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

‘Blame shunting’ by providers leads to poor emergency care, says NHSE

The ‘inability or unwillingness’ of some NHS and social care providers to work together has contributed to an ‘unimaginable’ deterioration in emergency care performance, according to NHS England
The claim is made in the urgent care recovery plan for 2025-26, released by NHS England and the Department of Health and Social Care.
The plan includes a new target to reduce 12-hour accident and emergency waits and pledges to invest £370m of capital funding in improving urgent care and mental health facilities.
The plan said, “Each part of the system has responsibility for improving urgent and emergency care performance. However, blame shunting has become a feature in some poorly performing systems and can no longer be tolerated."
National urgent care director Sarah-Jane Marsh told HSJ that “the duty to collaborate and work together and do the best for patients is on all trust boards, and it shouldn’t rely on some overseer to make sure that happens. It’s a fundamental part of being a leader”.
Trusts will be told to ensure the proportion of patients waiting over 12 hours for admission, transfer or discharge from A&E remains less than 10%.
The 45-minute “maximum” ambulance handover time will become mandatory across all trusts ahead of winter, according to the plan. 
Chief executive of the College of Paramedics, Tracy Nicholls, said, “The plan sets out progressive structural proposals that have the potential to enhance public safety and strengthen paramedic autonomy. However, it may underestimate key challenges, including workforce readiness, the capacity of the mental health system, and practical implications of the Right Care, Right Person model. Without urgent alignment of funding, training, and alternative care pathways, there is a real risk that paramedics could be left navigating a reform process that shifts responsibility without equipping them with the necessary tools and support.
Read full story (paywalled)
Source: HSJ, 5 June 2025
Related reading on the hub:
How corridor care in the NHS is affecting safety culture: A blog by Claire Cox My experience of the 'Wait 45' policy - Florence in the Machine A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift  
Patient Safety Learning

'I'm terrified of food - but I can't get specialist eating disorder treatment'

A woman whose wait for a diagnosis of a lesser known eating disorder left her feeling like a "problem that cannot be solved" has called for reform of how the condition is treated by Northern Ireland's health service.
Sinead Quinn, from Londonderry, said binge eating compulsions had made her "a prisoner in her own home, afraid of food and afraid of herself".
Binge Eating Disorder (BED) is not currently treated by eating disorder services in Northern Ireland - patients are instead referred to general mental health services.
The Department of Health said regional adult eating disorder services were commissioned to treat anorexia, bulimia and atypical presentations of these conditions.
BED is the second most common eating disorder in the UK, after atypical eating disorders, according to UK health assessment body NICE, external.
The Department of Health said it did not collate data on how many people in Northern Ireland are living with BED.
It also said there was no current review of the way the condition is treated.
Experts say specialist care within the health service is urgently needed to help people get a formal diagnosis and recover from BED.
Prof Laura McGowan, from the Centre for Public Health at Queen's University, hopes the recently announced roll-out of a regional obesity management service for Northern Ireland would include screening of eating disorders like BED.
"BED is simply not widely recognised and the services for it not widely commissioned," she said.
"For BED patients, especially those living with obesity, there is such an unmet need."
Read full story
Source: BBC News, 5 June 2025
Patient Safety Learning

Trusts ordered to help with ‘heartbreaking’ diagnostic delays

NHS England has told trusts they must help neighbours to cut the number of children waiting for hearing tests, even if it affects their own performance.
NHS England co-medical director for secondary care Meghana Pandit has written to regional and integrated care board leaders warning that some areas have fallen behind in responding to serious concerns about paediatric audiology.
In 2023, an NHSE audit found that more than a thousand children might have been misdiagnosed or had problems missed. As of February, 1,374 children were still waiting to be seen, and of the 775 who had been assessed, 31 had suffered severe or permanent harm and another 76 moderate harm.
Trusts that have previously confirmed that children had diagnoses missed include Barts Health Trust, Worcestershire Acute Hospitals Trust, and Northern Lincolnshire and Goole Foundation Trust.
Professor Pandit said some areas had missed the national “ambition” of recalling and reassessing all patients by the end of March. They are then due to be discharged or have started treatment by the end of September.
ICBs now have until 20 June to submit detailed plans on how they will achieve this, and providers are expected to prioritise the reassessments.
The letter, written with chief scientific officer Sue Hill and diagnostics director Rhydian Phillips, said: “The risk of decline in an individual provider’s diagnostic six-week wait performance should not be a reason to decline support to this process. It has been agreed nationally that the review, recall and reassessment process should be prioritised in the short term.”
Read full story (paywalled)
Source: HSJ, 6 June 2025
Patient Safety Learning

Weight loss drugs linked to higher risk of eye damage in diabetic patients

Weight loss drugs could at least double the risk of diabetic patients developing age-related macular degeneration, a large-scale study has found.
Originally developed for diabetes patients, glucagon-like peptide-1 receptor agonist (GLP-1 RA) medicines have transformed how obesity is treated and there is growing evidence of wider health benefits. They help reduce blood sugar levels, slow digestion and reduce appetite.
But a study by Canadian scientists published in Jama Ophthalmology has found that after six months of use GLP-1 RAs are associated with double the risk of older people with diabetes developing neovascular age-related macular degeneration compared with similar patients not taking the drugs.
Academics at the University of Toronto examined medical data for more than 1 million Ontario residents with a diagnosis of diabetes and identified 46,334 patients with an average age of 66 who were prescribed GLP-1 RAs. Nearly all (97.5%) were taking semaglutide, while 2.5% were on lixisenatide.
The study did not exclude any specific brand of drugs, but since Wegovy was only approved in Canada in November 2021, primarily for weight loss, it is likely the bulk of semaglutide users in the study were taking Ozempic, which is prescribed for diabetes.
The study found that those who had been taking semaglutide or lixisenatide for at least six months had twice the risk of developing macular degeneration, compared with similar patients who were not taking the drugs. Patients who had been taking GLP-1 RAs for more than 30 months had more than three times the risk.
Marko Popovic, a co-author of the study and physician in the department of ophthalmology and vision sciences at the University of Toronto, said: “GLP-1 receptor agonists appear to have multiple effects on the eye, and in the case of neovascular age-related macular degeneration, the overall impact may be harmful.
“Based on our data, I would advise exercising particular caution when prescribing GLP-1 RAs to older [diabetic] patients or those with a history of stroke, as both groups were found to have an even higher risk of developing [the condition].”
Read full story
Source: The Guardian, 5 June 2025
Patient Safety Learning

Labour pledges to end 'corridor care' and long waits with almost £450m NHS investment in England

Nearly £450m is being invested in the NHS in England to cut hospital waiting times and tackle persistently failing trusts, the health secretary has announced.
Wes Streeting says his NHS reforms aim to deliver around 40 new centres to fast-track treatment for patients, up to 15 mental health crisis assessment units and almost 500 new ambulances.
It is part of an attempt to shift patients away from A&E and avoid unnecessary hospital admissions.
"No patient should ever be left waiting for hours in hospital corridors or for an ambulance which ought to arrive in minutes," said Mr Streeting.
"The package of investment and reforms we are announcing today will help the NHS treat more patients in the community, so they don't end up stuck on trolleys in A&E," he added.
In an example of the challenge facing the health secretary, Sky News on Wednesday revealed the scale of England's mental health crisis, exacerbated by a shortage of specialist beds and an overwhelmed social care network.
The new Urgent and Emergency Care Plan for England says more needs to be done to drive down long waits, cut delayed discharges and improve care for patients.
Read full story
Source: Sky News, 6 June 2025
Related reading on the hub:
How corridor care in the NHS is affecting safety culture: A blog by Claire Cox My experience of the 'Wait 45' policy - Florence in the Machine A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
Patient Safety Learning

I had to beg doctors for help, sepsis patient says

A man said he was left "begging for help" from doctors after he suffered life-changing injuries due to sepsis caused by failures at his local hospitals.
Paul Robinson, 70, developed recurring sepsis for almost a year after being hospitalised on multiple occasions in Brighton and Worthing.
The company director from Goring, in West Sussex, said: "I've lost my freedom, confidence, business, very nearly my family home, and almost my will to live."
Mr Robinson was diagnosed with cancer in 2018.
He successfully had a lump removed from his lung. But during chemotherapy, he became unwell and was diagnosed with sepsis.
He said he went through several relapses with sepsis and was in hospital for 13 days.
"I was left for 11 months with recurring, untreated sepsis – despite begging for help," he said.
Describing his care at Worthing Hospital and Royal Sussex County Hospital in Brighton, he said there was a breakdown in communication between nurses, doctors and departments.
He said there had been "systemic failures" and "ignored warnings" with his care.
"We asked for help 47 times, and we were ignored 47 times," he added.
"Every day I see NHS campaigns about spotting the signs of sepsis. We knew the signs, we pleaded for help, and nobody listened."
Read full story
Source: BBC News, 5 June 2025
Patient Safety Learning

Women and ethnic minorities less likely to be treated after diagnosis of deadly heart disease in England, study finds

Women, people from minority ethnic backgrounds, and those living in the most deprived areas of England are less likely to receive treatment after a diagnosis of a deadly heart disease, according to one of the largest studies of its kind.
Researchers at the University of Leicester analysed data from almost 155,000 people diagnosed with aortic stenosis – a narrowing of the valve between the heart’s main pumping chamber and the main artery – between 2000 and 2022 across England, from a database of anonymised GP records.
The study found that patients living in the most deprived areas were 7% less likely to be referred for secondary care after their diagnosis compared with patients in the least deprived areas, and 4% less likely to undergo a procedure to replace their aortic valve.
The analysis, funded by the National Institute for Health and Care Research (NIHR) and presented at the British Cardiovascular Society conference in Manchester, also found that women were 11% less likely to be referred to secondary care, such as a hospital specialist, after their diagnosis than men. Women were also 39% less likely to have a procedure to replace their aortic valve.
The study also found that black patients were 48% less likely to undergo a procedure to replace their aortic valve than white patients, with south Asian patients being 27% less likely. Both groups were more likely to be referred to secondary care, although the researchers say that this could reflect referrals for other heart issues not related to their aortic stenosis.
Read full story
Source: The Guardian, 5 June 2025
Patient Safety Learning

USA: Hospitals push back on low Leapfrog grades

Hospitals given “D” and “F” grades from The Leapfrog Group are rebuking the patient safety scores, arguing that Leapfrog’s grading was unfair. 
Piedmont Medical Center in Rock Hill, S.C., Huntsville (Ala.) Hospital and Madison (Ala.) Hospital said the scores are not accurate representations of their safety and quality performance. The hospitals did not report data to Leapfrog’s biannual safety grade survey — a factor they say contributed to the misleading scores. 
Leah Binder, president and CEO of Leapfrog, told Becker’s that, of the approximately 2,500 general acute hospitals it evaluates, about 20% did not report to Leapfrog’s spring 2025 survey. Of those hospitals, more than 400 received a grade of “C” or higher. 
“It is perfectly possible to get a good grade and not report to the Leapfrog survey we use,” Ms. Binder said. “We use the Leapfrog survey when we have that data. We impute scores for the data when we don’t have it. I think the measures that the hospitals are concerned about are four out of the 30 measures we use in the hospital safety grade. So if these hospitals did well on more of those 30 measures, there would be no issue whatsoever. They’d be getting an “A,” “B” or “C,” but they are actually performing, in some cases, very poorly on some measures that come from CMS, so that’s an area where we would strongly encourage them to focus their attention.”
In a statement shared with The Herald, Piedmont claimed that “Leapfrog’s scoring system deceives patients and rewards hospitals that either pay them or supply free data for their flawed survey, while punishing those that do not participate with inaccurate scores based on fabricated data.”
Ms. Binder said this claim is “factually incorrect,” adding there is no “pay-to-play” for hospitals to participate in the survey or receive a grade. The organization also does not charge the public to access hospital safety data, she said. 
In April, five hospitals part of Palm Beach Health Network filed a lawsuit against Leapfrog, alleging the rankings are based on flawed methodology and damage hospitals’ reputations. The hospitals — two of which received a “D” and one an “F” — said Leapfrog penalises organisations that do not submit data by doling out low ratings. 
Ms. Binder described the lawsuit as an attempt to suppress critical safety information.
Read full story
Source: Becker's Clinical Leadership, 2 June 2025
Patient Safety Learning

'I will fade away without vital pancreas medication'

A Kent man who has had three-quarters of his pancreas removed says he will "fade away" without a medication that there has been a nationwide shortage of since 2024.
Paul Elcombe, from Hartley, takes Creon three times a day, after major surgery three years ago left him no longer able to create enough enzymes to break down food.
As it stands, he has three and a half weeks worth of tablets left, having only had one prescription filled this year.
He said: "You need it to survive, without it [Creon] your body can't break down the food...it's as important as insulin is to a diabetic."
The nationwide shortage, which the Department of Health and Social Care (DHSC) says is a "European-wide" supply issue, has forced the 63-year-old and his wife to spend time travelling to different pharmacies in a bid to get the medication.
He said: "I know it sounds dramatic, but without it you will just fade away...it's very scary."
Read full story
Source: BBC News, 5 June 2025
Patient Safety Learning

People with cancer face ‘ticking timebomb’ due to NHS staff shortages

People with cancer face a “ticking timebomb” of delays in getting diagnosed and treated because the NHS is too short-staffed to provide prompt care, senior doctors have warned.
An NHS-wide shortage of radiologists and oncologists means patients are enduring long waits to have surgery, chemotherapy or radiotherapy and have a consultant review their care.
Hold-ups lead to some people’s cancer spreading, which can reduce the chances of their treatment working and increase the risk of death, the Royal College of Radiologists (RCR) said.
NHS cancer services are struggling to keep up with rising demand for tests, such as scans and X-rays, and treatment, created by the growing number of people getting the disease.
All radiology bosses surveyed said during 2024 their units could not scan all patients within the NHS’s maximum waiting times because they did not have enough staff.
“Delays in cancer diagnosis and treatment will inevitably mean that for some patients their cancer will progress while they wait, making successful treatment more difficult and risking their survival,” said Dr Katharine Halliday, the RCR’s president.
The findings are particularly worrying because research has found that a patient’s risk of death can increase by about 10% for each month they have to wait for treatment.
Nine out of 10 cancer centre chiefs said patients were delayed starting their treatment last year while seven in 10 said they feared workforce gaps were putting patients’ safety at risk.
Read full story
Source: The Guardian, 5 June 2025
Patient Safety Learning

Women warned weight-loss jabs may affect the pill

Women using weight-loss jabs have been warned by the UK's medicines regulator that they must use effective contraception.
The Medicines and Healthcare products Regulatory Agency (MHRA) says it is not known whether taking the medicines, such as Wegovy and Mounjaro, could harm an unborn baby.
It also warns that weight-loss jabs may make the contraceptive pill less likely to work in those who are overweight or obese.
There are concerns that the growing popularity of 'skinny jabs' means many women aren't using the drugs safely or getting the right advice.
It's thought the contraceptive pill may not be absorbed properly due to common side-effects of the jabs such as vomiting and diarrhoea, and because they slow the emptying of the stomach.
The MHRA says women should use contraception while taking GLP-1 medicines and for a certain period afterwards before trying to become pregnant - two months for Wegovy and Ozempic, and one month for Mounjaro.
It also advises that those using Mounjaro and taking an oral contraceptive should also use a condom for four weeks after starting the drug, or switch to another method such as the coil or implant.
Advice on contraception already appears in patient information leaflets that come with the medicines, but the MHRA has now issued its own guidance.
Read full story
Source: BBC News, 5 June 2025
Patient Safety Learning

Major AI project paused over patient data concerns

NHS England has paused a major AI project after concerns were raised about how the primary care records of 57 million people were used to train it.
The Joint General Practice IT Committee (JGPITC) – a collaboration between the Royal College of General Practitioners and the British Medical Association – wrote to NHSE last month to question the lawfulness of the Foresight AI project.
Foresight is the result of a data sharing agreement between NHSE and a consortium of researchers brought together by the British Heart Foundation. It will be used to predict potential future outcomes for patients that could be used to identify opportunities for early intervention.
In its letter, the JGPITC said it was “very surprised and extremely concerned” to learn of the project, which used the GPES Data for Pandemic Planning and Research dataset to train the AI model.
The committee said it had “serious concerns about the lawfulness of the data use for this project” and the “apparent absence of strict governance arrangements”.
An NHSE spokesperson said: “Maintaining patient privacy is central to this project and we are grateful to the Joint GP IT Committee for raising its concerns and meeting with us to discuss the strict governance and controls in place to ensure patients’ data remains secure.”
Read full story (paywalled)
Source: HSJ, 4 June 2025
Patient Safety Learning

Hospital 'deeply sorry' after 12-year-old's death

A hospital boss has apologised "unreservedly" after the death of a 12-year-old girl which led a coroner to raise concerns about the "discrimination of disabled children".
Rose Harfleet died at Royal Surrey County Hospital, in Guildford, on 30 January 2024, having attended its emergency department the day before with abdominal pain and vomiting.
Assistant coroner for Surrey, Karen Henderson, said in a recent report that there was a failure of the medical and nursing staff to appreciate Rose was clinically deteriorating.
The coroner said Rose, who from birth was diagnosed with mosaic trisomy 17 with global developmental delay, was "wholly reliant on her mother to advocate on her behalf".
But she said at the hospital no history was taken from Rose's mother and that the severity of her signs and symptoms were underestimated.
She said poor clinical decisions contributed to Rose's death.
"This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children," she added.
Read full story
Source: BBC News, 4 June 2025
Patient Safety Learning

Trump rescinds guidance protecting women in need of emergency abortions

The Trump administration on Tuesday rescinded Biden-era guidance clarifying that hospitals in states with abortion bans cannot turn away pregnant patients who are in the midst of medical emergencies – a move that comes amid multiple red-state court battles over the guidance.
The guidance deals with the federal Emergency Medical Treatment and Labor Act (Emtala), which requires hospitals to stabilize patients facing medical emergencies. States such as Idaho and Texas have argued that the Biden administration’s guidance, which it issued in the wake of the 2022 overturning of Roe v Wade, interpreted Emtala incorrectly.
In its letter rescinding the guidance, the Trump administration said that the Centers for Medicare and Medicaid Services (CMS) “will continue to enforce Emtala, which protects all individuals who present to a hospital emergency department seeking examination or treatment, including for identified emergency medical conditions that place the health of a pregnant woman or her unborn child in serious jeopardy. CMS will work to rectify any perceived legal confusion and instability created by the former administration’s actions.”
Abortion rights supporters said on Tuesday that rescinding the Biden administration’s guidance will muddy hospitals’ ability to interpret Emtala and endanger pregnant patients’ lives. Since Roe’s collapse, dozens of women have come forward to say that they were denied medical treatment due to abortion bans. A reported five pregnant women have died after having their care denied or delayed, or being unable to access legal abortions.
“This action sends a clear message: the lives and health of pregnant people are not worth protecting,” Dr Jamila Perritt, an OB-GYN and the president of Physicians for Reproductive Health, said in a statement. “Complying with this law can mean the difference between life and death for pregnant people, forcing providers like me to choose between caring for someone in their time of need and turning my back on them to comply with cruel and dangerous laws.”
Read full story
Source: The Guardian, 3 June 2025
Patient Safety Learning

Police investigate heart deaths at NHS hospital

Police have launched an investigation into the deaths of patients following heart operations at an NHS hospital, the BBC has learned.
Documents seen suggest patients suffered avoidable harm - and that in some cases their death certificates failed to disclose that the procedure contributed to their deaths.
One woman's operation at Castle Hill Hospital near Hull - that should have taken no more than two hours - has been described as a "disaster" by one medic.
She spent six hours in surgery and lost five litres of blood - all while under local anesthetic.
But none of this was mentioned on her death certificate, which recorded her as dying from pneumonia. Her family were also not told what had happened.
The documents raise concerns about the care that 11 patients received during a TAVI - Transcatheter Aortic Valve Implant - a procedure to replace a damaged valve in the heart, similar to adding a stent.
The department's TAVI mortality rate at the time was three times higher than the UK average, something patients and families were also unaware of.
The NHS body that runs Castle Hill, the Humber Health Care Partnership, told the BBC it had delivered improvements suggested by the Royal College of Physicians (RCP). In a statement, it said it was happy to directly answer any questions from the patients' families.
Read full story
Source: BBC News, 4 June 2025
Patient Safety Learning

Physician associates to be renamed to stop them being mistaken for doctors

Physician associates in the NHS will be renamed to stop patients mistaking them for doctors after a review found that their title caused widespread confusion.
Thousands of physician associates who work in hospitals and GP surgeries across the UK take medical histories, examine patients and diagnose illnesses but are not doctors.
However, Prof Gillian Leng, whose government-ordered review is looking into whether they pose a risk to patients’ safety, has concluded that they must be given a new name, so patients they treat are not misled into thinking they have seen a doctor, according to sources with knowledge of her thinking.
Doctors who fear the term has created widespread confusion among the public and risks undermining trust in the medical profession will regard ditching it as a major victory.
Wes Streeting, the health secretary, is expected to accept Leng’s recommendation and instigate the change, which could lead to physician associates being renamed “physician assistants” or “doctors’ assistants”. She will also specify in her final report, due later this month, that those who perform those roles must make clear to patients that they are assistants, not fully fledged medics.
Physician associates have been implicated in several high-profile patient deaths. Earlier this year, a coroner found that in February 2024 a physician associate (PA) in the A&E at East Surrey hospital had misdiagnosed 77-year-old Pamela Marking as having a nosebleed when she had a small bowel obstruction and hernia that required emergency surgery. She returned to the hospital two days later but she died soon after.
In her prevention of future deaths report the coroner, Karen Henderson, warned that the term “physician associate” was “misleading to the public” and that there was a “lack of public understanding of the role”.
Read full story
Source: The Guardian, 4 June 2025
Further reading on the hub:
Physician associates: What are the patient safety issues? An interview with Asif Qasim Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates
Patient Safety Learning
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