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

Patients dying of sepsis because medics too slow to spot it, warns NHS watchdog

Sepsis is causing thousands of deaths a year, a charity has said, as the NHS’s safety watchdog warned that doctors and nurses are too often slow to identify and treat it.
“The recognition of sepsis remains an urgent and persistent safety risk”, despite previous reports highlighting the large number of deaths it causes when diagnosed too late, according to the Health Services Safety Investigations Body.
Too often, relatives were ignored when they raised concerns about the condition of a loved one who later died of sepsis, the HSSIB said on Thursday.
It urged NHS trusts and staff in England to learn from mistakes which the UK Sepsis Trust estimates play a key role in as many as 10,000 avoidable deaths every year UK-wide.
The report from HSSIB is the latest in a series from bodies including the Parliamentary and Health Service Ombudsman (PHSO) and Care Quality Commission to reveal the large number of patients who die every year after NHS staff take too long to diagnose it.
“There have been initiatives to improve the recognition and timely treatment of sepsis over the last 20 years, yet it has persisted as a safety risk,” HSSIB said.
It published reports of three cases involving patients – named only as Barbara, Ged and Lorna – for whom a delay in spotting sepsis had severe consequences. Two of the patients died and the third had to have her leg amputated below the knee after starting on antibiotics too late.
The three incidents “show a consistent pattern of issues around the early recognition and treatment of sepsis”, said Melanie Ottewill, HSSIB’s senior safety investigator.
Dr Ron Daniels, the founder and chief medical officer of the UK Sepsis Trust, said that since the success of hospitals in England in 2016-19 at identifying and promptly treating sepsis, the NHS’s performance “has slipped backwards considerably”. That is because a financial incentive offered to hospitals, to screen anyone who might have sepsis and give them antibiotics within an hour – the approach recommended by the National Institute for Health and Care Excellence – ended.
“The quality of care has returned to its pre-2016 level – that is, a postcode lottery in patients’ chances of their sepsis being spotted. I’m appalled,” Daniels said.
“We estimate that of the 48,000 people a year who die of sepsis, at least 10,000 more lives could be saved if the NHS prioritised sepsis as an urgent clinical issue.”
Read full story
Source: The Guardian, 26 June 2025
Further reading on the hub:
Top picks: 11 resources about sepsis Dr Ron Daniels: Recognising sepsis
Patient Safety Learning

500 families in Oxford call for maternity unit to be investigated

Hours after giving birth, with her son rushed away to a high dependency unit, as she lay broken and bleeding, Morgan Joines overheard a midwife blaming her. 
Her son had been born with wet lung after an emergency and traumatic caesarean section.
"I overheard [the midwife] tell a student nurse I was the reason my son was ill, because I was too lazy to push," she told Sky News.
"I was broken. I genuinely believed for ages afterwards that I had failed my son."
Her son was born at John Radcliffe Hospital in Oxford, part of the Oxford University's Hospital Trust. Morgan is one of more than 500 families who say they have been harmed by maternity care at the Trust.
On Monday, the health secretary, Wes Streeting, announced a "rapid" national investigation into NHS maternity services.
A taskforce, chaired by Mr Streeting and made up of experts and bereaved families, will first investigate up to ten of the most concerning maternity and neonatal units.
And campaigners - calling themselves the Families Failed by OUH Maternity Services - are calling for Oxford to be on that initial list.
The CQC flagged issues around maintaining patient dignity, and said medicines were not always safely stored and managed. The unit did not manage the control of infection consistently it said, and wards were not always kept clean.
One mum told the campaign group she thought she was going to die after being left alone while in labour and denied pain relief.
Another said she is reluctant to consider having another child and feels a "profound loss of trust in the NHS".
Read full story
Source: Sky News, 26 June 2025
Sam

Patients with long-term conditions have worse experience

Patients with long-term conditions and those from a minority ethnic background have a significantly worse experience of NHS care, according to polling shared exclusively with HSJ. 
The survey by Ipsos, for the umbrella group National Voices, asked about people’s experience of person-centred and integrated care. A representative sample of 984 adults were interviewed around the beginning of this month. 
It found a significantly higher percentage of individuals with multiple long-term conditions – who are much more likely to be heavy users of the NHS – disagreed with the statement that “all the different professionals caring for you worked well together” (21% disagreed versus 11% among other adults).
The same percentage disagreed that “when you moved between services, settings or areas, there was a plan for what would happen next”.
A large majority (81%) were confident they could access information and advice to manage their own physical health, while it was a little less (70%) for mental health. But again, people with multiple LTCs were around twice as likely to say they could not get the necessary information or advice. 
Just 8% said they were not listened to when using NHS services – but this doubled to 16% among those with multiple long-term conditions.
Read full story (paywalled)
Source: HSJ, 25 June 2025
Related reading on the hub:
Improving healthcare services for people with ME and Long Covid: Patients share their challenges, and the actions needed
Patient Safety Learning

Watchdog 'acted irrationally' over gender clinic, court told

The High Court has heard claims that the health regulator, the Care Quality Commission, "acted irrationally" when it registered England's first private clinic offering gender treatment to under-18s.
The case, brought by a former nurse and a mother who wishes to remain anonymous, claims the watchdog did not consider all relevant information and should also have imposed conditions on the clinic.
The CQC says there is ample evidence that the clinic is committed to the safety and best interests of its patients.
Lawyers for the Gender Plus Healthcare Clinic, which was rated outstanding last year, called the legal action "fatally flawed".
The former nurse, Susan Evans, and the mother are challenging the CQC's decision to register the clinic in January last year.
They are also challenging a decision made last December to continue the registration and to allow the clinic to prescribe cross-sex hormone treatment to 16- and 17-year olds.
Tom Cross KC, barrister for the two women, told the court that in deciding the clinic should continue to be registered, "the CQC has acted irrationally".
He argued that the decision did not factor in some of the conclusions of last year's Cass Review into gender treatment for young people "which serve as important safeguards for children within the cohort and were obviously material".
Mr Cross expressed concern that the private clinic lacked the safeguarding measures required by the NHS and urged the court "at the very least" to require the CQC "to think again about the adequacy of the safeguards".
For the CQC, Jamie Burton KC said the regulator had found no evidence of "improper decision-making or anything that might flag a concern" and that the clinic was found to be "committed to the safety and best interests of its patients" and was acting "in line with national guidance".
Read full story
Source: BBC News, 24 June 2025
Patient Safety Learning

The plan to vaccinate all Americans, despite RFK Jr.

Professional medical societies, pharmacists, state health officials and vaccine manufacturers, as well as a new advocacy group, are mobilising behind the scenes to preserve access for vaccines as Health Secretary Robert F. Kennedy Jr. works to upend the nation’s decades-old vaccine system, according to public health experts.
The groups are discussing ordering vaccines directly from manufacturers and giving greater weight to vaccine recommendations from medical associations. And they are asking insurance companies to continue covering shots based on professional societies’ guidance instead of the federal government’s, according to more than a dozen people familiar with the conversations, including some who spoke on the condition of anonymity to share private discussions.
The moves come as Kennedy has replaced members of the key federal vaccine advisory panel to the Centers for Disease Control and Prevention that decides which vaccines are recommended for whom and whether they’ll be covered by insurance. Kennedy fired the 17-member committee earlier this month and handpicked eight new members, several of whom are vaccine critics.
But the extraordinary effort to create parallel systems of recommending, and perhaps even providing, vaccines faces major challenges, and some of the more ambitious goals have yet to be ironed out.
There is no guarantee that health plans will cover every shot without guidance from the CDC panel, known as the Advisory Committee on Immunization Practices, or ACIP. States, which determine school vaccine entry requirements, may make different decisions. And potential competing recommendations could sow confusion among doctors as well as patients if it becomes unclear which recommendations to follow.
Read full story (paywalled)
Source: The Washington Post, 24 June 2025
Patient Safety Learning

Millions of children at risk as vaccine uptake stalls

Progress in vaccinating children against a variety of life-threatening diseases has stalled in the past two decades - and even gone backwards in some countries - a new global study suggests.
The situation has been made worse by the Covid pandemic, leaving millions of children unprotected from diseases such as measles, tuberculosis and polio.
The researchers are calling for a concerted effort to provide better and more equal access to vaccines.
Child health experts warn that cuts to international aid budgets that fund vaccination programmes, combined with vaccine scepticism, are creating a "perfect storm".
The global childhood vaccination programme has been a huge success.
Since 1974, more than four billion children have been vaccinated, preventing an estimated 150 million deaths worldwide.
In nearly half a century until 2023, researchers say vaccine coverage doubled.
But since 2010 progress has stagnated, to the extent that there are now wide variations in vaccine coverage around the world.
A study, published in the medical journal The Lancet, external, says measles vaccinations have declined in nearly 100 countries.
Read full story
Source: BBC News, 25 June 2025
 
Patient Safety Learning

First NHS cyber attack death confirmed

A cyber attack caused a long wait for a blood test result which contributed to the death of a patient, HSJ can reveal.
The ransomware attack on the Synnovis pathology system last June saw more than a thousand operations cancelled as the laboratories used by two major hospital trusts were unable to report.
Since then, a harm review process has been taking place across: Guy’s and St Thomas’, King’s College and Lewisham and Greenwich hospitals; primary care across six boroughs; and two mental health trusts.
This morning, a spokesperson for King’s College Hospital Foundation Trust told HSJ: “Sadly, one patient sadly died unexpectedly during the cyber-attack. As is standard practice when this happens, we undertook a detailed review of their care.
“The patient safety incident investigation identified a number of contributing factors that led to the patient’s death. This included a long wait for a blood test result as a result of the cyber-attack impacting pathology services at the time. We have met with the patient’s family, and shared the findings of the safety investigation with them.”
Read full story (paywalled)
Source: HSJ, 25 June 2025
Patient Safety Learning

The 10-Year Plan vision for FTs and ICBs

A new operating model proposed by the government’s 10-Year Health Plan will radically reform the role and governance of foundation trusts and integrated care boards.
HSJ has seen a recent draft of the plan, which states that the strongest foundation trusts will be allowed to become “integrated health organisations”. These will be given the responsibility of managing the budget for the health and care of a designated population.
Meanwhile, the plan says elected mayors will take over from local authority leaders on integrated care boards, and the new role of the boards will often involve shaping the provider market.
The draft plan says the Department of Health and Social Care will seek to approve the first “new FTs” in 2026.
The authorisation will be undertaken by a unit within the DHSC, whose work will be overseen by an independent group of experts. There will be no return for Monitor, the standalone FT regulator.
The plan reveals FTs will no longer be required to have governors. The public and staff representatives will be replaced by more “dynamic” ways of reflecting their views.
Read full story (paywalled)
Source: HSJ, 23 June 2025
Patient Safety Learning

Areas of England to get extra NHS funding announced

NHS funding will be diverted to working-class communities, the health secretary is set to announce.
Wes Streeting is expected to announce the measure as part of the upcoming NHS 10-year plan, set to be focused on closing health inequalities, during a speech in Blackpool today.
About £2.2bn will be spent on staff, medicines, new technology and equipment in rural communities, coastal towns and working-class regions, according to the Department of Health.
The money, which was previously set aside to plug financial holes in the health service, can now be reinvested where it is "most needed", the department said.
It added that NHS leaders have spent months cutting "wasteful" spending, such as on "back office" functions and agency staff, while reducing forecast deficits by health trusts.
GP funding will be reviewed under the new plan, as surgeries serving working-class areas receive an average of 10% less funding per patient than practices in more affluent areas.
Read full story
Source: Sky News, 25 June 2025
Patient Safety Learning

‘Robustly manage’ staff who ‘lack compassion and openness’, NHSE tells trusts

Trust chief executives have been told to “robustly manage” staff who repeatedly “demonstrate a lack of compassion or openness” over failings in maternity care.
It comes after health and social care secretary Wes Streeting announced a rapid investigation into failings at 10 trusts.
NHSE CEO Sir Jim Mackey and chief nursing officer Duncan Burton have written to trust leaders, saying: “We can’t accept the status quo.” The letter warns of “challenging conversations” to come with leaders in some organisations.
It does not provide examples of what “robust” management would involve. It says every trust with responsibilities for maternity and neonatal care needs to:
Be rigorous in tackling poor behaviour and culture by addressing examples of this without delay; Listen directly to families who have experienced harm when concerns are raised or identified while also creating the conditions for staff to speak up; Retain a “laser focus” on tackling inequalities, discrimination and racism within services. It promises a “new anti-discrimination programme” from August to support leadership teams to improve culture and practice. Trusts should also accelerate plan to provide enhanced continuity of care for those in the most deprived neighbourhoods; and Review its approach to reviewing data on maternity and neonatal services, monitoring outcomes and experience. Read full story (paywalled)
Source: HSJ, 24 June 2025
Patient Safety Learning

Deaths linked to new crisis care policy

Coroners have issued multiple warnings about deaths linked to police refusing to respond to people in mental health crisis, prompting fresh concerns about “gaps in support”.
Several coroners have raised concerns about the “Right Care, Right Person” (RCRP) policy – agreed across the police force and NHS – since it was introduced nationally in 2023. This includes two new Prevention of Future Death reports issued during the same week.
The policy was introduced despite concerns in the NHS and from patient groups, after police forces said they were attending far too many incidents of people in mental health crisis. They argued they were under huge demand pressure and that these calls should be the responsibility of the NHS. However, health services are also often unable to respond.
Rebecca Sutton, assistant coroner for County Durham and Darlington, said in her report into the death of Sophie Cotton that there was “a refusal to the request that the police attend, even when a family member was expressing the view that there was a real and immediate risk to life”. Ms Cotton died by suicide in January this year, and was found after her family forced entry into her house, hours after they raised serious concerns about her welfare.
Ms Sutton also said the RCRP advice to contact mental health services “appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises”.
In response to the recent coroners’ concerns, a National Police Chiefs’ Council spokesperson told HSJ: “We are closely monitoring any comment from coroners on RCRP to ensure that if there is any learning for policing or our partners, that it is disseminated nationally.”
Read full story (paywalled)
Source: HSJ, 24 June 2025
Patient Safety Learning

Families call to meet PM over maternity failings

Parents involved in an independent review into Nottingham's maternity services say they want to meet Prime Minister Sir Keir Starmer to talk about the failings in care across the NHS.
On Monday, Health Secretary Wes Streeting announced a "rapid" investigation into maternity care in England.
Sarah and Jack Hawkins, whose daughter Harriet was stillborn in 2016 following maternity failings at Nottingham City Hospital, are calling for more action in the form of a statutory public inquiry.
Earlier this year Nottingham University Hospitals (NUH) NHS Trust - which is at the centre of the largest ever review into NHS failings - was given a record £1.6m fine over failings around the deaths of three babies.
Dr Hawkins said similar reviews into NHS failings had taken place and not achieved the results families had wanted, which is why he has backed calls for a national judge-led public inquiry.
"I think we're very clear that it's been tried before in various subtly different ways, and it will not work," he said.
"What we absolutely have to have is a statutory public inquiry, where people give evidence under oath, and are at risk of perjury in a court, just like the Post Office inquiry.
"There are thousands and thousands of avoidably dead babies and children in this country, in a system run by the state."
Read full story
Source: BBC News, 24 June 2025
Patient Safety Learning

At-home cervical screening tests offered in England

Women who have delayed coming forward for cervical screening will be offered a test to be taken at home, NHS England has said.
The DIY test kits, available from January, contain a long cotton-wool bud to swab the lining of the vagina.
The test is for human papillomavirus (HPV), which causes most cervical cancers, and women between the ages of 25 and 64 are offered it every few years.
The Department for Health and Social Care in England said the scheme would tackle "deeply entrenched barriers" that keep women away from cervical screening.
This can be due to embarrassment, discomfort, lack of time as well as religious or cultural concerns.
Just 68.8% of women currently take up the offer of cervical cancer screening - well below the NHS England target of 80%.
Younger women, those with a disability, ethnic minority communities and LGBT+ groups are more likely to miss appointments.
A recent trial showed the rollout of home test kits across England could increase the proportion screened to 77% over three years.
Hazel Stinson, 49, from Kent, suffers from chronic fatigue syndrome and was last able to visit the GP for a cervical screening six years ago.
She says she is "absolutely thrilled" that at-home testing is being rolled out across England.
"This will mean that I and millions of other people just like me will be able to have the test when otherwise they might not be able to do it," she added.
Ms Stinson said as someone with chronic fatigue, which is also known as myalgic encephalomyelitis or ME, "the most important thing is to advocate for yourself".
Read full story
Source: BBC News, 24 June 2025
Related reading on the hub:
Top picks: 9 resources about improving access to cervical screening The Eve Appeal: What adjustments can you ask for at your cervical screening? Catching cancer early: what more can we do as GPs? Improving healthcare services for people with ME and Long Covid: Patients share their challenges, and the actions needed
Patient Safety Learning

Manage ADHD like diabetes, says NHSE taskforce

An inability to access NHS attention deficit hyperactivity disorder (ADHD) services has resulted in a “significant growth” in the use of unregulated private providers, according to a report from a national taskforce.
The first report of NHS England’s ADHD taskforce found the long-waiting lists to access ADHD diagnosis and treatment services was resulting in “two-tier access… one for those who can pay and another for those who cannot”, which “drive health inequalities”.
Published on Friday, it called on policymakers to “shift rapidly to accessible, regulated and generalist models of care in the community, including primary care and other sectors outside the NHS”.
It called on the National Institute for Health and Care Excellence to reconsider that ADHD always requires a highly specialised, secondary care workforce.
“[NICE] should clearly define the meaning of specialist to enable greater involvement of primary care…this approach would align ADHD management with the way other common conditions, such as diabetes, are managed.” 
Read full story (paywalled)
Source: HSJ, 22 June 2025
Patient Safety Learning

I sat through an inquest into my toddler’s avoidable death

My son had a tummy ache. The next day he died after being discharged from a London hospital
One morning last July, my son, Finlay, had a tummy ache. We took him to the GP who suggested A&E if things didn’t improve. Later that afternoon we took him to the Whittington Hospital in north London where, over nine gruelling hours, we ticked off the increasingly familiar list of deathly NHS misery and systemic failure.
Paediatric A&E was described as “exceptionally” busy by staff. At that time the Whittington’s internal policies judged their staffing levels “unsafe”, though this wasn’t communicated to the A&E department. The conditions were filthy, we spent most of our time in the corridors where Finlay was repeatedly examined on my knee. Throughout the nine hours, no complete set of observations was ever taken, which no one seemed to notice. We asked to move to Great Ormond Street Hospital on a number of occasions but were rebuffed.
Key diagnostic resources — an ultrasound and an in-house surgical consultation — were not available. The few tests they managed were botched: an X-ray was misread, and a wildly anomalous blood test remained unexplained.
Still with no observations and no clue as to the blood test, we were discharged around 1am. When we woke up at 8am, Finny wasn’t breathing. I tried and failed to resuscitate him on his play mat. A dozen ambulance crew and police came and similarly failed. He was then taken back to the Whittington where he died.
In the face of this life-deranging calamity, the Whittington’s response was awful: cold, confused and incompetent. We had to beg for a referral for grief support. We repeatedly insisted that the Whittington could not investigate itself. This was just one piece of the wider NHS approach: sloppy correspondence with spelling mistakes and incorrect details, including our name.
Ultimately, the coroner wrote a “narrative” verdict. After putting the boot into the Whittington’s ineptitude, she concluded: “However, it is unclear whether, if all care had been delivered as it should have been, Finlay’s life would have been saved. He would have had a chance.”
At the time of writing, the coroner is still considering whether to issue another PFD notice.
Systems should be defined by what they do, not what they are supposed to achieve. The PFD system, it seems to me, exists more to document repetitive disaster than prevent it. And so, tomorrow, or next month, or next year, another family will learn that their child died in reasonably preventable circumstances, from causes already flagged by coroners, through institutional failures long documented in previous PFD reports. They will sit through the same ceremonial farrago, learning that their devastating loss was neither inevitable nor unforeseen, but recorded, bureaucratically forgotten, and condemned to repeat.
Read full story (paywalled)
Source: The Times, 22 June 2025
Patient Safety Learning

Top medics issue warning over heart drug - AstraZeneca accused of 'misreporting' data

Millions of patients at high risk of a fatal heart attack could be taking a drug that may not even be effective, top doctors have warned. 
Anti-clotting pill ticagrelor was approved for use on the NHS in 2011 after trials claimed it could prevent one in five deaths after a heart attack.
The twice-daily pill, sold as Brilinta, is given to people with acute coronary syndrome —a sudden reduction of blood to the heart—reducing the risk of deadly clots and strokes.
Now, experts have discovered 'evidence of serious misreporting' in two clinical trials, pivotal to getting the drug approved in the UK and US, 'raising doubts over its approval'. 
The BMJ investigation claimed the 'primary endpoint' results—the key measure to determine whether a treatment is effective—for both trials were inaccurately reported in leading cardiology journal Circulation. 
It also said around a quarter of the readings from machines used in the trials were not included in the data sets, the US medicine's regulator, the Food and Drug Administration (FDA) used to approve the drug. 
Dr Victor Serebruany, an expert in cardiovascular pharmacology at Johns Hopkins University in Maryland, who has been critical of the drug for over a decade said: 'It's been obvious for years that there is something wrong with the data. 
"That the FDA's leadership could look past all these problems—on top of the many problems their own reviewers identified and are now being discovered by The BMJ—is unconscionable. 
"We all need to know how and why that happened.
"If doctors had known what happened in these trials, they would never have started using ticagrelor."
Read full story
Source: Mail Online, 20 June 2025  
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