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Keep up to date with the latest news, research and activity in patient safety.

Persistent and widespread medicine shortages putting patients at risk

Patients are facing serious harm due to persistent and widespread medicine shortages, MPs and peers have warned in a new report.
The All-Party Parliamentary Group (APPG) on pharmacy called for urgent action to prevent critical shortfalls from becoming the "new normal", highlighting the impact that shortages are having on patients with ADHD, menopause and diabetes.
Steve Race, chairman of the APPG on pharmacy, said many MPs “have received a growing volume of correspondence from constituents who are understandably anxious about the availability of their medicines”.
“Whether it is a parent unable to access antibiotics for a sick child, an elderly patient facing delays in obtaining life-sustaining medication, or a pharmacist overwhelmed by the need to source alternatives, the human impact is both visible and deeply troubling,” he wrote in the report.
The report said that while medicine shortages are “not a new phenomenon”, they have “become increasingly severe, persistent, and disruptive” in recent years – leading to consequences for patients, staff and the wider health service.
“Medicines shortages have moved from isolated incidents to a chronic structural challenge for both the NHS and pharmacy sector,” he said.
“As the government continues to recognise and invest in the expanded clinical role of community pharmacy, we must ensure the medicines supply chain underpinning that care is equally robust, resilient and patient-focused.
“Pharmacy is central to NHS recovery and transformation, but frontline teams cannot safely expand clinical services while daily supply disruptions continue to impact the health of patients.”
Read full story
Source: The Independent, 8 July2025
Related reading on the hub:
Medicines shortages: minimising the impact on patients (a blog by Catherine Picton) Medication supply issues: A pharmacist’s perspective Medication supply issues: Mast cell activation syndrome (MCAS)
Patient Safety Learning

Several children ‘seriously unwell’ amid rise in measles cases as alert issued by NHS

A measles outbreak on Merseyside has left several children “seriously unwell”, a top NHS hospital has warned as it urged people to get vaccinated to help combat the spread of the disease.
The rise in cases, according to an alert on Alder Hey Children’s Hospital websites, is also driving an increase in patients attending its A&E.
The news comes amid falling coverage of the Measles, Mumps and Rubella (MMR) vaccine across England, with the most recent data showing an 88 per cent coverage compared to a high of 95 per cent in 2016-17.
In an open letter, published on Monday, the trust’s senior directors warned: “Measles is putting children and young people at risk within our communities and our hospital. Several children are seriously unwell and receiving treatment at Alder Hey Children’s Hospital.
“Measles is on the rise amongst our children. We can all help stop it. Get vaccinated now.”
It warned that the reason there are more cases of the virus is because fewer people are having the Measles, Mumps and Rubella (MMR) vaccine.
The most recent annual report for 2023-24 showed London had the lowest coverage rates at 81.8 per cent, while the North West had 88.8 per cent. The target set by the World Health Organisation for MMR vaccine coverage is 95 per cent.
The trust said the number of children being treated at Alder Hey hospital over measles is increasing and warned “children in hospital who are very poorly for another reason, are at higher risk of catching the virus.”
Read full story
Source: The Independent, 7 July 2025
Patient Safety Learning

Charity prepares legal challenge after NHS board pauses ADHD referrals for over-25s

A charity supporting people with attention deficit hyperactivity disorder (ADHD) is preparing a legal challenge against a regional NHS board that has temporarily stopped accepting referrals for adults over 25.
Coventry and Warwickshire integrated care board said any new referrals for people over 25 would be paused from 21 May to reduce waiting lists for children.
Several other ICBs, including Herefordshire and Worcestershire and some in London, have previously paused ADHD referrals but have accredited other providers for GPs to send referrals to under “right to choose” legislation.
ADHD UK understands that this is the first time that local people aged over 25 will be able to obtain an assessment only by paying privately, which one former patient did at a cost of £1,500.
The charity is beginning the process to mount a legal challenge under the right to choose legislation, which allows patients to choose their provider for certain healthcare services when referred by their GP.
Henry Shelford, the chief executive of ADHD UK, said: “It’s ridiculous. We know one in 10 men and boys and one in four women and girls with ADHD will at some point try to take their own life, so we know there’s a danger.
“We also know that ADHD medication can have a significant positive effect and you can’t get it unless you have a diagnosis. It’s part of the discrimination and a lack of taking ADHD seriously that we face every day.”
Read full story
Source: The Guardian, 7 July 2025
Patient Safety Learning

DHSC board will block unfunded safety recommendations

A “revamped, revitalised and reinforced” National Quality Board will decide what safety and quality recommendations the NHS will adopt, with an eye to their cost-effectiveness, the long-awaited Dash Review has said.
Penny Dash’s review into patient safety suggests the NQB – which has existed since 2009 – should be co-chaired by herself as chair of NHS England, with Care Quality Commission chair Sir Mike Richards. When NHSE is abolished it will be co-chaired by the Department of Health and Social Care’s lead non-executive director for quality.
The new board will act as a “clearing house” to coordinate and prioritise recommendations, avoiding “unfunded mandates being imposed on the system without due consideration”, Dr Dash recommended. It cites “those arising from reports, reviews, inquiries, investigations, guidance and activities of various bodies” being “imposed on providers without due diligence”.
The NQB should have a role in monitoring the implementation and impact of recommendations from previous reviews and inquiries, the report added. 
Dr Dash’s report, which had been widely trailed, is highly critical of what health and social care secretary Wes Streeting has described as a “labyrinth” of regulators and patient bodies and the “mission creep” pursued by some of them.
The report says that, over the last decade, there has been a shift towards patient safety over other areas of quality of care, but “relatively small improvements have been seen” in safety.
Read full story (paywalled)
Source: HSJ, 8 July 2025
Patient Safety Learning

USA: Patients with ultra-rare diseases worry new FDA rules will leave them without treatment

US drug regulators have increasingly signalled a focus on faster approvals and rare diseases, but patients with ultra-rare ailments fear they are falling through the cracks, especially given challenges to conducting clinical trials.
One drug, elamipretide, garnered a narrow recommendation from independent advisers for the US Food and Drug Administration (FDA), but the agency rejected the drug’s application in May and recommended another potential pathway for approval.
Patients and advocates worry about new rules on who may receive the medication during this process, and whether the drug will reach approval before the pharmaceutical company runs out of funding for it.
It underscores the challenges of making progress on rare and ultra-rare diseases while also making sure treatments are safe and effective.
Read full story
Source: The Guardian, 6 July 2025
Patient Safety Learning

The deadlines and targets in the 10-Year Plan

A private funding business case for health centres, and publishing minimum employment standards, are among the first dated objectives in the 10-Year Health Plan. 
The plan was published without a chapter which had been expected to set out delivery details. However, HSJ has analysed the document and presented many of the significant dated targets and deadlines below.
This year, patients can expect publication of league tables of NHS trusts and foundation trusts. Officials must prepare a business case ahead of the autumn Budget to get permission to start agreeing private funding deals for new “neighbourhood health centres”.
Over the next three years, targets include 2% year-on-year productivity gains in the NHS; introduction of new minimum employment standards for staff; making the first integrated health organisations (IHOs) “fully operational”, and growth of the NHS App.
After that, the aim is to address doctor training bottlenecks, grow the nursing workforce and ensure the majority of NHS providers are operating in a surplus.
For 2035, the end of the 10-Year Health Plan, there are a slew of ambitious goals: every trust is expected to achieve foundation status, the majority of outpatient care will take place outside hospitals, patient and hospital care will be transformed by the use of AI and wearable tech, and health system geography will be aligned with local government.
Read full story (paywalled)
Source: HSJ, 4 July 2025
Patient Safety Learning

Waste of time and money in hospitals makes you want to cry, NHS England chief says

NHS England’s new chief has lamented the waste of time and money within the health service and said it makes her “want to cry”.
Dr Penny Dash, chair for NHS England, said there is poor management in hospitals which means the NHS “absolutely” wastes too much money.
The former hospital doctor and management consultant, who was appointed in March to help Health Secretary Wes Streeting’s reform of the NHS and oversee the abolishment of NHS England, also said that erratic care across England – which leads to the poorest people receiving some of the worst treatment – is a “stain on our country”.
Speaking two days after the publication of the government’s 10-year plan for the NHS, she told The Sunday Times: “We’ve got some GP practices where less than 2 per cent of people with diabetes get the right care but in other GP practices it’s 80 per cent. That cannot be right.
“I think it is a stain on our country that we have some of the poorest communities receiving the poorest care. We’ve got fewer GPs per head of population in the parts of the country that need them most than we do in the parts of the country that need them least.”
According to the paper, Dr Dash will use an upcoming report on patient safety, due to be published on Monday, to highlight that £6 billion a year is being lost due to poor disease management where best practice is not followed.
Addressing stories of patients suffering and missing appointments due to admin errors, Dr Dash said “you just want to cry”. She added: “There is poor management — we have operating theatres that don’t start on time and that has a really high cost.”
Read full story
Source: The Independent, 6 July 2025
Patient Safety Learning

Consultancy called in to review trust's staff 'experience'

A trust grappling with concerns over culture has commissioned an independent review into staff experience.
Doncaster and Bassetlaw Teaching Hospitals Foundation Trust has brought in consultancy The Value Circle to carry out the work.
In a message to staff seen by HSJ, trust CEO Richard Parker said: “We are undertaking an independent review of what it feels like to work at DBTH to help us understand what’s working well, and what could be improved to make it even better for all of us.
“For this to really make a difference, it’s important that the independent team hears from as many colleagues as possible… everything you share will be treated in complete confidence.”
The trust confirmed it was broadening a mandatory well-led review to also look at “colleague experience”.
HSJ previously reported that the trust is in a row with the British Medical Association over the circumstances surrounding a senior clinician being off work. It has also faced criticism from a departing governor and consultants.
Read full story (paywalled)
Source: HSJ, 7 July 2025
Patient Safety Learning

Pregnant patients received ‘inappropriate’ medication due to pharmacy coding errors

GP practices have been asked to review records after pregnant patients at some pharmacies were ‘incorrectly coded’, receiving ‘inappropriate supplies’ of medications as a result.
NHS England undertook an investigation into the recording of pregnancy status in the Optum PharmOutcomes IT system for the Pharmacy Contraception and Pharmacy First Services, after receiving incident reports.
It found that ‘multiple records’ were found where a patient ‘has been incorrectly coded as pregnant’. It also found that some patients received ‘an inappropriate supply of medication’, including where patients have been coded correctly as pregnant and should have been excluded from the supply of medication.
In a message to practices in Essex, seen by Pulse, NHS England said that a clinical advisory group confirmed that this is a patient safety incident that ‘requires action to prevent potential harm’ to impacted patients, and that patients ‘must be informed in line with duty of candour guidance’.
Pharmacists and pharmacy technicians can now add updates from Pharmacy First, blood pressure and contraception consultations to GP patient records via the GP Connect Update Record functionality, which means that the coding errors transferred to the GP record although the functionality is not yet contractual.
NHS England told Pulse that GP practices were asked to review their records and take ‘any other action as appropriate’, but the commissioner did not confirm to Pulse how many patients have been affected by the coding errors.
Read full story
Source: Pulse, 2 July 2025
Patient Safety Learning

‘Irrelevant’ training will stop next year, vows 10-Year Plan

The government’s 10-Year Health Plan has vowed to stop “repetitive” and “irrelevant” training that takes up NHS staff time.
The document said: “Our first step will be to reverse the accumulation of centrally dictated training requirements, which irritate staff and add unnecessary burdens to their working day.
“It is often repetitive, irrelevant to the work that staff do and has little or no impact on the quality of care that patients receive. By April 2026, we will have completely reformed mandatory training.
“As we transform the centre and push power out to staff and citizens, we will work with providers and professionals to identify more opportunities to ease the burden on frontline workers, remove central edicts, and allow a more flexible approach to workforce development.”
The plan also commits to using technology to increase clinical capacity, including through UK-registered health professionals working abroad to provide remote services to NHS patients.
NHS England has estimated that unnecessary mandatory training is wasting more than 100,000 days of staff time every year.
Read full story (paywalled)
Source: HSJ, 3 July 2025
Patient Safety Learning

'Pictures of health' cut skin cancer check waits

Digital imaging of suspected skin cancers has dramatically cut waiting times for diagnosis and treatment in Nottinghamshire.
Clinical photographers in parts of the county now see patients referred by GPs typically within a couple of days, rather than them having to wait what used to be sometimes weeks to see a consultant for just an initial appointment.
The imaging includes using artificial intelligence (AI) smartphone software, which then sees pictures sent to a consultant dermatologist to assess, without needing to meet the patient.
Sherwood Forest Hospitals NHS Foundation Trust said the approach was freeing up specialists' time to focus on surgery.
Fiona Hayward-Lyon, from Farndon in Nottinghamshire, is one of nearly 2,000 patients seen by the trust with suspected skin cancer who have benefitted from faster access to diagnosis.
The service was fully introduced in June 2024 and one year on, has been described as a "big success" by the trust.
Consultant dermatologist Dr Ritu Singla said the photography service allowed medics to reassure patients sooner if they did not have cancer.
"We can rule out lots of benign [non-cancerous] lesions, which are the bulk of cases," she said.
"It also enables us to start treatment sooner for those patients where cancer has been diagnosed."
Read full story
Source: BBC News, 3 July 2025
Patient Safety Learning

National virtual ward system promised in 10-Year Plan

The government will procure a single virtual ward system to underpin its promised “neighbourhood health service”, the 10-Year Health Plan has said.
The document said: “We will undertake national procurement for a new platform available to all NHS provider organisations. This will include the ability to remotely monitor patients, with data flowing through to the NHS App and Single Patient Record – enabling proactive management of patients to become the new normal.”
Virtual wards, also known as hospital at home, have been widely trialled across the NHS already, with some research pointing to reduced hospital admissions and financial savings.
There was no date given for when this would be launched.
The news clarifies the digital underpinning of “neighbourhood health services” and which bodies would commission it, following the downgrading of integrated care boards.
The plan said the new system would enable “proactive management of patients to become the new normal, reaching out at the first signs of deterioration to prevent an emergency admission to hospital”.
Read full story (paywalled)
Source: HSJ, 3 July 2025
Patient Safety Learning

Twelve key takeaways from Labour’s 10-year NHS plan

The 10-year NHS plan aims to make healthcare more digital, focus on preventing ill health and provide more services locally, rather than in hospitals. It will greatly expand the NHS app and increase the use of AI and other technology.
Structural changes aim to bring routine healthcare closer to patients, with the aim that most outpatient care will happen outside hospitals, while new neighbourhood health centres will provide most services so that acute hospitals can focus on looking after the most unwell.
The main measures include:
1. NHS app becoming a “doctor” in patients’ pockets
2. Patient league tables from this summer
3. Integrated digital patient records
4. Patients referring themselves for hearing tests, counselling, podiatry and back pain
5. Digitised “red book” system of recording baby and child health records
6. Greater use of AI and genomic sequencing and free wearable devices in some areas
7. One million people being offered a personal health budget by 2030, with everyone eligible by 2035
8. Community health hubs providing a “one-stop shop” for integrated care
9. Treatment targets brought back and promises to end “corridor care”
10. Specialist mental health emergency departments
11. Expanded access to weight loss jabs and anti-obesity measures
12. More NHS staff
Read full story
Source: The Guardian, 3 July 2025
Patient Safety Learning

Lucian Leape, whose work spurred patient safety in medicine, dies at 94

The Institute for Healthcare Improvement (IHI) and the IHI Lucian Leape Institute (LLI) honour the life and legacy of patient safety luminary Lucian Leape, MD who has died at the age of 94.
A giant in health care, Dr. Leape is widely considered the parent of the modern patient safety movement. His participation in the landmark Harvard Medical Practice Study in the 1980s, and the subsequent publication of its findings in 1991, helped establish the field of patient safety. He and his colleagues pulled back the curtain on the true scope of adverse events and preventable error in health care. Dr. Leape devoted four decades of his life and career to raising awareness of the magnitude of preventable medical harm, and more importantly, building communities and mechanisms for action to eliminate harm to patients and the workforce.
Dr. Leape also left his mark as a member of the Institute of Medicine’s Quality of Health Care in America Committee, which published the seminal works in the patient safety movement, To Err Is Human: Building a Safer Health System (2000) and Crossing the Quality Chasm (2001). He was the founding chairman of the LLI, which was formed in 2007 by the National Patient Safety Foundation (NPSF, which merged with IHI in 2017) to provide a strategic vision for improving patient safety. He was an active member of the think tank bearing his name through the remainder of his life.
Lucian Leape was both a literal and figurative tower of courage and transparency who challenged healthcare’s status quo acceptance that harm to patients was an acceptable, collateral consequence of healthcare. He eschewed the notion that safety should primarily depend on, or be blamed on, individuals who provide direct patient care. Instead, under his direction, the LLI pursued five transforming, yet under addressed system-level concepts deemed essential for safety including medical education reform, accelerating care integration, workforce safety and joy and meaning in work, partnering with patients, and transparency.
Lucian’s spirit and influence live on in the continued work of the LLI, the IHI, and the countless individuals and institutions that relentlessly pursue safe, person-centered care delivered in psychologically safe, fair and just, and respectful environments. His groundbreaking insights illuminated pathways to healing broken systems, harvesting the best of leaders and the workforce, and ensuring the centeredness of patients first amid the complexity of health care. While we mourn the loss of a remarkable mentor, colleague, and friend, we celebrate the gift of his life and career. His indelible influence will continue to shape our commitment to patient safety for generations.
Read full story
Source: Institute for Healthcare Improvement, 2 July 2025
Patient Safety Learning

10-Year Plan published without delivery chapter

The government’s 10-Year Health Plan has been published without a planned chapter on how the changes it proposes will be delivered.
The draft of the Plan seen by HSJ last week included an index page which listed a ninth chapter entitled “Change begins”. The published Plan contains just eight chapters plus an introduction.
HSJ understands the delivery chapter was due to be written by the Department of Health and Social Care’s lead non-executive director, and former health secretary, Alan Milburn. Its omission has surprised many very senior NHS figures close to the plan’s development who had expected it to be included.
One told HSJ that the delivery chapter would have “focused heavily on the immediate tasks” to be undertaken by the service in the next three years and therefore might have “looked a little odd within a 10-Year Plan”.
They added: “You can be certain that there will be [a delivery plan] though.”
One suggestion is that the delivery plan might be incorporated into the NHS England planning guidance for 2026-27, which it is proposing to publish much earlier than in previous years, possibly as early as September.
Read full story (paywalled)
Source: HSJ, 3 July 2025
Patient Safety Learning

Women poisoned by fake Botox

An aesthetic beautician left one woman fighting for her life and several others seriously ill in hospital after injecting them with Toxpia, an illegal Botox-type anti-wrinkle treatment. 
The patch over Kaylie Bailey's left eye is a daily reminder of when her beauty treatment nearly killed her.
The 36-year-old mum-of-three from Peterlee, County Durham, had paid Gemma Gray £75 for three "Botox" injections, half of what it had cost on a previous visit - the bargain turned out to be too good to be true.
Within days, Ms Bailey was struggling to see.
Doctors at Sunderland Royal Hospital were initially baffled and diagnosed her with ptosis, an eye condition characterised by the drooping of the upper eyelid, and told her to go home to rest.
The hospital trust said that when Ms Bailey was discharged she had been advised to visit her GP if her condition worsened, and it had been explained to her that her symptoms were probably related to the treatment she had had.
It added that botulinum toxicity was a very rare condition "not seen by the majority of doctors during their careers".
But when her condition deteriorated over the following days, Ms Bailey rushed back to hospital where this time she was told she had botulism, a rare but life-threatening condition caused by a bacterium.
By that point, she was one of 28 people to have been diagnosed with the toxic poisoning in north-east England after having anti-wrinkle jabs.
Ms Bailey stopped breathing and required resuscitation.
She spent three days on the Intensive Care Unit and was treated with an anti-toxin.
The Department of Health and Social Care said people's lives were being put at risk by "inadequately trained operators in the cosmetic sector" and the government was looking into new regulations.
"We urge anyone considering cosmetic procedures to consider the possible health impacts and find a reputable, insured and qualified practitioner," a spokesperson said.
Read full story
Source: BBC News, 3 July 2025
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