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

‘Nothing to see attitude’ to safety incidents uncovered at hospital

A troubled trust has revealed a backlog of more than 100 incidents requiring “high-level” safety investigations, as an external report warned of a “nothing to see” attitude towards governance.
Some 113 investigations were “closed without proper investigation”, with 428 incidents still “open”, board papers for Medway Foundation Trust suggest. Executives warned they had been forced to seek external help to tackle some of the backlog.
Most of the incidents, which the trust says require investigations or further action under the Patient Safety Incident Response Framework, were in medicine and emergency care.
The Trust is also having to carry out duty of candour processes for 59 cases where there was no or insufficient evidence that patients had been contacted, which it said was a “serious governance concern”. Some of these dated back to 2024.
In a strongly worded report to the board, its quality assurance committee said there were “significant governance and safety concerns requiring urgent attention”, and that the trust needs to move from “identification of issues to demonstrable improvement”.
The board papers also reference an external review carried out by Steve Lennox, a former chief nurse and improvement director, which suggested some staff in the governance team had a “nothing to see” approach to potential patient safety cases.
Read full story (paywalled)
Source: HSJ, 30 July 2026
Patient Safety Learning

Strangled patient's sisters say unsafe care risks 'more deaths'

The sisters of a man strangled to death on a mental health ward by another patient have described the healthcare system for people with severe psychotic illness as "inadequate, misguided and plain wrong".
An inquest into the death of Richard Laversuch, 63, found on Wednesday he was unlawfully killed by Owen Herbert, then aged 18, at Parklands Hospital, Basingstoke, in 2021. Multiple "failures" by heath staff were identified by the inquest jury.
"They just don't recognise how serious psychotic illness is," Richard's sister, Bridget Ryan, told the BBC.
Hampshire and Isle of Wight Healthcare NHS Foundation Trust apologised to the men's families and accepted responsibility for its failures.
Hampshire coroner Nicholas Walker said Richard's death was "utterly avoidable".
"It has to change," her sister Cathy Laversuch agreed, "otherwise there will be more deaths, more terrible things happening and more heartbreak for more families."
She added: "Something went wrong at every single stage, so it's not a safe system and can lead to catastrophic consequences."
Read full story
Source: BBC News, 30 July 2026
Patient Safety Learning

Supply fears over life-saving blood pressure medication taken by millions of Britons

A life-saving blood pressure medication taken by millions is in short supply forcing pharmacies to ration prescriptions.
Ramipril is a prescription medication used to treat high blood pressure, heart failure and lower the risks of strokes.
It works by relaxing and widening blood vessels to allow blood to flow more easily.
But the medication, which is taken by about 6 million people in the UK, is in critical supply and health chiefs have put the pills under a “serious shortage protocol” (SSP), which limits patients to just one month's supply of the drug until 30 October.
Pharmacists have called on the government to change official guidance so they can offer patients an alternative drug without consulting their GP.
“Millions of patients rely on Ramipril and although there are alternative medicines available, supplies of these must be managed carefully by the government to ensure subsequent demand can be met,” Olivier Picard, chair of the National Pharmacy Association said.
"The government should allow pharmacists to make appropriate substitutions to Ramipril prescriptions to ensure patients do not have to go back to their GP to find an alternative,” he added.
Read full story
Source: The Independent, 29 July 2026
Patient Safety Learning

Burnham wants NHS savings to help pay for social care

Ministers will look at how much can be saved from NHS budgets by improving adult social care before increasing taxes to fund the reforms, Andy Burnham has said.
The prime minister gave a speech in north London today to make several social care announcements.
This included launching a “big conversation” public engagement, led by Baroness Louise Casey, which will consider setting out different options for a National Care Service and how to pay for them.
The PM also revealed that Baroness Casey’s social care review, which began under Sir Keir Starmer, will now report within the next year, rather than in 2028 as had been planned.
However, asked after the speech whether government can realistically transform care without raising taxes, Mr Burnham argued: “It is possible from existing budgets to do much more.
“I mentioned… people [are] coming into hospital unnecessarily from social care settings, then having a long length of stay in hospital as a result of that unnecessary admission, and then a long period where they’re medically fit to leave but can’t, because the care is not available.”
He quoted the annual cost of delayed discharges linked to social care at £2.5bn, and said: “If you add all of it up you are talking [about] several billion pounds a year [that] is lost from the lack of a preventive front-end social care service that’s well supported.”
The PM added: “Before we talk about tax rises [we] first have to look the public in the eye and say, ‘are we doing everything we can do from within what we’ve got?’”
Read full story (paywalled)
Source: HSJ, 29 July 2026
Patient Safety Learning

'Never events' at Wales' largest health board more than double in a year

The number of "never events" at the largest health board in Wales more than doubled in a year, according to its latest report.
Never events are serious, largely preventable patient safety incidents that should not happen if national safety guidance is followed.
Betsi Cadwaladr University Health Board (BCUHB) logged 11 never events in 2025-26, increasing by six compared with the previous year.
The health board with the second-highest total recorded seven incidents.
The report said the level of "avoidable harm" remained a "serious concern" for the health board, which is "committed to ensuring ongoing improvements".
Examples of never events can include operating on the wrong part of the body, leaving surgical instruments inside a patient after an operation or administering medication by the wrong route.
The report said investigations focused on identifying system and process failures rather than individual blame, so "meaningful learning" can be achieved.
"Where required, immediate actions are taken to protect patient safety while investigations are completed," the report added.
It said the board had a "clear commitment to strengthening systems and learning to support a continued reduction in never events" and hopes to achieve zero never events in 2026-27 and future years.
Read full story
Source: BBC News, 28 July 2026
Patient Safety Learning

Hospital running out of space for bodies after rise in deaths

A trust warned it was running out of mortuary space and not meeting new standards, following national concerns about post-death care in the NHS.
Royal Cornwall Hospitals Trust raised the concerns in board papers for an extraordinary meeting last week.
The trust’s board risk register noted that an inability to provide adequate capacity could lead to the loss of its Human Tissue Authority licence, which would mean “all mortuary related activity… would have to cease”.
It also warned that periods of “increased activity” could lead to its mortuary services “not [having] capacity to store all the deceased… even when our contingency measures have been activated”.
The trust’s mortuary in Truro has space for 79 deceased patients, and the trust has had to activate contingency plans over the past 12 months due to “an increase in the number of deaths and an increase in the length of stay”, the board paper said.
This has included utilising private funeral home capacity, transferring bodies to West Cornwall Hospital in Penzance, and using four “temporary storage units”.
Read full story (paywalled)
Source: HSJ, 29 July 2026
Patient Safety Learning

Black people’s risk factors for stroke ‘rising faster than for white people’

Stroke risk factors including high blood pressure and diabetes are rising faster among people from Black African and Caribbean backgrounds compared with their white counterparts, according to analysis.
Researchers at King’s College London analysed data from more than 8,500 adults over a 30-year period from the South London Stroke Register, one of the longest-running population-based stroke registers in the world.
The study found that while the prevalence of stroke risk factors, including diabetes and hypertension, were increasing faster among Black people, those from Black African backgrounds were also twice as likely to experience stroke without a prior risk factor diagnosis than white people, at a rate of 12% compared with 6%. About one in six people across the UK will have a stroke in their lifetime.
Diabetes was about twice as common in Black Caribbean and Black Africans on the stroke register compared with white participants, and high blood pressure was 29% more prevalent in Black Caribbean and 47% more prevalent in Black African people. Although diabetes rates increased for all ethnic groups over the 30-year study period, they increased most rapidly among Black African participants, rising from 21% between 1995 and 2004 to 41% between 2015 and 2024.
Dr Eva Emmett, a research fellow at King’s College London and the lead author of the study, said: “Our study shows that the prevalence of pre-stroke hypertension and diabetes is higher and increasing faster in ethnic minority and lower socioeconomic groups. Together with Black people’s younger age at stroke and higher likelihood of having a stroke without a prior risk factor diagnosis, these findings call for targeted and earlier primary prevention efforts.
“NHS health checks, which screen for hypertension and diabetes, begin at the age of 40. However, this may be too late for higher-risk groups who often experience stroke at a younger age.”
She called for “universal improvements in cardiovascular risk detection” as well as more targeted prevention strategies, such as younger screening age for those most at risk.
Read full story
Source: The Guardian, 28 July 2026
Patient Safety Learning

Provider fined £600k over death

A provider has been fined more than £600,000 over the death of a 33-year-old mental health patient who sought a private admission after being turned down by the NHS.
Priory Healthcare Limited pled guilty to failing to provide safe care and treatment at one of its hospitals in Surrey, resulting in avoidable harm, the regulator has announced.
Staines Magistrates’ Court fined Priory Healthcare Limited £600,000, and ordered it to pay a £2,000 victim surcharge and costs of £11,645. The prosecution was brought by the Care Quality Commission.
Amy Henderson died in March 2022 after she admitted herself to Priory Hospital Woking as a voluntary patient, following a significant deterioration in her mental health, including experiencing suicidal thoughts.
A coroner’s report said: “She was diagnosed with postpartum depression. She was advised to become an informal patient in the NHS, but there was no bed available so she would have had to wait in the hospital until a bed could be found. She decided to seek a private admission the following day.”
On admission, she was assessed as being at high risk. However, a coroner found that neglect had contributed to Ms Henderson’s death, as the hospital had failed to “adequately manage a known and previously identified ligature risk”.
Ligature point audits flagged the risk in March 2020 and May 2021, but no action was taken.
Read full story (paywalled)
Source: HSJ, 28 July 2026
Patient Safety Learning

USA: National leaders unveil a vision for the future of patient safety

What if we could build the safest health system possible from scratch? That's the question posed by Safe By Design: Reimagining Health Care Around the Prevention of Harm, a new white paper that introduces the fictional yet realistic Ambition Health System as a blueprint for designing health care around the prevention of harm rather than reacting to it.
Prepared by the Coalition for Advancing Safer Healthcare (CASH), an initiative convened by the Jewish Healthcare Foundation (JHF) and the Pittsburgh Regional Health Initiative (PRHI), Safe By Design moves beyond incremental improvements to today's fragmented healthcare system. Instead, it offers expert-informed recommendations that health system leaders can begin implementing now.
Developed through the leadership of CASH's four partner hubs—the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University, the MedStar Health National Center for Human Factors in Healthcare, the Joan & Irwin Jacobs Center for Health Innovation at UC San Diego Health, and The University of Utah Center for Evaluation of Health AI—the report also draws on the expertise of more than 100 national leaders in patient safety, healthcare delivery, technology, policy, and patient advocacy.
Read full article.
Source: Jewish Healthcare Foundation, 28 July 2026
Mark Hughes

Machine that keeps lungs alive outside the body set for NHS use

A machine that keeps donated lungs alive outside of the body is set for use on the NHS, offering hope for the 170 people waiting for a new lung.
The move by the National Institute for Health and Care Excellence (Nice) will give organs that would otherwise be discarded a chance to be transplanted. According to NHS Blood and Transplant (NHSBT), only 23% of all lungs that meet suitability criteria for transplants are used.
The machine warms donated lungs to body temperature and pumps a fluid through them that mimics blood plasma. It also ventilates them to mimic normal breathing. The machine allows transplant teams to treat infection, drain excess fluid, reinflate collapsed areas and monitor how the lungs are functioning.
Read full article.
Source: The Independent, 27 July 2026
Mark Hughes

GPs and ambulance trusts must do more to combat winter pressures, insists NHS England

Primary and community care will be expected to play a much bigger role in helping the NHS deal with winter pressures this year, NHS England has told the service.
NHSE has also issued a specific set of measures that ambulance trusts must undertake as part of the service’s winter response for the first time.
The 2026-27 winter planning guidance  instructs integrated care boards to ensure GPs have enough capacity to meet demand, including during “surge periods”, and to check they are contractually compliant in their ability to offer online consultations, same-day appointments, and NHS 111 direct booking. 
Read full article (paywalled).
Source: Health Service Journal, 28 July 2026
Mark Hughes

Health board records highest number of 'never events' in Wales in 12-month period

Betsi Cadwaladr University Health Board recorded the highest number of "never events" in Wales last year, according to its latest annual report. The health board logged 11 new never events during 2025/26 – an increase of six compared with the previous year.
The report states the Welsh health board with the second-highest total recorded seven. The figures are contained in the health board’s annual report, which is due to be discussed at its annual general meeting on Wednesday, July 29.
Never events are serious, largely preventable patient safety incidents that should not happen if national safety guidance is followed. Examples of never events can include operating on the wrong part of the body, leaving surgical instruments inside a patient after an operation, or administering medication by the wrong route. 
Read full article.
Source: North Wales Live, 28 July 2026
Mark Hughes

Hundreds of thousands of women access free morning-after pill at NHS pharmacies in first 5 months

Hundreds of thousands of women have accessed the morning-after pill at high street pharmacies in the first 5 months since the NHS made it available free-of-charge.
New NHS figures show that almost 305,000 doses of the emergency contraceptive pill were supplied at pharmacies between October 2025 and March 2026 without women needing to book a GP or sexual health clinic appointment.
Now women can visit their local pharmacy and have a confidential consultation with a pharmacist or trained pharmacy technician, before receiving the emergency contraceptive pill on the same day.
Pharmacy teams can also support women with their ongoing contraception.
Since February 2024, pharmacies have carried out more than 1.2 million consultations for women continuing their oral contraceptive pill, alongside a further 192,000 consultations for women starting it.
Around 4 in 5 people in England live within a 20-minute walk of a community pharmacy, and by making both emergency and ongoing contraception available closer to home, the NHS is making it easier and more convenient for women to access the support they need.
Read full article.
Source: Department of Health and Social Care, 28 July 2026
Mark Hughes

NHS England hires charity chief to create new directorate

NHS England has appointed a charity CEO to the new role of national director of patient experience.
National Voices chief executive Jacob Lant will take up the role in the autumn, and will oversee the creation of a new “patient experience directorate” across NHSE and the Department of Health and Social Care.
Mr Lant will be tasked with “overhauling” the complaints system, and strengthening how the service listens to, and involves, the public in the role jointly created by NHSE and the DHSC.
Read full article (paywalled).
Source: Health Service Journal, 27 July 2026
Mark Hughes

Ebola cases in DR Congo surpass 3,000 - as health workers go on strike

The Democratic Republic of Congo (DRC) has recorded more than 3,000 confirmed cases of Ebola, as it continues to battle the fastest-growing outbreak of the disease in history.
According to government data, the number of Ebola cases has increased to 3,075, while the number of deaths has risen to 1,354. That comes just three days after the DRC reported more than 1,000 deaths from the outbreak, which was declared on 15 May and is driven by the Bundibugyo strain that has no approved vaccines or treatments.
This outbreak has killed people at a faster rate than any previous outbreak, including the 2013-2016 epidemic, which killed more than 11,000 people out of 28,000 cases, and is considered the worst on record.
Meanwhile, around 100 health workers at an Ebola treatment centre in eastern DRC have gone on strike over unpaid performance bonuses, disrupting care for patients in the epicentre of the country's rapidly growing outbreak.
Read full article.
Source: Sky News, 26 July 2026
Mark Hughes

‘Divisive and toxic’ culture found at trust

A damning review of a trust’s senior leadership found “adversarial and mistrustful” relationships had fostered “a divisive and toxic culture”, and staff felt “fearful, anxious and unable to speak openly”, HSJ reports.
Authors of the unpublished review said the relationship between Mersey Care Foundation Trust’s board leaders was “widely regarded as dysfunctional, resulting in a pervasive culture of anxiety across the organisation”.  
They also warned a focus on internal politics was “seen to detract from patient care, operational performance, and staff wellbeing”. 
Read full article (paywalled).
Source: Health Service Journal, 27 July 2026
Mark Hughes
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