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

Staffing vital to high hear and treat rates, say trusts

Some 30,000 emergency ambulance trips could be avoided every month if trusts provided more advice over the phone, according to NHS England figures.
The proportion of emergency calls dealt with through hear and treat ranges from more than 20 per cent at the best-performing trusts to less than half that in other areas.
Typically, this involves patients being given advice such as self-care, seeing a GP or pharmacist, or being directed to an alternative pathway for urgent care.
Based on February’s figures, released by NHS England, an additional 30,000 patients could have been seen if every trust matched the performance of West Midlands Ambulance Service University Foundation Trust and London Ambulance Service Trust, both of which dealt with 20.6 per cent of patients in this way.
London Ambulance Service Trust has managed more than one in five patients through hear and treat while seeing an additional 500 to 520 calls each day this winter.
Michael Ward, deputy director of clinical safety and compliance at LAS, told HSJ the initiative had helped lessen demand on hospitals.
He said the trust had boosted recruitment of both band 6 clinical advisers and band 7 clinical support managers, to support control room staff. Advice to control room staff on the most clinically appropriate pathway is readily available, including a 24/7 clinical safety officer.
The trust has also worked to make these roles attractive for staff, with the provision of training and development plus timely feedback on decisions, he said, adding that the roles were attractive to paramedics who no longer want the physical strain of frontline work.
“I think there is scope for more hear and treat,” Mr Ward said. “There is a natural ceiling but I don’t think we have reached it yet.”
Read full story (paywalled)
Source: HSJ, 19 March 2025
Patient Safety Learning

Black communities asked to join health research

eople from black ethnic backgrounds are being encouraged to take part in a research programme aimed at tackling health inequalities.
The Improving Black Health Outcomes (IBHO) BioResource programme at University Hospital Southampton (UHS) will explore how African-Caribbean communities develop and experience different health conditions.
Those taking part would be tested and matched with various research programmes into conditions including sickle cell, diabetes, heart and kidney disease.
David Stockley, NIHR BioResource Southampton Manager at UHS, said the volunteers would be playing a "vital role" in developing future healthcare provision.
UHS said the study was set up as historically, people from African and Caribbean heritage have been under-represented in health studies, meaning knowledge and treatments as a result of research have been predominantly based on white populations.
Mr Stockley said the new initiative aimed to "close the gap".
"The IBHO BioResource will help us better understand and address health conditions and their unique impacts on black people and their loved ones, ensuring everyone benefits from fair and inclusive research," he added.
Read full story
Source: BBC News, 20 March 2025
Patient Safety Learning

Maternity unit to be closed despite safety fears

An integrated care board has decided which of the five maternity units on its patch should close despite concerns from clinical leaders the move could increase deaths.
North Central London Integrated Care Board yesterday announced plans to close the maternity unit at Royal Free Hospital in north London.
The move will have to be approved at the ICB’s board meeting next week and by NHS England. The ICB has said it wants to close the service in the face of stretched staffing and reduced demand.
But the plans have proved controversial among some clinicians. Last year, the clinical leaders of the Royal Free’s maternity services wrote to their chief executive saying the closure could increase maternal mortality.
NCL ICB medical director Jo Sauvage said: “We have a declining birth rate in our area, and the need for more complex support for mothers, pregnant people and their babies is growing.
“Our services are not currently set up to meet the needs of everyone that uses them. Doing nothing is not an option and we have carried out extensive work to make sure we are able to make the right decision for local families.”
Read full story (paywalled)
Source: HSJ, 19 March 2025
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Private notes and emails reveal inside story of hospital struggle to stop Lucy Letby

Could killer nurse Lucy Letby have been stopped sooner?
She was convicted of killing seven babies and attempting to murder seven more. Now a public inquiry is examining whether bosses at the Countess of Chester Hospital failed to act fast enough when suspicions were raised.
The inquiry is not examining the question of Letby’s guilt. Instead, it is exploring how she was able to kill repeatedly, hearing more than 60 days of witness evidence and reviewing thousands of emails, text messages and handwritten notes.
The hurried memos from doctors about babies collapsing in Letby’s presence and curt replies from hospital execs reveal, in vivid detail, the chaos behind the scenes.
Judith Moritz, who has covered the Letby case from the start, looks at the evidence to piece together how events unfolded - and why it took more than a year to stop a killer.
Read full story
Source: BBC News, 19 March 2025
Patient Safety Learning

Keeping with Kennedy’s advice, measles patients in the US turn to unproven treatments

Struggling to contain a raging measles epidemic in West Texas, public health officials increasingly worry that residents are relying on unproven remedies endorsed by Robert F. Kennedy Jr., the health secretary, and postponing doctor visits until the illness has worsened.
Hospitals and officials sounded an alarm this week, issuing a notice explaining which measles symptoms warranted immediate medical attention and stressing the importance of timely treatment.
“I’m worried we have kids and parents that are taking all of these other medications and then delaying care,” said Katherine Wells, director of public health in Lubbock, Texas, where many of the sickest children in this outbreak have been hospitalized.
Some seriously ill children had been given alternative remedies like cod liver oil, she added. “If they’re so, so sick and have low oxygen levels, they should have been in the hospital a day or two earlier,” she said.
In his first public statements about the outbreak, Mr. Kennedy faced intense backlash for minimizing the situation, saying it was “not unusual” and falsely claiming that many people hospitalized were there “mainly for quarantine.”
In the following weeks, Mr. Kennedy altered his approach, offering a muted recommendation of vaccines for people in West Texas while also promoting unproven treatments like cod liver oil, which has vitamin A, and touting “almost miraculous and instantaneous” recoveries with steroids or antibiotics.
Read full story (paywalled)
Source: New York Times, 15 March 2025
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Thirlwall: Guilty or not there was ‘total failure of safeguarding’ at Letby trust

Lady Thirlwall has rejected calls from senior managers to pause the official inquiry into the deaths of infants at the Countess of Chester Hospital.
On the last day of hearings yesterday, she said — regardless of the outcome of a referral to the Criminal Cases Review Commission by Lucy Letby’s legal team — her final report would highlight “a total failure of safeguarding at every level”.
The neonatal nurse was convicted of the murder of seven babies and the attempted murder of others at two trials in 2023 and 2024. Appeals were rejected.
Lady Thirlwall’s inquiry was tasked with looking at three things: the experience of families at the trust, whether suspicions should have been raised earlier and the police called, and the effectiveness of governance and processes.
The legal team representing the former chief executive, nursing director, medical director, and HR director wrote to the inquiry last month to argue that the new evidence produced by Letby’s lawyers and the possibility of the convictions being overturned undermined the basis of the inquiry.
Lady Thirlwall said at the start of the inquiry that she had dismissed doubts about the safety of Letby’s conviction as “noise”.
She added: “The inquiry has been conspicuously fair. [It] does not become unfair because there is a possibility that all the convictions are unsafe. I completely accept and have approached the inquiry in this way; [that] it is essential to guard against hindsight in covering the actions of people eight, nine, and 10 years ago…
“It is not the actions of Lucy Letby I am scrutinising, it is the actions of the people in the hospital, what they knew and should have known at the time.
“There are already large numbers of concessions about what wasn’t done that should have been done [at] the organisations, the hospital, including the doctors and the managers. And that managers should have communicated better with patients and provided pastoral care to the doctors.”
She noted an “acknowledgement that there was a total failure of safeguarding at every level and that will not change. Inevitably [that] will feature in any report.”
Read full story (paywalled)
Source: HSJ, 19 March 2025
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Long Covid health staff 'abandoned and forgotten'

Healthcare workers with Long Covid say the government needs to do more to support those left with life-changing disabilities since catching the virus.
Nurse Rachel Hext, 37 from Paignton, insisted she caught Covid in her job as a nurse in a small community hospital in Devon.
"We were clapped and called heroes, and now those of us who have been bereaved or disabled by it have been forgotten," she said.
The government said it knew Long Covid could have a debilitating impact on people's physical and mental health, that there was a "range of support for staff" and it was funding research into it.
Mrs Hext is one of a group of healthcare workers with long Covid who have taken their fight to the High Court to try to sue the NHS and other employers for compensation.
The staff, from England and Wales, said they believed they first caught Covid at work during the pandemic and said they were not properly protected from the virus.
She said: "I want acknowledgement and I want support for the people who need it.
"Long Covid is absolutely life-changing. It's devastated us as a family."
Read full story
Source: BBC News, 20 March 2025
Related reading on the hub:
"Forgotten heroes" – the sequel: a blog and resources from David Osborn The pandemic – questions around Government governance: a blog from David Osborn Healthcare workers with Long Covid: Group litigation
Patient Safety Learning

Three deaths linked to listeria detected in NHS desserts

Three deaths are being investigated as part of a listeria outbreak linked to desserts supplied to NHS hospitals and care homes.
The UK Health Security Agency (UKHSA) confirmed it is investigating the deaths as well as two non-fatal cases between May and December of last year.
One death was recorded as listeriosis. Two other people were known to be infected with listeria bacteria at the time of their death.
The bacteria was detected in a chocolate and vanilla mousse and a strawberry and vanilla mousse, both supplied by Cool Delight Desserts, UKHSA said - although it was not confirmed as the source of the infections.
The threshold of listeria found in the desserts was known to be below the legal threshold of what healthy people can tolerate, the PA news agency reported.
The Food Standards Agency said that the desserts were being removed from the supply chain as a precaution while investigations continue.
The five patients were aged between 68 and 89. All had underlying health conditions and were in hospital at the time of infection.
Read full story
Source: BBC News, 19 March 2025
Patient Safety Learning

My mother was told her tumour was benign – five years later she died

A woman whose mother died five years after a cancer misdiagnosis is calling for second opinions on oncology scans to be made mandatory.
Louise Hickman, from Ipswich, was told in 2019 that a mass removed from her ovary was benign and that she would not require any further treatment.
But in 2022, the “kind and caring mother” was diagnosed with ovarian cancer after she returned to Ipswich Hospital with worsening symptoms.
Later tests confirmed her initial cyst found three years earlier had indeed been cancerous and in July 2024, she passed away, aged 47.
Her daughter, Chloe, said she believes her mother’s outcome may have been different if she was correctly diagnosed in 2019, and is now campaigning to make it mandatory to have oncology scans checked by two experts.
A report issued to Ms Hickman and her family by the East Suffolk and North Essex NHS Foundation Trust following her mum’s death accepted that the 2019 cyst should have been “adequately sampled and referred for an expert opinion” at the time.
A clinical opinion included in the report also stated that the “missed diagnosis with delay in treatment caused significant harm”.
She has launched a petition calling for the government to implement “Louise’s Law”, which would make it mandatory that benign oncology scans are sent for a second expert opinion.
Read full story
Source: The Independent, 19 March 2025
Patient Safety Learning

Mum fought in vain to save son while waiting for ambulance, but a terrible error had been made

A 35-year-old man from Cardiff died after collapsing at home despite his mother and brother trying to give him CPR. Martyn Wright collapsed at home, and it has since been found that there were errors in the way his family's calls to the ambulance service were handled.
Martyn's mum, Claire, claimed that calling 999 was a "lottery". In a statement to WalesOnline, she, said: "Through lived experience, we have learned our 999 emergency service cannot be relied upon even when there is clearly an immediate risk to life, it's now quite simply a lottery. An ambulance initially allocated to attend my son who collapsed at home suddenly in December, 2022, was stood down in error by a novice 999 call-handler, this caused a significant delay to him receiving vital treatment.
"Despite our younger son performing CPR on his unconscious brother, when they did arrive 45 minutes later as a result of a follow up call made by myself, Martyn was tragically beyond help." Martyn's case was referred to the Public Services Ombudsman for Wales, who has found there were errors in the handling of his case. 
On the day of his collapse, Martyn was at home with his mum and brother. Two 999 calls were made. The first call was incorrectly downgraded from a red priority to "green 2". The second call was also not handled appropriately, with incorrect information given to Mrs Wright about resuscitation. As a result, the ambulance arrived 32 minutes late.
Through it all, Mrs Wright and her son were, the report said, "attempting to deliver CPR without instruction or support". Mrs Wright complained about how the calls were handled, how the attending paramedics kept a record of events and whether the outcome for Martyn would have been different had the ambulance arrived earlier. The ombudsman found that the Welsh Ambulance Service trust did not properly manage the two 999 calls made after Martyn had collapsed.
Read full story
Source: Wales Online, 18 March 2025
Patient Safety Learning

Texas charges midwife in first arrest under state’s abortion ban

A Houston-area midwife was arrested for providing illegal abortions, Texas Attorney General Ken Paxton (R) said Monday, marking the first criminal charges under the state’s near-total abortion ban.
Maria Margarita Rojas, 49, was charged with the illegal performance of an abortion and practicing medicine without a license, Paxton’s office said in a news release.
Rojas owned and operated health clinics in Waller, Cypress and Spring, Paxton’s office said. Her facilities employed unlicensed people who presented themselves as medical professionals, officials alleged.
Performing an abortion in Texas is punishable by up to life in prison and up to $100,000 in civil penalties. Abortions are only permitted when a pregnant woman is at risk of death or “substantial impairment of a major bodily function.”
The law targets anyone who performs or helps set up an illegal abortion, including people who facilitate the distribution of abortion pills. Women seeking abortions can’t be charged under the state’s law.
“In Texas, life is sacred,” Paxton said in a statement Monday. “I will always do everything in my power to protect the unborn, defend our state’s pro-life laws, and work to ensure that unlicensed individuals endangering the lives of women by performing illegal abortions are fully prosecuted. Texas law protecting life is clear, and we will hold those who violate it accountable.”
Marc Hearron, interim associate director of ligation at the Center for Reproductive Rights, an organization that aims to protect reproductive rights, condemned Paxton’s efforts to ban abortions.
“While details of this case remain unclear, we know that Texas officials have been trying every which way to terrify healthcare practitioners from providing care and to trap Texans,” Hearron said in a statement. “Their ultimate goal is to end abortion access for all Texans entirely — and they will throw people in jail to get there.”
Read full story (paywalled)
Source: Washington Post, 18 March 2025
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Children operated on by now-suspended surgeon 'are being let down again', lawyer warns

Children who underwent operations with a now-suspended surgeon at a Cambridge hospital are being let down again by a lack of information and transparency from the hospital's trust, according to a lawyer representing one of the families.
Last month, Addenbrooke's Hospital announced it had contacted the families of nine children whose complex hip surgeries "fell below" the expected standard, following an external review.
The orthopaedic surgeon, who has not been named, has since been suspended while a second external review is carried out.
But families are said to be "frustrated" by a lack of communication from Addenbrooke's, which is yet to release the findings of the first review.
A lawyer instructed by one of the families has accused Cambridge University Hospitals NHS Foundation Trust of failing to follow official guidance in their handling of the patients and their families.
Catherine Slattery, associate solicitor at Irwin Mitchell, told Sky News: "Families should feel they are being supported through this process, and that their child is the centre of this investigation.
The National Patient Recall Framework - for patients "recalled" by a healthcare provider after a problem has been identified - states that the patient's needs should "always be placed at the centre" of the process.
The guidance adds: "There should be appropriate and compassionate engagement with patients to ensure that the process remains patient focused."
Read full story
Source: Sky News, 19 March 2025
Patient Safety Learning

NHS robots and scanners ‘must be used more intensively’

Expensive scanners and surgical robots are underused and “lying fallow” at NHS hospitals, a report has said.
Analysis shows a tenfold difference in how often NHS trusts use surgical robots — cutting-edge machines used for minimally invasive surgery that cost about £1.5 million each.
There are also huge regional variations in the use of CT and MRI scanners, which help to diagnose illnesses including cancer and cost about £1 million each.
Experts urged the NHS to ensure that each machine was used to the utmost to boost productivity and tackle hospital waiting lists of 7.4 million people.
The report also warned that hospitals are failing to make full use of surgical robots, which can blitz through waiting lists by speeding up recovery times. In 2022 Buckinghamshire Healthcare Trust used its surgical robot less than once a week while other NHS hospitals used theirs nine times a week.
Jonathan Eida, a researcher at the TPA, said: “Our analysis of high-value machines in the NHS further adds to the body of evidence that the health service is not in a healthy state.
“It is absolutely absurd for such expensive equipment to lie fallow, particularly given the swollen waiting lists. If Labour wants to deliver the efficient and productive health service that taxpayers are paying for, maximising the use of these machines has to be a priority.”
Read full story (paywalled)
Source: The Times, 16 March 2025
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Former directors call for Letby inquiry to be paused

Lawyers acting for four former executive directors at the Countess of Chester Hospital have called for the Thirlwall inquiry to be paused while the criminal charges against Lucy Letby are reviewed.
Acting for the former hospital leaders - chief executive Tony Chambers, medical director Ian Harvey, director of nursing Alison Kelly and HR director Sue Hodkinson - Kate Blackwell KC asked inquiry chair Lady Thirlwall to consider halting all or part of the proceedings until the Criminal Case Review Commission had made a decision about allowing another appeal or retrial.
She stated there was a risk the real causes of the infants’ deaths could be missed. 
Letby was convicted in 2023 of murdering seven babies and attempting to kill six more. She was later found guilty of another attempted murder charge at a second trial. The offences happened in 2015 and 2016. The Court of Appeal upheld her convictions last year.
But a new legal team for Letby has referred her convictions to the CCRC, raising concerns about the disclosure of evidence and citing new evidence from senior clinical experts that contradicts what the juries heard.
However, families of the jailed nurse’s victims said the senior managers were attempting to evade responsibility for their “many failures”.
“The applications to stop the inquiry are, on Letby’s part, an attempt to control the narrative, and on the part of the executives to avoid criticism,” said Richard Baker KC, representing the parents of 12 of the babies.
Read full story (paywalled)
Source: HSJ, 18 March 2025
Patient Safety Learning

Precautions could have stopped baby deaths

"Reasonable precautions" could have prevented the deaths of three newborn babies, a fatal accident inquiry has found.
Leo Lamont, Ellie McCormick and Mira-Belle Bosch all died within hours of their births in two Lanarkshire hospitals, in 2019 and 2021.
The report found all three deaths could "realistically" have been avoided had different advice been given by midwives or procedures followed.
The McCormick family said they could "never have imagined" the amount of failures that led to their daughter's death and called it a "catalogue of errors".
The inquiry ruled "defects" within the system contributed to each death, including that there was a "lack of an effective means" to highlight risks in one of the pregnancies and that midwives had no guidance to assess preterm labour symptoms.
Sheriff Principal Aisha Anwar KC made 11 recommendations for the future, including creating a "trigger list" to identify and assess early labour symptoms.
Among these are reviewing electronic patient information records to improve alerts for at risk mothers, and having a direct telephone line to each maternity unit in Scotland for ambulance crews.
In a statement, the McCormick family said: "The family could simply never have imagined the scale of both the individual and systems failures that came to light during the inquiry.
"What seemed to be flaws with the electronic system of record keeping actually turned out to be a catalogue of errors with numerous opportunities to avoid the tragic outcome that followed."
Read full story
Source: BBC News, 18 March 2025
Patient Safety Learning

Teen died from asthma attack after she was wrongly discharged from hospital

A coroner has voiced serious concerns over a recurring "lack of observations" at London's Royal Free Hospital following the death of a teenager.
Sixteen-year-old Billie Wicks died after suffering her first ever asthma attack. Her parents rushed her to the Hampstead hospital on 17 September last year, but a new report reveals the A&E department was "understaffed" that night.
The coroner's concerns highlight a potential systemic issue at the hospital regarding patient monitoring.
Senior coroner for Inner North London, Mary Hassell, said that Billie should have had routine checks, or observations, taken every hour.
If she had these observations, then medics would have recognised the severity of Billie’s illness, Ms Hassell said.
“Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived,” she wrote in a prevention of future deaths report.
“Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review.
“That senior medical review would have changed the course of her management and saved her life.”
Read full story
Source: The Independent, 18 March 2025
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