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  2. Stephen Acton joined the community
  3. Event

    This workshop runs over TWO dates. This booking includes both workshop sessions. One ticket covers both parts. Part 1: Tuesday 2nd March 2027, 09:30-13:00 Part 2: Monday 15th March 2027, 09:30-13:00 Help develop the foundations, behaviours, and systems needed for effective patient and family involvement in the most frequently used of the PSIRF Learning Response Tools, After Action Review. This is a practical, interactive workshop for healthcare staff with existing AAR knowledge, who want to build confidence and consistency in involving patients and families. Across two half-day online workshops, and a structured audit to be undertaken between the two, participants will learn how to set AARs up for success, create psychologically safe conditions, manage challenges in real time, and support patients and staff after the review. The programme focuses on embedding meaningful patient involvement as part of everyday PSIRF learning. Suitable for: People who lead AARs in healthcare settings, and those who help guide and advise their organisation in implementing Patient Safety Incident Response Framework and the required patient engagement About the organisers: Advancing Quality Alliance and Judy Walker Associates have joined forces to create and deliver this unique workshop because both organisations are committed to enabling healthcare providers to make progress in fully embedding the Patient Safety Incident Response Framework and its principles of compassionate and proportionate learning responses. Outcomes: To know the key components for setting up the AARs for success for the individual patients, and staff as well as the organisation. To know what your individual organisations’ strengths and weaknesses are in creating the conditions for successfully using AAR with patients. To know how to create psychologically safe conditions for learning in an AAR. To know how to respond when challenges arise during an AAR. To know when best to use AAR (including Duty of Candour) and when not. To know what to do after the AAR is completed – navigating challenges and supporting patients and staff. To know how other health providers are working to involve patients and their families in AAR. Register AAR with Patients October 2026 Flyer A4.pdf
  4. Today

  5. Event

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    This workshop runs over TWO dates. Part 1: Tuesday 3rd November 9.30 to 13.00 Part 2: Wednesday 11th November 9.30 to 13.00 One ticket covers both sessions. Help develop the foundations, behaviours, and systems needed for effective patient and family involvement in the most frequently used of the PSIRF Learning Response Tools, After Action Review. This is a practical, interactive workshop for healthcare staff with existing AAR knowledge, who want to build confidence and consistency in involving patients and families. Across two half-day online workshops, and a structured audit to be undertaken between the two, participants will learn how to set AARs up for success, create psychologically safe conditions, manage challenges in real time, and support patients and staff after the review. The programme focuses on embedding meaningful patient involvement as part of everyday PSIRF learning. Suitable for: People who lead AARs in healthcare settings, and those who help guide and advise their organisation in implementing Patient Safety Incident Response Framework and the required patient engagement About the organisers: Advancing Quality Alliance and Judy Walker Associates have joined forces to create and deliver this unique workshop because both organisations are committed to enabling healthcare providers to make progress in fully embedding the Patient Safety Incident Response Framework and its principles of compassionate and proportionate learning responses. Outcomes: To know the key components for setting up the AARs for success for the individual patients, and staff as well as the organisation. To know what your individual organisations’ strengths and weaknesses are in creating the conditions for successfully using AAR with patients. To know how to create psychologically safe conditions for learning in an AAR. To know how to respond when challenges arise during an AAR. To know when best to use AAR (including Duty of Candour) and when not. To know what to do after the AAR is completed – navigating challenges and supporting patients and staff. To know how other health providers are working to involve patients and their families in AAR. Register AAR with Patients October 2026 Flyer A4.pdf
  6. News article
    People living with brain cancer will get a faster route from research to treatment, under four steps set out by the Prime Minister. This follows the Prime Minister and Health Secretary’s meeting in Downing Street with Archie Goodburn today, the 25-year-old swimmer with inoperable brain cancer who made an emotional plea to the Prime Minister on BBC Breakfast. Archie has campaigned for faster progress on brain cancer, and today’s steps build on the issues raised: An immediate expert review, led by Professor Anthony Chalmers, Chair of the Brain Tumour Group within the UK Collaborative for Cancer Clinical Research, reporting within three months. Leading brain cancer experts will assess what has changed for patients since a 2018 government review, and what is still holding progress back. A national action plan to follow. The review’s findings will shape a plan to get new treatments out of the lab and to patients faster. A new national brain cancer clinical lead to drive this work forward, appointed by the Department of Health and Social Care. The Prime Minister has asked the MHRA to complete its review of the rules for medicines that treat rare conditions - known as orphan drugs - in two years rather than three. Bringing forward any changes to these rules could help patients get promising new treatments sooner. Alongside this, patients, families and charities will help design a drive to get more people onto clinical trials. Read full story Source: Gov.UK, 14 October 2026
  7. Tracy Wynn joined the community
  8. News article
    In its new report, Training physicians for the future: a blueprint for reforming postgraduate medical training, the Royal College of Physicians (RCP) warns that years of underinvestment in medical education, eroded learning opportunities and inadequate accountability for training quality risk undermining patient care, worsening workforce pressures and leaving the NHS without the senior clinicians it will need in future. RCP research illustrates the urgency of the need for reform. In a 2025 RCP next generation survey of more than 1,000 resident doctors working in UK clinical settings, just 26% felt prepared for the next step in their career and only 65% expected to remain working in the NHS in 5 years’ time. Developed by a writing group of resident doctors, the report calls for medical education to become a visible, protected and accountable part of delivering NHS services. The call for greater accountability reflects a longstanding pattern in medical training: concerns have been identified repeatedly but meaningful action has failed to follow. Professor Mumtaz Patel, RCP president, said: "High-quality medical training is fundamental to safe, effective patient care. Resident doctors today will become the consultants, clinical leaders, educators and researchers on whom patients will depend for decades. "Yet education is still too often treated as something that can be postponed or cancelled when services are under pressure. That is a false choice. If we properly support resident doctors, they will be more effective in developing their skills and expertise, provide better care and are more likely to remain in the NHS. "We know what good medical training looks like. What has been missing is clear ownership and accountability for delivering it. Training quality must become as visible and consequential as the financial, operational and patient-safety measures against which NHS organisations are already held to account." The new RCP report says that resident doctors and their educational supervisors should have protected time for learning, observation, feedback and reflection, supported by staffing levels that enable education to take place without compromising patient care. Skills developed through research, leadership, education and locally employed roles should be recognised consistently, while national standards, examinations and minimum clinical experience must continue to protect patient safety. Read full story Source: RCP, 14 October 2026
  9. News article
    The abolition of NHS England will have to be formally delayed beyond April 2027 unless decisions about future national structures are made within days, HSJ understands. Officials believe the timetable will have to be pushed back if the government does not finalise its decision imminently. This is due to the time it will take to carry out staff consultations and transfer at least 10,000 people out of NHSE, as well as legal and financial processes associated with abolishing the huge arm’s length body. Most of its functions are due to be transferred into the Department of Health and Social Care, but ministers are considering proposals to transfer the employment of thousands of its staff to a new NHS agency, instead of the department. The proposals for new structures when NHSE is abolished – including creation of the proposed new national quango – have been awaiting ministerial sign-off for months. The Health Bill, which will set up a single patient record and formally abolish NHSE, is currently going through the House of Lords. The government does not have a majority and peers have said they plan to oppose some of its measures, potentially introducing further delays to the process. Read full story (paywalled) Source: HSJ, 15 October 2026
  10. News article
    Commissioners have demanded an action plan after an “increase of inpatient deaths” at a mental health trust already subject to a statutory inquiry into at least 2,000 deaths. The rise at Essex Partnership University Foundation Trust is recorded in Essex Integrated Care Board’s quality summary for the second quarter (July to September), published in papers for its meeting on 15 October. The ICB said an action plan had been “requested to assure patient safety governance is in place”. The papers do not say how many deaths there have been, over what period, or which units are affected. EPUT chief nurse Ann Sheridan said: “Sadly at times we do see deaths on our wards – these can be for a number of reasons and our priority is always to support families and to ensure that we fully understand the cause and circumstances. “We care for 100,000 people across the wider trust and many of our patients have complex health needs. It’s important that we look into individual circumstances, working closely with families and partners.” The Lampard Inquiry is examining the deaths of mental health inpatients in Essex between 1 January 2000 and 31 December 2023, including people who died within three months of discharge. It is due to report in 2028. Read full story (paywalled) Source: HSJ, 14 October 2026
  11. Nyla joined the community
  12. Content Article
    Victoria Wilkins, Associate Safety and Learning Lead (North) at NHS Resolution, shares insights from a recent Northern Safety and Learning network meeting where four pilot trusts discussed their progress in implementing Martha’s Rule and shared their learning with other members.
  13. Content Article
    Following this year's Picker Experience Network (PEN) Awards, their 'Learning from the best' report maps the 2026 winners against the priorities of the 10-Year Plan for Health. This report highlights where best practice is already happening and provides further details on the projects that won this year. For the full details of all shortlisted entries in 2026, PEN's Book of Best Practice is also available.  Congratulations to the overall winner, University College London Hospitals NHS Foundation Trust (UCLH) and The Lighthouse Centre, who were recognised for their outstanding work to improve care for children who have experienced sexual abuse or exploitation. Its child-centred, trauma-informed model provides an alternative to fragmented care pathways. You can find out more about their winning entry here. 
  14. Content Article
    The prevailing strategy for combating surgically related adverse events (AEs) is to anticipate and prevent them by learning from adverse events (Safety-I). However, not all AEs can be anticipated or prevented in complex systems. This requires more focus on how daily work succeeds, that is, resilient and adaptive behaviour (Safety-II). Learning from success and promoting a positive patient safety culture (PSC) are key global strategies for eliminating preventable AEs. As a patient safety initiative, Learning from Excellence (LfE) captures episodes of successful everyday work and is thus, a system for applying a Safety-II perspective. However, its effect on PSC has not been evaluated. This study aimed to explore whether the implementation of LfE in a postanaesthesia care unit over a 16-month period changed the nurses’ perceptions of the measurable PSC dimensions ‘work engagement’, ‘teamwork climate’, ‘working conditions’ and ‘safety climate’. The authors concluded that LfE did not have a significant effect on PSC after 16 months implementation. Further longitudinal experimental studies are needed to measure the effect of LfE on PSC. Future research should focus on the role of psychological safety in LfE and assess whether reflexive spaces add value to LfE.
  15. Content Article
    The Royal College of Physicians (RCP) has published a new report setting out a blueprint for reforming postgraduate medical training across the UK. Training physicians for the future: a blueprint for reforming postgraduate medical training calls for medical education to become a visible, protected and accountable part of NHS delivery.
  16. Yesterday

  17. Community Post
    The Health Services Safety Investigation Body (HSSIB) investigation into the decontamination of surgical instruments produced the NHS England Estate Bulletin on Competency framework for Decontamination departments. With the new Care Quality Care (CQC) Premises Assurance Model (PAM) Safety Hard (section 16), does this go far enough in identifying the risks to patients? Medical devices are strictly Regulated by the MHRA yet the governance of the Surgical instruments is sitting in IPC, Decontamination. These high risk class IIa and Class III, medical devices under PAM technically cross Safety Hard (section 16) and Safety Soft (section 2) . Does the MDSO or the decontamination lead report on surgical instruments for PAM?
  18. Kylie joined the community
  19. Marc Slabbert joined the community
  20. Florinda joined the community
  21. Sara Amani joined the community
  22. Content Article Comment
    The epistemic exclusion of harmed patients in the patient safety field: A call to action from Richard von Abendorff - Patient engagement - Patient Safety Learning - the hub https://share.google/LWYoxCW9sxy4WpJLd
  23. GemmaB joined the community
  24. Teresa fogarty joined the community
  25. News article
    Doctors must be more transparent with patients and families about the role of antimicrobial resistance (AMR) in deaths, especially among cancer patients, the UK’s special envoy on AMR says. Speaking at the World Health Summit in Berlin, Sally Davies—England’s previous chief medical officer—said it was common for families to understand a death as being caused by cancer without being told that an untreatable infection had contributed. Instead, greater openness and patient advocacy were needed to urge political action on AMR, she argued. “When patients die … the relatives think of cancer and they had an infection. No one says actually it was untreatable; it was AMR,” she said. “AMR is much more common in cancer patients, and one in four have serious infections. We’ve got to be much more open. Read full story (paywalled) Source: BMJ, 12 October 2026
  26. News article
    Suicide rates among men in their early 50s across England and Wales have hit a record high, extending a persistent trend of elevated numbers within Generation X, official figures reveal. A total of 532 suicides were recorded among men aged 50 to 54 in 2025, equating to 28.0 deaths per 100,000 people. This rises from 27.3 per 100,000 in 2024, marking the highest level for this age demographic since contemporary data collection began in 1981, according to the Office for National Statistics (ONS). The figure also represents the highest rate recorded across any age category for both men and women. The ONS highlighted that higher rates of suicide have "followed" Generation X men over recent decades. David Mais, head of mortality statistics at the ONS, said: “Sadly, today’s figures show that suicide rates in England and Wales remain elevated, with the overall rate among the highest recorded this century. “Men in their early 50s are at most risk, reflecting a pattern of increased rates that has followed Generation X men over the past few decades.” Sonya Trivedy, an executive director at the suicide support charity Samaritans, said middle-age “can be a particularly challenging stage of life”, often characterised by long-term relationship breakdown, money worries, worsening physical health and caring responsibilities for both children and older parents. Read full story Source: The Independent, 13 October 2026
  27. News article
    Leading campaigners have accused ministers of “suppressing” a report that is understood to set out significant concerns raised by families harmed by their experiences of maternity care investigations. The Maternity Investigations and Review Tools Process evaluation was commissioned by ministers in 2025 following concerns raised by parents about national review processes undertaken following late miscarriages, stillbirth, and neonatal deaths. The MATREP project carried out an independent evaluation of Perinatal Mortality Review Tool investigations carried out by trusts and those conducted by the Maternity and Newborn Safety Investigations programme. HSJ understands the project, run by University of Manchester researchers, was completed and received by the Department of Health and Social Care (DHSC) by mid-2025. But the report’s findings, said to include complaints from parents about MNSI and PMRT processes, have still not been made public. A DHSC spokesman said it was “considering the findings and recommendations” and that researchers were “able to share” these if they wished. However, bereaved families disputed this and said the report was being suppressed, while researchers said they could not put the report into the public domain yet because it was still going through a publication process. Read full story (paywalled) Source: HSJ, 13 October 2026
  28. News article
    The amount of time children in England spend on screens at school could be harming their "physical and developmental health", a group of more than 150 clinicians has warned. GPs, paediatricians and other specialists said in an open letter to Education Secretary Lucy Powell and Health Secretary Yvette Cooper that tablets and laptops are being used without a full understanding of their long-term health impacts, including on eye health. The clinicians said they are prescribing glasses, hearing aids and speech therapy to children "for a problem that is unintentionally being made worse in our schools". The group of clinicians said nearly one million children are using screens in most lessons, despite studies suggesting a rise in short-sightedness. They pointed to an analysis of 276 studies covering 5.4 million participants around the world. That analysis, they claimed, found a rise in short-sightedness among children and adolescents from around 24% in 1990 to almost 36% by 2023, warning the condition is associated with an increased risk of a range of eye health problems. One of its signatories was Dr Becky Foljambe, an NHS GP and founder of Health Professionals for Safer Screens. She told BBC Radio 4's Today programme parents had not been given the chance to "opt out" of the "excessive" use of screens in schools, which risks children "just not thriving" in education. She said an "explosion" in short-sightedness "cannot be put down to genetics alone". Read full story Source: BBC News, 13 October 2026
  29. Content Article
    Patient experiences reported online can reveal safety incidents in healthcare organisations, but they can only translate into quality improvement if organisations engage with them. Accordingly, healthcare organisations’ responses to online feedback offer a new data source on corrective culture, namely, the norms and practices for identifying, interpreting, and acting on safety incidents. This study explored the feasibility of using a large language model to reliably code these responses for two candidate indicators of corrective culture: engagement and organisational learning. The results indicate that large language models can reliably code engagement in these responses, while their ability to code organisational learning remains inconclusive. Organisational culture in healthcare is usually assessed with staff surveys, which rely on self-report. Large language models could complement surveys by measuring observed behaviour in naturally occurring data, although whether engagement reflects corrective culture requires external validation.
  30. Content Article
    On 20 October 2025, the then-Secretary of State announced the decision to commission an independent review into maternity and neonatal services at Leeds Teaching Hospitals NHS Trust (LTHT). This was due to: LTHT having one of the highest extended perinatal mortality rates. hearing families’ experiences. the ‘inadequate’ rating in the latest Care Quality Commission (CQC) report. The purpose is to review the care women, babies and families received in a maternity and neonatal context, identify any failings and recommend actions for improvement. For clarity and consistency, references to ‘women’ throughout this document are intended to include women and all birthing people, including those who do not identify as women. During the defined time period, the governance and leadership of the trust and the extent to which the regulators were aware of issues will be reviewed to determine if the regulatory response was sufficient.
  31. Content Article
    This NHS Resolution thematic review explores learning from suicide-related compensation claims made against mental health trusts in England. The report highlights opportunities to strengthen communication, support effective family involvement, improve risk assessment processes and address organisational factors that can influence patient safety and care.
  32. Content Article
    The National Audit of Inpatient Falls (NAIF) has published its 2026 annual report, Beyond hip fracture: reporting on the expansion to include other injuries for the first time.  This is the first NAIF report to extend beyond hip fracture, providing broader insights into the prevention, assessment and management of patients who sustained a fracture, head injury or spinal injury following an inpatient fall. The report highlights opportunities for trusts and health boards to improve patient safety and outcomes. It also introduces a new key performance indicator on timely pain management following an injurious fall and sets out key recommendations to strengthen participation and falls governance, standardise post-fall processes, and improve patient outcomes.
  33. Last week

  34. Event

    When teams are facing pressure and uncertainty, finding time for open conversations can be difficult. This session explores how listening to staff, understanding their experiences and acting on their feedback can support learning and everyday improvement. Attendees will hear reflections from Lara Mott at ImproveWell, followed by a focused exploration of maternity data, emerging patterns and what these mean for teams on the ground. The session will offer practical ways to encourage staff voice and use insights to inform improvement. What you will learn: Why communication becomes even more critical during periods of pressure and uncertainty How to support staff voice and encourage open, honest conversations What maternity data is revealing about current challenges and trends How to use data insights to inform learning, improvement, and decision making It is particularly relevant to Directors and Heads of Midwifery, Neonatal Leads, Maternity Governance Leads and senior clinical leaders. Attendees will also receive our Creating the Conditions for Safer Maternity and Neonatal Care guide and a Maternity Data Snapshot summarising the session’s key insights. Registration link: https://meet.zoho.eu/wujc-ufm-fro
  35. Content Article
    Evidence is limited on how people experience government-commissioned inquiries, what they value about them and the impacts of procedures. This study applies realist logic to examine the experiences of those designing and participating in a government-commissioned restorative approach to harm associated with surgical mesh use in Aotearoa New Zealand. Attention is paid to divergent perspectives about harm and responsibility, desired outcomes, and the multiple identities that shaped people's responses to the programme.
  36. Event

    This virtual conference focuses on the role of the Coroner, the coronial investigation and inquest process, and preparing effectively for a Coroner’s Inquest. The conference will provide an important update on current developments in the coroner system, including the impact of the statutory Medical Examiner system and Death Certification Reforms on referrals, investigations and learning from deaths. The conference will explore the Coroner’s investigation from notification and referral through to the inquest, preparing witness statements and giving evidence, supporting staff involved in proceedings, and understanding what families want and need from the process. Practical sessions will provide an opportunity to understand how an inquest works in practice and develop confidence in preparing for and attending Coroner’s Court. Following the introduction of statutory Medical Examiner scrutiny, all deaths in England and Wales now undergo independent review either by a Medical Examiner or through investigation by a Coroner. Emerging national evidence suggests that the reforms are leading to fewer unnecessary referrals to coroners and more appropriate use of the coronial process. The conference will examine how Medical Examiners, Coroners, patient safety teams and clinical governance functions can work effectively together to identify concerns and ensure learning leads to improvement. The conference will also consider how organisations manage PSIRF learning responses, complaints, claims and coronial investigations in parallel. HSSIB has highlighted that coroners’ expectations can influence organisations’ choice of learning response under PSIRF, demonstrating the importance of clarity around the different purposes and requirements of patient safety learning and the coronial process. There will be a strong focus on learning from deaths and Prevention of Future Deaths reports, including identifying themes, responding effectively within the required 56-day timeframe and ensuring recommendations and concerns result in demonstrable and sustained improvement. Delegates will also be updated on the developing Public Office (Accountability) Bill, widely known as the Hillsborough Law. The Bill proposes a statutory duty of candour and assistance for public authorities and public officials engaging with inquests, inquiries and investigations, alongside provisions designed to improve the participation and representation of bereaved families. This conference will enable you to: Understand the role of the Coroner and current developments in the coroner system Understand notification and referral of deaths and when a Coroner has a duty to investigate Examine the impact of the Death Certification Reforms and statutory Medical Examiner system Understand the relationship between Medical Examiners, Coroners and organisational learning from deaths Reflect on a family’s experience and understand what bereaved families want from a Coroner’s investigation and inquest Understand the Coroner’s investigation, the scope of an inquest and the role of Interested Persons Develop your skills in preparing for an inquest, including writing witness statements and giving evidence effectively Learn from the experience of Coroners and healthcare professionals who have attended Coroner’s Court Improve support for staff before, during and following an inquest Understand how PSIRF learning responses, complaints, claims and coronial investigations can be managed effectively in parallel Explore openness, candour, disclosure and the implications of the developing Public Office (Accountability) Bill/Hillsborough Law Understand Prevention of Future Deaths reports, the 56-day response requirement and current Chief Coroner arrangements Identify key strategies for learning from deaths and ensuring findings lead to sustained improvement Understand how learning from mortality reviews, Medical Examiner scrutiny, patient safety responses and bereaved-family concerns can be brought together Reflect on your own practice and identify areas for improvement Support CPD professional development and provide evidence for revalidation. This conference provides 5 hours’ training for CPD, subject to peer group approval for revalidation purposes. Register
  37. News article
    Under fire health chiefs were accused of prioritising the environment over patient safety at a deadly superhospital. The Queen Elizabeth University is being probed by an Inquiry which is set to make its conclusions in the coming months, and has been labelled "safe" by John Swinney and Angela Constance. NHS Greater Glasgow and Clyde's (NHSGGC) handling of the scandal is being scrutinised, with officials accused of mistreating whistleblowers who raised concerns about the near £1bn Glasgow premises. Opened in 2015 "before it was ready," the construction was botched amid issues with the ventilation and water systems. The Crown Office is probing potential corporate homicide over seven deaths linked to the building, including children. Patients and families still fear the QEUH is not safe, with the ventilation in some key rooms, housing the most vulnerable patients, still not at recommended levels. A Times story quoted expert Andrew Poplett, who has conducted audits of the building and is an engineer specialising in healthcare ventilation. The recommended number of air charges per hour for healthcare settings is six, but at the QEUH most rooms had a system that delivers two to for an hour. He said that while the air cooling system at the QEUH was good for reducing greenhouse gas emissions, it did not meet health standards: "It appeared that the environmental consideration to make the hospital as energy efficient and as green as possible took priority over the clinical requirement." Still to this day, not all wards at the hospital have been independently verified, with the bone marrow transplant ward being replaced due to safety concerns after mould and water ingress were reported. Rooms in the Royal Hospital for Children reported similar issues, as well as problems with the water supply. Read full story Source: Scottish Daily Express, 11 October 2026
  38. Event

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    Improving medicines data across health and social care is the focus of this year’s PRSB AGM, with Dr Melanie Ivarsson, CEO of the Health Data Research Service (HDRS) as the keynote speaker. Melanie has a background in neuroscience research and medicines development and led the creation of Moderna’s mRNA vaccine against Covid-19. Register
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

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