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

A surgeon was flagged as dangerous — she kept operating for ten years

Hospital bosses were warned about an NHS surgeon almost nine years before she was eventually suspended over botched operations on children.
A joint investigation by The Sunday Times and Sky News has discovered a confidential report written for managers at Cambridge University Hospitals Trust in 2016 that identified problems with the surgical technique and practice of Kuldeep Stohr, a paediatric orthopaedic surgeon.
A series of recommendations were made in the report but Stohr was allowed to continue operating. Managers at the hospital told staff the investigation into Stohr had not raised any concerns.
Almost a decade on, Stohr has been suspended by the trust after a new review identified at least nine children whose care “fell below the standard” expected. The trust has begun a review of 800 other patients, including around 560 children, 140 adults and 100 emergency patients, who were operated on by Stohr. It has also commissioned an investigation into what action was taken after the 2016 report.
Read full story (paywalled)
Source: The Times, 10 May 2025
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Baby death NHS trust reaches 'turning point'

Two maternity units in Kent have shown signs of improvements three years after a damning independent review found up to 45 babies might have survived if they had received better care, a report has said.
The Care Quality Commission (CQC) report rated maternity services at William Harvey Hospital in Ashford and Queen Elizabeth The Queen Mother Hospital in Margate as good, two years after they were downgraded to inadequate.
The CQC said "significant improvements" had been made at both units to safety, leadership, culture, the environment and staffing levels.
Tracey Fletcher, chief executive of East Kent Hospitals University NHS Foundation Trust, said the report was "an important milestone in our continuing work to improve our services".
Serena Coleman, CQC's deputy director of operations in Kent, said: "We found significant improvements and a better quality service for women, people using the service and their babies.
"This turnaround in ratings across both services demonstrates what can be achieved with strong and capable leaders who focus on an inclusive and positive culture."
Kaye Wilson, chief midwife for the South East at NHS England, said: "This report marks a turning point for services at East Kent and is the result of the commitment, determination and sheer hard work of midwives, obstetricians and the whole maternity team."
Read full story
Source: BBC News,15 May 2025
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Top doctor warns government ‘neglecting’ old people as figures suggest thousands of A&E patients died waiting for bed

The UK's top A&E doctor has accused the government of “neglecting the oldest and sickest patients” as figures suggest a record 320 people a week may have died needlessly in A&E last year due to waits for hospital beds.
Dr Adrian Boyle, the Royal College of Emergency Medicine president, has warned that current government policy on A&E is focused on cutting waits for “cut fingers and sprained ankles” while neglecting older people, who are most likely to die and spend days on trollies.
The Royal College of Emergency Medicine (RCEM) estimates there were more than 16,600 deaths of patients linked to long waits for a bed, an increase of a fifth on 2023 and a record since new A&E data has been published.
The figures come after the NHS’s target to see 95% of patients within four hours was cut to 78% for 2025/26. There is no national target for the number of people waiting 12 hours, the length of time linked to excess emergency care deaths, but last year more than 1.7 million patients waited 12 hours or more to be admitted, discharged or transferred from A&E.
Dr Boyle said the figures were “the equivalent of two aeroplanes crashing every week” and were devastating for families.
Read full story
Source: The Independent, 15 May 2025
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Councils and trusts to help failing GP practices under ‘neighbourhood’ plan

Nominated “integrator” organisations – which could be NHS provider trusts or councils – will help GP practices “at risk of failure”, under new plans for London’s neighbourhood health service.
Proposals were published this week by the capital’s five integrated care boards, NHS England’s London region, local councils, the Greater London Authority, London Health and Care Partnership, and the Office for Health Improvement and Disparities, with support from the Londonwide Local Medical Committees. The work was carried out jointly with the PPL consultancy.
Their plans say that “place partnership” teams – subdivisions of the ICBs, normally matching boroughs – will have to decide “footprints of neighbourhoods”, based on local information and data, such as mapping of capacity, demand, local assets and needs.
Many existing primary care networks (which are partnerships of GP practices) are likely to have to “re-align”, it indicates, as neighbourhood team “boundaries [will] not automatically be defined by existing PCN footprints, except where these boundaries align with recognisable neighbourhoods”. Some PCNs that don’t match may agree ways to work across several smaller integrated neighbourhood teams (INTs).
Read full story
Source: HSJ, 14 May 2025
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System is failing people with simultaneous mental health and substance misuse problems

People who have both substance misuse problems and mental health disorders are being overlooked by the NHS, leading to avoidable harm and even suicides, say experts.
Better coordination between services, monitoring of outcomes, and training for clinicians on how to treat the conditions simultaneously are needed to tackle this problem, said the authors of a report1 on co-occurring substance misuse and mental health (CoSUM) disorders.
The report from the Royal College of Psychiatrists says people with CoSUM disorders experience poorer health, worse engagement with work, and higher mortality and rates of suicide than people who have either a mental illness or a substance misuse disorder.
Read full story (paywalled)
Source: BMJ, 13 May 2025
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USA: Columbia to pay $750m to hundreds of victims of gynaecologist

An ex-doctor is now costing Columbia University over $1 billion after a new sex abuse settlement with nearly 600 victims in a deal approved in Manhattan Supreme Court on Monday.
Columbia University agreed to the record-breaking $750 million settlement with 576 victims of disgraced gynaecologist and convicted sex criminal Robert Hadden — with a per-case average of $1.3 million, the attorney for the victims announced. 
"This settlement is not about money — it's about accountability," said victim Laurie Maldonando.
"Columbia University enabled sadistic abuse," said Maldonando, who was a patient of Hadden’s for nearly a decade, "and now, they’ve been forced to face the truth."
In 2023, Hadden was sentenced to 20 years in prison for preying on — and sexually abusing — hundreds of vulnerable patients during his years as a gynaecologist at prestigious Big Apple hospitals, including ones associated with Columbia University and New York-Presbyterian.
"For far too long, Columbia and New York-Presbyterian have prioritized protecting their reputations over protecting their patients," said attorney Anthony T. DiPietro, who has battled with Columbia in court on behalf of hundreds of Hadden victims since 2012. 
DiPietro said he discovered a "smoking gun" that year — a letter penned by the then-head of Obstetrics and Gynecology at Columbia in 1995, apologizing for "Hadden’s assault" and undercutting the institution’s claims they were unaware — by digging around the Utah basement of a client.
The attorney had already secured $277 million in previous settlements against Columbia for Hadden victims, bringing the hospitals' total payouts to just over $1 billion with Monday’s agreement.
"We deeply regret the pain that his patients suffered, and this settlement is another step forward in our ongoing work and commitment to repair harm and support survivors," said a spokesperson for the university, who "commended" the survivors for their "bravery." 
Read full story
Source: Fox News, 6 May 2025
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The RCPsych cannot support the Terminally Ill Adults (End of Life) Bill for England and Wales in its current form

The Royal College of Psychiatrists (RCPsych) is calling on MPs to consider serious concerns about the Terminally Ill Adults (End of Life) Bill for England and Wales, ahead of the pivotal Commons Report stage debate and Third Reading.  
With too many unanswered questions about the safeguarding of people with mental illness, the College has concluded that it cannot support the Bill in its current form. 
RCPsych is once again sharing its expert clinical insight to support MPs in making informed decisions ahead of the debate in Westminster on Friday 16 May 2025.  
During the Committee stage of the parliamentary process, the College raised questions about the assessments of the coordinating doctor and independent doctor, and is now raising further questions about the multidisciplinary panel (which would include a psychiatrist) being proposed by the Bill. 
Dr Lade Smith CBE, President of the Royal College of Psychiatrists, said: 
"After extensive engagement with our members, and with the expertise of our assisted dying/assisted suicide working group, the RCPsych has reached the conclusion that we are not confident in the Terminally Ill Adults Bill in its current form, and we therefore cannot support the Bill as it stands. 
"It’s integral to a psychiatrist’s role to consider how people’s unmet needs affect their desire to live. The Bill, as proposed, does not honour this role, or require other clinicians involved in the process to consider whether someone’s decision to die might change with better support. 
"We are urging MPs to look again at our concerns for this once-in-a-generation Bill and prevent inadequate assisted dying/assisted suicide proposals from becoming law."
Read press release
Source: RCPsych, 13 May 2025
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Charity boss slams 'reprehensible' health trusts

Health trusts have repeatedly tried to prevent coroners from issuing Prevention of Future Death reports in order to protect their reputations, an inquiry has heard.
Deborah Coles, director of the charity Inquest, told the BBC the "reprehensible" behaviour was a pattern "played out across the country" but was "exemplified" in Essex.
She gave evidence at the Lampard Inquiry, which is looking into the deaths of more than 2,000 people being treated by NHS mental health services in Essex between 2000 and 2023.
In her evidence to the inquiry, Ms Coles said the "lack of candour" on the part of mental health trusts in Essex was the reason a statutory public inquiry needed to be held.
"It's difficult to say how traumatising that is for families when they sit in at an inquest… and then see legal representatives try and effectively stop a coroner from making a Prevention of Future Deaths report, external, which is ultimately about trying to safeguard lives in the future - and I find that reprehensible," she said.
"We are talking here about trying to protect lives and also remember those who've died where those deaths were preventable."
Read full story
Source: BBC News, 13 May 2025
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GPs split over assisted dying plans, BBC research suggests

Family doctors in England are deeply divided on the issue of assisted dying, BBC research on plans to legalise the practice suggests.
The findings give a unique insight into how strongly many GPs feel about the proposed new law - and highlight how personal beliefs and experiences are shaping doctors' views on the issue.
BBC News sent more than 5,000 GPs a questionnaire asking whether they agreed with changing the law to allow assisted dying for certain terminally ill people in England and Wales.
More than 1,000 GPs replied, with about 500 telling us they were against an assisted dying law and about 400 saying they were in favour.
Some of the 500 GPs who told us they were against the law change called the bill "appalling", "highly dangerous", and "cruel". "We are doctors, not murderers," one said.
Of the 400 who said they supported assisted dying, some described the bill as "long overdue" and "a basic human right".
It comes as MPs will this week again debate proposed changes to the controversial bill, with a vote in parliament expected on whether to pass or block it next month.
If assisted dying does become legal in England and Wales, it would be a historic change for society.
Read full story
Source: BBC News, 14 May 2025
Patient Safety Learning

Government has no clear plan for NHS England abolition, say MPs

The government is abolishing NHS England without a clear plan for how it will be achieved and how it will benefit frontline care, a cross-party group of MPs has warned.
Ministers announced in March that the body responsible for overseeing the health service in England would go, with its functions brought into the Department of Health and Social Care.
But the Public Accounts Committee said it was concerned about the uncertainty being caused and urged the government to set out a clear plan within the next three months.
The government said the move would eliminate "wasteful duplication" and that detailed planning had started.
Alongside the changes at a national level, the 42 local health boards responsible for planning services are also having to shed around half of their 25,000 staff.
Committee chair and Tory MP Sir Geoffrey Clifton-Brown said the changes to NHS England and local health boards amounted to a major structural reform.
He said strong decision-making and experienced staff would be vital to manage a period of "huge pressure" for the NHS.
"It has been two months since the government's decision to remove what, up until now, has been seen as a key piece of machinery, without articulating a clear plan for what comes next – and the future for patients and staff remains hazy," he added.
Read full story
Source: BBC News, 14 May 2025
Patient Safety Learning

NHS medical negligence liabilities hit £58.2bn amid calls to improve patient safety

The NHS’s total liabilities for medical negligence have hit an “astounding” £58.2bn amid ministers’ failure to improve patient safety, an influential group of MPs have warned.
The Commons public accounts committee (PAC) said the “jaw-dropping” sums being paid to victims of botched treatment and government inaction to reduce errors were “unacceptable”.
The Department of Health and Social Care (DHSC) has set aside £58.2bn to settle lawsuits arising from clinical negligence that occurred in England before 1 April 2024, the PAC disclosed.
“The fact that government has set aside tens of billions of pounds for clinical negligence payments, its second most costly liability after some of the world’s most complex nuclear decommissioning projects, should give our entire society pause,” said Sir Geoffrey Clifton-Brown, the PAC chair.
“This is a sign of a system struggling to do right by the people it is designed to help,” he added.
The PAC urged ministers to take urgent steps to reduce “tragic incidences of patient harm” and to also end a situation where lawyers take an “astronomical” 19% of the compensation awarded to those who are successful in suing the NHS. That amounted to £536m of the £2.8bn that the health service in England paid out in damages in 2023-24 – its record bill for mistakes.
“Far too many patients still suffer clinical negligence which can cause devastating harm to those affected,” and the ensuing damages drain vital funds from the NHS, the report said.
Read full story
Source: The Guardian, 14 May 2025
Patient Safety Learning

Should health systems disclose when they’re using AI?

Should health systems tell patients when they’re using AI? UC San Diego Health says yes.
The health system uses a generative AI tool from Epic that drafts MyChart patient portal messages for providers. But UC San Diego Health notifies patients when the responses are drafted by AI with the disclosure: “Part of this message was generated automatically and was reviewed and edited by [name of physician],” according to a May 9 NEJM AI article.
Members of the organisation’s AI governance committee debated whether it was necessary, as providers use other documentation shortcuts and generative AI could elicit concern from patients, but ultimately came to the same conclusion.
“Transparency is necessary, as AI-assisted replies may stand out to patients — especially if they differ from clinicians’ usual communication style,” wrote the authors, UC San Diego Health Chief Medical Information Officer Marlene Millen, MD, Professor Ming Tai-Seale, MD, and Chief Clinical and Innovation Officer Christopher Longhurst, MD.
Lack of transparency “could lead to patients questioning the authenticity of the replies, potentially damaging the crucial doctor-patient trust,” the authors wrote. “With tens of thousands of physicians nationwide using AI to support patient communication, now is the time to begin transparent disclosure.”
Read full story
Source: Becker's Health IT, 12 May 2025
Sam

Doctor accused of falsifying artificial mesh records

A surgeon found to have left patients in "agony" after using artificial mesh to treat prolapsed bowels faces allegations he falsified medical notes.
Tony Dixon was suspended after the surgery was found to have caused harm to hundreds of patients at two hospitals in Bristol.
Now, a new hearing will examine Dr Dixon's records. He is accused of dishonestly creating patient records long after he was involved in their care, something he "strongly denies".
The Medical Practitioners Tribunal Service (MPTS) will begin Monday. It will examine claims medical records for seven patients contained false information, and were not created at the correct time.
A spokesperson for Dr Dixon said: "[He] always endeavoured to provide the highest standard of care to his patients.
"He strongly disputes falsifying any medical records and will provide his detailed evidence about those serious allegations to the tribunal, initially by way of a detailed witness statement which he has provided to the General Medical Council."
Read full story
Source: BBC News, 12 May 2025
Sam

Asthma figures show ‘shocking’ health inequalities in England, charity says

People from minority ethnic backgrounds in the most deprived areas of England are up to three times more likely to need emergency treatment for asthma than their white counterparts, analysis has found.
Analysis of NHS statistics conducted by the charity Asthma and Lung UK found that Asian people with asthma from the most deprived quintile in England are almost three times more likely to have an emergency admission to hospital than their white counterparts. Black people with asthma in the most deprived quintile are more than twice as likely than their white counterparts to be admitted to hospital.
People with chronic obstructive pulmonary disease (COPD) aged between 45 and 54 in the most deprived quintile are nine times more likely to be admitted as an emergency than those in the least deprived quintile, according to the analysis.
Sarah Sleet, the charity’s chief executive, said the figures highlighted “shocking health inequalities in our society”.
Sleet said: “The UK has the worst death rate in Europe for lung conditions and they are more closely linked to inequality than any other major health condition. The fact that people from the most deprived communities and from ethnic minority backgrounds are much more likely to reach crisis point is yet another wake-up call.
“Social disadvantages – including poor housing, mould, damp and air pollution – can both cause chronic lung conditions and make them worse. And it’s the poorest in society and those in ethnic minority communities who are more likely to be living in low-quality housing and in areas with high levels of air pollution.”
Read full story
Source: The Guardian, 12 May 2025
Sam

People in mental health crisis waiting up to three days in A&E in England

Thousands of people in a mental health crisis are enduring waits of up to three days in A&E before they get a bed, with conditions “close to torture” for those in such a distressed state.
At one hospital, some patients have become so upset at the delays in being admitted that they have left and tried to kill themselves nearby, leading nurses and the fire brigade to follow in an attempt to stop them.
A&E staff are so busy dealing with patients seeking help with physical health emergencies that security guards rather than nurses sometimes end up looking after mental health patients.
The findings are included in research by the Royal College of Nursing. Its leader, Prof Nicola Ranger, called the long waits facing those in serious mental ill health, and the difficulties faced by A&E staff seeking to care for them, “a scandal in plain sight”.
The RCN’s research into “prolonged and degrading” long stays in A&E also disclosed that:
Some trusts that previously had no long waits for mental health patients now have hundreds. The number of people seeking help at A&E for mental health emergencies is rising steadily and reached 216,182 last year. The recruitment of mental health nurses has lagged far behind the rise in demand. The number of beds in mental health units has fallen by 3,699 since 2014. Rachelle McCarthy, a senior charge nurse at Nottingham university hospitals NHS trust, said: “It is not uncommon for patients with severe mental ill health to wait three days. Many become distressed and I totally understand why. I think if I was sat in an A&E department for three days waiting for a bed I would be distressed too.”
Read full story
Source: The Guardian, 13 May 2025
Sam

Trust’s corridor care death sparks CQC concerns

Vulnerable patients at a struggling A&E died or needed intensive care after their needs “were not met” while being cared for in corridors and waiting areas, inspectors have warned after an unannounced inspection.
The Care Quality Commission has raised concerns about how some of the “most vulnerable patients” were being treated in temporary escalation spaces at the Royal Cornwall Hospital in Truro, according to a document published in board papers this month.
NHSE has said systems should “consider reporting the number of patients” in temporary escalation spaces, which include corridors or makeshift wards. Its guidance followed the broadcast of a Channel 4 documentary that included scenes of patients being neglected in corridors in the Royal Shrewsbury Hospital.
Published CQC reports have since raised concerns about corridor care, but senior figures told HSJ the findings at the Royal Cornwall were among the most severe of this kind.
The inspectors said one 96-year-old woman in a temporary escalation space died following a fall and staff “were unaware of the risk of falls due to lack of verbal handover”.
Another patient “with a history of delirium” suffered a fractured collarbone from a fall in the same area of the hospital.
In another case, an incontinent patient was transferred to a “fit to sit” area but by the end of the day “had deteriorated and was in intensive care”.
The CQC’s letter said: “We were concerned the most vulnerable patients were not having their needs met when cared for in a temporary escalation space.
“We weren’t assured that every ward is accounting for additional patients in the temporary escalation areas in terms of staffing numbers and skill mix.”
Read full story (paywalled)
Source: HSJ, 13 May 2025
Further reading on the hub:
Corridor care: are the health and safety risks being addressed? The crisis of corridor care in the NHS: patient safety concerns and incident reporting A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces
Sam
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