership relates to improving productivity in healthcare. Stephen Rocks said that The Health Foundation had recently held a event with people sharing their success stories in other sectors which bore out the importance of this. They noted that this stressed the importance not only of those at the top of the organisation, but also the vital role of middle management. He reflected that the people at the top set the vision, at the bottom are the ground people doing things, and in the middle you're having to respond to people and understand their concerns as well as trying to carry out that vision. Investment was needed across all these levels. Sanjiv Sharma also noted the need to balance this focus on helping those in leadership roles be the best they can be. Sanjiv emphasised the importance of having proper support mechanisms in place as too often we create environments in the healthcare system where people are faced with a “just get on and do it attitude”. Share your insights What are your views on how best to align patient safety and productivity? Share your thoughts on this article and the issues raised by commenting below (sign up first for free). Find out more about the Patient Safety Forum 2026 You can read more about different discussions and panel sessions at this year’s event in the below: Safe systems, safe cultures: reflections from the Patient Safety Forum 2026 Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026 Designing AI with patient safety at its core: Reflections from the Patient Safety Forum 2026 Inside the NHS quality debate: Key takeaways from Penny Dash’s keynote at the Patient Safety Forum 2026
  15. Last week
  16. Content Article
    Holderness Health recently won the Regional NHS Excellence Award in the Quality Improvement category for the work they have been doing to support their palliative patients. Recognising that you only get one chance to do this right for palliative patients, they have introduced a number of improvements to help patients and their families at the most difficult times of their lives. Embracing a whole practice approach, Holderness Health have a working group with representatives from key areas of the practice who can quickly respond to a query or support a patient or family member to get what they need, when they need it. The introduction of their 'Gold Line', which is a dedicated number that is prioritised above other calls, means patients can get through to them quickly when they need to and can be reassured that they can reach out to someone for help. For the team, this identifies that the caller is a 'Gold' call so the staff member knows just how important the call is. If the team member cannot help with the query, they will find somebody that can. They provide a Gold pack available for patients, that provides some useful information about ours and other services, including contact numbers. There’s also some information on advanced care planning, when and if they want to discuss this. Find out more about the work they are doing from their website link below.
  17. Content Article
    The Patient Safety Commissioner, Prof Henrietta Hughes, has written to No.10 to request further information in relation to the Hughes Report exercising her statutory powers under the Medicines and Medical Devices Act for the second time since her appointment. The deadline for a response to her request is 16 July.   Prof Hughes has asked for information on: Internal and cross-government discussions held in relation to the Hughes Report, including ministerial and official-level meetings, engagement and correspondence. Actions taken beyond DHSC in response to her recommendations, over and above the information previously provided including policy decisions and considerations of feasibility and cost. Future plans and – crucially – clarity on outstanding actions in order for Ministers to make a decision on redress and the timetable for a full response to her recommendations, as well as details of relevant planned work. The Commissioner said: “Nearly two and a half years ago, the Hughes Report set out clear and urgent recommendations shaped by the experience of patients harmed by valproate and pelvic mesh and the systemic failures that followed. It provided compelling evidence of enduring gaps in recognition of harm, access to redress, and the adequacy of support available to affected patients. These are not new concerns, but as the Hughes Report highlighted, they continue to have significant consequences for those who have been harmed and indeed continue to do so. “The recommendations in the Hughes Report are direct and actionable. They address fundamental issues in how the system responds to harm, including the need for timely acknowledgment, fair and accessible routes to compensation, and a more coordinated, compassionate response from Government and public bodies. The continued absence of visible and timely progress against these recommendations risks perpetuating the very harms and inequities the Hughes Report identifies.  “Given the seriousness of these findings, and the continued impact on patients and their families, it is disappointing that the Government still hasn’t provided a substantive response to the Hughes Report. There is a clear need for transparency and accountability regarding the Government’s response. Understanding what action has been taken, and where progress has been made, is essential to driving improvement and restoring confidence with patients and the public. “
  18. Content Article
    How are you really using Patient Safety Incident Response Framework (PSIRF) learning response tools and After Action Review (AAR) in practice? In 2024, Judy Walker Associates Ltd captured a snapshot of early adoption. Now, Judy is revisiting that picture to understand what’s changed, what’s working well and where further support is needed. If you’re working in patient safety, governance or service improvement, she would really value your insight. The survey takes just 10 minutes to complete and the results will be shared widely. As a thank you, participants can opt in to a Prize draw for a FREE PLACE (for you or a colleague) at one of the AAR Conductor Professional Development Days that Judy Walker will be running in October. Your experience will help shape future support and strengthen learning across the system. Take part here
  19. News Article
    NHS executives could have their contracts rewritten to ensure they can be held to account for any actions taken while working for previous employers, NHS England’s chief executive has said. Sir Jim Mackey’s intervention came after it was revealed that many executives called to give evidence to the inquiry into the Nottingham maternity care scandal had refused to do so. Inquiry chair Donna Ockenden said this had left “gaps” in the inquiry’s knowledge of how patients were failed. Ms Ockenden’s review revealed all current Nottingham University Hospitals Trust staff approached to give evidence did so. However, 29 others, including “relatively recent former executives” did not. Meanwhile just five of 14 integrated care board and clinical commissioning group managers contacted agreed to speak to the review. The Nottingham Maternity Families Group said those who had refused “to engage constructively and with candour in this review process” had provided “further proof you are unfit to keep mothers and babies safe”. The statement added: ”Questions need to be asked by senior leaders and regulators whether you are fit to work for our NHS.” Sir Jim told a conference held by the The Institute for Public Policy Research think tank today that: “Everybody needs to be accountable for their actions. We’re looking at changes we can make to leaders’ contracts. A lot of people often leave and then it’s very difficult to hold them accountable for what happened on their watch. We’re going to try and make some changes to make… [it] more easy to hold them to account.” Read full story (paywalled) Source: HSJ, 25 June 2026
  20. News Article
    Members of staff from yet another NHS trust have been sacked for inappropriately viewing patient medical records, HSJ can reveal. Cambridge University Hospitals Foundation Trust told staff last week it had dismissed five staff and has since told HSJ the patients whose records were viewed had been told, as had the Information Commissioner’s Office. The trust said the dismissals had taken place in recent months. Sky News has reported CUH is also investigating why 40 members of staff accessed files belonging to a three-year-old attacked by a crocodile in a zoo last week. The latest snooping revelations come just days after the ICO declared that the number of cases of NHS staff viewing patients’ records without legitimate reasons had become a “worrying trend”. ICO boss Paul Arnold made his remarks just hours after HSJ revealed more than 1,400 reports of “unauthorised access” to patient data had been disclosed to the watchdog since 2019. This also follows staff inappropriately accessing the records of the victims of the 2024 Southport attack, as revealed by HSJ last month, and similar intrusions happening to the records of the Nottingham stabbing victims in 2023. Read full story (paywalled) Source: HSJ, 26 June 2026
  21. News Article
    The government is under renewed pressure to decide on compensation for individuals who have suffered avoidable harm from pelvic mesh and the epilepsy drug sodium valproate. More than two years after the Hughes Report called for a two-stage redress scheme, its author, Professor Henrietta Hughes, England’s patient safety commissioner, has expressed disappointment over the "continued absence of visible and timely progress". Campaigners insist compensation "is not optional and is long overdue". Transvaginal mesh implants, used for pelvic organ prolapse and incontinence after childbirth between 1998 and 2020, have caused debilitating harm, leading in some cases to women having their bladders or bowels removed. The Hughes report had suggested victims should start to receive interim compensation payments from 2025. It said an interim award of £25,000 was the “median amount patients said would be appropriate”. However, Prof Hughes said the Government has still not given a “substantive response” to her recommendations. She has written to No 10 for more information under the Medicines and Medical Devices Act, with a response deadline set for 16 July. Kath Sansom, founder of campaign group Sling the Mesh, said the “evidence has been undeniable about the thousands of women living with devastating, irreversible injuries caused by treatments they trusted”. “These women did everything right. They trusted their doctors. And for that trust, they’ve paid with their health, their jobs, their savings, and for some their marriages, but moreover their sense of self,” she added. “This is not good enough. They should not be forced to fight through the courts for justice over a piece of plastic mesh that has shattered their lives. “The Government must act now. Full, fair and urgent financial compensation is not optional, it is long overdue.” Read full story Source: The Independent, 26 June 2026
  22. Content Article
    This article offers a socio‑legal analysis and reflection on the Robbie Powell case, drawing on official reports, legal judgments, investigations and subsequent policy reforms. It highlights an unequal fight for the truth. Reinforcing why Robbie’s Law must stand beside Hillsborough Law. When justice depends on a family’s social capital, not the facts, cases like Robbie Powell’s are sidelined—yet his fight for an individual Duty of Candour strengthens every truth‑and‑justice campaign, not least Hillsborough Law. The Robbie Powell case is the landmark case on Duty of Candour in the UK. It exposed major failings in public accountability and led to the call for a Robbie's Law. However, all too often the Robbie Powell case is ignored and/or misrepresented. The details of the case, which remains unresolved, are uncomfortable for the healthcare professionals, legal advisors and for the State. Authorities avoid it because it implicates individual clinicians, healthcare staff, healthcare leaders, expert witnesses and politicians. The family’s persistence is admirable but embarrassing for institutions. This article attached aims to set the record straight.
  23. News Article
    Hospitals in England are declaring critical incidents with radiotherapy machines, MRI scanners, cooling units and IT systems failing owing to the extreme heat. Four doctors have described their experiences on the frontline that they say feels unsafe and dangerous for patients amid the worst NHS heatwave crisis in years. “On Wednesday, I led a ward round on an AMU [acute medical unit]. The office I started from was shared with eight other staff members, and the wall-mounted thermometer read 36C [96.8F]. No spare fan, and certainly no air conditioning, was available. “Out of seven patients reviewed, four of them had adverse effects due to the extreme heat. These included falls due to postural hypotension, and multiple pre-renal AKIs [acute kidney injuries]." “This heatwave has pushed patient care into concerning territory. In the heat, corridor care has become more serious and more unsafe. “We are now ‘reverse parking’ patients opposite one another because there is simply nowhere else to put them. Privacy and dignity disappear instantly. We are breaking bad news in corridors with other patients listening because there’s no room to go anywhere else. “We are resuscitating patients in corridors after cardiac arrest. This should never happen in a modern health system." Read full story Source: The Guardian, 25 June 2026
  24. News Article
    Trusts must check records stretching back to 2016 to ensure any failings that have taken place in their mortuaries have been reported to the regulator. Reportable incidents can include accidental damage to a body, and disposal or retention of organs against family wishes. The move by the Human Tissue Authority (HTA) follows revelations of poor practice involving neo-natal bodies at Nottingham University Hospitals Trust (NUH) and the arrest of two men. The Nottingham maternity review found “multiple failings” to report incidents to the HTA. The HTA inspected NUH in March this year. The inspection “identified a critical shortfall relating to serious and long-running failure to report incidents to the HTA”. Inspectors found eight bodies “showing advanced deterioration” which had not been transferred to a freezer because of the lack of sufficient capacity at Queen’s Medical Centre. The deceased were routinely stored in bags in a refrigerated area because of the lack of freezer space, it added. A review of incidents found on the trust’s internal systems showed that 73 had not been reported to the HTA of the last 10 years. It also found 10 “shortfalls” in procedures and processes – three of which were critical. Read full story (paywalled) Source: HSJ, 24 June 2026
  25. News Article
    Children who need life saving emergency surgery after a serious injury are almost six times more likely to die if in poorer countries than in wealthier ones, according to an international study led by the University of Cambridge. The research, published in The Lancet Child & Adolescent Health, analysed 237 children aged 18 and under who underwent trauma laparotomy – emergency surgery for severe abdominal injuries – in 85 hospitals across 32 countries. Traumatic injuries, including those caused by road traffic accidents and violence, are among the leading causes of death and disability in children and adolescents worldwide. This study looked at children who needed emergency surgery for severe abdominal injuries, comparing their care and outcomes across hospitals around the world. Overall, 8% of children in the study died within 30 days of surgery. After taking account of differences between patients and settings, children treated in countries with lower levels of development were almost six times more likely to die than those treated in countries with higher levels of development. The study found major differences in the care children received, which are likely to be important in understanding why outcomes were worse in poorer countries. Children often faced longer delays before reaching hospital and before receiving surgery. They were also less likely to receive a blood transfusion, have a CT scan, receive medicine used to reduce bleeding, or be operated on by a consultant surgeon. Children also made up a larger share of these cases in poorer countries than in wealthier ones. This suggests that poorer countries may face a double challenge: more children needing emergency surgery after trauma, and less access to the care needed to treat them. Read full story Source: Surgery, 15 June 2026
  26. Content Article
    Independent online prescribing has expanded rapidly in recent years, driven by increased patient demand for convenience, long NHS waiting times for some services, and a broader shift toward digitally enabled models of care. This Health Services Safety Investigations Body (HSSIB) investigation focuses on challenges for independent prescribing organisations in accessing clinical information held by the NHS to inform safe prescribing decisions for the patients who use their services. It also explores how gaps in NHS patient information about medication prescribed by independent prescribing organisations creates risks for the delivery of safe care. For both NHS and independent prescribing organisations, having limited information about a patient’s medical history and the medications they are being prescribed creates a challenge to making safe decisions about ongoing care and treatment. The investigation also explores the complex regulatory landscape within which independent prescribing organisations sit. In this regulatory framework, regulators may have jurisdiction over different aspects of a single independent prescribing organisations. The investigation explored the challenges this posed and the impact it had on these organisations’ ability to provide safe care. The findings of this investigation are offered to support the safe delivery of care for patients who use independent prescribing organisations and NHS services. Findings Independent prescribing organisations without an NHS contract do not typically have access to a patient’s NHS medical records. This can affect their ability to verify patient information. Some independent prescribing organisations use photos or videos of a patient’s NHS App to verify information about the patient’s medical history. This is beyond the purpose of the NHS App and creates patient safety risks as the app is not designed to hold a verified complete picture. Independent prescribing organisations have systems to identify multiple requests for medication from the same patient, address or payment method, but this information is not currently shared outside of their organisation. No independent prescribing organisations currently have ‘write access’ to patients’ NHS medical records – that is, the ability to enter information directly into a record. This creates the potential for gaps in medical records which can impact on the identification of potential contraindications (factors in an individual's condition or medical history that make it unwise to pursue a particular line of treatment) and complications. NHS GPs are being relied upon to provide clinical information to independent prescribing organisations but have limited capacity to provide this. The different approaches to such information requests also create uncertainty among GPs around whether the requests are legitimate and whether they should respond. Lack of access to patients’ NHS medical records is a barrier to independent prescribing organisations providing safe care in line with standards, regulations, and best practice. A large amount of data is gathered by independent prescribing organisations which could inform patient care, but there is no way to feed this back into the NHS. This data often relates to medications more commonly prescribed by independent prescribing organisations, such as those for weight loss, and has implications for understanding the safety of these medications. The Care Quality Commission and General Pharmaceutical Council have arrangements to work together in relation to organisations registered with both regulators, but these arrangements could be made clearer to providers. HSSIB makes the following safety recommendations HSSIB recommends that the Department of Health and Social Care develops a policy and implements a mechanism to enable appropriate NHS patient information to be shared with independent prescribing organisations. This is to ensure independent prescribing organisations can access verified patient information, with patients’ consent, to inform prescribing decisions. HSSIB recommends that the Department of Health and Social Care undertakes a review to explore the options and determine an appropriate mechanism for write access to health records for independent prescribing organisations. This would inform future developments such as the Single Patient Record, improve the currency of patient information held digitally by NHS organisations, and may remove some burden from general practices. HSSIB recommends that the Department of Health and Social Care works with relevant organisations, including Digital Clinical Excellence and the Coalition for Responsible Digital Health, to develop a framework to enable the sharing of safety critical information relating to patients known to multiple independent prescribing organisations. This would create a cross-organisational safeguard for patients who may be at risk of harm, and supporting safe prescribing. HSSIB makes the following safety observations Independent prescribing organisations can improve patient safety by ensuring that patient information contained in the NHS App is not used as a sole source of verification when making clinical decisions, as this is outside the purpose of the App and can result in patient safety risks. National healthcare organisations and independent prescribing organisations can improve patient safety by working together to design mechanisms for receiving information held by independent prescribing organisations. Such data may help to inform NHS care and provide insights into the safety profile of medications predominantly prescribed in the private sector.
  27. Content Article
    Friends and Family Test (FFT) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, using a simple question which asks how likely, on a scale ranging from extremely unlikely to extremely likely, they are to recommend the service to their friends and family if they needed similar care or treatment. Data on all these services is published on a monthly basis.
  28. News Article
    Mothers and newborns across the country will be better protected, as landmark patient safety measure Martha’s Rule will be rolled out to all maternity settings in England, following a string of serious and sustained failures at maternity wards in the Nottingham University Hospitals NHS Trust (NUH). Donna Ockenden’s review - the largest into maternity and neonatal services in NHS history - considered the experiences of maternity care for 2,500 families and found women ignored or complaints dismissed, missed opportunities to identify deteriorating patients and a culture of silencing both junior staff and parents. The government will commit to rolling out Martha’s Rule across maternity and neonatal wards in England to ensure every parent can request a rapid review from an independent medical team if a baby or mother’s condition is deteriorating and they are concerned this is not being responded to. The scheme - which is helping transform the NHS’s culture and has been rolled out for inpatients in every acute hospital in England - has already been piloted in 15 maternity and neonatal settings, with rollout to more expected this year. NHS data shows that there have already been over 2,100 calls to Martha’s Rule requiring changes in a patient’s treatment, with over 600 calls leading to potentially life-saving interventions to transfer them to enhanced levels of care. Read full story Source: Department of Health and Social Care, 24 June 2026
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