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This webinar will explore how organisations across adult social care are using co-production to shape digital services, data use and innovation alongside the people most affected by them. The discussion will focus on a critical question: Who gets to influence how digital data is collected, used and acted on in adult social care? Too often, digital transformation happens to people rather than with them. This session will examine what happens when people with lived experience are genuinely involved in decision-making, service design and digital innovation from the beginning, not simply asked for feedback once decisions have already been made. The webinar will highlight examples where co-production has worked well because: people had real influence and shared ownership services listened and adapted digital approaches reflected people’s actual lives and needs organisations built trust through transparency and collaboration The session will also explore where organisations have struggled, including: consultation being mistaken for co-production digital systems being designed without end-user input communities feeling unheard or excluded power remaining with organisations rather than people The conversation will centre the voices of: people drawing on care and support unpaid carers and families frontline staff communities affected by digital change every day. Register

Earlier this year, Clare Collins from Northumbria Healthcare NHS Foundation Trust gave a presentation at the Patient Safety Management Network (PSMN) meeting on how their Trust has aimed to improve patient safety though a project to remove caffeinated drinks. In this blog, Clare shares their journey and what they have learned about implementation, engagement, organisational readiness and sustainability.  From a practical idea to a patient safety movement What started as a simple question: “Could changing the type of tea and coffee routinely served on our wards improve patient safety?”, has evolved into a growing quality improvement programme with local, regional and international interest. As a team, we wanted to explore whether a small and practical change to everyday care could contribute to safer, calmer and more restorative ward environments. At Northumbria Healthcare NHS Foundation Trust, we developed the Decaf by Default initiative to explore whether routinely offering decaffeinated tea and coffee to patients could help reduce toileting related falls, improve sleep and hydration, and support calmer, safer ward environments. The project has since expanded across multiple inpatient settings, generated strong staff engagement, and prompted wider conversations around organisational readiness for cultural change in patient safety. Why consider going decaf? For many years, staff across our wards routinely offered caffeinated hot drinks to patients as the default option. While this was often seen as a normal part of care and comfort, emerging conversations within our Care for the Older Person community raised questions about whether this practice unintentionally contributed to avoidable harm. Several factors prompted further exploration: NICE guidance recommends reducing caffeine intake in relation to urinary incontinence and pelvic organ prolapse in women. Caffeine can increase urinary urgency and frequency, potentially increasing the risk of toileting-related falls. Caffeine may negatively impact sleep and contribute to agitation. Non-caffeinated drinks can support hydration, rest, recovery and overall wellbeing. A review of Datix reports also identified that approximately 25% of inpatient falls over a one-month period were related to toileting activities, particularly within older people’s services. This led us to consider whether a relatively small environmental and behavioural change could contribute to safer care. Building the foundations: organisational readiness and engagement One of the strongest themes highlighted through discussions at the PSMN meeting was that success depended less on the decaf itself, and more on organisational readiness, staff engagement and shared ownership. From the outset, we did not approach this as a top-down instruction. Instead, the project focused on creating curiosity, shared ownership and practical collaboration. With senior nursing support, we established a quality improvement multidisciplinary community to explore the issue collectively. Staff from a range of professions and settings contributed ideas, concerns and learning throughout the process. Importantly, we also connected with University Hospitals Leicester, who had previously undertaken similar work. This external collaboration provided valuable insight, reassurance and practical learning. Several factors helped support implementation: Clinical ownership Ward teams were encouraged to shape how the initiative worked within their own environments rather than applying a rigid model. This helped improve engagement and sustainability. Preserving patient choice The initiative was never about removing patient choice. Patients could still request caffeinated drinks if preferred. A Taste the Difference challenge helped staff and patients explore perceptions around decaffeinated drinks. While around 55% of participants noticed a taste difference, approximately 85% said they would be willing to switch once they understood the potential benefits. Consistent messaging Simple, practical education materials were developed for staff, patients and carers, including posters, conversations at ward level and patient information leaflets. For example, digital teams looked at incorporating brief health promotion messaging into discharge documentation: “While in hospital, you were given decaffeinated tea and coffee. It may help to continue this at home.” This will reinforce the intervention beyond admission and encourage patients and carers to consider whether continuing reduced caffeine intake at home might support sleep, continence, anxiety management or falls prevention. Communities of interest One of the most important learning points was the value of building communities of staff who were genuinely interested in improving patient safety. Enthusiasm and local leadership often became stronger drivers than formal instruction. As discussed during the PSMN presentation, staff ownership proved critical to successful implementation. Challenges and learning The project generated important discussions and learning. Questions raised during the PSMN presentation included whether rapid caffeine withdrawal effects had been observed. While no specific reports had been identified, the team acknowledged that individual caffeine intake prior to admission is often unknown. Alternative approaches, such as limiting caffeinated drinks to mornings only, were explored and trialled in one location by a member of the PSMN but were not found to be sustainable in practice. Another PSMN member reported that in their care home, although they had adopted the change successfully, they had not seen a reduction in toileting-related falls. This highlighted the importance of local context, fall data and ongoing evaluation over a longer time period. From local project to wider movement Following pilot work in 2024-2025, Decaf by Default was adopted Trust-wide in December 2025. Since then, interest has continued to grow across the region and beyond. The project is now being explored more widely through collaboration with: the regional NHS Alliance the North East and North Cumbria Integrated Care Board patient safety networks and quality improvement communities. There has also been increasing international interest in the concept as organisations look for low-cost, scalable interventions that may contribute to safer care environments. Alongside the Trust-wide rollout, work has also begun to extend the learning into care homes across Northumberland and North Tyneside. This has created opportunities to explore how similar approaches may support resident wellbeing and reduce risks associated with continence, sleep disturbance, anxiety and falls within community-based settings. A small community pilot project has been developed involving community nurses and Allied Health Professionals (AHPs). Participating staff carry supplies of decaffeinated tea and coffee within their clinical bags and are able to offer this as part of broader lifestyle conversations and personalised care interventions. The aim is not simply to replace drinks, but to encourage wider discussion around hydration, sleep, continence, falls prevention and anxiety management in a practical and accessible way during routine community contacts. What has perhaps resonated most strongly is that the project demonstrates how a relatively small cultural and environmental changes can stimulate wider conversations about patient safety, prevention and personalised care. Key reflections Looking back on the journey so far, several lessons stand out: Small changes can create meaningful conversations about patient safety. Organisational readiness matters as much as the intervention itself. Staff ownership and engagement are essential for sustainability. Preserving patient choice supports acceptability. Quality improvement requires curiosity, testing and adaptation. Simple interventions may have wider wellbeing benefits beyond their original aim. Most importantly, the initiative has highlighted the value of frontline teams identifying opportunities to improve care through practical, evidence-informed innovation. Related resources Go decaf! How a simple change on our wards could reduce falls, slips and trips What happened when we went decaf – the story so far How going decaf could boost patient safety by reducing falls in hospitals Patient flyer - go decaf How to join the Patient Safety Management Network You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. Do you have a patient safety initiative you would like to share more widely. We'd love to hear from you and share it on the hub. Share here (you will need to be a member of the hub and signed in) or email [email protected].

This conference focuses on recognising and responding to the deteriorating patient, and ensuring best practice in the use of NEWS2. The conference will include national developments, including recommendations on NEWS2, the national PIER approach to the effective management of acute physical deterioration in health and care, the November 2025 NICE Sepsis Guidance, and implementation of Martha’s Rule. The conference will also include reflections on implementing the recommendations from the Healthcare Safety Investigation Branch report Investigation into recognising and responding to critically unwell patients. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/deteriorating-patient-summit or email [email protected] Follow the conference on X @HCUK_Clare #DeterioratingPatient hub members receive a 20% discount. Email [email protected] for a discount code.

This virtual conference focus on the role of the Coroner and preparing and attending Coroner’s Inquests. The conference will also update delegates on the implications of the 2024 Death Certification Reforms and roles, responsibilities and information flows under the new system. From preparing for an inquest, to ensuring change occurs as a result of the prevention of future death reports and local learning the conference will provide an important update on the coroner role and inquest process. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/coroner-role or email [email protected] Follow the conference on X @HCUK_Clare #CoronerRole hub members receive a 20% discount. Email [email protected] for a discount code.

This article provides an overview of an Adjournment Debate in the House of Commons discussing the implementation of recommendations from the Review of patient safety across the health and care landscape. The debate focused on the proposed transfer of functions of the Health Services Safety Investigations Body (HSSIB) to the Care Quality Commission (CQC). What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on. Review of patient safety across the health and care landscape On 7 July 2025, the Department of Health and Social Care (DHSC) published the findings of the Review of patient safety across the health and care landscape in England, chaired by Dr Penny Dash. The review looked at six specific organisations that were established to either assure—or contribute to improving—the safety of care, while also making reference to the wider landscape of organisations influencing quality of care. Its final report issued a number of recommendations, which included several proposed changes organisational changes: Transferring the functions of the HSSIB to the CQC. Closing Healthwatch England, moving its functions to a new directorate for patient experience in DHSC. Combining the statutory functions of Local Healthwatch relating to healthcare with involvement and engagement functions in Integrated Care Boards (ICBs), with social care functions transferred to local authorities. Transferring the hosting arrangement of the Patient Safety Commissioner for England to the Medicines and Healthcare products Regulatory Agency (MHRA). Closing the National Guardian’s Office, transferring its functions to NHS England. Contributions from Bernard Jenkin MP This debate was tabled by Sir Bernard Jenkin MP. He made a number of points concerning the transfer of the functions of the HSSIB to the CQC. He said that safety management is intrinsic to safety and public confidence in other safety-critical activities, such as aviation, but is alien to NHS culture. He asked without HSSIB, which independent body will promote a coherent understanding of safety system management in health, and who is to hold the NHS and Government to account for safety failures. He stated his view that neither the National Quality Board (NQB) nor the CQC should control investigations. He noted that the Air Accidents Investigation Branch cannot be prevented from making independent recommendations by the Civil Aviation Authority, the Transport Secretary or airlines themselves. He asked therefore why should the NQB, which will be subject to political direction, be allowed to decide what safety recommendations should be made and what should be investigated. He highlighted that the Dash Review incorrectly states that HSSIB was originally established to look at specific cases or incidents of severe harm, but it has since broadened its work into making more systemic recommendations. He noted that it was always intended by Parliament that HSSIB should make systemic recommendations arising from the investigation of specific incidents or groups of incidents. He questioned whether the CQC in its role as regulator and compliance enforcer could also be an independent investigator. He said that the Dash Review also says that the CQC internal successor should collaborate through the NQB to agree the scope of any investigations it carries out and agree the recommendations. He described this proposal as a direct attack on the independence of investigations. He stated that the Dash Review fails to look at the comparative cost of HSSIB investigations versus the cost of public inquiries. He noted that HSSIB at the moment only costs £6.3 million per year. He suggested that to save money the Secretary of State should request that HSSIB conducts far more investigations into matters which he thinks are important, provided that he also provides the funding for the necessary capacity. An example he gave was that HSSIB, has conducted eight investigations into mental health suicides since 2023. Each was completed in a few weeks or months, costing a total of £850,000. In comparison, he noted that the Lampard inquiry into the Essex partnership university trust, also investigating patient safety concerns in mental health, is expected to cost more than £5 million. Contributions from other MPs Jeremy Hunt MP highlighted concerns that moving HSSIB into the CQC, which has a legal duty ot act on information it receives, creates a worry for people talking to HSSIB that the information that they give to it may no longer be protected as they currently are. Anna Dixon MP noted that recent inquiries into maternity services, infected blood and pelvic mesh underline that professionals and those working inside the NHS must be able to speak freely when things go wrong in order to learn lessons and that that this is only possible with an independent investigating organisation. James Naish MP stated his concerns about the abolition of Healthwatch. He noted that there is a strong desire to see independent patient voice maintained outside the system and that Healthwatch was established due to issues within health structures, including, notably, the Mid Staffordshire scandal. Jim Shannon MP emphasised the need for lessons learned on data collection, streamlined complaints and patient safety culture are shared with the Northern Ireland Assembly Minister, Mike Nesbitt, as health is a devolved matter. Rachael Maskell MP stated that there was a wider issue, which she felt that the Health Bill completely misses, around the accountability systems within the NHS. She stated that these reforms are not going to deliver accountability, but will weaken it, and as a result we will see more requests for investigations into patient safety. Government response Responding to this debate on the Government’s behalf, Preet Kaur Gill MP, Parliamentary Under-Secretary of State for Health Innovation and Safety, made the following points: The investigation function within the CQC will be expert and full time, and it will be able to conduct investigations in the same cheap and quick way that HSSIB does now. In future, there will be the same opportunity to use the CQC investigation function instead of needing a public inquiry as there is currently with HSSIB. The criteria for disclosing protected information outside the investigative function are set out in the Bill. Those criteria set a high bar for any disclosure—as high as it is currently with HSSIB—and the CQC will publish further guidance setting out much more detail. As the Bill sets out, the CQC will appoint a responsible person who will decide whether the case matches the criteria and whether it warrants information sharing outside the safe space. That person is likely to be the CQC’s chief executive officer. Dash reforms are not about saving money; they are about strengthening patient safety and patient voice across the system. She stated that the abolition of HSSIB and the transfer of its functions to the CQC play an important part in making the system of patient safety much more effective. The NQB has been revitalised by giving it a stronger role in providing a single, authoritative view of quality across the system. That will help reduce duplication, bring greater clarity to recommendations and ensure that effort is focused where it has the greatest impact. The purpose of these reforms is not to weaken investigation, but to strengthen the link between investigation, learning and improvement. The investigation function in the CQC will have autonomy to launch investigations into any part of the health system and will be able to make recommendations on any part of the system, just as HSSIB does now. There will be no barrier to an investigator finding out that CQC inspections are causing unintended harm. The Health Bill also allows for the investigation function to make recommendations to the CQC in its report, and the CQC would be legally required to respond to such recommendations. How to watch the debate You can watch the full debate here and find the full transcript on Hansard at the bottom of this page. Related reading Review of patient safety across the health and care landscape: Patient Safety Learning's response (15 July 2025) The future of the Health Services Safety Investigations Body: a recent discussion at the Patient Safety Management Network Is the patient voice fading? Reflections on patient safety in a changing NHS

Francine Gilmore, a patient with vestibular migraine, has written a report in a personal capacity* examining a patient safety gap where migraine prescribing overlaps with mental health risk. Drawing on Freedom of Information responses from 26 organisations and related evidence, the report identifies fragmented safeguards, unclear ownership and potential barriers to suitable treatment for clinically complex patients. In this blog, Francine shares her experience, the findings from her report and the actions she would like to see taken. The findings point to a clear need for change: migraine pathways must make mental health risk visible, owned in governance, recorded in clinical systems and reviewed for patient-safety learning. *The full report can be downloaded from the attachment at the end of the page. My (wobbly) journey I did not set out to write a patient safety report. I was trying to understand why so many medicines with potential contraindications had been offered to me. Quite literally a year to the date, since returning from the USA after my 30th birthday, I have been living with ongoing symptoms of what is now known to be vestibular migraine. The dizziness is relentless. When the dizziness starts, I am a safety risk. The headache pain can make life unbearable. So can photophobia, when ordinary light becomes too much to tolerate. Sunglasses are my new best friend. Somewhere along the way, I entered a state of medical hypervigilance. I was angry, frightened and exhausted. It felt as though, in trying to repair my physical health, I was once again being asked to risk my mental health. Every treatment decision felt like a game of medical Whac-a-Mole: solve the migraine problem, worry about mental health issues popping up later. Returning to full-time work has been a huge achievement. But doing so while still managing pain, dizziness and photophobia has also shown me how much invisible effort this condition demands. Yet migraine is only part of my picture. I also live with bipolar disorder and have a history of suspected serotonin syndrome (a serious condition caused by medications that build up high levels of serotonin in the body requiring hospitalisation). That means migraine treatment is not simply about whether a drug might help. It is also about whether it could destabilise my mental health, interact with other risks or cause another kind of harm. There. I have disclosed it publicly, likely where my professional networks will see it. But I am saying it because it matters and I know the risks. Managed mental illness should not be a nice to have consideration; it should make joined-up prescribing decisions more important. Before appointments, I print reports listing the medicines I am concerned about. I sit there trying to explain what I can and cannot take, aware that I may sound difficult, but also aware that I am the person who will live with the consequences if those risks are missed. I could probably deliver a TED Talk entitled 10 Things I Hate About Migraine Prophylaxis Options. The trouble is that there are considerably more than ten. The evidence The report is based on Freedom of Information responses and related information routes. The project file covers 26 organisations or evidence routes and more than 30 documents, so 1000+ pages of evidence. I used AI as a research and drafting tool, but every substantive finding was checked against the underlying evidence. Given the volume of material and the impact of disabling migraine, this was an accessibility tool as much as a drafting tool. The Migraine Trust states that migraine affects around one in seven people. My report also cites systematic review evidence showing increased odds of depression in people with migraine, increased odds of anxiety, and estimated bipolar disorder prevalence among people with migraine of 5.9% in population studies and 9% in clinic-based studies. The relationship is clinically relevant because migraine, mood disorders and some preventive medicines can overlap through neurological, psychiatric and medication-safety pathways. For patients already managing mental health medication, migraine prescribing is rarely a cleanly separate issue. There is also crossover in the medicines themselves. Amitriptyline, venlafaxine and nortriptyline are antidepressants and migraine preventives, while topiramate and valproate raise neuropsychiatric or psychiatric safety considerations. Greater occipital nerve blocks may also involve steroid exposure. Only last week I was offered lamotrigine and had to point out that this is also a centrally acting medicine with psychiatric relevance, particularly for someone with bipolar disorder. What I found in my research was a system that could point to safeguards in theory, but not clearly show who owned the risk in practice. NICE guidance, the British National Formulary, product warnings, local formularies, prescribing systems, referral routes and clinical judgement all matter. For patients like me, that gap affects which medicines feel safe to try, how much responsibility we are forced to carry and whether the whole picture is visible to the people making decisions. It also affects access. Some patients cannot safely use standard migraine preventives because of psychiatric history, psychotropic medication, previous adverse reactions or physical contraindications. If access to some specialist treatments depends on trying previous prophylaxis options, pathways need to show how contraindication, intolerance or clinical unsuitability are recorded and counted. Otherwise, patients can fall into a cruel gap: too complex for the standard route but not clearly signposted towards safer alternatives The report makes practical recommendations: clearer flagging of mental health and medication-safety risks defined ownership of the prescribing interface triggers for psychiatry or specialist pharmacy input better documentation and escalation processes recognition of contraindication, intolerance and clinical unsuitability when assessing access to specialist migraine treatments. Parliamentary questions asked On the eve of Patient Safety Learning publishing my report and blog, something unexpected happened. A number of parliamentary questions had already been tabled in the House of Commons about the issues the report raises. To me, the early answers seemed to confirm the gap the report had identified. On 15 June 2026, the Department of Health and Social Care (DHSC) said it had made no specific assessment of national arrangements for identifying, recording and acting on psychiatric history, psychotropic medication or previous psychiatric adverse drug reactions before someone starts a preventive migraine treatment. A second answer pointed to the Getting It Right First Time (GIRFT) programme as a way of reducing variation in migraine access. That sounded promising, until two follow up answers narrowed the position again. The DHSC then confirmed it had no plans to look any further than its 15 June position. Asked whether GIRFT covers governance for this prescribing interface, it confirmed on 1 July that it does not. GIRFT sets no formal governance requirements here. Those decisions are left to local providers and commissioners. Then came the House of Lords answer. On 6 July, the Government confirmed that the Medicines and Healthcare products Regulatory Agency (MHRA) now plans to review the evidence on mental health and related risks for licensed migraine prophylaxis medicines after receiving a report from a patient. It will consider whether product warnings need updating, and will look at suspected adverse drug reactions reported in the psychiatric disorders category. The answer records that this followed a report made to the MHRA. So the question is no longer just whether the risks are recognised. It is this: if the MHRA moves, how quickly will the rest of the system move with it?