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

Plan to modernise 1,000 GP practice buildings

Funding is being given to around one in six GP practices in England to help them improve their buildings, the government says.
Around £102m is being provided to expand and modernise surgeries, with work getting under way this summer. The government said it was the biggest public investment in facilities for five years.
It comes as satisfaction levels with GP service have hit record-low levels and figures suggest two in five GPs are reporting their practices are not fit for purpose.
Health Secretary Wes Streeting called it a "significant step", but warned it would not solve all existing problems overnight.
Under the plan, some of the projects will involve converting office space into clinical consulting rooms as well as building new practices.
Mr Streeting said: "These are simple fixes for our GP surgeries, but for too long they were left to ruin, allowing waiting lists to build and stopping doctors treating more patients."
Read full story
Source: BBC News, 6 May 2025
Patient Safety Learning

Assisted dying bill to include protection for NHS staff not wishing to take part

NHS staff including doctors, nurses and pharmacists who do not wish to take part in assisted dying will have specific protection against discrimination under a new amendment from the bill’s sponsor Kim Leadbeater, backed by ministers.
Leadbeater, who is hoping to shore up support for the bill before a crucial Commons vote next week, will add the additional protections for any staff involved in the proposed process, including ancillary staff, who will not have to give any reason for their refusal.
The private member’s bill, which faces its next Commons stage next Friday (16 May), currently says doctors and health professionals may refuse to take part.
But the Guardian understands this will be extended to any person who may possibly be involved in the process and will be amended to say “no person is under any duty to participate in the provision of assistance”.
There will also be an amendment to the current Employment Rights Act that will specifically ban discrimination, dismissal or disciplinary action if a person chooses not to participate.
“Choice is at the heart of the bill,” Leadbeater said. “Assisted dying is not for everyone and nor should it be. But for those who do make that choice, the bill that MPs will be debating again in less that two weeks, contains even more protections and is more effective and workable than it was before.”
Read full story
Source: The Guardian, 5 May 2025
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Doing nothing on social care 'untenable', MPs warn

A failure to fix England's social care system is costing the country in financial and human terms, cross-party MPs have warned.
Doing nothing to reform social care for older and disabled adults is an "active" and "untenable" decision, according to a report from Health and Social Care Select Committee.
It says successive governments have put too much emphasis on the cost of reforming the system, and future plans will be doomed to fail unless the government understands and measures the "cost of inaction".
The government, which has set up an independent commission which has just started work, said it had "hit the ground running" but acknowledged there was "much more to do".
"Taxpayers are currently paying £32 billion a year for a broken system" propped up by contributions from unpaid carers "equivalent to a second NHS", the report said.
The committee found that social care is consuming an increasing proportion of councils' budgets, crowding out spending on other services.
It added that social care makes up an integral part of the government's NHS reforms and cannot be a separate process.
Read full story
Source: BBC News, 5 May 2025
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US scientist who touted hydroxychloroquine to treat Covid named to pandemic prevention role

A proponent of using the drug hydroxychloroquine to treat Covid-19 despite scant evidence of its efficacy has been named to a top pandemic prevention role at the Department of Health and Human Services, the Washington Post reports.
Steven J Hatfill is a virologist who served in Donald Trump’s first administration, during which he promoted hydroxychloroquine to treat the virus in the early months of the pandemic, when vaccines and treatments were not yet available. He recently started as a special adviser in the office of the director of the administration for strategic preparedness and response, which prepares the country to respond to pandemics, as well as chemical and biological attacks.
The Trump administration embraced using the antimalarial drug hydroxychloroquine, along with other drugs such as ivermectin and chloroquine, as treatments against Covid-19, despite concerns over both their efficacy and potentially serious side-effects. In June 2020, just months after the pandemic started, the Food and Drug Administration warned against using hydroxychloroquine and chloroquine to treat Covid-19 over “reports of serious heart rhythm problems and other safety issues”, even after Trump approved the ordering of millions of doses of the drug from Brazil for US patients.
Last year, a study released at the onset of the pandemic that promoted hydroxychloroquine to treat Covid-19 was withdrawn by the publisher of the medical journal.
In an interview with the Post, Hatfill defended his support of hydroxychloroquine, which remains in use to treat diseases including lupus and rheumatoid arthritis. “There is no ambiguity there. It is a safe drug,” Hatfill said, noting that “they gave the drug to the president” in 2020.
Read full story
Source: The Guardian, 5 May 2025
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NHS trust declined to refer nurse to regulator over sexual assault and harassment allegations

A senior nurse was struck off over allegations of sexual assault and harassment, after a colleague reported him to a regulator when a hospital refused to refer her case.
The colleague, also an NHS nurse, first raised a complaint against Niyi Okegbola with managers at South London and Maudsley NHS Hospital four years ago, alleging he sexually assaulted her on trust premises.
But after an 18-month investigation, the colleague, Holly*, was told the case against Mr Okegbola “did not meet the threshold”, and he would be returning to work.
She then referred the matter to the Nursing and Midwifery Council, which struck off Mr Okegbola after finding 35 different allegations proven against him over actions that were “sexually motivated” toward her and four other staff from 2019 to 2022.
The NMC tribunal found it was more likely than not that he had touched or attempted to touch the breasts of two people working at the trust.
The panel added he had “breached professional boundaries” on numerous occasions and “repeatedly [harassed] more than one colleague over a prolonged period of time”.
Speaking for the first time since Mr Okegbola was struck off, Holly has accused the trust of having a “culture of acceptance” and failing to protect female staff.
Holly, whose name has been changed, told The Independent: “There is a complete lack of awareness about these things happening in the NHS. It’s very much hidden under the carpet, I felt like they [the trust] didn’t know how to handle this."
Read full story
Source: The Independent, 5 May 2025
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Pharmacists face daily inappropriate demands for antibiotics, survey finds

Pharmacists are facing inappropriate demands for antibiotics every day, with some patients stockpiling them for holidays despite the threat posed by antimicrobial resistance, a report says.
Staff receive requests for the drugs to treat minor ailments such as coughs and colds even if they are not needed, according to the National Pharmacy Association (NPA), which represents 6,000 independent community pharmacies in England. Its survey found 79% of pharmacists were having to refuse requests for antibiotics from patients at least once a day.
A quarter of pharmacists said patients frequently returned partially used antibiotics, while 37% were aware of patients regularly hoarding them for a later date. Half-used courses of antibiotics were being posted on local social media groups, the NPA said.
Other issues include patients requesting antibiotics from their pharmacy before going on holiday just in case of illness, and people returning from abroad with huge quantities of antibiotics for conditions not treated by them in the UK.
Olivier Picard, the chair of the NPA, said: “These are concerning findings and shows there are widespread misconceptions about the role that antibiotics can play among some patients.
“Although antibiotics may be an appropriate course of treatment for some conditions, for other ailments like viral coughs and sore throats, they may not be effective. This could also mean antibiotics may not be effective for treating more serious conditions, posing a risk to patient safety."
Read full story
Source: The Guardian, 6 May 2025
Related reading on the hub:
Top picks: Key resources on antimicrobial resistance
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More than 1m older people in England waited over 12 hours in A&E last year

More than 1 million older people a year in England are forced to wait longer than 12 hours in A&E, with many having to endure “degrading and dehumanising” corridor waits on trolleys.
The number aged 60 and over waiting more than 12 hours to be transferred, admitted or discharged increased to 1.15 million in 2024, up from 991,068 in 2023. The figure was 305,619 in 2019, according to data obtained by the Royal College of Emergency Medicine (RCEM) under freedom of information laws.
A report by the RCEM also found the risk of a 12-hour wait in an emergency department in England increased with the age of the patient. People aged 60 to 69 had a 15% chance of waiting 12 hours or more. For those aged 90 and over, the likelihood rose to 33%.
“The healthcare system is failing our most vulnerable patients – more than a million last year,” said Dr Adrian Boyle, the president of the RCEM. “These people are our parents, grandparents, great-grandparents.
“They aren’t receiving the level of care they need, as they endure the longest stays in our emergency departments, often suffering degrading and dehumanising corridor care. It’s an alarming threat to patient safety. We know long stays are dangerous, especially for those who are elderly, and puts people’s lives at risk.”
As well as long waits, the RCEM report found many older people were missing out on vital checks in A&E. Of patients aged over 75, only 16% were screened for delirium – a reversible condition linked to an increased risk of death. Fewer than half (48%) of patients were screened for their risk of falls.
Read full story
Source: The Guardian, 6 May 2025
Patient Safety Learning

NHSE could impose new cancer system on struggling trusts

Trusts failing to meet cancer standards may be encouraged to use a new tool on the federated data platform, HSJ understands.
NHS England today announced the launch of the Cancer 360 tool on the FDP, which it says will help clinicians to “identify and address delays immediately” in cancer treatment pathways. 
In a media briefing attended by HSJ, NHSE said no trust would be “forced” to take up the tool. It said there would be “no questions asked” if another system was already in place and the organisation was meeting performance targets, such as the faster diagnosis or 62-day referral-to-treatment standards.
However, there “would be a conversation” about the need to use Cancer 360 if a trust had another system in place and was not meeting standards, officials confirmed.
Read full story (paywalled)
Source: HSJ, 4 May 2025
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Trust investigated for manslaughter over three deaths

A trust is being investigated for manslaughter in relation to the death of three patients, HSJ has learned.
HSJ understands the three patients died by suicide while inpatients at Leicestershire Partnership Trust’s Bradgate Unit, in Glenfield Hospital, between September 2020 and July 2021.
Leicestershire Police confirmed it was investigating “offences relating to corporate manslaughter and gross negligence manslaughter” in relation to the deaths.
A police spokesperson told HSJ: “The investigation remains ongoing. No charges have been brought at this time.”
The trust said: “Leicestershire Partnership Trust is fully cooperating with the police. We are unable to comment any further while the investigation is ongoing.”
It comes as an employment tribunal brought by Mariam Benaris, previously a consultant at the unit, who is alleging wrongful dismissal, has heard concerns about safety on the unit during the peaks of the pandemic.
Dr Benaris told the tribunal she and other staff raised concerns with trust leaders and a healthcare regulator about unsafe practices at the Beaumont Ward of the Bradgate Unit at that time. The ward was being used for all new admissions as part of infection control procedures. 
Read full story (paywalled)
Source: HSJ, 2 May 2025
Patient Safety Learning

Suppliers to help design Streeting’s ‘single patient record’

NHS England is asking suppliers for advice on designing the “single patient record” (SPR), which is seeking to create a “single version of the truth” across the NHS and social care.
It has launched a “pre-market engagement” on proposals for the SPR, which is intended to connect all individuals’ NHS and social care data.
Documents reveal NHS England envisages the new system should “make the most of the existing NHS technology estate”, such as electronic patient records, but also asks suppliers which current technology will be “no longer required” when the SPR is introduced.
It appears the SPR will effectively replace existing “summary care records”, which collate limited information from across various services, but will include significant extra functions.
It says summary care records are “not comprehensive” as they are “read only” and “present data from care settings in tandem rather than creating a single version of the truth”.
The SPR will also crucially go further by enabling staff and patients to write to the single shared record, rather than only reading from it.
According to NHSE it will enable services to “better coordinate care between providers, make discharge summaries electronic, build neighbourhood health systems and run national vaccination and other direct care programmes”.
Read full story (paywalled)
Source: HSJ, 2 May 2025
Related reading on the hub:
Digital-only prescription requests: An elderly woman sent round the houses The challenges of navigating the healthcare system: Sue's story  
Patient Safety Learning

Florida hospitals sue Leapfrog over safety rankings

Five hospitals that are part of Palm Beach (Fla.) Health Network have filed a lawsuit against The Leapfrog Group, alleging the patient safety organization’s rankings are based on flawed methodology. 
The complaint, filed April 30 in the U.S. District Court for the Southern District of Florida, claims the rankings unfairly damage the hospitals’ reputations. 
“Leapfrog fails to fairly evaluate hospitals that do not complete its hospital survey, and rather than indicating that there is insufficient data to issue a grade to non-participating hospitals, it instead assigns a score equivalent to the ‘Worst Hospital’s Score’ on several measures,” Palm Beach Health Network said in a statement. “This flawed methodology does not accurately reflect hospitals’ performance on patient outcomes.” 
The hospitals that filed the complaint are Delray Medical Center in Delray Beach; Good Samaritan Medical Center in West Palm Beach; Palm Beach Gardens Medical Center; West Boca Medical Center in Boca Raton; and St. Mary’s Medical Center in West Palm Beach. The complaint was filed a day before The Leapfrog Group published its latest round of hospital safety grades. Three of the hospitals that filed the complaint received an “F” grade and two earned a “D.” 
The complaint also alleges Leapfrog’s safety grades are “distorted by undisclosed financial incentives” and penalize hospitals that do not submit data for participation by assigning “artificially low ratings.” 
Leah Binder, president and CEO of Leapfrog, described the lawsuit as an attempt by hospitals to suppress critical safety information from the public.

“When we look at these hospitals’ results from CMS, we see preventable suffering and death far exceeding the national average, and even the national average is too high,” she said in a statement. “These hospitals may wish to withhold their hospitals’ Safety Grades from the community they serve, but Leapfrog intends to fully defend its expert, proven and long-standing methodology to prevent that from happening and publish Grades for all eligible hospitals, including these hospitals.”
Read full story
Source: Becker's Hospital Review
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RFK Jr and health agency falsely claim MMR vaccine includes ‘aborted fetus debris’

Health secretary Robert F Kennedy Jr and his department have made a series of misleading statements that alarmed vaccine experts and advocates in recent days – including that the measles, mumps and rubella (MMR) vaccine includes “aborted fetus debris”.
Health department officials released statements saying they could alter vaccine testing and build new “surveillance systems” on Wednesday, both of which have unnerved experts who view new placebo testing as potentially unethical.
“It’s his goal to even further lessen trust in vaccines and make it onerous enough for manufacturers that they will abandon it,” said Dr Paul Offit, an expert on infectious disease and immunology and the director of the Vaccine Education Center at Children’s Hospital of Philadelphia, about the statements and Kennedy. “It’s a fragile market.”
“All new vaccines will undergo safety testing in placebo-controlled trials prior to licensure – a radical departure from past practices,” an HHS spokesperson told the Washington Post in response to questions about general vaccine policy and the measles vaccine. The department did not clarify what it meant by “new vaccine”.
The department spokesperson also described new surveillance systems for vaccines, “that will accurately measure vaccine risks as well as benefits – because real science demands both transparency and accountability”, but did not elaborate on the design of those systems.
Prior to being confirmed to the role of health secretary, Kennedy was arguably the nation’s most prominent anti-vaccine advocate and led a non-profit known for prolific misinformation. He also earned money by referring clients to law firms suing vaccine makers.
Among the claims Kennedy spread was that medications cause “autoimmune injuries and allergic injuries and neurodevelopmental injuries that have long diagnostic horizons or long incubation periods, so you can do the study and you will not see the injury for five years”, he said in an interview in 2021, according to reporting by the Post.
Kennedy also claimed this week that the MMR vaccine includes “aborted fetus debris”. The rubella vaccine, like many vaccines, is produced using decades-old sterile fetal cell lines derived from two elective terminations in the 1960s.
Read full story
Source: The Guardian, 1 May 2025
Patient Safety Learning

US health agency’s ‘review’ advocates for therapy for youth gender dysphoria

The federal health department released what it described as a “comprehensive review” of pediatric gender dysphoria – advocating for therapy instead of medical care for youth whose gender identity does not match their assigned sex.
The 409-page report claimed that while the harms of such medical treatment are “sparse”, medical treatment should be avoided in favor of therapy for youth diagnosed with gender dysphoria.
“Our duty is to protect our nation’s children – not expose them to unproven and irreversible medical interventions,” said Dr Jay Bhattacharya, the National Institutes of Health (NIH) director. “We must follow the gold standard of science, not activist agendas.”
The report contradicts the guidance of America’s largest medical associations, including the American Medical Association, which urged state governments to “stop interfering in the healthcare of transgender children”. A study published this year found gender-affirming care is rare among US youth, with fewer than one in 1,000 children receiving hormones or puberty blockers.
The review is in response to one of the first executive orders signed by the president, titled: “Protecting children from chemical and surgical mutilation,” which called for a review of evidence by the health department within 90 days.
“Evidence for harms associated with paediatric medical transition in systematic reviews is … sparse, but this finding should be interpreted with caution,” the report states.
“Inadequate harm detection in paediatric gender medicine may reflect the relatively short period of time since the widespread adoption of the medical/surgical treatment model; the failure of existing studies to systematically track and report harms; and publication bias.”
Read full story
Source: The Guardian, 1 May 2025
Patient Safety Learning

Hospital criticised for ‘poor’ and ‘defensive’ investigations

A hospital trust has been criticised for its “poor” and “defensive” investigations into three deaths, which a coroner has linked to care by a single surgeon. 
Heidi Connor, senior coroner for Berkshire, investigated three deaths that occurred within three months at Royal Berkshire Foundation Trust. Each death followed surgery by consultant colorectal surgeon Daniel McGrath, whose “management” of each case was criticised by experts cited by the coroner. 
The coroner’s prevention of future deaths report about the death of Lorraine Parker, who died most recently of the three on 30 March 2024, was published last week and examined the trust’s death investigations processes across each of the three cases.
Ms Connor found the trust’s structured judgement reviews - which investigate care failings following a patient death - to be “at best, poor” and “at worst, defensive”, and warned the trust that its overall death investigation process “is not working well”. 
In addition, the coroner questioned “whether the trust has done enough to deal with the concerns about this particular surgeon” following the three deaths. 
There is no note of a restriction on Mr McGrath’s practice according to the General Medical Council register. However, Royal Berkshire told HSJ it has “worked closely with the coroner and the GMC” on measures to oversee his work. He has also been removed from surgical duties.
Looking at how the trust handled investigations into the three deaths, the coroner’s report noted the trust did not carry out a “detailed [Patient Safety Incident Response Framework] report”, which supports responses to patient safety incidents, into any of the deaths. 
Read full story (paywalled)
Source: HSJ, 1 May 2025
Patient Safety Learning

Stark social divides in infectious disease admission rates in England, study finds

People in the most deprived areas of England are almost twice as likely to be admitted to hospital as a result of infectious diseases than their least deprived counterparts, according to a major study.
The report, by the UK Health Security Agency (UKHSA), analysed NHS and government data to look at the state of health inequalities in England due to infectious diseases and environmental health hazards.
The analysis found a stark regional divide across England: those living in the north-west of the country were 30% more likely to be admitted to hospital for an infectious disease, with 3,600 admissions for every 100,000 people between September 2023 and August 2024, compared with the average for England, which stood at 2,800 for every 100,000.
The study found that inequality was highest in the case of respiratory infections, with an estimated additional 260,000 admissions due to inequalities associated with deprivation. People living in the 20% most deprived areas of England were twice as likely to be admitted to hospital for respiratory diseases, seven times as likely for tuberculosis and six times for measles, than their counterparts from the least deprived areas.
Prof David Taylor-Robinson, an academic co-director at Health Equity North and professor of public health and policy at the University of Liverpool, said: “This report echoes past research showing that deprived communities, typically in the North of England, bear the brunt of health inequalities.
“It is particularly troubling to see the high number of hospital admissions due to infectious diseases, especially as some of these are preventable diseases.”
Read full story
Source: The Guardian, 2 May 2025
Patient Safety Learning

NHSE reorganisation plans delayed

The first draft of a “high-level plan” for merging NHS England into the Department of Health and Social Care has been delayed, officials have acknowledged.
NHSE’s new leaders Sir Jim Mackey and Penny Dash told staff a month ago they wanted the restructure to move quickly.
They had hoped to deliver an initial picture of “what the new organisation might look like by the end of April”, but “this is taking slightly longer than we’d hoped”, according to a note to staff today.
The internal message said: “We expect to run an all staff briefing for NHS England and DHSC later in May [with an update].” 
HSJ understands NHSE and DHSC have also so far failed to recruit a national transition director to oversee the merger. They had hoped to quickly bring in a senior and experienced manager, but discussions with at least one potential recruit have fallen through.
Read full story (paywalled)
Source: HSJ, 1 May 2025
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