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Dr Ahmad Zia joined the community
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News article
A mental health trust in east London, where a man was killed by a fellow patient, has been warned further deaths may occur unless staff issues are addressed. Hugo Flint Cahan, 34, was strangled by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre, which provides care for acutely mentally ill men, in January 2023. The coroner has sent a report to the Trust and NHS England raising serious concerns about the care the two men received. It follows a six-day inquest in September during which the senior coroner for east London, Graeme Irvine, concluded that neglect had more than trivially contributed to Cahan's death. On the night of Cahan's death, staff on the ward were found to have been asleep on the job and on their phones for long periods. East London NHS Foundation Trust (ELFT) says the failings identified were "wholly unacceptable" and that it has undertaken a "significant programme of work" to improve inpatient services. The coroner's Prevention of Future Deaths report highlights 14 concerns. These include failing to carry out "timely and thorough observations" of patients, then falsifying records "in the safe knowledge that staff on duty would not report or escalate the deception". The document also says there were delays in starting CPR on Cahan when he was discovered, that staff misled the police as to what the patients had been doing on the night of the incident, and that staff colluded with each other to take two-hour unauthorised breaks. Read full story Source: BBC News, 2 October 2026 -
News article
NHS England intends to “improve operational grip” on GP performance and has warned it may lead to “contractual action”. NHSE board papers reveal it is introducing “a range of actions” designed to “strengthen” its confidence in improved primary care performance. The actions include: “Agreeing local improvement trajectories and recovery plans where required; [and] disseminating best practice from high performers.” Individual practices will receive “tailored letters” detailing their performance and stressing the “potential for contractual action” should they fail to meet required standards. The 2026-27 GP contract requires practices to deal with all patients they identify as being clinically urgent on the same day. NHSE has set a national target of 90%, first announced in the medium-term planning framework in October 2025. The subsequent neighbourhood health framework said the NHS aimed to achieve this by March 2027. No integrated care board area is currently reaching the target. Practices themselves decide which patients are clinically urgent. NHSE guidance says this is “a prospective judgement made on the basis of the information available at the point of first assessment”, rather than a retrospective one. Read full story (paywalled) Source: HSJ, 2 October 2026 -
Content Article
The Patients Association hear often from patients and their loved ones that the care they receive is not what they had hoped for, that something has gone wrong, or that they are now unsure where to go from there. In this blog the Patients Association reflects on the slogan ‘Safe care for life’ for this year's World Patient Safety Day. -
Content Article
Doug Woodcock and Marieke Emonts share Newcastle upon Tyne Hospitals' Family Health Board governance improvement journey. -
News article
NHS England’s internal whistleblowing champions have raised concerns that the organisation is bringing in staff “without due process”. The body’s Freedom To Speak Up annual report, to be discussed at its board meeting today, highlighted concerns that individuals were being appointed “without any formal process or job description, which the [FTSU] panel escalated to HR for investigation and response”. It added: “The panel remained concerned about the level of corporate assurance relating to awareness of these workers, and the impact on existing teams of bringing them into NHSE without due process. As such, the panel viewed this as a governance matter that should be visible to the board.” NHSE introduced a “consistent route” for recording new joiner details in summer, the report said. The FTSU report for 2025-26, by chief operating officer and FTSU lead Sarah-Jane Marsh, also found: Staff facing “bullying, harassment, or psychological abuse” from their managers and a “lack of support” from leaders when they speak up. Concerns raised about “adherence to HR policies”. Leaders’ engagement with FTSU had “notably reduced” following the announcement NHSE would be abolished. Read full story (paywalled) Source: HSJ, 1 October 2026 Further reading on the hub: Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Key themes emerging from our ‘Speaking up for patient safety’ interview series -
Content Article
Organisations across health and care are using and experimenting with AI to solve problems in clinical and non-clinical settings. This includes redesigning workflows, reducing pressure on staff and existing NHS services, and improving patient experience. Some organisations are also using larger-scale AI technologies from the likes of Microsoft and Anthropic to develop agentic AI solutions for more complex problems. Agentic AI refers to systems that can carry out tasks or workflows with a degree of autonomy while operating within defined rules and human oversight. The King's Fund brought health and care leaders together to reflect on the opportunities, risks and practical realities of adopting agentic AI across services. -
Dr Taimoor Ahmed joined the community
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Content Article
Coroners have warned public bodies six times in three years about the threat medicine shortages pose to patients. The Pharmaceutical Journal looks at the deaths behind those warnings and what pharmacists and patient groups say must change. Further reading on the hub: Creon shortages: “It’s just another thing patients with cystic fibrosis could do without” Medication supply issues: A pharmacist’s perspective Medicines shortages: minimising the impact on patients (a blog by Catherine Picton) Yesterday
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Camelia joined the community
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News article
The National Counselling and Psychotherapy Society (NCPS) has launched a campaign calling on the government to guarantee choice of therapist in NHS mental health support, warning that people who don't respond to NHS Talking Therapies currently have nowhere else to turn unless they can pay for therapy privately. The campaign, ‘Lost for Words’, comes ahead of the government's Mental Health Strategy for England, due to be published this autumn. NHS Talking Therapies is the main mental health service available through GPs in England, and for many people it works well. But NCPS analysis shows the scale of the gap for those it doesn't reach: Of the 1.8 million referrals made every year, only 19% result in reliable recovery. Just 37% of people referred complete a full course of treatment, meaning 63% drop out before finishing. Even among those who do complete treatment, only 50.5% reliably recover (hovering around or under this figure year-on-year). Meg Moss, Head of Public Affairs and Advocacy at NCPS said: "Getting therapy that works shouldn't depend on your ability to pay for it. There are more than 75,000 trained, accredited counsellors and psychotherapists working in the UK right now. The question isn't whether the support exists. The question is who gets access to it." Dr Djalil Baiou, GP, Trentside Medical Group “While NHS Talking Therapies provides an important service, having access to an in-house counselling service gives patients an additional and genuinely different therapeutic option. In particular, the counselling approach provides an alternative to the predominantly CBT-based interventions that patients may have previously experienced or that may not suit their individual needs or preferences. We regularly see patients for whom a less structured, more exploratory form of talking therapy is valuable, and having greater choice allows psychological support to be better tailored to the individual rather than relying on a single therapeutic model”. Read more Source: The National Counselling and Psychotherapy Society -
Anita Kataria joined the community
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News article
ADHD UK has threatened legal action against an NHS organisation over its decision to impose a minimum two-year wait for attention deficit hyperactivity disorder and autism assessments. In a legal letter to West Yorkshire NHS integrated care board (ICB), seen by the Guardian, the charity alleges that the decision to force patients to wait at least two years for such assessments was unlawful and says it will seek a judicial review if the board fails to reverse the policy. West Yorkshire ICB introduced the two-year minimum wait this year, affecting thousands of people with possible ADHD or autism in Leeds, Bradford, Kirklees, Calderdale and Wakefield. West Yorkshire is not the only ICB to ration access to assessment for neurodiversity. The Guardian revealed last week that it was one of four – alongside Devon, Somerset, and North East and North Cumbria – to have imposed minimum waits amid spiralling costs due to the volume of assessments being sought. A further 11 have introduced other mechanisms to ration the number of assessments. ADHD UK claims West Yorkshire failed to follow correct procedures, alleging the ICB breached equalities legislation, denied patients their legal right to choose non-NHS care, failed to involve patients, carers or the public in the decision, and that the decision ran counter to NHS contract regulations. Read full story Source: The Guardian, 1 October 2026 -
News article
Two porters who won an employment tribunal against the Countess of Chester Hospital Trust said their victory shows whistleblowers are "still penalised". Last month, the trust said its culture had "improved" after the Thirlwall Inquiry found former bosses had "intended to punish" doctors who raised concerns about nurse Lucy Letby. A tribunal this year found porters John Crayton and Thomas Jones had been "inappropriately interrogated" after raising concerns about the way deceased patients were transported. The pair said the ruling showed they had been "unlawfully victimised". The trust said it accepted the tribunal's findings but "encourages all colleagues to speak up". The porters raised concerns in 2024 that they were having to transport "exposed" bodies that were not in body bags, which they said posed an infection risk. They said there was no protection for their forearms because of the trust's policy that staff had to be bare below the elbows. Crayton claimed there was a risk of "psychological damage" from transporting bodies showing "signs of a traumatic death". The tribunal in Manchester found the pair had been "inappropriately interrogated" by their line manager after a senior mortuary worker identified them as the possible authors of a whistleblowing complaint submitted anonymously through the trust's Freedom to Speak Up policy. It heard their line manager questioned them and other porters in an attempt to "get to the bottom of who had broken the chain of command". Read full story Source: BBC News, 1 October 2026 Further reading on the hub: Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Key themes emerging from our ‘Speaking up for patient safety’ interview series -
News article
The NHS’s success in driving down the cost of drugs has meant fewer medicines are available for patients, a government minister has admitted. Chris McDonald, minister for science, innovation and investment at the Department and Health and Social Care and the Department for Business, Innovation, Science and Trade, said: ”If you do an international comparison, the NHS runs extremely lean… it does a huge amount with its budget. “But the consequence of that is, we’ve heard the NHS is world leading in driving down the cost of pharmaceuticals, and as a result there are a number of pharmaceuticals we don’t have available on the NHS.” The NHS has historically been regarded as a world leader in pushing down the cost of medicines, although industry groups have said the UK lags behind other comparable nations in access to new ones. The government has committed to doubling the NHS spend on new medicines to 0.6 per cent of GDP by 2036, as part of a wider UK-US trade deal. The share of the NHS budget going on drugs will also rise from 10 per cent to 12 per cent, according to the agreement. Under the plans, the cost-effectiveness threshold used by NICE (the National Institute for Health and Care Excellence) to evaluate whether to adopt new medicines has been lowered, meaning more drugs will be approved. The move has been welcomed by industry but has faced criticism from MPs and think tanks over concerns that it will divert funding from existing NHS services. Read full story (paywalled) Source: HSJ, 30 September 2026 -
Rachel Corrner joined the community
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News article
An NHS trust has apologised after an independent review found that eight babies might have survived with better maternity care, admitting it has "failed families". The stillbirths all occurred at the East Kent Hospitals NHS Trust's hospitals between June 2025 and March 2026. An independent review ordered by the trust found systemic issues lay at the heart of the failures. These included failures to manage high risk pregnancies, provide appropriate triage, identify foetal growth concerns, and make appropriate use of interpreter services. Since the report, a further seven stillbirths have occurred, including three last month. A review into those deaths has now been ordered. All the stillbirths occurred after 34 weeks gestation. Papers for a board meeting on Thursday contained a report by the acting CEO of the trust, Dr Des Holden, who apologised to the families involved. Dr Holden wrote: "On behalf of the board, and personally, I am very sorry and apologise to the women and families, and their communities, where failings in our care are at the heart of these devastating outcomes." The board papers contained a further report, headed Response to the Independent Stillbirth Review, which said four cases were assessed as having care deficiencies likely to have affected the outcome for the baby. In a further four cases, care issues were identified that may have contributed to the outcome. The review found "recurrent and systemic weaknesses in the management of high-risk pregnancy, foetal surveillance, maternity triage, escalation and organisational learning", documents said. Read full story Source: BBC News, 30 September 2026 -
Content Article
In this blog, Naomi Fulop, board member of Covid-19 Bereaved Families for Justice and Professor of Health Care Organisation and Management UCL, argues that although the UK Covid-19 Inquiry has exposed serious systemic failures around the procurement of personal protective equipment (PPE), meaningful accountability remains largely absent. She says that the Covid-19 Inquiry’s findings on the Government’s High Priority Lane, or 'VIP Lane', reveal a procurement system that was biased, poor value for money and harmful to the pandemic response. -
Dr Sardar Imran joined the community
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Content ArticlePatient Safety Learning posted an article in Medicines and Healthcare products Regulatory Agency (MHRA)
The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines, medical devices and blood components for transfusion in the UK. This roundup provides a summary of their latest safety advice for medicines and medical device users. It includes details of medicine recalls, medical device field safety notices and details of how to report drug reactions and device incidents. -
Content Article
The Covid-19 Bereaved Families for Justice has created a tracker to monitor the UK Government’s progress in implementing the recommendations of the Covid-19 Inquiry. Experience of previous public inquiries into healthcare scandals over the past 30 years shows that shockingly few recommendations are ever fully implemented, in part because there is too little pressure on ministers to follow through. This tracker is designed to change that by scrutinising the Government’s response, exposing delays and failures, and ensuring ministers are held to account. It provides an assessment of actions taken in response to each recommendation and will be used to apply maximum pressure on the Government to deliver the changes needed to prevent the mistakes of the pandemic from being repeated. You can click on each module to see a detailed assessment of each recommendation. Separate assessments of actions taken by the devolved administrations will be published in late 2026. -
Content Article
In this blog for World Patient Safety Day 2026, Kim Ball, Jane Ball and Rose Gallagher share what this year's theme means to nursing from their perspective, through the lens of prevention, safe staffing, and sustainability. Last week
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Zee Parveen joined the community
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Jode joined the community
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News article
The government is rolling out a Healthy Babies programme to every local authority in England, as part of its efforts to expand a Sure Start-type system of help for deprived children and families. It aims to support parents with infant feeding, their mental health and building strong bonds with their babies, alongside health visits, midwifery care and wider services. The scheme seeks to follow the principles of Sure Start, a network of centres offering integrated services for the under-fives and their families, launched in 1998 under a Labour government. Sure Start was seen as one of that government’s major successes, with one study saying it generated longer-term savings worth twice the system’s cost. But much of that scheme was dismantled amid massive spending cuts by the Conservatives. The new policy of family hubs will commit £500m to opening 1,000 centres from April 2027. Announcing the expansion of the Healthy Babies programme at the Labour conference in Liverpool, Yvette Cooper, the Health and Social Care secretary, is expected to say that the programme will reach up to 1,000 family hubs over the next two years. Since the election the Labour government has opened new family hubs across England, but more than half of local authorities have hubs without Healthy Babies services. “Something is missing in half of communities … the Healthy Babies services – mental health support for mums and dad, the feeding and bonding support for your new baby. That changes now,” Cooper will say. “We will bring back the Sure Start health services into every family centre. One of the Labour party’s greatest achievements, restored to families throughout the land.” Read full story Source: The Guardian, 30 September 2026 -
News article
Details of the serious concerns raised by the Care Quality Commission about the collapsing Humber Health Partnership hospital group have been uncovered by HSJ. The regulator served section 29A warning notices on group members Hull University Teaching Hospitals Trust and Northern Lincolnshire and Goole Foundation Trust in July in response to ongoing patient safety concerns. The warning notices, which have now been seen by HSJ, show the CQC is unhappy with the rate of progress achieved by the group. This was “insufficient due to the scale of work required”, and meant “patients remained at risk of harm”. A review of serious incidents undertaken by the watchdog found “limited evidence” that learning was taking place, with the same factors “repeatedly” identified. These included staffing pressures and inconsistent policies, particularly on medicines management. The group was also criticised for its poor record on infection control. The CQC said these failings were “part of a longer-term pattern, with little evidence of improvement over time”. Read full story (paywalled) Source: HSJ, 29 September 2026 -
News article
The chair of a major public inquiry has admitted they are often “hugely expensive”, time-consuming, and popular with politicians who are keen to pass the buck to the next minister. Tom Kark KC, who recently completed the Muckamore Abbey Hospital Inquiry into serious abuse at a Belfast mental health unit, told HSJ’s Patient Safety Congress in Telford today that such probes address a clear public need, but typically do not give bereaved families closure. He also questioned why once the chair’s job is finished, they relinquish any power over their recommendations, and how they are implemented. The leading lawyer, who was also chief counsel to the Mid Staffordshire public inquiry and carried out a review of the Fit and Proper Person Test (FPPT), warned in addition that the government’s plan to regulate managers must not become a “weapon or a stick to punish poor performance”. Mr Kark told the event: “When something goes wrong, particularly in the NHS… there is very often a knee-jerk reaction to set up a public inquiry. Politicians in general quite like public inquiries because generally, by the time a public inquiry is reported, that [politician] has gone, and it’s the next one’s problem. “There is certainly a problem about the timing of public inquiries and how long they take. We [Muckamore] actually took four years, and we were regarded as being extremely rapid… and that tells you something.” Read full story (paywalled) Source: HSJ, 29 September 2026 -
Content ArticleAnonymous posted an article in Florence in the Machine
Martha’s Rule gives patients and families a vital way to escalate concerns when they believe a patient’s condition is deteriorating and they are not being heard. However, increased awareness of Martha’s Rule has also led to more calls about complaints, waiting times and other issues outside its intended scope. In an anonymous blog, a critical care outreach nurse in an acute NHS Trust explains why, as the scheme expands, the NHS must preserve its patient-safety focus by setting clear expectations, providing suitable routes for other concerns and supporting staff who handle difficult calls. -
Content Article
In an era of patient-centred care and growing concern over misconduct in medical settings, why do women still lack the right to choose women consultants for examination and treatment? Equality legislation has resulted in significant improvements in the workplace for women, both in terms of pay and career paths albeit with some way still to go. It is startling, however, just how primitive our society remains in respect of the treatment of women in other areas of their lives. This article from Charles Davey addresses one of these areas – medical care, specifically the right for women to elect examinations and care by women medical practitioners. -
Content Article
To mark World Patient Safety Day and the 2026 theme of ‘Safe care for noncommunicable diseases’, the Royal College of Surgeons of Edinburgh (RCSEd) has produced a series of blogs. Operating as One to Deliver Safe Care for Life Focus on Rare Congenital Conditions Transforming Transition & Lifelong Outcomes Safety Hurdles of the Head and Neck Cancer Pathway - Safe Care Strategy Safe Surveillance is a Systems Issue Patient Safety in Cardiac Surgery is a Team Game Patient Safety in Major Joint Replacement Surgery How Could You Have Forgotten My Catheter Doctor, I Haven't How Metabolic Bariatric Surgery is Changing How We Can Prevent, Repair and Learn -
Content Article
The concepts and arguments in this article use multiple sclerosis (MS) as an example (I have had it for 35 years), but they can be applied across many diseases. MS patients are handed detailed, formalised information about the risks of taking a drug and vague, inconsistent, information about the risks of leaving the disease untreated or undertreated. This opinion piece argues that the imbalance distorts decision-making, often in the direction of delay, and that the usual justification (not wanting to frighten people) makes the problem worse. It asks who is actually placed to assemble long-term comparative data on delayed and low-efficacy treatment, names registries and industry as the candidates, and sets out what a patient-facing 'disease risk sheet' would need to contain. Speculation is labelled as such. It ends with a direct challenge to anyone working in MS research, registries, charities or industry to say whether such a dataset already exists. Read it if you work on treatment decision support, risk communication or registry outputs, or if you want the case for why the current comparison is not a fair one. This article was first published on LinkedIn on 14 January 2026. -
EventThis conference brings together leading experts and experienced NHS practitioners to provide a practical guide to embedding Martha’s Rule across hospital services. The conference will examine the caregiver’s perspective, implementing the three core components, communicating effectively with patients and families, and overcoming cultural and operational barriers. The programme will explore how to embed the Patient Wellness Question into routine care and ensure concerns are recorded, reviewed and acted upon. Delegates will consider how to use the six core standards to assess reliability, identify gaps and provide assurance to senior leaders. The conference will also focus on using Martha’s Rule data to understand outcomes, identify variation and improve wider deterioration and escalation systems. Legal, governance and human factors considerations will be discussed, including independent rapid review, documentation, psychological safety and responding constructively when concerns are escalated. Martha’s Rule forms part of the wider national approach to managing acute physical deterioration through prevention, identification, escalation and response—the PIER approach. The day will include interactive case discussions and practical exercises to support delegates to translate national requirements into reliable everyday practice. This conference will enable you to: Reflect on Martha’s story and the importance of listening to patients, families and carers. Understand the three core components of Martha’s Rule and the March 2027 implementation requirement. Embed the Patient Wellness Question into routine care and escalation processes. Use the six core standards to assess reliability and identify areas for improvement. Communicate Martha’s Rule clearly and ensure equitable access. Use implementation data, feedback and outcomes to drive improvement. Understand key governance, legal and human factors considerations. Develop a culture where patients, families and staff feel able to raise concerns. Integrate Martha’s Rule with existing deterioration pathways and the PIER approach. Support continuing professional development and provide evidence for revalidation. Register hub members receive a 20% discount. Email [email protected] for discount code.
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EventA different approach to Structured Judgement Reviews (SJRs); using them as a triage tool and avoiding the use of poor and very poor to better align with PSIRF. This course looks at moving SJRs away from questions of avoidability of harm and instead looks at how they can be used to determine what type of learning response should follow a patient’s death. The explicit judgements of poor and very poor that are in traditional SJR models are no longer helpful and delegates will be provided with updated and positive alternatives that focus on organisational learning. Who should attend Healthcare professionals tasked with deciding on an appropriate learning response following the death of a patient. Healthcare professionals who undertake Structured Judgement Reviews who wish to align these with PSIRF principles. Key learning objectives Where SJRs fit in the overall clinical governance structure of their organisation, why they are being conducted and what questions they are designed to answer How to organise case notes for effective review; use of timelines What other sources of evidence to consider Making explicit judgements around quality of care; evidence base and standards used When and how to escalate potential issues with professional conduct Register hub members receive a 20% discount. Email [email protected] for discount code.
