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Staff Briefing highlighting the changes CQC have made recently
Community PostHi Everyone There has been a great deal of conversations been had in the media surrounding the changes CQC are making in relation to the single assessment changes etc. I was wondering if anyone has a staff briefing pack they are willing to share that gives an overview of the forthcoming changes. Thanks Ian
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Ania joined the community
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PSA joins 38 regulators in healthcare AI pledge
News articleThe Professional Standards Authority for Health and Social Care (PSA) and 38 health and social care regulators and registers have committed to developing shared principles for the use of AI across the UK. The organisations have signed a joint Statement of Intent supporting the safe, effective and ethical use of AI by health and social care professionals. The work aims to bring greater consistency to regulatory expectations, while protecting patients, service users and public confidence as the use of AI across health and social care grows. The statement highlights the need for clarity on when patients and service users should be told that AI is being used in their care. It also says professionals must remain accountable for decisions made with AI-assisted tools. The signatories comprise the PSA, 10 professional regulators and the Accredited Registers Collaborative (ARC), which represents 28 Accredited Registers. They include the General Medical Council, Nursing and Midwifery Council, General Dental Council, General Pharmaceutical Council and Health and Care Professions Council. Caroline Corby, chair of the PSA, said that “as AI becomes increasingly embedded in health and care, regulation must keep pace”. “Confidence by the public and professionals in the benefits of AI rests on appropriate safeguards, accountability and consistency in expectations about how it is used. “By working together, we can take a preventative approach to regulation that supports innovation while maintaining professional standards,” she added. Read full story Source: Digital Health, 17 September 2026
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Patient Safety Learning started following PSA joins 38 regulators in healthcare AI pledge
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Making decisions together: Supporting conversations about bladder and bowel products and services
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There is concern that decisions around care and products for patients with bladder and bowel intimate care needs are being made on the basis of cost to the NHS, at the expense of patients receiving the right care and treatment for their needs. Working in partnership with patients, the Patients Association and Coloplast have developed a number of resources that are designed to support patients understand their rights and get access to the products and services they need. At this free Patients Association webinar, you'll hear about patients' experiences of accessing bladder and bowel products and services, including some of the challenges people face in getting care that meets their individual needs. It will explore the importance of shared decision-making between patients and healthcare professionals, and how working together can help ensure people have a say in decisions about their care and are able to access the products, treatment and support that are right for them. You'll also hear from the team that developed the resources about how they can help patients understand their rights, have more informed conversations with healthcare professionals, and advocate for their individual needs. Register -
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NHS trust to review 4,500 more breast cancer cases after failings
News articleHospital chiefs in County Durham have agreed to review up to a further 4,500 breast cancer cases after failings including delayed diagnoses and unnecessary surgeries were found. Hundreds of patients suffered harm under County Durham and Darlington NHS Foundation Trust, according to a review of cases dating back to 2023. The BBC previously investigated the failings and has spoken to multiple women affected, including one who said she felt "mutilated" and the trust's mistakes were "absolutely unforgivable". Ahead of agreeing to expand the review to cases dating back to 2015, members of the trust's board offered "sincere" apologies for the failings and harm caused. At an extraordinary meeting of the board held in Durham, board chair Alison Marshall said: "I would like to offer a sincere apology to all the women and their families who have been affected by the failings in our breast services. "I can't imagine the impact that has had." She said they could "not turn back the clock" but would be "open, honest and transparent" about the failings. Read full story Source: BBC News, 24 September 2026
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Letby trust criticised over fetus storage
News articleThe trust where Lucy Letby worked has been heavily criticised for how it looks after the bodies of fetuses. The Countess of Chester Hospital did not have procedures in place to check the condition of bodies of babies and fetuses and a “small number” were incorrectly kept in refrigerators instead of freezer storage, according to the Human Tissue Authority. The trust told HSJ this involved two fetuses and no babies. Moving a body to a freezer after 30 days is normally recommended because of the risk of deterioration. Failure to do so is regarded as a “critical shortfall”, its more serious censure, by the HTA. The authority also discovered a number of “major shortfalls” at the trust. These included a risk of families viewing the wrong body or the wrong body being released to funeral directors. The use of three identifiers before a body is viewed or released is standard practice but the inspection team found that operating procedures at the Countess of Chester did not always comply with this approach. Some forms used by the trust to authorise the release of bodies say families only need to confirm two identifying details and can “rely on the name of the deceased if attendees do not know the date of birth”. SOPs – such as weekly checks of bodies – were not always carried out, while one 2025 review included no “physical audit of bodies”. Read full story (paywalled) Source: HSJ, 23 September 2026
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NHS staff investigated over access to dead teenager's medical records
News articleThe mother of a teenage boy who died in hospital has said she is "deeply concerned and hurt" after learning his medical records may have been accessed inappropriately for years after his death. Paula McGowan, whose 18-year-old autistic son Oliver died in 2016, was told that at least five members of staff at Bristol Foundation NHS Trust may have accessed his records without permission as recently as this year. The trust said it was "deeply sorry" for any stress and anxiety caused. It said it had voluntarily referred itself to the Information Commissioner's Office. It is the latest case involving concerns that NHS staff may have accessed patient records without a legitimate professional reason. In July the head of NHS England, Sir Jim Mackey, issued a "stark warning" that staff could face the sack or even prison for doing so. Oliver, who had a mild learning disability and epilepsy, died in 2016 at Southmead Hospital in Bristol after being given anti-psychotic medication that his family had repeatedly warned he should not receive. After requesting information about his medical records, his mother was told that 38 people had accessed the data since his death, with 637 items viewed and 67 printed off. Most access was appropriate and linked to complaints, legal proceedings, and the coroner's inquest into his death. But three nursing staff not involved in his care are currently under formal investigation after initial inquiries could find no evidence they had a legitimate reason to view her son's records. Read full story Source: BBC News, 24 September 2026
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Millions in England unaware they have ‘silent killer’ condition, research reveals
News articleOnly half of people being treated by a GP for high blood pressure in England have it under control, and millions more are completely unaware they have the “silent killer” condition, research reveals. Most people with hypertension (59%) are in the dark and undiagnosed, raising their risk of stroke, heart attack and early death, according to the largest ever study of its kind. Even among those who are diagnosed and receiving medication via their family doctor, in 50% of cases their blood pressure is out of control, the Oxford University study of 1.4 million adults suggests. Researchers said the findings, published in journal BMJ Public Health, suggested the current approach to detecting and treating high blood pressure in England was “not fit for purpose”. Wenyu Liu, a medical statistician at Oxford Population Health and lead author of the study, said: “While hypertension is largely a ‘silent killer’, the current approach to detecting and treating high blood pressure is not fit for purpose. “Our study highlights the prevalence of hypertension across demographics. This underscores the need for population-wide prevention strategies alongside targeted treatment for people at high cardiovascular risk.” Read full story Source: The Guardian, 23 September 2026
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Barriers and facilitators for the implementation of a nationwide falls prevention pathway for older adults in the Netherlands (July 2026)
Content ArticleFalls contribute significantly to injury and mortality among community-dwelling older adults, with societal costs expected to rise. In the Netherlands, a nationwide falls prevention pathway, aligned with World Falls Guidelines was introduced. This includes case finding, multifactorial falls risk assessments, evidence-based interventions and sustained exercise programs. This study explores its implementation, focusing on barriers and facilitators.
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Health Innovation Network: National Patient Safety Improvement Programmes 2025-2026 impact report
Content ArticleThe National Patient Safety Improvement Programmes 2025-2026 impact report highlights the NHS's commitment to continuous improvement in patient safety. The report details the progress made in implementing various safety initiatives, such as Martha's Rule, which allows patients and families to request rapid reviews of deteriorating conditions. It also discusses the implementation of a new early warning system for staff treating children and the rollout of tools for early identification of deterioration in maternity and neonatal care.
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The hidden millions in healthcare: why Sunshine legislation matters
Content ArticleIn this blog, Kath Sansom, founder of Sling the Mesh, argues that Sunshine legislation, which requires pharmaceutical and medical device companies to publicly disclose payments to healthcare professionals and organisations, is essential for improving transparency and patient safety. She highlights concerns that undisclosed financial relationships can influence research, prescribing and treatment recommendations, potentially leading to patient harm.
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Patient Safety Commissioner Strategy 2026-2028
Content ArticleThe Patient Safety Commissioner for England's strategy for 2026-2028 sets out an ambitious programme of work to make medicines and medical devices safer and ensure patients’ voices shape decisions across the healthcare system. It outlines practical action to address some of the most pressing patient safety challenges facing healthcare today, including strengthening safeguards around remote prescribing, improving medicines information, enhancing monitoring of medical devices and ensuring artificial intelligence is introduced safely and transparently.
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Robyn Purcell joined the community
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Yesterday
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Tom Vanacker started following Martha’s rule to be expanded to every A&E in England
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The power of collaboration: the untold story of World Blood Donor Day and World Patient Safety Day (17 September 2026)
Content ArticleGlobal health days endorsed by the World Health Assembly (WHA) play a distinctive role in elevating priority issues, mobilizing political commitment, and catalysing collective action. Among them, World Blood Donor Day (WBDD) and World Patient Safety Day (WPSD) stand out as landmark initiatives that emerged not only from technical necessity but also through sustained collaboration among Member States, WHO, and key partners including international organisations, professional bodies, civil society, and advocates. WBDD and WPSD have become influential global platforms for advancing safety, solidarity, and health system action. Yet the processes behind their establishment, including the consultations, negotiations, consensus building, and collaborative efforts that culminated in their adoption through WHA resolutions, remain largely undocumented. In this article, Neelam Dhingra offers a first-hand account of how these two global health days were conceived, negotiated, and established, drawing on more than two decades of leadership and programme coordination in blood safety (2000–2014) and patient safety (2014–2024) at WHO headquarters in Geneva, Switzerland. The article examines collaboration as the critical enabler of success and distils lessons for global health governance. While both initiatives involved extensive contributions from Member States, WHO, international organizations, professional bodies, civil society, and advocates, this article covers their development trajecto
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Tom Vanacker joined the community
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Experiences of vaginal access procedures - TIGER UK survey: Report 1
Content ArticleTIGER UK is a not-for-profit community interest company (CIC) set up to help improve experiences of gynaecological care and procedures. It stands for Together Improving Gynaecology Experiences and Research. This report shares the first findings from TIGER UK’s community survey on experiences of vaginal access procedures. More than 700 people responded, providing valuable lived experience insight. Key findings Pain and support 59% of respondents had experienced severe pain (7/10 or above) during a vaginal access procedure. Experiences of severe pain were reported for all but one of the 21 procedures listed. Prevalence of severe pain was highest in hysteroscopy, endometrial biopsy and IUD insertion. Nearly half (47%) of those who experienced severe pain said they did not feel appropriately supported by healthcare staff. Preparation and consent 44% of respondents who had experienced severe pain said staff had explained beforehand that they might experience pain, while more than a third (35%) said they had not been prewarned. Among those who had experienced severe pain and had been warned about the possibility of pain, 62% said the description they received did not reflect the intensity of the pain they actually experienced. Half of the respondents (50%) said that something unexpected had happened during a vaginal access procedure. 44% said they had always felt able to stop a procedure at any point, while more than a third (36%) said they had not. Emotional impact, adjust
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Lily Rookes joined the community
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Open wounds and eyes that can't close - women warn about cheap bleph eyelid surgery
News article"Everyone made it out to be so easy, but my face felt like it was on fire and there was a horrible smell of burning skin," says Nikita Morgan, as she describes her eyelid surgery. She decided to get a blepharoplasty, or a "bleph", removing skin from just above the eyes - after seeing videos about it on social media. Even though she was given a local anaesthetic, Nikita felt extreme pain. Oculoplastic surgeons - doctors specialising in surgery around the eyes - say a concerning number of patients are reporting problems from cheap bleph surgery, typically carried out abroad. They have told the BBC the demand for this procedure, which normally costs thousands of pounds in the UK, has increased as part of a wider aesthetic trend to tighten, smooth and lift the face. Surgeons say complications have been linked to clinics across mainland Europe, Africa and Asia, and, when they occur, the lack of aftercare puts a burden on the NHS. UK surgeons have also told us they have seen patients unable to close their eyes properly after treatment abroad. Read full story Source: BBC News, 23 September 2026
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Hospitals given two months to put CCTV cameras in neonatal units
News articleTrusts have been told to fit CCTV in neonatal units by the end of November and to “urgently” tell staff and boards that child death protocols cover babies who never leave hospital. National chief nursing officer Duncan Burton and chief operating officer Sarah-Jane Marsh said in a letter to all local organisations on Tuesday that last week’s inquiry report was a “sobering moment”. Lady Justice Thirlwall reported on the events surrounding the murder and attempted murder of babies at the Countess of Chester Hospital Foundation Trust between 2015 and 2016, for which neonatal nurse Lucy Letby was convicted in 2023 and 2024. The letter said trusts should: Install CCTV cameras in neonatal units focused on storage fridges, cupboards or units by 30 November. Inform all relevant staff and the board about the Sudden and Unexpected Death in Children protocol by Monday 28 September (if the trust has a neonatal unit). Ensure all neonatal units meet requirements for access control and storage of insulin by 31 March 2027. Consider the Thirlwall report findings at their next public board meeting. Read full story (paywalled) Source: HSJ, 23 September 2026
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‘Ghost patient’ policy wrongly removing at-risk people from GP lists, doctors say
News articleAn NHS policy to remove “ghost patients” from GP lists is inadvertently leaving some of the poorest people in England without vital healthcare, analysis has found. Under previous NHS rules, inactive patients at risk of being removed from their GP practice were given six months to respond to outreach. But under NHS England’s accelerated list validation timeline, introduced last October, patients now have only three months to reply. According to analysis by Healthtech-1, registered GP lists in English practices declined by 483,019 patients between October 2025 and July 2026, with the most deprived fifth of practices accounting for about 138,400 of the net decline – just under 30% of the national decline. While GP lists need reviewing as people move away or die, GPs have said the accelerated timeline has inadvertently led to patients from deprived areas being incorrectly removed, creating barriers to receiving treatment. Consequently, GPs and practice managers have reported having to re-register vulnerable and elderly patients, creating an additional administrative burden. De-registering patients can also cause gaps in care and disruption to treatment. Read full story Source: The Guardian, 23 September 2026
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Charmaine Joy Clements joined the community
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Shyamala Manibalan joined the community
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olgasun joined the community
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Reflections on the National Commission into the Regulation of AI in Healthcare recommendations
Content ArticleIn September 2026, the National Commission into the Regulation of AI in Healthcare published its recommendations to the Medicines and Healthcare products Regulatory Agency (MHRA) for a future regulatory framework. The report contains around 44 recommendations, including staged authorisations, a rebalancing of evidence towards the post-market phase and financial penalties for manufacturers who put patients at risk. In this blog, Clive Flashman, Patient Safety Learning's Chief Digital Officer, shares his personal reflections on this. He sets out the five recommendations he most strongly supports, and five gaps that need addressing before the cross-government response is published. One of the key gaps is that the Learn from Patient Safety Events (LFPSE) service does not appear anywhere in the report's 119 pages.
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‘Investing in nurses’ confidence is an investment in patient safety’ (Nursing Times, 18 September 2026)
Content ArticlePatient safety is often discussed in terms of policies, protocols and clinical competence. While these are fundamental, they are only part of the equation. Safe nursing practice also depends on something less tangible but equally important: the confidence of the nursing workforce. Confidence enables nurses to question decisions, escalate concerns, seek support and advocate for patients. When confidence is undermined, safe practice is inevitably compromised.
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AI patient complaints: GPs and hospitals get advice after wave of algorithm generated letters
News articleHospitals and general practices across the country are asking patients to “describe their experience in their own words” amid a rise in overly complex AI written complaints. In new guidance, GPs have said that, although they understand AI tools such as ChatGPT can help patients organise their thoughts, they can also “make it harder for practices to understand what actually happened.” This is because AI tools can provide “incorrect information, add details that are not true, include laws, rules, or rights that do not apply, use language that is too formal or difficult to understand, or make your complaint longer than it needs to be.” Created by Gloucestershire Local Medical Committee (LMC) and shared across the country, the guidance reads: “You do not need to use legal words or quote laws or NHS rules for us to take your complaint seriously.” Similar advice has also been provided to hospital patients. Stockport NHS Trust told patients that “while there can be benefits to using AI, we encourage complainants to describe their experience in their own words wherever possible.” Although the trust “will not reject a complaint simply because it is complex or because AI has been used,” it has urged patients to keep their complaint “focused on the issues that matter most” to them. Read full story Source: BMH, 21 September 2026
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In short supply. Estimating the shortfall of registered nurses in the NHS in England (RCN, 22 September 2026)
Content ArticleA new report shows how England’s NHS could be short of at least twice as many registered nurses as first thought, as testimony from nursing staff shows how workforce shortages have led to fractures, delays to life-saving medication and brain bleeds. It includes new analysis of hospital trust board papers which reveals that hundreds of patient safety incidents are taking place each month linked to having too few registered nurses on shift. The report from the Royal College of Nursing found that despite the clear evidence of harm caused by too few registered nurses, the number of doctors has grown nearly twice as fast. Had nurse numbers grown at the same rate as doctors since 2009, England's NHS would have more than 77,000 additional nurses today. Overall, the analysis found that based on the increase in NHS activity since 2009, including admissions, attendances and appointments, the health service is actually short by an estimated 55,000 registered nurses to deliver care safely, more than double the official number of NHS vacancies, which stands at 23,046 as of August. Included in the report is an audit of recent trust board papers which shows that some hospitals are reporting hundreds of “red flag” patient safety incidents a month. These are safety reports arising from staff shortages including delays to pain relief, essential medication and missed care.
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ALS joined the community
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Safer Handling of Hazardous Medicinal Products: Pharmacy Practice and the Case for Change
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Hosted by the Safer Healthcare and Biosafety Network (SHBN), this webinar will explore the pharmacy practice and implementation challenges shaping Hazardous Medicinal Products (HMP) handling today, as well as the evidence and policy consensus needed to drive safer practice for the future. It will feature presentations from: Louisa Knowles, Advanced Pharmacist for Technical Services, University Hospitals Birmingham NHS Foundation Trust Joseph Williams, Vice Chair of BOPA and Lead Cancer Pharmacist, The Christie NHS Foundation Trust Louisa will draw on her experience in pharmacy aseptic services to introduce hazardous medicinal products and the role of closed system transfer devices (CSTDs) in reducing occupational exposure. She will discuss the risks associated with HMP handling in pharmacy, the evidence behind CSTD use, and the barriers that have limited their wider implementation. Joseph will address the policy and evidence environment shaping the case for change. He will discuss the recently published first edition of a multidisciplinary consensus document on safe management of HMPs, evidence from the SHBN’s HMP Roundtable, and feedback submitted to the Health and Safety Executive (HSE). He will also share what these developments could mean for future pharmacy policy and practice. This session is intended for nurses, pharmacists, oncology healthcare professionals, safety leads, educators and policymakers with an interest in the safe handling of hazardous medicinal products and the systemic changes needed to better protect the healthcare workforce. Sign up here. Webinar Safer Handling of Hazardous Medicinal Products Pharmacy Practice and the Case for Change .pdf -
Lowri Tonge joined the community
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Cut NHS red tape and boost productivity to prevent 20,000 early deaths a year in England, report urges
News articleThe NHS in England could prevent 20,000 deaths and save £33bn a year by cutting red tape and boosting productivity, a report says. Research by the Health Foundation found the health service has been held back for decades by excessive regulation, short-term planning and insufficient capability to deliver major change. But rewiring the NHS, the world’s largest single healthcare system, by harnessing new technology, empowering staff and increasing capital investment could save both lives and money, it found. There is “substantial scope to improve outcomes within the funding already available to the NHS”, which could result in up to four extra years of good health for people on average, the report said. In terms of where deaths could be prevented, focusing on diagnosing cancer earlier and finding people with high blood pressure or conditions such as diabetes quicker would be key, it added. The report called for a series of changes, such as releasing the NHS from unnecessary regulation, reporting and compliance tasks, as well as launching a “test-and-learn” approach to scaling up things that could improve productivity, such as use of artificial intelligence. “Our analysis suggests that if the NHS in England achieved outcomes closer to the best-performing comparable health systems, without spending more each year, it could potentially result in 18,500–20,600 fewer deaths each year from treatable causes and 2.5 to 4.5 additional years that people spend in good health on average,” the report said. Read full story Source: The Guardian, 22 September 2026
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Martha’s rule to be expanded to every A&E in England
News articleMartha’s rule, which lets NHS patients, staff and relatives request a review of their care, is being expanded to every A&E in England, health officials have announced. The system gives patients, their loved ones and health workers the right to ask for a different medical team to examine the care being provided on inpatient wards and to recommend changes. It has already potentially saved hundreds of lives, official figures show. Now it will be rolled out to every emergency department in England, including waiting rooms, offering “a critical new lifeline” to improve care and save more lives, NHS England said. The system is named after Martha Mills, 13, who died in 2021 from sepsis after a bicycle accident. A coroner found she would probably have survived if she had been moved to the intensive care unit at King’s College hospital in London when she began deteriorating. In the first 16 months of the scheme after its introduction in England in 2024, helplines received more than 10,000 calls, potentially saving 446 lives, figures show. Thousands of patients were either moved to intensive care, received drugs they needed or benefited from other changes as a direct result of the calls. In June this year, the initiative was expanded to every maternity and neonatal unit in England, giving women and parents the right to a second opinion about the care of a mother or baby. From this month, it will be expanded to A&E units. It means patients, loved ones and staff in busy emergency departments will be able to call a dedicated phone number to trigger an urgent review if a patient’s condition is deteriorating and they think their concerns are not being listened to. Read full story Source: The Guardian, 22 September 2026
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Investigations launched into potential harm at children’s service
News articleA major acute trust has launched two reviews over care failures potentially affecting 130 children, HSJ has learned. Nottingham University Hospitals Trust wrote to everyone on the list for its scoliosis service to inform them that it had launched an internal investigation and commissioned a separate external review. It said, “some patients may not have received the level of medical monitoring that we would expect whilst they were waiting for surgery.” In the letter sent on Friday, seen by HSJ, NUH chief operating officer Andrew Hall said the trust was “truly sorry”. It said it was not aware of specific concerns about their care, but was “seeking additional external reassurance”. In 43 of the cases, however, the trust said “immediate concern has been identified” – such as longer waits for monitoring – and in these “we have [already] reached out to those patients and their parents/carers to consider next steps.” HSJ understands NUH discovered that missed appointments may have been discovered at the end of last year, and the internal review took place earlier this year. However, it did not contact most of the families until nine months later. It has not explained the delay. It said it does not yet know the level of any harm caused. However, children whose scoliosis goes unmonitored risk deteriorating to the point where intervention becomes more complex. Read full story (paywalled) Source: HSJ, 22 September 2026
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We’re providing ‘pretty awful’ care, says CEO
News articleA hospital trust is providing a “pretty awful” standard of care, its interim chief executive has declared. The blunt statement was made by David Loughton – who joined University Hospitals of Liverpool Group in the summer – at a board meeting on Thursday. He said there had been “enormous progress” with partners to fix some of its clinical problems, which had to be addressed before financial gaps could be tackled. But he added: “I think you’ve got to take a cold, hard look at the quality we are providing at the present time, which is pretty awful.” Pressed for examples, he said six patients had spent a day in the discharge lounge before returning to a hospital bed on Tuesday night “because we cannot get non-emergency ambulances” to transport them elsewhere. He added: “I met in detail with the renal teams and some of the quality of what we’re providing to patients who are coming here three times a week for the foreseeable future [for dialysis] is really poor.” But he said: “The problem here is it is not down to this organisation. I’ve come into this, and I can freely say… the system leaves an awful lot to be desired at how it works together, or it doesn’t work together, and we’ve got to fix some of the problems in the community to impact in the hospitals.” Read full story (paywalled) Source: HSJ, 21 September 2026