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EventWhen teams are facing pressure and uncertainty, finding time for open conversations can be difficult. This session explores how listening to staff, understanding their experiences and acting on their feedback can support learning and everyday improvement. Attendees will hear reflections from Lara Mott at ImproveWell, followed by a focused exploration of maternity data, emerging patterns and what these mean for teams on the ground. The session will offer practical ways to encourage staff voice and use insights to inform improvement. What you will learn: Why communication becomes even more critical during periods of pressure and uncertainty How to support staff voice and encourage open, honest conversations What maternity data is revealing about current challenges and trends How to use data insights to inform learning, improvement, and decision making It is particularly relevant to Directors and Heads of Midwifery, Neonatal Leads, Maternity Governance Leads and senior clinical leaders. Attendees will also receive our Creating the Conditions for Safer Maternity and Neonatal Care guide and a Maternity Data Snapshot summarising the session’s key insights. Registration link: https://meet.zoho.eu/wujc-ufm-fro
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Content Article
Evidence is limited on how people experience government-commissioned inquiries, what they value about them and the impacts of procedures. This study applies realist logic to examine the experiences of those designing and participating in a government-commissioned restorative approach to harm associated with surgical mesh use in Aotearoa New Zealand. Attention is paid to divergent perspectives about harm and responsibility, desired outcomes, and the multiple identities that shaped people's responses to the programme. -
EventThis virtual conference focuses on the role of the Coroner, the coronial investigation and inquest process, and preparing effectively for a Coroner’s Inquest. The conference will provide an important update on current developments in the coroner system, including the impact of the statutory Medical Examiner system and Death Certification Reforms on referrals, investigations and learning from deaths. The conference will explore the Coroner’s investigation from notification and referral through to the inquest, preparing witness statements and giving evidence, supporting staff involved in proceedings, and understanding what families want and need from the process. Practical sessions will provide an opportunity to understand how an inquest works in practice and develop confidence in preparing for and attending Coroner’s Court. Following the introduction of statutory Medical Examiner scrutiny, all deaths in England and Wales now undergo independent review either by a Medical Examiner or through investigation by a Coroner. Emerging national evidence suggests that the reforms are leading to fewer unnecessary referrals to coroners and more appropriate use of the coronial process. The conference will examine how Medical Examiners, Coroners, patient safety teams and clinical governance functions can work effectively together to identify concerns and ensure learning leads to improvement. The conference will also consider how organisations manage PSIRF learning responses, complaints, claims and coronial investigations in parallel. HSSIB has highlighted that coroners’ expectations can influence organisations’ choice of learning response under PSIRF, demonstrating the importance of clarity around the different purposes and requirements of patient safety learning and the coronial process. There will be a strong focus on learning from deaths and Prevention of Future Deaths reports, including identifying themes, responding effectively within the required 56-day timeframe and ensuring recommendations and concerns result in demonstrable and sustained improvement. Delegates will also be updated on the developing Public Office (Accountability) Bill, widely known as the Hillsborough Law. The Bill proposes a statutory duty of candour and assistance for public authorities and public officials engaging with inquests, inquiries and investigations, alongside provisions designed to improve the participation and representation of bereaved families. This conference will enable you to: Understand the role of the Coroner and current developments in the coroner system Understand notification and referral of deaths and when a Coroner has a duty to investigate Examine the impact of the Death Certification Reforms and statutory Medical Examiner system Understand the relationship between Medical Examiners, Coroners and organisational learning from deaths Reflect on a family’s experience and understand what bereaved families want from a Coroner’s investigation and inquest Understand the Coroner’s investigation, the scope of an inquest and the role of Interested Persons Develop your skills in preparing for an inquest, including writing witness statements and giving evidence effectively Learn from the experience of Coroners and healthcare professionals who have attended Coroner’s Court Improve support for staff before, during and following an inquest Understand how PSIRF learning responses, complaints, claims and coronial investigations can be managed effectively in parallel Explore openness, candour, disclosure and the implications of the developing Public Office (Accountability) Bill/Hillsborough Law Understand Prevention of Future Deaths reports, the 56-day response requirement and current Chief Coroner arrangements Identify key strategies for learning from deaths and ensuring findings lead to sustained improvement Understand how learning from mortality reviews, Medical Examiner scrutiny, patient safety responses and bereaved-family concerns can be brought together Reflect on your own practice and identify areas for improvement Support CPD professional development and provide evidence for revalidation. This conference provides 5 hours’ training for CPD, subject to peer group approval for revalidation purposes. Register
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News article
Under fire health chiefs were accused of prioritising the environment over patient safety at a deadly superhospital. The Queen Elizabeth University is being probed by an Inquiry which is set to make its conclusions in the coming months, and has been labelled "safe" by John Swinney and Angela Constance. NHS Greater Glasgow and Clyde's (NHSGGC) handling of the scandal is being scrutinised, with officials accused of mistreating whistleblowers who raised concerns about the near £1bn Glasgow premises. Opened in 2015 "before it was ready," the construction was botched amid issues with the ventilation and water systems. The Crown Office is probing potential corporate homicide over seven deaths linked to the building, including children. Patients and families still fear the QEUH is not safe, with the ventilation in some key rooms, housing the most vulnerable patients, still not at recommended levels. A Times story quoted expert Andrew Poplett, who has conducted audits of the building and is an engineer specialising in healthcare ventilation. The recommended number of air charges per hour for healthcare settings is six, but at the QEUH most rooms had a system that delivers two to for an hour. He said that while the air cooling system at the QEUH was good for reducing greenhouse gas emissions, it did not meet health standards: "It appeared that the environmental consideration to make the hospital as energy efficient and as green as possible took priority over the clinical requirement." Still to this day, not all wards at the hospital have been independently verified, with the bone marrow transplant ward being replaced due to safety concerns after mould and water ingress were reported. Rooms in the Royal Hospital for Children reported similar issues, as well as problems with the water supply. Read full story Source: Scottish Daily Express, 11 October 2026 -
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Improving medicines data across health and social care is the focus of this year’s PRSB AGM, with Dr Melanie Ivarsson, CEO of the Health Data Research Service (HDRS) as the keynote speaker. Melanie has a background in neuroscience research and medicines development and led the creation of Moderna’s mRNA vaccine against Covid-19. Register -
News article
A doctor has been accused of examining patients with blood-stained gloves. Dr Syeda Siddiqui is due to face a misconduct tribunal after being investigated by the General Medical Council (GMC), which regulates the register of doctors able to practise in the UK. Dr Siddiqui is alleged to have examined two patients on 7 August 2024 at the Community Health and Eyecare Ltd Clinic (CHEC) in Warrington, Cheshire, with non-sterile gloves contaminated with the blood of a previous patient. She also faces a similar allegation that she examined a patient at CHEC's Stockport clinic on 10 December 2024 with non-sterile, contaminated gloves. Dr Siddiqui had been carrying out "minor operations" on other patients prior to the incidents outlined. The GMC also alleged that Dr Siddiqui, who qualified from the University of Manchester in 1984, collected used, non-sterile equipment to take home. A notice of the hearing stated the doctor claimed that it was "normal practice" at another CHEC branch when she knew that was untrue. Read full story Source: BBC News, 13 October 2026 -
News article
Women with autoimmune conditions are up to 74% more likely than men to be told their symptoms are psychological or psychosomatic, and face much longer waits for a diagnosis and treatment, a study suggests. Hundreds of millions of people – about one in 10 globally – are affected by autoimmune conditions, which can cause a range of health issues including fatigue, muscle pain and rashes. But research by the University of Cambridge and University of East Anglia suggests a stark gender divide when it comes to how signs of the conditions are handled by doctors. Women are more likely to have their conditions wrongly attributed to psychiatric causes, more likely to have symptoms misdiagnosed as psychosomatic, and more likely to experience delays in getting a diagnosis, according to the study. The lead author, Melanie Sloan, said: “The damage caused to women by these types of misdiagnosis can be very long lasting in terms of trusting doctors and their own self-esteem.” Sloan, a researcher in the department of public health and primary care at Cambridge and UEA, said some women were forced to wait years before finally getting a diagnosis, causing long delays to treatment for their condition. Read full story Source: The Guardian, 13 October 2026 -
News article
The transfer of a children’s cancer service, ordered after years of safety concerns, has been delayed again and will not happen before 2028. Guy’s and St Thomas’ Foundation Trust, which is due to run a new centralised paediatric principal treatment centre at the Evelina London Children’s Hospital in Lambeth, said essential approvals from the Building Safety Regulator were “taking more time than originally anticipated”. When NHS England London confirmed the switch in 2024 – which will replace a current service led from the Royal Marsden site in Sutton – it said it would take place from “October 2026 at the earliest”. That date later slipped to March 2027. Papers for the Royal Marsden FT’s board meeting on 30 September said GSTT now expected the transfer in “February or March 2028 at the earliest”. The Marsden’s board was asked to endorse its position that the transfer “cannot safely proceed” without confirmed estates readiness, specialist air-filtered rooms, diagnostic arrangements, and funding for the workforce and the transition period. It was also asked to back continued escalation through NHSE London’s regional oversight board. The PTC for children aged one to 15 in south London, Kent, Surrey, and Sussex is currently run from the Marsden’s Sutton site, which has no paediatric intensive care unit. Children who need intensive care are transferred to St George’s Hospital in Tooting. The Marsden’s papers said such transfers averaged seven a year. A 2019 HSJ investigation revealed that multiple unpublished reviews had found the model unsatisfactory, and that it had been implicated in a series of incidents and child deaths. Concerns had been an “open secret” for almost a decade, one informed figure said at the time. Read full story (paywalled) Source: HSJ, 13 October 2026 -
News article
Kelly O'Shea says she has woken from more than one operation to be told adequate resources were not available to do the procedure she needed. The 32-year-old, who lives with chronic pain, felt there was no alternative but to pay £20,000 for the endometriosis treatment she needed, out of frustration and desperation. It comes as gynaecologists warn specialist centres in Wales dealing with complex cases of endometriosis are in jeopardy and a national service must be commissioned. The deputy minister for women's health in Wales said the current set up was "not sustainable" and is discussing options for a regional or national service to be established. Changes are being introduced by national accreditation body British Society for Gynaecological Endoscopy (BSGE) highlighting the resource challenges faced by hospitals in Wales. Clinical staff say it has been made worse because of the funding differences between England and Wales. They say unless more resources are found to increase capacity and dedicate teams to endometriosis care, BSGE-accreditation requirements will not be met, which would lead to a downgrading of services, a potential skills exodus and large numbers of patients being sent to England for care. At a recent cross-party Senedd group on women's health, gynaecologists said Wales either needed a nationally commissioned service or an overhaul of the funding model to better reflect the true cost of the specialist care. Read full story Source: BBC News, 12 October 2026 -
Content Article
In this 2 minute video, Chief Medical Officer for The UK Sepsis Trust, Ron Daniels explains how antibiotics can enter your food chain, and how this is having an impact on sepsis and antimicrobial resistance. Read the transcript -
Content Article
Preventable harm continues to be a major problem in health care. The WHO estimates the global rate of patient harm is 1 in every 10 patients, and that roughly half of harm is preventable. There has been progress in improving safety over the last quarter century, but rates of patient harm remain high. One reason is that essential patient safety concepts have not been adopted as a central part of professional education and training. We do not expect clinicians to learn anatomy or pharmacology on the job. Why do we expect patient safety can be learned that way? A principal reason for the foot dragging is inertia. Anatomy and chemistry have been the mandatory foundation for medical education for over a hundred years. Since that time, curricula have expanded, but the persistent assumption has been that well-trained, conscientious clinicians will not make errors. Systems thinking, which explains how flawed structures, policies and processes lead to errors and harm, has not been a part of that training. By allowing this mindset to persist, we are setting up future clinicians to fail. If we want safer care, teaching about safety must play a more central role in medical education. In this paper, Albert Wu suggests that this should begin as early as possible, stretching back into pre-professional education and even grade school. Yesterday
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Siobhan Millar joined the community
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Content Article
Generative artificial intelligence (AI) systems now summarise health-related search results, answer medical questions and offer guidance people once sought from clinicians. These systems bring real benefits, including plain-language explanations of medical information, around-the-clock availability and expanded access for people facing language or literacy barriers. They also carry new risks: inaccurate guidance can harm people at scale, and malicious actors can now generate personalised health misinformation at negligible cost. In this Perspective published in Nature, the authors argue that these risks are largely invisible to the institutions responsible for protecting public health. When AI guidance causes harm, no record exists outside the platform, no channel allows users to report it and no independent researcher can measure the consequences. The authors trace these invisible risks across two settings: incidental exposure online and active seeking through search engines and chatbots. Minimising harm from AI-generated health information requires making it observable. The authors therefore offer recommendations that aim to improve transparency, mitigate harm at the point of delivery and assign accountability, ranging from voluntary platform measures to regulatory ones. -
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News article
Maternity wards across the United States are facing a wave of closures as cuts to federal Medicaid funding take effect, experts have warned. According to analysis by the non-profit Protect Our Care, 52 maternity wards have closed since the HR1 bill was announced in July 2025, with a further eight having announced their upcoming closure. The bill, which will fully come into effect in the new year, will result in many adults covered through Medicaid having to meet new work requirements and being subject to more frequent eligibility checks, while there will be less federal funding for states for Medicaid. Hospitals which have already permanently closed their maternity wards include the Centra Southside Community hospital in Virginia and St Mary’s Sacred Heart hospital in rural north-east Georgia, which both cited upcoming federal policy changes to Medicaid as a reason. Experts are expecting to see more closures of maternity units in the run-up to and after the federal changes to Medicaid come into effect in the new year. “We’re deeply concerned that these changes already have and will continue to worsen an already serious maternity care crisis,” said Erin Jones, senior director of legislative and strategic counsel of the non-profit March of Dimes. “Reduced funding and restrictions on how states finance Medicaid will put additional pressure on state budgets and hospitals, increasing the risk that communities lose essential maternity services and specialized providers close to home.” Read full story Source: The Guardian, 11 October 2026 -
Edfae5510301ab896b9985939ede84edYour reflection seems spot on. It would be really interesting to understand which balancing measures are being considered as part of the review of Martha’s Rule, particularly to explore any unintended consequences alongside the intended benefits.
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News article
Calls are continuing for a fresh investigation into the death of former UN peacekeeper Ryan Wallace. Scotland’s Patient Safety Commissioner, Karen Titchener, backs politicians who say lessons should be learned from Ryan’s death as the case raises questions about how patients with complex and unexplained illnesses are supported. The intervention comes amid growing criticism of NHS Forth Valley’s refusal to carry out a Significant Adverse Event Review following Ryan’s decision to end his life at a clinic in Switzerland on 18 August. NHS Forth Valley insists concern raised by Ryan and his family were investigated through its complaints process and later upheld by the Scottish Public Services Ombudsman. But his widow, Marianne Wallace, argues that investigation only examined events and concerns raised at that time. She said: “Their investigation did not examine the years that followed when Ryan’s health continued to deteriorate, he was given a succession of different diagnoses and treatment plans, and we felt forced to spent more than £60,000 on private healthcare as we searched for answers.” Scottish Conservative Shadow Health Secretary Miles Briggs last week called on the health board to commission an investigation voluntarily, despite there being no requirement to do so because Ryan died outside Scotland. Titchener said: “I can’t comment on the details of his care, and it isn’t my role to investigate this individual case, but his story raises questions. The whole system should want to understand what happens when someone lives for years with unexplained symptoms, conflicting diagnoses, and complex medication, and feels they need to look elsewhere for answers. “A complaint process tells us whether individual decisions were reasonable at the time. It doesn’t always tell us what we could learn from the whole journey. Learning shouldn’t stop because a complaint has been closed.” Read full story Source: The Sunday Post, 11 October 2026 -
News article
A GP who entered incorrect data while completing death certifications will be suspended for 10 months, a fitness-to-practise tribunal has ruled. At the time of the events that led to the suspension, Dr Lea Cramsie was practising as a salaried GP for a practice in Glasgow which provided care to people living in nursing homes, according to documents released by the Medical Practitioners Tribunal Service (MPTS). The MPTS said that the allegations were related to Dr Cramsie completing medical certificates of cause of death and ticking the box to confirm the deaths had been reported to the procurator fiscal ‘when she knew they had not’; this would exclude the deaths from being selected for review by the Death Certification Review Service. The documents said that the allegations related to ‘31 occasions’. In Scotland, the procurator fiscal has a duty to investigate certain deaths, such as those which are sudden, suspicious, accidental or unexplained, with specific guidance for GPs on when a death should be reported. The initial concerns were raised with the GMC on 26 June this year by the deputy medical director for primary care for NHS Greater Glasgow and Clyde. The referral to the GMC was further to a local investigation by the health board which arose from ‘concerns that had been raised around death certificate completion’. The GMC acknowledged that Dr Cramsie had described herself as ‘dealing with what she considered to be a disproportionate workload of death certificates’. The regulator submitted that Dr Cramsie’s workload ‘might provide some explanation for the misconduct’, but that the evidence from other practice members did not suggest that the workload was considered ‘unusually onerous’. Read full story Source: Pulse, 9 October 2026 -
News article
An ongoing potential corporate manslaughter investigation is looking into the deaths of four patients, a court has heard today. Police have been investigating allegations of neglect and mistreatment of patients on the stroke unit at Blackpool Victoria Hospital since 2018. Since then, two staff members have been jailed for poisoning patients, and a murder inquiry launched into the death of patient Valerie Kneale after a violent sexual assault. The investigation, known as Operation Bermuda, was also expanded to cover potential gross negligence or corporate manslaughter charges in 2023. In an update to Blackpool and Fylde coroner’s court, the patients were named as 86-year-old Margaret Mary Hamilton and Geoffrey Duckworth, 81-year-old Peter Whittaker, and 75-year-old Joan Walker. Detective chief inspector Mark Dickinson also told the court that the Care Quality Commission had investigated the deaths of the four patients but decided not to prosecute the trust. DCI Dickinson said Operation Bermuda was originally launched to investigate allegations that patients on the stroke ward were being sedated with the drug Zopiclone without any clinical need. DCI Dickinson said: “The investigation also identified other patients believed to have received poor care. Likewise, in the case of four patients, potential causal links were identified between the care they received and their death.” Read full story (paywalled) Source: HSJ, 9 October 2026 -
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Content Article
Risa Mallory is a retired psychotherapist from Canada and a hub Topic leader. After a serious cardiovascular event in 2018 she became a patient advocate, collaborating with organisations across the globe. In this blog, Risa says that when patients are listened to, respected, and engaged as partners, treatment adherence becomes about collaboration rather than compliance. Last week
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News article
Lives could be saved and the public better protected against future epidemic and pandemic threats through a £33.2 million UK Government investment in vaccines against some of the world’s deadliest infectious diseases. This investment will help scientists to develop, test and deploy vaccines faster when new health threats emerge, both supporting people in low and middle-income countries (LMICs) and, in turn, protecting the UK by strengthening pandemic preparedness and improving resilience to future epidemic and pandemic threats. The programme has already demonstrated the value of investing, having supported development of the Oxford/AstraZeneca COVID-19 vaccine. This latest investment will help researchers respond more quickly to future threats. Supported by the UK Vaccine Network and delivered through Innovate UK, the funding will target diseases including Ebola, plague, Marburg, Lassa fever, Nipah virus, chikungunya and Mayaro. Eight projects will advance promising vaccines, clinical trials and technologies that can make vaccine design and manufacture faster and more effective. The new awards will build the research, clinical trial and technical capability needed to develop, test and deploy vaccines at speed. They will also help make vaccines affordable, accessible and ready for use in countries at greatest risk. Read full article. Source: Department of Health and Social Care, 8 October 2026 -
News article
Along-awaited review aimed at identifying “systemic changes” to Scotland’s crisis-hit maternity services has begun. The nine month-long nationwide review will examine how care can be improved for women, babies, and families across the country. The independent review is being chaired by the maternal and child health expert, Professor Christine McCourt, who is expected to submit her findings and recommendations in July 2027. The Scottish government said the review will take a “whole-system approach,” drawing on data, evidence and the direct experiences of women, families and staff at every level of care. However, some bereaved families have voiced misgivings about the scope of the review, and warned that it was in danger of becoming an “absolute insult” as a result. Read full article. Source: The Scotsman, 5 October 2026 -
Edfae5510301ab896b9985939ede84edThank you for the reflection. This gave me a lot to think about. One thought that stayed with me was whether off-mandate requests might actually be a signal of unmet needs elsewhere in the system. If patients and families repeatedly choose Martha's Rule for concerns it wasn't designed to address, perhaps that reflects a perception that it is the pathway most likely to result in someone listening and responding. That feels like an important insight, not just about Martha's Rule, but about the wider governance environment in which it sits.
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The publication of the National Commission into the Regulation of AI in Healthcare's recommendations comes at a critical time for NHS organisations looking to realise the benefits of artificial intelligence, safely and effectively. With many leaders seeking greater clarity around regulation, governance and deployment, this webinar, hosted by the NHS Alliance, will explore what the recommendations mean in practice. Key takeaways Interpret the Commission's recommendations and what this means for your organisation. Understand how to navigate the evolving AI regulatory and governance landscape. Identify practical steps to support safe, effective AI adoption and service improvement. What it will cover Takeaways from the Commission's recommendations on AI adoption. The current barriers to implementation. How regulation can enable safe and trusted AI deployment. The practical steps required to realise benefits for patients, staff and services. The opportunity to hear from our expert panel and take part in a live Q&A session. Register here. -
Content Article
This report sets out the findings and recommendations of an independent review into prevalence and support for mental health conditions, ADHD and autism. The review, chaired by leading clinical psychologist Professor Peter Fonagy with the support of vice chairs Professor Sir Simon Wessely and Professor Gillian Baird, found that mental distress has increased substantially among children and young people. The findings show this has been driven by several factors, including social media, financial insecurity, increased uncertainty about the future, poorer sleep, and reduced feelings of connection and belonging. While referrals and diagnoses for ADHD and autism have risen significantly, the review found that population-level prevalence of these conditions appears broadly stable. -
Content Article
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This Health Services Safety Investigation Body (HSSIB) learning resource is aimed at learners with roles in healthcare safety investigation, including investigation, commissioning, oversight and involvement. By the end of this resource, you will be able to: Understand why you would use SEIPS in an investigation. Explain the elements of the SEIPS framework in their relation to a patient safety event. Justify the use of SEIPS as part of a safety investigation. -
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