All news
Showing .
Past hour
-
E3b996f19893bf6acec711e149fde762Following Julie's blog, we heard from a patient who has had similar experiences. She was happy for her story to be shared below:
Today
-
Content Article
When someone dies by suicide, or by a self-inflicted death, including in a psychosis, or a mental health homicide (when a person is killed by someone experiencing mental illness), it is initially called an unexplained death by the Police and it is referred to the Coroner in the area the person died. For families the processes that follow can be confusing and distressing. Trying to navigate your way through these processes at a time of profound traumatic grief can feel almost impossible. This brief guide from Making Families Count provides an overview of what might happen and signposts you to further information and sources of support. -
Community PostMany healthcare organisations are introducing Artificial Intelligence (AI) into work systems that were not designed for high levels of automation. In practice, this often means that new tools are added locally while team structures, responsibilities, interfaces, and escalation routes remain unchanged. The result can be more cognitive load, fragmented coordination, and unclear ownership rather than safer care. A safer approach is to redesign the work system itself: the teams, tasks, technologies, and governance that shape day-to-day clinical work. One practical step is to model team structures and work processes explicitly so that roles, interfaces, risks, and control measures are visible, traceable, and reusable. This can also provide a structured basis for Large Language Models (LLMs) to support governance tasks such as incident summaries, handover drafts, and training scenarios, all under human oversight. In healthcare, the question is not whether Artificial Intelligence will be used, but whether it will be introduced into work systems that are already difficult for staff to coordinate safely. When a new tool is added without clarifying responsibilities, interfaces, or decision authority, the likely result is not transformation but cognitive load: more interruptions, more workarounds, and less clarity about who should do what, when, and on what basis. That matters for patient safety because poorly aligned work systems can weaken handovers, delay escalation, and increase cognitive burden in already demanding settings. For that reason, I believe the starting point should be the work system, not the tool. Team organisation needs to be designed around the real demands of care: the patient journey, the coordination load between professions, the need for escalation, and the information required to act safely. In practical terms, that means defining clear team boundaries, explicit interface agreements between teams, and reliable modes of collaboration for shared problem-solving and specialist support. This makes accountability more transparent and reduces the risk that important tasks fall through the cracks. A useful next step is to model team structures explicitly. Using, e.g., Sparx Systems Enterprise Architect and SysML (Systems Modelling Language), it is possible to describe not only system structure but also behaviour, requirements, and team interfaces consistently. In a healthcare context, that can include teams, roles, responsibilities, decision points, escalation routes, handover dependencies, risks, and existing control measures. The value is not modelling for its own sake. The value is that operational knowledge becomes structured, reviewable and reusable across governance, training and redesign work. Once this information is modelled in a disciplined way, there is also a plausible route to safer use of Large Language Models. Rather than asking an LLM to generate advice from unstructured discussion alone, organisations can use structured models as a controlled knowledge base, the "Single-Source-Of-Truth". Under human review, that can support practical outputs such as incident summaries, handover drafts, training cases, draft requirements, and options for redesign. The important point is that the model provides consistency and traceability: users can see which role, task, interface, or risk the output is based on. In a patient safety setting, that is far more defensible than relying on text-based documents alone. This last point is an informed systems-engineering inference from structured modelling practice. My view is that healthcare organisations will get more value from AI when they first make their work systems visible. If we want safer care, we need to design for human-AI collaboration in the same disciplined way that we design for staffing, escalation, and accountability. Models will not replace professional judgment, but they can make coordination, governance, and learning more reliable. That is where the patient safety opportunity lies.
-
Community PostThanks for the systems perspective Stefan. Modelling the organisation(s) is one of those foundational pieces of work that would not only support technical/digital evolution including "AI" deployment but also many other aspects of healthcare operational management and practice. From a clinical perspective I remain highly sceptical of the readiness of the system, professionals and society for generative AI such as LLMs and I am also concerned about the deliberate design of a lot of GenAI that explicitly mimics human outputs without explicit disclosure of the source. I would make a key distinction of the use of LLMs and Gen AI between "hot" and "cold" usage by which I mean use in live workflows (I will stick to clinical as that is my main domain but equally might apply to others) versus in preparation or analysis of material where there is no time pressure of the sort that is almost the norm in clinical practice. The reliance on human checking will fail and as you allude to the existing ways of working are not being adapted (and in practice may not be capable of adapting) to the insertion of LLM based technology as currently design/implemented. It is mainly the failure mode that is the issue even if effectiveness was not in question. Detecting errors and therefore preventing harms is demonstrably harder in a human like output which when produced at greater volume, as LLMs tend to, and under time or intensity constraint is more likely to occur. To go back to your point, there are many foundational pieces of work, architecture, systems change and more that should be in place before introducing a significant disruptor into a complex often chaotic and high risk environment.
-
News article
When Poppy Russell died in April 2021 at the Princess Royal Hospital in Telford shortly after birth, her parents were left bereft. What followed made matters harder to bear - her mother was blamed for the death. An inquest would later conclude that Poppy's death was preventable. But instead of walking away from the trust that had failed them, Neil and Katie Russell are now working with it to bring compassionate care back into the NHS. "We could have very easily been consumed by hate and anger and rage at what happened – and those feelings are still there," said Katie. "But if no change comes from what happened to Poppy, then what's the point?" During her pregnancy her mother told midwives that she had tokophobia, a fear of natural birth and wanted a caesarean section. Katie said she was repeatedly told however that she "couldn't just ask for a c-section." When she went into labour, Katie was induced and then "we were left in a room for long periods of time where I had no care," she explained. "Finally, when we got into the labour suite, I wasn't monitored appropriately and they missed signs that Poppy was in distress." In a bitter irony, Poppy had to be delivered by emergency caesarean. By then however, she had developed a hypoxic brain injury and died later the same day. An inquest into her death found that had Poppy been born an hour earlier, she would have survived. The Shrewsbury and Telford NHS Trust (SaTH), which ran the hospital, subsequently blamed Katie for her daughter's death. They said she had refused foetal monitoring; the inquest concluded that was untrue. "The trust left us in an appalling position," said Neil Russell. "Not only were they found to have neglected our care, but in the months and years following, we uncovered that members of staff had tried to cover it up. “Losing your daughter is one thing, but then to find that there was a cavalcade of lies was almost as bad." Following the inquest in 2023 the trust said: "We recognise there were failings in the care we provided and we are truly sorry." Read full story Source: BBC News, 8 October 2026 -
Content Article
The government is committed to bringing down waiting times for elective care in England, aiming to achieve 92% of waits within 18 weeks by the end of the current parliament (at the latest in July 2029). In September 2025, The Health Foundation projected that – based on trends over Labour’s first year in power – 92% of waits would last up to 20.3 weeks by July 2029, falling just short of the headline pledge. This analysis shows that, over the 12 months to July 2026, the percentage of waits within 18 weeks improved from 61.3% to 65.4%. The waiting list also fell by 62,000 to 7.33 million, and the share of waits longer than 52 weeks improved from 2.6% to 1.5%. -
News article
NHS chiefs have told ministers that their top health manifesto pledge - to restore the 18-week elective target by 2029 - is “not going to happen”, as a new analysis confirms the service is significantly off track. The intervention by the NHS Alliance, which represents the large majority of trusts and integrated care boards, follows experts questioning whether ministers should abandon the 18-week pledge last month. Health and social care secretary Yvette Cooper has highlighted other priorities, such as maternity and early years, since her arrival in July. The Health Foundation’s analysis published today projects the NHS will fall “a long way short” of the 2029 target if current trends continue, with the 92nd percentile wait nearly twice the 18-week standard by the end of the Parliament (see chart below). Responding to the think tank’s findings, NHS Alliance acute lead Matthew Hopkins said it was time for “an honest conversation” about the target, and to “acknowledge [meeting it] this Parliament is not going to happen”. He said: “Now with a change of prime minister and secretary of state, attention is turning to reform of social care, maternity and early years, and frailty services. We can’t have everything, everywhere all at once. “Let’s be honest about where we can get to with the resources available, so there is a clear understanding of what can and cannot be achieved.” Read full story (paywalled) Source: HSJ, 8 October 2026 -
News article
An ambulance trust is “not assured” the 45-minute limit on hospital handovers can be consistently delivered this winter, after repeated requests from hospitals to “pause” it. East Midlands Ambulance Service Trust’s winter plan, presented to its board last month, says support is needed for “a zero tolerance to pausing the process”, given “current requests for pauses”. Under the “release to respond” protocol, crews hand over their patient and leave after 45 minutes at hospital. NHS England’s urgent and emergency care plan for 2025/26 said the maximum, which 17 trusts were missing last summer, should “now be delivered without exception, including in the winter months”. Anna Parry, managing director of the Association of Ambulance Chief Executives, said: “There may be exceptional circumstances in which the protocol needs to be temporarily paused or suspended, for example where there are specific clinical safety concerns, during a declared incident or where there is exceptional system failure. However, these should be strictly governed, escalation-based exceptions, agreed between ambulance and acute trusts, rather than becoming a routine response to operational pressure.” She said any suspension should only be considered after actions to reduce pressure within the hospital had been exhausted. Sarah Noonan, chief operating officer of University Hospitals of Northamptonshire, the group formed by Kettering General and Northampton General, said: “Only when our emergency departments and inpatient services are at full capacity may we need to temporarily hold ambulance crews, while recognising the impact this can have on patients waiting for an ambulance in the community.” Read full story (paywalled) Source: HSJ, 8 October 2026 -
News article
A proactive pharmacist home visit service for housebound patients found that 30% had not received a medication review for more than five years, while 64% had not received a medicines review for more than two years. This was despite 66% of the patients involved living with five or more long-term conditions and 70% being at risk of medication-related harm. In some cases, “patients had gone more than 20 years or had never had a documented medication review”, the lead pharmacist for the project told delegates at the Royal College of Pharmacy’s Delivering a Healthier Wales conference, held in Cardiff on 25 September 2026. However, a pharmacist home-visiting project has enabled more than half of its patients to reduce their medication, improving rates of falls and hospital visits. Tracey Witherall, lead pharmacist for Aneurin Bevan Health Board’s Primary and Community Care Academy, shared an update on the Home Visit Project. This has run since summer 2024 and supports 349 housebound patients aged between 23 years and 103 years, with an average age of 80 years. The project was developed as part of efforts to improve access to care for the area’s most vulnerable patients, who are often frail, with high levels of polypharmacy and multimorbidity, Witherall said. “Visiting patients’ houses allows me to identify medication adherence issues and safeguarding issues, alongside other challenges such as loneliness, bereavement, poor mental health, housing problems, and unmet care needs. “All of these factors impact how patients manage and take their medication, and increases the risk of falls, worsens their long-term conditions and can result in avoidable hospital admissions.” Read full story Source: The Pharmaceutical Journal. 5 October 2026 -
Content Article
Earlier this year, NHS England ran a national review of the clinical risk management standards DCB0129 and DCB0160: the two standards that govern how health IT systems are assessed for safety before and during use.[1] In this blog, Clive Flashman, Patient Safety Learning's Chief Digital Officer, summarises his response to that review. His central argument is that the standards are the right instrument and should not be replaced, but that in practice they have been reduced to a documentation exercise completed to satisfy procurement. Three things would change that: Putting patients inside the framework rather than outside it. Connecting digital safety incident data to national learning through the Learning from Patient Safety Events (LFPSE). Giving clinical safety officers the time, authority and protection their role has never had. Yesterday
-
E3b996f19893bf6acec711e149fde762Martha's Law is one of the NHS's success stories, but the tragedy is that it takes suffering and public campaigning to carry out what should be getting done already. You mentioned operational pressures. Surely this is ripe for AI? Surely patients deserve objective second opinions? We have the technology.
-
Event
until
This is a free, 1-hour, live online webinar, delivered by Ben Tipney. This session will cover the following: What does Psychological Safety mean? Is it simply 'Being Nice'? Is Psychological Safety a panacea, and can you have too much of it? Hints and Tips for building Psychological Safety in Practice Register -
Content Article
The Regulators’ Pioneer Fund from the Department for Science, Innovation and Technology awarded funding to the Care Quality Commission to test the use of ambient voice technology (AVT) during regulatory assessments. The aim of the project was to explore how AVT could support CQC assessment activities beyond how service providers use it when delivering care to patients. -
Event
until
The Health Services Safety Investigations Body look into serious cases where there is a risk to the safety of NHS patients. Learning Disability England and the Health Services Safety Investigations Body are working together on this. You are invited by the Health Services Safety Investigations Body to come to a meeting about how people with a learning disability in England get help when they are unwell. The meeting will bring together people with a learning disability, carers and staff to share experiences. What we talk about at the meeting will be kept private and confidential. The Health Services Safety Investigations Body will write a report to help improve care in the NHS. That report will not include anybody’s name. Register -
Content Article
According to a report from the Royal College of General Practitioners, around two-thirds of patients trust their GP for advice on how to live healthily, yet three quarters of GPs say they lack the time to offer preventive care, which may include advice on lifestyle, vaccinations and self-care. It argues that a stronger preventive approach could lead to better patient outcomes, reduced health inequalities, fewer avoidable hospital admissions and a more sustainable NHS. The report focuses on the role general practice can play in prevention, and the support needed to create the capacity for this work. -
News article
The New York governor, Kathy Hochul, declared a state of emergency on Monday in response to a dramatic spike in measles cases in the state. Hochul’s administration said the emergency declaration was in response to a “growing number of measles cases across rural areas of New York and neighbouring states”, including Pennsylvania, which has been grappling with a deadly outbreak that is its largest in more than three decades. The declaration expands the pool of people who can administer vaccines against measles and allows more individuals to order testing. It comes as there have been 108 confirmed cases of measles in New York so far for the year, up from just one reported case in 2023. In Pennsylvania, which neighbours New York, five people have died after contracting the disease, and there have been 198 hospitalisations. The state surpassed 1,000 measles cases on Monday while Ohio has also seen an increase. “After reviewing the latest data on measles cases in New York state, I am declaring a State Disaster Emergency to strengthen our ongoing efforts to confront this disease,” Hochul said. “No one should get seriously ill or die from a vaccine-preventable disease. That is why I have taken steps to increase the number of health professionals who can vaccinate and test. These emergency measures will protect New Yorkers and support our community partners as they work tirelessly to address the spread of this disease.” Read full story Source: The Guardian, 6 October 2026 -
Community PostPatients are increasingly being asked to access online systems to: request prescriptions or make medication requests access healthcare records and test results make appointments communicate health concerns sign consent forms. These developments can have a positive impact but they can also carry potential challenges, as highlighted in this recent blog - Digital-only prescription requests: An elderly woman sent round the houses. We'd like to hear your experiences of using online systems in healthcare. Have they made things easier? Does it feel like your care is more joined up for it? Have any of these changes been challenging? If so why? Comment below (sign up first for free) or contact us directly at [email protected] to share your experience.
-
Community PostBasil Bekdash replied to Patient_Safety_Learning's topic in Digital health and care service provisionHi Benedict, Would be interested in any thoughts you had on this very adjacent topic.....https://www.pslhub.org/forums/topic/2396-reimagining-health-and-care-data-systems/
-
News article
Children under 10 should not be given obesity drugs or GLP-1 weight-loss injections such as Mounjaro and Wegovy, new global guidelines, external from the World Health Organization (WHO) say. Most of these medications are only licensed for children or adolescents older than this, but some doctors prescribe them off-label, and drug companies are testing them in children as young as six. WHO says the care should focus on healthy eating and exercise, not medicine or surgery, although they do not oppose drug trials. Some digital technology, such as activity trackers and any online games that encourage the player to be more active and move, might be useful, it says, based on the limited evidence available. Estimates suggest 170 million children and adolescents worldwide are obese. That includes 70 million children aged 5–9. Obesity prevalence in this age group has quadrupled since 1990, rising from 2% to 8%. In 2024, 35 million children under the age of five were overweight. Obesity increases the risk of many different diseases, including type 2 diabetes. Dr Luz De Rigil, Director of Nutrition and Food Safety at WHO, said: "For children under 10, WHO does not recommend obesity medicines, bariatric surgery or weight-management devices. This is a strong recommendation." Read full story Source: BBC News, 7 October 2026 -
News article
At least five trusts are reviewing their rates of repeat breast cancer surgery after recording levels significantly above the maximum expected level, HSJ has learned. Their high rates were identified in this year’s National Cancer Audit, published last month. While these can be caused by multiple and complex factors – and there is no suggestion at this stage of avoidable patient harm – the metric is a significant patient safety marker. For example, it was a factor in triggering the high-profile breast cancer care investigation which uncovered significant patient harm at County Durham and Darlington Foundation Trust. A review of up to 4,500 cases continues. HSJ contacted trusts which recorded rates more than 5 per cent above the maximum level expected by NATCAN auditors. Airedale Foundation Trust, Buckinghamshire Health FT, Royal Berkshire FT, Blackpool Teaching Hospitals FT and Torbay and South Devon FT all recorded rates that were more than 5% above the maximum level expected by National Cancer Audit Collaborating Centre (NATCAN) auditors, who examined the period between January 2021 and December 2023. Read full story (paywalled) Source: HSJ, 7 October 2026 -
Content Article
To mark World Patient Safety Day 2026, Voices for Safety released a special episode featuring Prof Alarcos Cieza, Head of Management of Non-communicable Diseases at the World Health Organization (WHO), and Prof Maria Panagioti from The University of Manchester and NIHR PSRC: Greater Manchester. The conversation explores a WHO-commissioned meta-analysis on patient safety and non-communicable diseases, led by Prof Maria Panagioti. Last week
-
News article
.png.0e8485a88df16366d5fab5230e47296c.png)
The UK Government has confirmed it will accept all 44 recommendations made by the National Commission into the Regulation of AI in Healthcare, published 10 September, and has set out how they will be delivered across the UK. Alongside the response, the Medicines and Healthcare products Regulatory Agency (MHRA) is opening the call for applications for the third phase of AI Airlock, its regulatory sandbox for AI-enabled medical devices, with testing themes directly informed by the Commission’s recommendations. The Commission concluded that the current regulatory approach must evolve for AI technologies by designing a more proportionate, lifecycle-based framework. The Government's response commits the UK to developing a world-leading agile approach to AI device regulation that supports innovation while maintaining patient safety and public trust. The reforms aim to ensure patients can benefit from safe, effective and trusted AI more quickly, while maintaining robust safeguards as technologies evolve. Among the first steps set out in today’s response, the MHRA is also committed to issue draft guidance by December 2026 on a new approach to managing changes to AI-enabled medical devices as they adapt and improve over time, moving towards a regulatory system that is designed to maintain safety while supporting timely access to innovative devices. The MHRA will also begin next year by consulting on how to qualify and classify AI-enabled devices, the first recommendation of the National Commission. Other commitments include exploring new staged authorisation pathways, allowing promising AI tools to be used in the NHS earlier under close supervision while further real-world evidence is gathered. A full implementation roadmap, setting out timelines and responsibilities across all 44 recommendations, will be published by Spring 2027, with regular progress updates to follow. Read full article. Source: MHRA, 6 October 2026 Related Reading Patient safety and the regulation of AI in healthcare (Patient Safety Learning) Reflections on the National Commission into the Regulation of AI in Healthcare recommendations (Clive Flashman) -
News article
Staff at a trust subject to a statutory inquiry are paralysed by fear, a review has discovered. Essex Partnership University Foundation Trust is under scrutiny by the Lampard Inquiry, which is examining the deaths of over 2,000 services users in the organisation’s care. It began in 2023 and is expected to report by 2028. An external review of how the trust is coping has been undertaken by the King’s Fund and charity brap. This has revealed the impact of the Lampard Inquiry, service pressure, and financial constraints on senior managers, middle managers, and frontline staff. Read full article (paywalled). Source: Health Service Journal, 6 October 2026 -
News article
Women across the country will be better supported to spot the signs of breast cancer and know where to turn for help as the UK Government announces its first partnership to help deliver its renewed Women’s Health Strategy. Marking Breast Cancer Awareness Month, the Department of Health and Social Care will partner with the UK’s largest breast cancer charity, Breast Cancer Now, over the next 3 years, giving women practical information to build confidence in checking their breasts, recognising changes, and seeking advice sooner - particularly in underserved areas. It comes as new research from Breast Cancer Now reveals almost a third (29%) of women in England who regularly check their breasts do not feel confident to notice a change, while just over one in 10 (11%) of those checking less than once a month say it’s because they do not know what to look out for. One in 5 (20%) UK adults also say they are not confident they would know where to find trusted information about breast cancer if they had concerns. Women will also be provided with better support after their treatment, including clear information to understand the possible signs of breast cancer returning or spreading and how to live a healthy lifestyle post breast cancer treatment. Healthcare professionals will receive additional training, alongside a practical toolkit for healthcare teams, so they can provide the best possible advice to women adapting post-treatment. Read full article. Source: Department of Health and Social Care, 5 October 2026 -
News article
Women report suffering more pain than men, a major new global study has found. That was true for all types of pain the researchers measured, and comes amid continuing concern about the gender pain gap, which means women are less likely to be prescribed the pain relief they need. Researchers from all over the world carried out “one of the largest harmonisation efforts in pain epidemiology to date”. Data was collected from more than 6 million people from 118 countries from 1990 to 2025, and included people from aged five years to more than 100. The research, published in Nature Medicine, looked at how pain, as the leading global cause of disability, was distributed both around the world and across the human lifespan. It found women’s self-reported pain across 11 bodily sites – head, face, neck or shoulder, foot or ankle, hand or wrist, elbow, chest, back, stomach or abdomen, hip and knee – was higher than for men. Read full article. Source: The Guardian, 5 October 2026
.png.0e8485a88df16366d5fab5230e47296c.png)
