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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. Yesterday
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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 -
Julia Hande joined the community
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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 -
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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. Last week
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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 -
D0a5e5841132b7b13cd84aa130841a61An 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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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
