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'I was blamed for my baby's death, now NHS needs to change'
News articleWhen 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
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Two years down, three to go: is progress on waiting times stalling? (The Health Foundation, 8 October 2026)
Content ArticleThe 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%.
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NHS bosses admit defeat on 18-week pledge
News articleNHS 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
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Hospitals seek ‘pause’ on ambulance handover rule
News articleAn 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
Today
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Two in three housebound patients had no medication review for more than two years
News articleA 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
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My submission to the national review of clinical risk management standards DCB0129 and DCB0160 (September 2026)
Content ArticleEarlier 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
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Martha's Rule: A valuable patient safety tool facing new challenges
De0dc54a408b9a1365d933e8920191d8Martha'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.
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Psychological safety webinar
Event
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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 -
Regulators Pioneer Fund report: Ambient voice technology in regulatory practice (CQC, 10 September 2026)
Content ArticleThe 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.
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HSSIB: Learning disability listening event
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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 -
RCGP: The general practice role in evidence-based and equitable prevention (September 2026)
Content ArticleAccording 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.
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New York governor declares state of emergency after spike in measles cases
News articleThe 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
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What is your experience of using online systems to access your records, prescriptions or wider healthcare?
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.
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What is your experience of using online systems to access your records, prescriptions or wider healthcare?
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/
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New global guidelines warn against obesity drugs for children under 10
News articleChildren 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
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High repeat surgery rates under review at five trusts
News articleAt 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
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Voices for Safety Podcast – World Patient Safety Day 2026: Safe care for non-communicable diseases
Content ArticleTo 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
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UK Government backs recommendations of NHS doctors-led AI Commission
News articleThe 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)
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‘Organisational shame’ driving defensive behaviour at inquiry trust
News articleStaff 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
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UK Government joins forces with Breast Cancer Now
News articleWomen 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
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Women suffer more pain than men across the whole body, major global study finds
News articleWomen 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
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Ten NHS trusts referred over monitoring consent
News articleTen mental health trusts have been reported to the health regulator after problems with patient consent procedures when monitoring patients using camera technology. The issue emerged during the latest hearings of the Lampard Inquiry, which is examining the deaths of more than 2,000 people who spent time in mental health units in Essex between 2000 and the end of 2023. The infrared technology is used in patients' bedrooms and can monitor breathing and pulse without staff having to enter the room. NHS England told the inquiry it had passed information to the Care Quality Commission (CQC) after reviewing the use of digital monitoring systems, including Oxevision. Read full article. Source: BBC News, 6 October 2026
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From principles to practice: an actionable framework for AI governance in healthcare organisations (24 September 2026)
Content ArticleArtificial intelligence (AI) technologies are being rapidly adopted in healthcare, yet organisational governance often lacks the processes needed to oversee their safe and responsible use. Previous AI governance frameworks largely focus on high-level AI ethics principles, leaving healthcare organisations struggling to translate these principles into practice, assess risk and embed AI oversight into existing processes. This study published in BMJ Digital Health and AI aimed to develop and validate a practice-oriented AI governance framework for healthcare organisations. The framework provides healthcare organisations with a structured approach to assessing, governing and monitoring AI systems throughout their life cycle and may support the safe and responsible adoption of AI in practice. Further research is needed to evaluate the framework across diverse healthcare settings and emerging AI technologies, including generative and agentic AI.
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The side effects from dopamine agonists the doctors don't tell you about
Content ArticleIn this opinion piece, Julie Gould draws attention to the side effects of the dopamine agonists she was prescribed for restless legs syndrome. She says that GPs are failing to warn and monitor patients about the serious and often under-recognised behavioural and psychological side effects of dopamine agonists, including augmentation and impulsive control disorder. Julie has set up the Dopamine Agonist Action Group with three fellow activists whose lives have been affected by dopamine agonists, calling for improved communication around the risks and better support for sufferers.
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NIHR: Ways we are supporting safer care for non-communicable diseases
Content ArticleWorld Patient Safety Day 2026, celebrated on 17 September, focused on safe care for non-communicable diseases, encouraging communities, healthcare practitioners, organisational leaders and policymakers to work together to tackle patient safety challenges and reduce harm for people living with long-term conditions. The six NIHR Patient Safety Research Collaborations are committed to improving patient safety and addressing health inequalities, including the challenges faced by people living with non-communicable diseases. Explore some of the ways in which NIHR PSRCs are helping to improve patient safety and health outcomes for people living with non-communicable diseases.