Host Dr Louise Gorman is joined by:

• Prof Nicola Mackintosh, Professor in Social Science applied to Health at the University of Leicester and research co-lead at the NIHR Greater Manchester Patient Safety Research Collaboration (GM PSRC).
• Dr Julie Roberts – Research Fellow at the SAPPHIRE group (Social science, APPlied Healthcare and Improvement Research), University of Leicester.

Our World Patient Safety Day blog series

1.    The safety issues affecting children in intensive care

hub topic lead, Peter Sidgwick, consultant in the Paediatric Intensive Care Unit (PICU) and Associate Medical Director at Great Ormond Street Hospital, reflects on working in PICU and highlights some of the risks. He discusses the safety measures in place that mitigate these risks and keep children as safe as possible while they are in PICU.

2.    Addressing racial inequalities in paediatric diabetes

Dita Aswani and Fulya Mehta are both consultant paediatricians and NHS England national advisors for Children and Young adults’ diabetes. In this blog, they outline racial inequalities that persist in paediatric diabetes and present five key areas for change. In summary they talk about what healthcare professionals can do to reduce inequalities through their own practice. 

3.    The role of UK ambulance services in supporting safe maternity and newborn care

Ambulance services play a pivotal role in ensuring the safety of mothers and their newborns during urgent and emergency situations. In this blog, Ann Moses, Patient safety response lead, and Stephanie Heys, Consultant Midwife, from the Northwest Ambulance Service consider this in more detail.

4.    Evidencing the impact of culture on patient safety – a new tool from MNSI

In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks about a new patient safety tool, COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety). This is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings.

5.    Children with eating disorders: a patient safety focus

Eating disorders are serious mental health problems that can severely affect the quality of life of children and their families. In this blog, Hope Virgo, an award-winning mental health campaigner, explores the patient safety issues affecting children with eating disorders and their families. Hope highlights how lack of investment and understanding is leading to avoidable harm and shares five key actions for change. 

6.    We need to make inclusive communication standard practice for children’s safety

Communication challenges can make children particularly vulnerable to patient safety incidents. In this blog, Rachael Grimaldi, Co-Founder and Chief Medical Officer of CardMedic, talks about the importance of embracing inclusive communication not just as a ethical imperative, but a practical pathway to safer outcomes.

7.    The Green Maternity Challenge: delivering safe, low carbon care

Angela Hayes is a Nurse Fellow and Project Lead at The Centre for Sustainable Healthcare. In this article she tells us more about the Green Maternity Challenge and draws on three case studies to highlight it’s success in delivering low carbon, equitable and safe maternity care. The case studies look at local screening for newborn developmental hip dysplasia, supporting breast-feeding and reducing health-inequalities for Albanian-speaking women. 

8.   Patient safety in humanitarian settings

In this article Anna Freeman, a nurse and quality of care advisor for Médecins sans Frontières / Doctors Without Borders, describes the challenges faced in assuring patient safety in humanitarian settings and offers suggestions for how international medical aid organisations can build patient safety systems.

Webinar

To help celebrate this year’s WPSD, the RCSEd are hosting a webinar at 7pm GMT on World Patient Safety Day itself (17 September) covering the importance of system design in helping to ensure safety for neonates and children.

Podcast

Claire Morgan, Consultant in Restorative Dentistry, Dental Council Member and Deputy Chair of the College’s Patient Safety Group, alongside Gregory Ekatah, Consultant Colorectal Surgeon and Convenor RCSEd Let’s Talk Surgery Podcast Series, will be in conversation with Professor Sanjiv Sharma, Paediatric Intensive Care Consultant, past Great Ormand Street Hospital for Children Medical Director and current Chief Medical Officer at Barts Health NHS Trust. We will hear about Professor Sharma’s journey to paediatric surgery leader including his motivations, ambitions and challenges, together with his reflections on WPSD 2025 and what the day means to him as a clinical leader in the paediatric space. 

Infographics

The College have released a series of infographics summarising key aspects of newborn and child safety. These cover: 1) the scale of the problem in paediatric patient safety, 2) the main causes of poor newborn and child health, 3) the potential solutions to addressing paediatric patient safety concerns, and 4) safe dental care for every newborn and every child. 

Recorded inspirational talk

Professor Warwick Teague, Consultant Paediatric Surgeon, Director of Trauma Service & Clinical Lead Burns Service, Royal Melbourne Hospital, Australia, and RCSEd ad Hominem Fellow, has recorded an inspirational talk for us on how to reduce injuries in children. Warwick is a passionate and highly engaging speaker and this talk is sure to be enjoyed by many. 

Educational vignettes

A series of Educational Vignettes have also been produced to highlight some of the RCSEd’s training workshops which aim to improve the surgical care provided to newborns and children. Amanda McCabe, Consultant Paediatric Surgeon and RCSEd Council Member, outlines the College’s Basic Skills in Paediatric Surgery Workshop, a biannual one-day course to help optimise fine motor skills in the novice surgeon for neonatal cases.

Steven Powell, Consultant Head and Neck Surgeon and Chair of the College’s Surgical Specialty Board (SSB) in Otolaryngology, shares details about the College’s Surgery and The Child Workshop. This course, with a faculty of paediatricians, psychologists, anaesthetists and surgeons, is designed to bridge the peri-operative knowledge and non-technical skills gap in adult surgeons who are also called upon at times to treat children as part of their practice.

Blogs

The College will be running a series of blogs on key surgical topics in newborn and child patient safety. These have been provided by patients, families and carers, alongside members of the College’s Patient Safety Group, College Council and the wider College fellowship. The College’s eleven Surgical Specialty Boards (SSBs) have been asked to provide blogs on key issues in the care of children in their individual specialty that they would like to highlight.

The blogs provide examples of how patients, clinical teams and health care organisations can work together to improve the safety of newborns and children when undergoing medical and surgical care.

Surgery

• Keeping our Children Safe. National strategies to improve safety in healthcare for children
• Building Hope Through Training: how one surgeon will begin to transform paediatric care in South Sudan
• Urology: Testicular Torsion
• The best care for any newborn or child involves delivering the best care for their mother
• Designing the build for safety – how can we achieve this?
• Patient Safety in Children’s and Neonatal Surgery: A Global Perspective
• Patient safety from the start – how SAS/LED surgeons can lead from the front
• What Have We Got Left to Learn About Safety in Paediatric Surgery?
• Paediatric Head Injury: a global health challenge with stark inequalities
• Neonatal Hydrocephalus: the Importance of early diagnosis and management in a global context
• Top Patient Safety tips for resident doctors in paediatric surgical practice
•  Parent and Carer Insight in Paediatric Surgery: an essential data point
• Effective Handover: an important patient safety tool in paediatric surgical specialities
• Lasers aren’t toys: preventing injuries and protecting children’s eyes
• Neonatal airway safety
• Safety for neonatal hearing
• Auditing Services for Developmental Dysplasia Hip Reduces Need for Surgical Intervention in Children
• Safety considerations for managing intra-abdominal conditions in the pregnant surgical patient
• Bridging the gap: ensuring safe transfer of urological care for young patients
• The Importance of Early Identification of a Cleft Palate

You can download all the resources from the RCSEd website link below or from the QR code below:

Further reading on the hub:

• Patient Safety Learning: World Patient Safety Day 2025
• Patient safety for babies and children: key resources
• World Patient Safety Day 2025 at the Royal College of Surgeons of Edinburgh

Me first: children and young people centred communication

A tool co-produced with children and young people to help health and social care professionals communicate with children of different ages and abilities. 

Safety portal (Royal College of Paediatrics and Child Health)

Explore patient safety theory, learn about the NHS patient safety syllabus, share ideas for quality improvement and access summaries of the latest alerts and reports. Use what you learn to drive improvements in paediatric patient safety. 

WHO: Patient safety from the start! Protecting every child’s health journey

This video, produced by the World Health Organization for World Patient Safety Day 2025, looks at the unique challenges children face in healthcare through the story of six-year old Amiya.

Infection prevention and control (Great Ormond Street Hospital)

This page explains what the Infection Control Team are doing to prevent hospital infections at Great Ormond Street Hospital (GOSH) and what patients, carers and families can do to help minimise the risk of infections during a child's stay.

Podcast: Involving children, young people and their families in making healthcare safer (RCPCH)

In this episode of the RCPCH podcast series, they speak with Dr Jane Runnacles, consultant paediatrician at St. George's Hospital, and Dr Victoria Dublon, paediatric diabetes consultant at the Royal Free Hospital. Both are champions of improvement work that puts the young person and their needs first.

A parents’ guide to recognising jaundice in Black and Brown babies

This infographic, designed by Dr Helen Gbinigie and Dr Oghenetega Edokpolor, in collaboration with FiveXMore and Bliss, serves as a guide for parents' for recognising jaundice in Black and Brown babies, including where and how to seek help. Download the guide.

Do You Know My Child? Continuity of Nursing Care in the Pediatric Intensive Care Unit

The objective of this US-based analysis, was to explore the delivery of continuity of nursing care in the PICU from the perspective of both parents and nurses.

The healthiest generation of children ever: A roadmap for the health system (The Children and Young People’s Health Policy Influencing Group)

The report and roadmap set out recommendations for how the health system can put babies, children and young people at the heart of everything it does. 

Maternity and neonatal safety champions toolkit (NHS England)

This toolkit provides information and resources that will help you in your role as a safety champion to develop strong partnerships, promote positive professional cultures, and support the delivery of the safest care possible through best practice.

Child Health Clinical Outcome Review Programme (National Confidential Enquiry into Patient Outcome and Death)

The Child Health programme is one of four Clinical Outcome Review Programmes which are designed to help assess the quality of healthcare, and stimulate improvement in safety and effectiveness by systematically enabling clinicians, managers and policy makers to learn from adverse events and other relevant data. 

Avoiding Brain Injury in Childbirth (ABC) 

The Avoiding Brain Injury in Childbirth (ABC) programme aims to reduce avoidable brain injury in childbirth by improving care. This programme supports maternity teams with evidence-based tools and protocols to ensure consistent, timely, and coordinated care.

Core20PLUS5 – An approach to reducing health inequalities for children and young people (NHS England)

Core20PLUS5 is a national NHS England approach to support the reduction of health inequalities at both national and system level. The approach defines a target population cohort and identifies ‘5’ focus clinical areas requiring accelerated improvement.

A resident doctor at the end of their rotation through the PICU where I worked asked me how I can keep coming back to such a high-stakes, high-risk job, day in, day out. At the time, I didn’t have a ready answer—I think I told them that I loved what I did, and that was enough. That answer still holds true, but I now know that this passion is only sustainable because I understand and have confidence in the systems that surround me and my team, which keep our patients as safe as possible while they are in our care.

Risks in PICU

There are lots of reasons that risks are high in PICU—the list makes a sobering read. Our patients’ clinical condition can change within minutes, they can’t always communicate their needs and their care often involves complex, high-risk interventions. Their unique anatomy and physiology—smaller airways, faster metabolic rates and narrower margins for error—mean that clinical deterioration can be swift and severe. Seemingly minor missteps in airway management, fluid balance or medication calculation can have significant negative consequences.

Protocols and technology

Protocolised practice and technology go a long way to mitigating these risks. As an example, the risk of medication errors is high in PICU, largely due to the need for weight-based calculations, the absence of standard dosing for many drugs and the fact that many of our patients are dependent on several medications to sustain life. Solutions to the risk that surrounds this include double-checks for high-alert medications, standardised concentrations, smart infusion technology with built-in dose limits and electronic prescribing with clinical decision support.

Structured safety tools—such as pre-procedure briefings, closed-loop communication, and checklists—are proven to reduce errors. Similarly, care bundles for prevention of ventilator associated pneumonia and central line associated blood stream infections, and early rehabilitation and mobilisation bundles to ensure quick recovery from critical illness, all ensure that the harm accrued by our patients due to the therapies we use is as low as it can possibly be.

A positive safety culture

However, protocols and technology can only take a team so far, and the risks we see in PICU are not fully mitigated by these. The most sophisticated equipment is only as safe as the team operating it. Communication failures, unclear role allocation and cognitive overload remain significant contributors to patient safety incidents. As is so often true in life, the quality and maturity of the relationships within and across all members of the team affects how well the team functions. At it’s best, that team function and culture allows an environment in which every team member, regardless of seniority, feels empowered to speak up and participate in reflection upon and learning from a potential risk or actual patient safety incident.

With a positive safety culture, regular incident reporting becomes the norm, debriefing after critical events feels safe not threatening, and mortality and morbidity discussions become focused on deep learning and achieving real improvement for the next patient.

Family and carer involvement

There are two other teams that contribute in untold ways to safety in PICU—our patients' families and carers, and the systems and organisations with whom we benchmark our clinical outcomes.

The overwhelming majority of patients in PICU have loved ones looking out for them—focused on their monitors, their subtle signs and signals of recovery or deterioration and willing them better.

Family and carer engagement is a super-power in PICU—a voice of advocacy, an interpreter and a crucial reminder of the human at the centre of the tubes, wires, pumps and machines.

Properly curated activity, risk and performance data and the benchmarking of clinical outcomes that it allows may be less ‘human’ than family and carers, but it is critical in helping the team know where their practice falls in relation to their peers. Signals, acted upon early, allow improvement or evolution of clinical practice when patients are experiencing harm that may not be visible in an individual patient's story but becomes clear when a sufficiently well-organised data set is analysed.

In PICU safety is not just a checklist—it’s an ongoing, team-wide commitment to vigilance, precision and adaptability.

Our patients’ resilience is remarkable, but it is our responsibility to ensure the environment around them is as safe as possible. And when they are safe, I can feel safe in my practice and keep coming back to do the job I love.

Racial inequalities – stark and persistent

A key objective of the Children and Young adults’ diabetes programme at NHS England is to reduce unwarranted variation in diabetes care and outcomes. Children of all ages, regardless of where they live, the colour of their skin, or the economic circumstances of their family, should receive equitable care in order to thrive, and live well with their diabetes.

Racial inequalities in paediatric diabetes are stark and persistent, with multiple data highlighting disparities in outcomes, access to technology, and care experiences.

Disparities in glucose levels

HbA1c is a blood test that reflects your blood glucose levels over the past two to three months. It is used to diagnose and manage diabetes. Higher readings indicate worse blood sugar control.

Children and young people of Black ethnicity with type 1 diabetes consistently have higher average HbA1c levels than their White peers, even when using the same diabetes technologies and with similar mean glucose levels. Data also shows that Black children in the least deprived areas have similar HbA1c levels to White children in the most deprived areas. These gaps have persisted for years despite overall National improvements.

These disparities increase the likelihood of long-term complications—including retinopathy, kidney disease, and cardiovascular issues—especially when combined with systemic delays in intervention.

Children and young people with type 2 diabetes are more likely to come from ethnic minority backgrounds or live in more deprived areas (six times as likely if living in most deprived quintile versus least deprived).[1]

Preventable medical emergencies

Hybrid Closed Loop systems (sometimes known as an artificial pancreas) help to keep blood glucose levels in target range by automatically adjusting insulin levels using real time sensor readings. Better blood glucose levels lead to improved HbA1c outcomes. Access to this technology is lower among Black and Asian children, independent of socioeconomic status. If children don’t have equal access to diabetes technology like Hybrid Closed Loop systems, episodes of hypoglycaemia or ketoacidosis may go unnoticed until they become emergencies. [2]

Diabetic ketoacidosis (DKA), where a lack of insulin causes harmful substances to build up in the blood, can be life threatening and needs urgent treatment. DKA at diagnosis is a preventable medical emergency—it’s a symptom of delayed recognition, reduced access, and missed opportunities for earlier intervention.

DKA at diagnosis follows the lines of social and racial inequality with the following comparative rates; White 39.6%, Asian 42.7% and Black 48.6%. [2]

Barriers to equitable, safe care

There are genetic and biological factors which predispose individuals or groups to certain health conditions, and these cannot be altered. However, these risks are compounded by discrimination within healthcare systems.

When services are not equitably accessible, culturally responsive, or designed to meet diverse needs, existing vulnerabilities are intensified. What begins as a biological risk can escalate into a systemic injustice—where people aren’t just more likely to get sick, but less likely to be cared for appropriately when they do. If services aren’t inclusive or fail to adapt to local needs, early signs of problems—like psychosocial distress or erratic blood glucose—may be overlooked.

• Structural factors like bias, cultural mismatch, and systemic barriers, contribute to disengagement from services and reduced trust in healthcare professionals.
• Reduced trust undermines shared decision-making. When families experience bias or feel culturally misunderstood, they may disengage from services, making it harder for clinicians to tailor treatment or catch safety concerns early.
• Inconsistent communication. Language barriers, unconscious bias, or lack of culturally safe care can lead to miscommunication about insulin dosing, sick day rules, or when to seek help—all of which raise safety risks.

Five key areas for change

1. Equity-focused commissioning

This means allocating resources not based on equal distribution, but in proportion to need. For example, targeting investment in areas of deprivation or in communities with poorer health outcomes can close the gap over time. Metrics should measure fairness as well as overall performance.

2. Data transparency and granularity

Gathering and disaggregating data by ethnicity, socioeconomic status, geography, and age uncovers patterns that aggregate figures hide. There are still big gaps in ethnicity data. But the real impact comes when this data is complete and drives local action—such as redesigning pathways that currently disadvantage certain groups.

3. Co-production and community leadership

Communities affected by inequality must be central in designing solutions. That doesn’t just mean “feedback,” but real influence over priorities, language, and delivery—especially in populations historically underserved or blamed.

4. Workforce representation and cultural safety

A healthcare system that reflects the diversity of the population and fosters safe, inclusive environments is more likely to build trust and reduce disparities. That includes tackling racism, both interpersonal and systemic.

5. Narrative change

We need to replace deficit-based narratives (“non-compliant families,” “hard-to-reach groups”, “poor attender”, “frequent flyer”, “lack of motivation”) with systemic ones with full understanding of what they mean (“health inequities”, “institutional racism”, “under-resourced systems,” “barriers to access”, “structural vulnerability”, “cumulative disadvantage”) and shift responsibility to where it belongs.

What can healthcare professionals do?

On a personal level we should develop genuine and compassionate curiosity of lives by trying to imagine being in someone else’s shoes to understand what they experience and how that feels. This means questioning your own bias, building relational safety by asking questions to listen, and having a trauma-based approach in order to consider structural barriers, not just clinical ones. Document the context of a person, and not just their behaviour.

Wider than that:

• collect and use data with purpose
• use the data as a mirror, not a defence, and let the data speak even when it is uncomfortable
• understand the structural determinants of your organisation
• understand how other systems intersect with health (eg education, immigration, housing)
• name and acknowledge racism for what it is, not just ‘inequality’ or ‘diversity’.

Engage in Poverty Proofing training with your teams and managers, seeking to identify, challenge, and remove the structural barriers that perpetuate disadvantage, ensuring that no child, young person, or family is excluded, stigmatized, or underserved due to financial hardship.

Use tools such as YoungType2 (by DigiBete), a dedicated platform and app for young people up to age 25 living with type 2 diabetes or at risk of it, co-produced with families and communities. It includes culturally sensitive content which is accessible and easy to understand, and translated in other languages, on food, activity, sleep, relationships, emotional wellbeing, school and work and school life—especially relevant for communities disproportionately affected by early-onset type 2 diabetes. 

Diabetes Africa is doing some standout work, especially when it comes to equity in diabetes technology access for Black, African, and African-Caribbean populations in the UK. Their Technology Equity Toolkit is particularly relevant for paediatric and young adult care, and highlights awareness to promote culturally responsive solutions.

References

[1] National Paediatric Diabetes Audit (NPDA) spotlight audit, 2025.

[2] National Paediatric Diabetes Audit Admissions report (NPDA) 2015-2020, July 2023.

Substantial increases in coverage are necessary in many countries and territories, with those in sub-Saharan Africa and south Asia facing the greatest challenges.

Recent declines will need to be reversed to restore previous coverage levels in Latin America and the Caribbean, especially for DTP1, DTP3, and Pol3.

These findings underscore the crucial need for targeted, equitable immunisation strategies. Strengthening primary healthcare systems, addressing vaccine misinformation and hesitancy, and adapting to local contexts are essential to advancing coverage.

COVID-19 pandemic recovery efforts, such as WHO's Big Catch-Up, as well as efforts to bolster routine services must prioritise reaching marginalised populations and target subnational geographies to regain lost ground and achieve global immunisation goals.

The researchers say that with reduced oxygen targets:

• 50 more children would survive in the UK each year
• the NHS could save £20 million per year.

The findings suggest that, if oxygen targets for children in intensive care were reduced across the NHS, 50 more children would survive every year. In total, children would spend 6,000 fewer days in intensive care.

Lower oxygen targets could be particularly beneficial in countries where resources are scarce, the researchers say, or at times of crisis (such as during a pandemic).

Related reading on the hub:

A parents’ guide to recognising jaundice in Black and Brown babies