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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.
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EventAny staff with responsibility for implementing the duty of candour and/or PSIRF and those responsible for quality; safety; clinical governance; safety investigations; complaints; CQC compliance; or patient experience/ involvement would benefit from attending this one-day training. The course will provide participants with an in-depth knowledge and understanding of how to not only comply with the duty of candour and the Patient Safety Incident Response Framework (PSIRF), but to do so in an emotionally intelligent way, with empathy and compassion for all involved. Practical guidance on complying with the regulations and guidance The “grey areas” and what people most often get wrong Using emotional intelligence to understand the difficult emotions experienced by patients/those closest to them and staff following patient safety incidents What empathy and compassion mean in practice Handling difficult and emotive conversations well Making a meaningful apology How Duty of Candour and PSIRF work alongside other policies and procedures including complaints; litigation; Martha’s Rule and the soon to be introduced “Hillsborough Law” How the new “Harmed Patient Pathway” can help you get it right 7 How to ensure communication moves beyond compliance and frameworks but remains emotionally intelligent and personal Register hub members receive 20% discount. Email [email protected] for discount code.
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EventA clear, factual walkthrough of what happened, where, and when — and how a patient safety concern became blurred, delayed, and distorted by a disciplinary process. Delegates will explore the key lessons from the NHS internal investigation and the emerging recommendations from the Thirlwall Inquiry, with a focus on whether similar vulnerabilities exist within their own Trust. What to expect: The Key Facts: What Happened, Where, and When How a Patient Safety Issue Was Blurred by a Disciplinary Investigation Key Lessons from the NHS Internal Investigation Key Lessons & Recommendations from the Thirlwall Inquiry Could This Happen in Your Trust? Who should attend? This course is open to Board members, Senior leaders, Patient Safety Specialists, Triumvirates, Safety and Governance Teams. Register hub members receive a 20% discount. Email [email protected] for code.
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EventThis practical masterclass introduces statistical process control in a clear, accessible and confidence-building way. Participants will learn how to understand variation, choose the right chart, interpret signals, avoid common mistakes and use SPC to support better improvement, assurance and decision-making. Healthcare teams are surrounded by data, but data alone does not lead to better decisions. Many services still rely on red, amber and green ratings, two-point comparisons, averages, rankings and narrative explanations that can obscure whether performance is genuinely changing. Statistical process control (SPC) offers a more useful way to understand variation over time, distinguish signal from noise, and decide when action is needed. This masterclass will demystify SPC for all attendees. It will explain the core concepts in plain language, using practical healthcare examples rather than mathematical theory. Participants will learn why plotting data over time matters, how common cause and special cause variation affect decision-making, when to use run charts, along with other chart types, and how to interpret process limits and rules for special cause variation. The session will link SPC to national expectations around improvement, productivity, quality, safety, operational performance and better use of data. It will support participants to move beyond simply producing charts towards using SPC as a practical tool for learning, improvement, assurance and leadership conversations. By the end of the masterclass, participants will be able to use SPC more confidently in improvement projects, service reviews, board reports and day-to-day management. This masterclass is aimed anyone who wants to use data for improvement and performance more effectively, including clinicians, operational managers, service managers, analysts, transformation leads, quality and safety teams, and executives and board members. It is particularly relevant for people who: Regularly review performance, quality, safety, access, flow, workforce or patient experience data; Support improvement projects or transformation programmes; Need to understand whether changes are leading to real improvement; Want to avoid overreacting to normal variation or missing important signals; Are involved in reporting data to teams, committees, executives or boards; Are new to SPC or have used charts but want greater confidence in interpretation. No advanced statistical knowledge is required. The session is designed for people who want SPC explained clearly, practically and without unnecessary jargon. Register hub members receive a 20% discount. Email [email protected] for code.
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News article
The United States government’s decision to block a major global declaration on pandemic preparedness “severely weakens” the effort, and signals intent to disrupt international cooperation, says Prof Lawrence Gostin, a leading expert on global health law from Georgetown University. The United Nations general assembly had been due to adopt a political declaration on pandemic prevention, preparedness and response on 25 September after a high-level meeting on the subject. The document would have seen countries agree to work together in solidarity to tackle global health threats and express concerns that the world remains unready to deal with future pandemics. However, the US delegate said it was “not in a position” to support the text, blocking its adoption by consensus – the UN process whereby negotiated documents are assumed to be agreed unless there is an objection. Dr Erica Schwartz, the director of the Centers for Disease Control and Prevention, said critical issues remained unresolved, referring to “the inclusion of divisive ideologies that lack definitional consensus” and references within the document to ongoing, WHO-led negotiations over the fair sharing of vaccines and drugs between countries in any future pandemic. It is understood that the Trump administration was unhappy with mentions of equity and universal access to sexual and reproductive healthcare services. Earlier this year, President Trump signed executive orders expanding a “global gag” rule that bans US aid recipients from work related to abortion to also include bans on diversity, equity and inclusion initiatives and what it called “gender ideology”. Read full story Source: The Guardian, 28 September 2026 -
Dbe3f6af03714338abe02f1454e271c3An important perspective on the future of patient experience intelligence. From a quality and patient-safety perspective, technology alone is not enough—its value comes from integrating data, patient voice, clinical workflows, and continuous quality improvement. The real opportunity is to move from fragmented feedback to actionable intelligence that helps healthcare teams identify gaps, prioritize improvement, and measure whether changes are actually improving patient experience and outcomes. Good infrastructure enables the journey; good design and strong quality governance create the value.
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PIxms joined the community
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EventJoin THIS Space 2026 to explore what works in healthcare improvement and innovation, what doesn’t, and why. Discover the latest evidence, share learning and connect with others committed to improving the quality and safety of healthcare. Evaluating AI for the NHS is there a better way? Patient and public involvement in digital transformation. Transgressive behaviour as a patient safety challenge. Improving governance of evaluation. Improving healthcare inclusively. ...and much more! Register
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News article
The winners of the HSJ Patient Safety Awards 2026 were announced last night, recognising outstanding efforts to make care safer. This year’s event attracted 427 entries, with 217 shortlisted across 25 categories. Categories included the Improving Medicines Safety Award, the Urgent and Emergency Care Safety Initiative of the Year, the Maternity, Midwifery and Neonatal Safety Initiative of the Year, and Patient Safety Team of the Year. The 25 awards span three broad areas: clinical and specialist excellence, organisation-wide change, and service and system innovation. They also include awards for digital clinical safety, surgical care, the use of data and analytics, and patient involvement. Opening the event, HSJ editor Alastair McLellan said patient safety had returned to the top of the health agenda over the past year, but warned the debate had focused overwhelmingly on maternity services. He said safety in emergency departments and acute wards was receiving less attention, with debate instead dominated by access and waiting times. He noted that long accident and emergency department waits, particularly those of more than eight hours, were strongly associated with increased mortality. Mr McLellan also praised those shortlisted for achieving improvements despite the pressures facing the NHS. He said work to prevent patient harm was not always welcomed amid unprecedented demand and the drive to recover performance, adding that the finalists’ achievements showed “what is possible in even the most unpromising situations”. Read full story (paywalled) Source: HSJ, 29 September 2026 -
News article
Hospitals are being hit by shortages of key drugs used to provide pain relief, prevent blood clots and tackle high blood pressure. Dozens of NHS trusts in England have encountered scarcities of aspirin, the painkiller co-codamol – a combination of paracetamol and codeine – and ramipril, a blood pressure tablet. Nine trusts have had problems getting enough supplies of two of those three common medications, while one ran short of all three. The shortages underline how precarious the health service’s supply chains for basic medicines have become in recent years as a result of trade disputes, global conflict and manufacturing problems. Pharmacists have said supply problems have become a “national crisis” and in some cases have left patients unable to access their usual medications for weeks at a time. Hospitals’ drug supply problems have emerged in freedom of information requests by Dr Rodolfo Catena, an expert in global health supplies at University College London, about stock levels of the three drugs. Sixty of the 184 trusts from which he sought figures responded. The most widespread shortage involved aspirin, which is used to reduce pain and the risk of blood clots. Twenty-six (62%) of the 42 trusts that responded about it had experienced disruption to their supplies between last December and March this year. Thirteen (31%) of the 42 trusts that replied on co-codamol had run short of that drug, which helps relieve muscle pain, period pain and toothache. York and Scarborough NHS trust’s supplies had been disrupted since May 2025, and Royal Wolverhampton NHS trust had trouble getting enough co-codamol for the 10 months between October 2025 and August this year. Read full story Source: The Guardian, 29 September 2026 Related 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) -
Content Article
Healthcare professionals frequently collect patient safety data, but many lack the knowledge and structured processes needed to interpret these data and translate findings into meaningful improvement actions. This gap results in underutilised opportunities to identify risks, apply evidence-based interventions, engage interdisciplinary teams, and measure impact. Addressing this gap helps the healthcare team more effectively use data to guide patient safety and quality improvement efforts. In this recorded webinar from the Patient Safety Authority, Andrea Atkinson, BSHCA, RRT, director of quality management; Christy Kitta, BSN, RN, quality and patient safety officer; and Ziad Dimachkie, MD, chief medical officer, all from Uniontown Hospital: Describe how patient safety data could be transformed into actionable insights to improve patient safety outcomes. Identify key sources of patient safety data and explained how each contributed to understanding safety gaps. Recognize strategies for engaging interdisciplinary teams and leadership in data‑informed patient safety improvement efforts. -
Content Article
The Sick List is a range of practical guides, made by patients, to help hospital stays, treatment days and recovery at home more comfortable and less stressful. The guides covers things from what eye masks help to actually block out hospital lights, to toiletries that will protect your dignity, to the random things no one tells you to pack in your bag but make a huge difference. If you're a patient about to go into hospital, or you know someone who is and would like to support them practically, this resource can really help. -
Content Article
Dominic Shadbolt, founder of PatientSignal and an multiple sclerosis (MS) patient of 35 years, has published a number of blogs on his Substack on AI in healthcare. -
Content Article
In this blog for the Parliamentary and Health Service Ombudsman, Paula Sussex writes about World Patient Safety Day. She says it is an opportunity to reflect on how we can make healthcare safer for everyone, and the importance of meaningful engagement with patients and families throughout their healthcare journey. -
News article
NHS England’s patient safety chief has said the service is having to “battle against a narrative” that it has not improved safety. Aidan Fowler, NHSE’s national director for patient safety, told HSJ’s Patient Safety Congress in Telford today that the narrative, which he described as “really challenging”, “sometimes says we haven’t made progress on patient safety when we know we have”. He said ministers had “understandably” wanted to suggest “everything that happened [during] the last government was terrible, and that includes some of the work that people here have done”. Dr Fowler said there “has been progress”, but this meant they “have to keep restating that, making the argument again”, which could “feel like quite hard work”. The NHS Patient Safety Strategy was launched in 2019, and the new NHS quality strategy published this summer suggested it would need another refresh in the near future. Dr Fowler admitted that some of this work, which has included changing the way the NHS responds to incidents through the Patient Safety Incident Response Framework, “is not very sexy”, so people have not heard about it. He added: “I get that if you try and explain to all our patients what PSIRF is, they’re going to struggle with [it], I understand that. “But I think that stuff has been foundational and important. We’ve created some bits of work that I think are really important, and we have made a difference.” The national director also stressed there was “of course much more to do”, and that improvement was a “continuous process”. Read full story (paywalled) Source: HSJ, 28 September 2026 -
Content Article
Is integrated patient experience intelligence finally possible in the NHS? Or will infrastructure without design leave us with expensive technology and limited value? For years, patient feedback has existed in frustrating fragmentation. Complaints sit in one system, surveys in another, Friends and Family Test (FFT) scores somewhere else entirely. All sit in a different system. None connected. No one recognises the patterns until harm has occurred. The infrastructure pieces needed to solve this are forming. The NHS Federated Data Platform (FDP) is operational. The NHS App is expanding. Patient Reported Experience Measures (PROMS) are being designed and validated. Large language models (LLMs) are proving capable of analysing unstructured feedback at scale. However, having these pieces available does not deliver integrated patient experience intelligence. That requires deliberate strategic design: decisions about what capabilities to build, data architecture purpose-fit for those outcomes, governance frameworks enabling appropriate uses, sophisticated analytical infrastructure, organisational change and sustained commitment. Ben Kenyon examines it all in this three-part series: Part 1 examines where we are today: the fragmentation challenge, why feedback sources don't connect and the safety signals we're losing as a result. Part 2 explores the infrastructure pieces now coming together: the FDP, NHS App and LLMs, and why deployment alone won't deliver integration. Part 3 shows -
Content Article
This guide from Taluvu looks at how to prepare for a GP appointment when there is a lot to explain. It covers: choosing the three things you would hate to forget gathering what you already know writing it down before you go rather than in the waiting room what to say in the first minute what to do if the words go and what to ask before you leave the room. Yesterday
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EventHealthcare is delivered through complex and constantly changing systems. Staff make difficult decisions while managing high workloads, interruptions, time pressures, new technology and competing demands. Human factors enables organisations to examine how these conditions interact with people, tasks, equipment, environments and organisational processes — and to redesign care so that safe practice is supported rather than dependent on individuals overcoming weaknesses within the system. The conference will also consider the growing human factors implications of electronic patient records, automation, ambient documentation and artificial intelligence. While digital technology can improve safety, productivity and access to information, poor usability, alert fatigue, automation bias and disrupted workflows can introduce new risks. Safe implementation requires technology to be designed around patients and staff, with frontline users involved in its design, testing and evaluation. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/a-practical-guide-to-human-factors-in-healthcare or email [email protected]. Follow the conference on X @HCUK_Clare #HumanFactors hub members receive a 20% discount. Email [email protected] for discount code.
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EventThis National Summit focuses on improving NHS complaints handling and supporting services to implement, embed and evidence adherence to the PHSO NHS Complaint Standards. The conference takes place at a critical time for complaints reform. The 10 Year Health Plan for England is clear that the NHS complaints procedure is far from where it needs to be, and commits to updating complaints regulations, setting clearer standards for the timeliness and quality of responses, improving response times, and increasing the use of AI tools to support faster collection and response to complaints data. For more information https://www.healthcareconferencesuk.co.uk/virtual-online-courses/nhs-complaints-summit or email [email protected]. hub member receive a 20% discount. Email [email protected] for discount code. Follow the conference on X @HCUK_Clare #NHSComplaints
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Content Article
People living with non-communicable diseases (NCDs) often require continuous, long-term care. However, in humanitarian contexts, conflict, displacement and other obstacles can disrupt access to healthcare. This complicates chronic disease management and compromises patient safety. In 2025, Doctors Without Borders/Médecins Sans Frontières (MSF) conducted 264,711 medical consultations for people with hypertension and 219,982 consultations for people with diabetes. In this blog we hear more about this work. -
News article
A coroner has issued an urgent warning that the failure to implement an emergency cardiac pathway could result in more deaths. Malcolm Budd, aged 65, was admitted to Royal Derby Hospital, part of University Hospitals of Derby and Burton Trust, in February with a suspected aortic dissection. This is a medical emergency in which a tear happens in the inner layer of the aorta, the body’s main artery. For a severe ‘Type A’ dissection – which requires emergency surgery – mortality increases by up to 2 per cent each hour without treatment. However, Mr Budd was not transferred to the specialist cardiac centre at Glenfield Hospital, part of University Hospitals of Leicester Trust, until almost 8.30pm, eight hours after he was first admitted to Royal Derby. NHS England published a Standard Operating Procedure and a toolkit which aimed to standardise and improve aortic dissection pathways in 2022. This has been implemented in other parts of the country but not the East Midlands. Dianne Hocking, assistant coroner for Leicester City and South Leicestershire, has now issued a Prevention of Future Deaths (PFD) notice in relation to this issue. The PFD was issued before the inquest into Mr Budd’s death begins next month due to the urgency of the coroner’s concerns. Read full story (paywalled) Source: HSJ, 28 September 2026 -
Content Article
A Pre-Inquest Review Hearing took place on the 21 July 2026 which heard that Mr Budd died on the 24 February 2026 aged 65 years. He was admitted to the Royal Derby Hospital on the 24 February 2026 at 12:26. He presented with sudden onset left sided jaw pain which radiated to the occipital region and thoracic spine. Suspecting aortic dissection or subarachnoid haemorrhage a CT scan was requested along with a D Dimer at 15:55. He was diagnosed with an aortic dissection following CT scan at 17:45 (reported at 18:03). There was discussion between the Year Two Foundation doctor and the on call cardiac surgeon in Derby. University of Hospital Nottingham cardiac team were contacted who confirmed that they were unable to deal with this type of surgery and Derby was advised to contact Glenfield who agreed to have Mr B admitted for surgery. Adult Critical Care Co-Ordination and Transfer Service (ACCOTS) was contacted and transferred Mr B to Glenfield Hospital, Leicester, arriving at 20:26 in ventricular fibrillation from which he could not be recovered and died at 20:45 despite resuscitation attempts. -
Prashant joined the community
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Content Article
This report explores the experiences of Black women who experienced mental health difficulties during pregnancy and after birth, and what happened when they needed support. These findings come from the mental health questions included in the 2025 Five X More Black Maternity Experiences Survey. It looked specifically at the experiences of 527 Black women who reported experiencing mental health difficulties, to better understand their experiences of accessing support and receiving care. Free registration required to access this report. -
News article
A friendly chat with your GP about your life, health and happiness was once a key part of the UK’s family doctor service. But most GPs no longer have time to have pastoral conversations, because they are too busy dealing with the country’s rising tide of illness, research reveals. Three out of four family doctors are now too time-pressed to talk to patients in depth about how they might stop smoking, lose weight or get more sleep, the Royal College of GPs has found. Intense demands and 10-minute appointment slots mean they also miss opportunities to discuss taking more exercise or review their medications to see if they still need to be on them. An RCGP survey of 2,316 GPs across the UK found that 75% had too little time to offer preventative healthcare, such as offering lifestyle advice and giving advice on vaccinations. The results have raised concern about the government’s drive for the NHS – especially GPs – to do more to prevent people getting ill in the first place. One health expert called them alarming. The college’s president, Prof Victoria Tzortziou Brown, who is a GP in east London, said: “General practice is dealing with enormous demand, so in a busy consultation we inevitably have to prioritise the problems that most need our attention that day. “We will always act on symptoms or findings that need investigation or treatment. What can be squeezed out is the time to step back and look more holistically at how we can help that patient stay well in the long term. “That might mean having a proper conversation with someone who smokes. We will of course advise patients about stopping smoking. But in a busy consultation there may not be enough time to explore in depth whether they want to stop, what has made it difficult in the past, what concerns they have and what support or treatment might work best for them. “It is often the depth of those conversations, rather than simply identifying a risk and giving brief advice, that requires time.” Read full story Source: The Guardian, 27 September 2026 -
News article
Ten NHS staff have been removed from duty or suspended after a data breach involving the digital medical records of three-year-old Noah Woods. Launching an "urgent" investigation, Dr Martin Mansfield, deputy chief medical officer at East Suffolk and North Essex NHS Foundation Trust, said that any unauthorised access of patient data was "completely unacceptable". The trust has apologised "unreservedly" to Noah's family and said disciplinary action would be taken if needed. A major search for Noah was carried out in the village of Brantham, Suffolk, after the child went missing on 15 September. His body was found the next day in a nearby pond by police divers. A spokesperson for the trust said 10 employees had been "removed from active duty or suspended whilst investigations are concluded". It comes after Sir Jim Mackey, the chief executive of NHS England, wrote to every trust on Friday, ordering stronger measures to tackle data breaches. "We have seen too many cases of people abusing that trust, and enough is enough," said Sir Jim. "Anyone who thinks they can satisfy their curiosity by looking at a patient's record should know this: they will be found out, they may lose their career and could end up with a criminal record." Read full story Source: BBC News, 27 September 2026
