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

New York rejects Louisiana request to extradite doctor who prescribed abortion pills

New York’s governor, Kathy Hochul, has rejected a request from Louisiana to extradite a doctor who was charged there with prescribing abortion pills to a pregnant minor.
'I will not be signing an extradition order that came from the governor of Louisiana,' Hochul said at a news conference in Manhattan. "Not now, not ever".
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Source: The Guardian, 14 February 2025
Patient Safety Learning

USA: Striking nurses, Providence have yet to meet or schedule talks since vote to reject contract

Negotiators for Providence and its striking nurses have not met since the two sides reached an ill-fated agreement a week ago, and they have no meetings on the books.
Nearly 5,000 nurses at all eight Providence hospitals in Oregon last week rejected a tentative agreement reached between the health system and their labor union, the Oregon Nurses Association, extending a strike that began 10 January 2025 and is now in its fifth week.
The rejected deal included wage increases, a one-hour penalty pay for missed meals and breaks, and provisions intended to codify language from a state hospital staffing law. It also offered a ratification bonus based on hours worked since a nurse’s last contract expired instead of retroactive pay raises.
Nurses had criticized the deal, arguing that it failed to adequately address chronic understaffing, patient safety concerns and demands for fair wages and benefits. Nurses also raised frustrations over their health benefits, citing difficulties accessing regular providers after Providence switched to Aetna for employee health plans this year.
Read full story
Source: The Oregonian, 12 February 2025
Patient Safety Learning

Letby trust CEO was forced out by ‘self-interested’ chair, tribunal finds

A foundation trust CEO was unfairly forced out of her role, after whistle blowing about the bullying behaviour of its chair, a tribunal has ruled.
Susan Gilby was CEO of the Countess of Chester Hospital Trust from 2018 until she was suspended and excluded from the premises in December 2022.
The events unfolded at a hugely consequential time for the hospital. Dr Gilby, a former intensive care consultant, joined as medical director in August 2018. But she was made acting CEO shortly after, when her predecessor Tony Chambers was forced to leave, amid a rift with paediatricians and others over the Lucy Letby case.
As she approached four years as CEO, the tribunal found Dr Gilby was the subject of a coordinated campaign instigated by chair Ian Haythornthwaite and carried out by chief people officer Nicola Price and two non-executives. The campaign was dubbed “Project Countess” and was “designed to protect the [chair] and manoeuvre [Dr Gilby] out of the trust”.
It was launched after Dr Gilby began raising concerns with directors in spring 2022 about Mr Haythornthwaite’s “confrontational and aggressive behaviour”.
The tribunal commented on Mr Haythornthwaite becoming angry with junior staff about the refurbishment of the trust offices while the “struggling organisation” faced “an erosion of public faith” in the trust against the backdrop of “a multiple murder inquiry”. This, it said, was “indicative of a chair prioritising his own self-interest above that of the trust and failing to work collaboratively with the CEO and staff”.
In summer 2022, Dr Gilby raised her concerns directly with Mr Haythornthwaite, who refused suggestions of mediation, and reacted angrily, banging his desk.
In September of that year, Dr Gilby “was subjected to concerted, aggressive and unjustified verbal attacks at the private board meeting [which] were not ’shut down’ by the [chair] when he could have and should have done so” according to the tribunal.
The tribunal found “on the balance of probabilities” the chair and two NEDs “had agreed before the meeting that [Dr Gilby] would be personally criticised and held accountable for [the trust’s] financial position and steps taken to remedy it”.
Read full story (paywalled)
Source: HSJ, 14 February 2025
Patient Safety Learning

RFK Jr sworn in as US Health and Human Services chief

Robert F Kennedy Jr, one of President Donald Trump's most controversial cabinet picks, has been sworn in as the next US Health and Human Services Secretary.
The former presidential candidate will now oversee key health agencies with about 80,000 employees and a trillion-dollar budget. Lawmakers on both sides of the aisle had questioned his baseless health claims and vaccine scepticism.
Kennedy is the founder of the anti-vaccine group Children's Health Defense, which gained prominence in the US for casting doubt on the safety and efficacy of childhood vaccinations and making the discredited claim that the shots are linked to autism.
Kennedy, the nephew of former President John F Kennedy, has denied that he is anti-vaccination, pointing out his own children are immunised. He insisted during his confirmation hearings that he merely supports more stringent studies and safety tests for injections.
During the hearings, lawmakers also grilled Kennedy on his promotion of health misinformation and knowledge of the US healthcare system.
He was asked to explain his stance on abortion, as he previously indicated that he was in favour of abortion rights. He responded by telling lawmakers he agreed with Trump that access to abortion should be controlled by individual states and that "every abortion is a tragedy".
Read full story
Source: BBC News, 13 February 2025
Patient Safety Learning

'My mum lost her dignity in 60 hour A&E wait'

The son of an 88-year-old woman who has been stuck in A&E for more than 60 hours said she had been stripped of her dignity.
Maureen Harman was taken to Wigan Infirmary in Greater Manchester on Monday evening, but as of Thursday afternoon had still not been admitted to a ward.
Her son, Nick Harman, told the BBC that for most of that time his mother had been lying on a trolley in a corridor along with many other patients.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust (WWL) apologised for the long waits and said it had been "extremely busy".
Mr Harman, 56, said: "She's sat on her bed, she's getting uncomfortable, there's people in corridors, there's people coming in escorted by police, drug addicts and things.
"Your dignity is just gone. You're doing things in the corridor, with people who are strangers."
Mr Harman stressed the staff "have been brilliant" but that the scene in A&E had resembled a "warzone".
On Wednesday BBC North West reported nearly 39,000 patients spent more than a day in the region's emergency departments because there were no hospital beds for them.
Read full story
Source: BBC News, 14 February 2025
Related reading on the hub:
Related reading on the hub:
The crisis of corridor care in the NHS: patient safety concerns and incident reporting How corridor care in the NHS is affecting safety culture: A blog by Claire Cox A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces
Patient Safety Learning

Sharp rise in cancer patients in England waiting months for treatment

The proportion of cancer patients in England experiencing long waits for treatment has almost trebled, figures show.
Analysis by Cancer Research UK exclusively for the Guardian shows there has been a nearly fourfold increase in the number of patients in England waiting more than 104 days for urgent cancer treatment, from just over 6,000 patients in 2016 to 22,000 last year.
In 2024, more than 11% of cancer patients waited longer than 104 days to start treatment, which was nearly triple the rate of 4.4% in 2016.
The latest figures from NHS England show a slight improvement in the number of patients treated on time. In December, 66.4% of patients were treated within 62 days of urgent referral, up marginally from 64.5% in November.
The target is to treat 85% of cancer patients within 62 days but this has not been met in any month since December 2015. Even if patients referred via screening or from their consultant are included, just under one-third of patients are still not treated on time.
According to Cancer Research UK, the last time the NHS consistently met the target to treat 85% of cancer patients within two months of urgent referral was in 2013.
Read full story
Source: The Guardian, 13 February 2025
Patient Safety Learning

Student died from sepsis after antibiotics error in London hospital, inquest hears

A consultant paediatrician warned medical colleagues treating her son that they had failed to give him life-saving antibiotics hours before he died from sepsis, an inquest has heard.
William Hewes, 22, a history and politics student, died on 21 January 2023 of meningococcal septicaemia at east London’s Homerton hospital, where his mother, Dr Deborah Burns, worked.
Burns brought her “very ill” son into the A&E at the hospital just after midnight and told her colleagues he was seriously ill and needed treating for meningitis, the inquest into his death heard on Thursday.
A doctor prescribed 2 grams of the antibiotic ceftriaxone within minutes of Hewes’s arrival and the medical team knew the drug had to be given as soon as possible. But due to a communication mix-up between the duty emergency registrar, Dr Rebecca McMillan, and nurses, the “life-saving” drug was not administered within the vital first hour of treatment, the inquest heard.
Burns said her son only got the antibiotics after she warned Dr Luke Lake, the acting medical registrar on duty at the time, about the failure to administer the drug. In written evidence read to the court, she said: “I told him I didn’t think William had the antibiotics. Luke reassured me, that they had been written up earlier. I replied: ‘Yes, but they have not been given.’”
Earlier, Dr McMillan recounted her distress when she realised at about 1.17am that the drug had not been administered by nurses as she requested.
She said: “I do recall standing outside the resus room with [nurse Marianela Balatico] where she asked if I was OK and said that I looked really upset when I realised that antibiotics had not been given.
“We had a conversation along the lines of we didn’t understand how this had happened. We were both upset when we realised that this hadn’t happened.”
Fighting back tears, McMillan said one of the “learning points” from Hewes’s death was the need “to be clearer who I’m giving instruction to”. She added: “I obviously thought that my instructions had been clear enough. I have thought about that moment over and over.”
Read full story
Source: The Guardian, 13 February 2025
Patient Safety Learning

Ambulance services underprepared for ‘mass casualty incidents’

Ambulance services would still struggle to respond effectively to a mass-casualty event like the Manchester Arena bombing, HSJ has learned, as nearly all have been denied the funding needed to bolster preparedness.
The public inquiry report on the May 2017 attack, which killed 22, was sharply critical of the emergency services’ response, including North West Ambulance Service Trust. The inquiry’s November 2022 report made nearly 150 recommendations to prepare for future attacks.
Crucially, ambulance trusts were told to review their capacity to respond to a mass-casualty incident – including whether they had enough trained specialist staff – then tell commissioners what extra funding they need to ”respond effectively”.
Gaps identified included the availability of 24/7 “critical care cars”, specialist practitioners in hazardous area response teams, and tactical commanders in operations centres.
But eight out of England’s 10 ambulance trusts have confirmed to HSJ – through Freedom of Information requests and follow-up enquiries – that they have not received funding from commissioners to cover what they found was needed.
HSJ understands that, while some trusts have strengthened specialist teams using other income, they have not received funding for the majority of what the reviews said was needed, and there are therefore still significant gaps in readiness.
Read full story (paywalled)
Source: 14 February 2025
Patient Safety Learning

Four in ten who took their lives in prison were denied adequate healthcare

Four in ten prisoners who took their own lives in custody were denied adequate healthcare before their deaths, according to damning new figures exposing the scale of neglect inside Britain’s overcrowded prisons.
Inmates are legally entitled to receive the same standard of healthcare as someone living in the community. However, official findings uncovered by The Independent show in 101 out of 233 self-inflicted deaths investigated by the prisons watchdog between 2020 and 2023, the mental or physical healthcare did not meet this requirement.
In each case a clinical reviewer assessed whether the care was equivalent to what they would expect outside of jail as part of investigations into the deaths by the Prison and Probation Ombudsman (PPO). In many of the self-inflicted deaths, failings related to mental healthcare.
The chairman of the justice committee, Andy Slaughter, said “we are failing people in custody” after the figures came to light, while the chief inspector of prisons, Charlie Taylor, warned “without any doubt” there will be more potentially preventable deaths if action is not taken to drive up standards.
“We see it frequently in prisons that we inspect that there are people who just aren’t getting the support that they need,” he told The Independent. “If someone needs treatment, they need treatment.”
Read full story
Source: The Independent, 14 February 2025
Patient Safety Learning

BMA challenge to GMC on 'medical professionals' term goes to court

A legal challenge brought by leading doctors against the medical regulator amid rising concerns over the use of physician associates is due to reach court. 
The British Medical Association (BMA) is bringing a case at the High Court in London against the General Medical Council (GMC), accusing the regulator of abandoning its responsibilities to patients' safety by blurring the lines between doctors and non-doctors.
The BMA claims the GMC has been using the term "medical professionals" to describe all those it regulates – doctors as well as physician and anaesthesia associates (PAs and AAs). The association says the term should only be used to refer to qualified doctors. The BMA maintains that PAs and AAs are neither doctors nor medically qualified, with the distinction crucial to patient safety.
It says there is evidence of widespread confusion in the public as to the roles of associates.
The GMC has stated that each profession type is prominently labelled on its public-facing registers, and in search functions, meaning that when patients search its registers it will be clear whether someone is a doctor, a PA, or an AA.
Read full story
Source: Medscape, 12 February 2025
Further reading on the hub:
Physician associates: What are the patient safety issues? An interview with Asif Qasim Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates
Patient Safety Learning

Advertising regulator launches nine investigations into weight loss jab ads

Nine investigations into weight loss jab adverts have been launched by the UK advertising regulator, which has raised concerns about the sheer volume of law-breaking involved in targeting the public with the drugs.
The Advertising Standards Authority (ASA) told The Independent it now has nine high-priority investigations underway into whether ads in various online media are promoting prescription-only medicines (POMs) in breach of its rules and the law.
Issues being probed include the use of unbranded injection or pen images, as well as claims such as “weight loss injections” and “Obesity Treatment Jab".
The ASA described the number of investigations running in parallel on the same topic as “significant” and said that tackling the issue is a “priority”.
Health secretary Wes Streeting has warned that the drugs “should not be taken to help get a body beautiful picture for Instagram” and must be treated as “serious medicines”. Drugs for weight management “should only be used by those tackling obesity,” he added.
The pharmacy regulator has now tightened prescription rules to prevent weight-loss medicines from being supplied “inappropriately”, with people now no longer able to get the drugs after completing a simple online questionnaire.
Groups including the National Pharmacy Association (NPA) had been calling for tougher rules after they learnt of people being wrongly prescribed the drugs without thorough checks, including some who already had a low body weight or who previously had eating disorders.
Read full story
Source: The Independent, 12 February 2025
Patient Safety Learning

'We are absolutely full': This hospital is outperforming most - but it is still on its knees

Marina Strange is 90 and lives alone. She had a heart attack last week, her third in two years. It took two hours for an ambulance to reach her. Marina was impressed.
"I was surprised the ambulance came within two hours. I thought that was very good," she told Sky News.
Marina was one of 8,449 patients to arrive at the care of Royal Berkshire NHS Trust by ambulance so far this winter, where Sky News has spent the past few months speaking to patients, consultants and those responsible for running the hospital.
Chief Executive Steve McManus said:
"Our ward occupancy at the moment is running around 99% of our beds, so we are absolutely full," he said.
"Almost half of [our respiratory unit] has been given over for patients with flu - and we’ve got a lot of very unwell patients at the moment. Each morning over the last few days we’ve been starting the day with another 20-30 patients in the emergency department waiting for beds, so the pressures are really significant."
Dr Omar Mafousi, the clinical lead at the hospital explains how a lack of beds in the main hospital affects the emergency care his team can provide.
“We say every year it gets a little worse. This year has felt worse than any other year that I remember and I’ve been a consultant for 15 years in emergency medicine.
“We can’t [have patients in A&E long term]. We’ve only got 20 major cubicles but 25 waiting for a bed. Some are on chairs, some are in the waiting room, but we have no space to bring patients off an ambulance to see and examine them.”
“Almost every single bay is full, there’s just one free at the moment. There are patients waiting to be transferred to the wards, and while we’ve been here in the last couple of minutes two more patients have been brought in by ambulance. Things in the emergency department change very very quickly”.
Read full story
Source: Sky News, 13 February 2025
Related reading on the hub:
How corridor care in the NHS is affecting safety culture: A blog by Claire Cox Reflections on a clinical shift: "After 20 years of nursing, this is one of the worst shifts I have ever completed" A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift  
Patient Safety Learning

Mental health patients with nowhere to go cost NHS £71m in England, report finds

A lack of supported housing was the biggest reason for delayed discharges from mental health hospitals in England last year, costing the NHS about £71m, according to a report.
Analysis from the National Housing Federation (NHF) found that in 2023-24 there were 109,029 days of delayed discharge because mental health patients were waiting for supported housing, and the number of people stuck in hospital as a result of housing-related issues had more than tripled since 2021.
In September 2024, waiting for supported housing was the single biggest reason mental health patients, fit for discharge, were unable to leave, accounting for 17% of all delays. This lack led to a strain on NHS capacity and a rise in patients being sent out of area for hospital admission, the report found.
Rhys Moore, director of public impact at the NHF, said: “Not only are tens of thousands of people, who deserve the opportunity to live a healthy, happy and independent life, being failed, but the shortage of these homes is increasing pressure on public services, increasing homelessness, and costing the NHS and ultimately the taxpayer more in the long run.”
A man in his 30s, who asked to remain anonymous, had struggled with drug addiction issues and was evicted shortly before he was admitted to a mental health hospital ward where he spent a number of weeks.
“I feel like I’m much better off in here than in hospital,” he said. “[The hospital] felt like I was all right. The way we were talking, I could tell they thought, you’re wasting my bed, you don’t need to be here. But I had been evicted, I had nowhere to go.
“I was really struggling in there, it was noisy and stressful at times. Living here, I feel like I can breathe and start getting myself back together again.”
Read full story
Source: The Guardian, 11 February 2025
Patient Safety Learning

ICBs ‘detached’ from patient safety risks

A new reporting system has left integrated care boards “detached” from patient safety incidents, a watchdog has found.
The Health Service Safety Investigations Body (HSSIB) said some ICBs first heard of an incident when they were asked to provide a media statement.
In a report published today it highlighted views that a new reporting framework had “eroded assurance activities and patient safety oversight.”
The NHS has largely moved from the serious incident framework – where incidents were investigated locally but ICBs played a key role – to the patient safety incident response framework (PSIRF), which is less prescriptive about how trusts need to react to incidents and is not based on the level of harm involved.
But the HSSIB report revealed widespread dissatisfaction among ICBs about the new model, with commissioners saying many PSIRF responses did not trigger a report, leading to them having less visibility of risks from incidents.
This was a particular concern when risks arose when patients moved between providers. ICBs were also often uncertain how risks were being mitigated and what providers had done as a result of incidents.
The safety body was also critical of the Learn from Patient Safety Events database, highlighting problems with “the useability and utility of the data”, with one ICB saying it had “3,000 incidents downloaded but no way of understanding them.” Multiple ICBs had escalated issues with this to NHSE as the data was not useful for identifying hazards and risks.
Helen Hughes, chief executive of the charity Patient Safety Learning, said issues with database were “not simply a technical problem with a new digital service.”
“They will result in missed opportunities to identify patient safety risks, learn from them and ultimately prevent avoidable harm to patients,” she said.
“With greater clarity around the roles, ICBs and ICSs have the potential to drive systemic improvements in patient safety. However, to do so effectively, they require enhanced tools, capacity, and a more integrated approach to digital solutions, such as LfPSE, that support patient safety.”
Read full story (paywalled)
Source: HSJ, 13 February 2025
You can read Patient Safety Learning’s response to this report here.
Patient Safety Learning

English dentists ‘walking away’ from NHS work as fees fail to cover costs

A growing “exodus” of dentists willing to provide care on the NHS threatens to exacerbate the crisis in patients’ access to treatment, the profession’s leaders have said.
Dentists are increasingly stopping doing NHS-funded work because their fees for many procedures do not even cover the costs involved, according to the British Dental Association (BDA).
The fact that NHS payments had not kept pace with rising costs was forcing dental surgeries in England to “operate like a charity” when carrying out work for the health service, it said.
The situation was so serious that dentists were in effect subsiding the NHS care they provided from their private work to the tune of about £332m a year, according to BDA analysis.
Dentists lost £42.60 every time they fitted dentures and £7.69 on each examination of a new patient’s dental health when the NHS was paying for the treatment, it said.
The findings come weeks after Wes Streeting, the health secretary, warned MPs that “NHS dentistry is at death’s door” and promised to take steps to save it from extinction.
The inability to get NHS dental care, and the consequent emergence of “DIY dentistry” and “dental deserts” across swaths of England, has become a key public and political concern in recent years.
Read full story
Source: The Guardian, 13 February 2025
Patient Safety Learning

Trust fined £1.7m for maternity care failures

An acute trust has been fined £1.7m — one of the largest penalties to date — after multiple failings in connection with the deaths of three babies under its care.
Nottingham University Hospital Trust admitted failings in the care of the babies and their mothers on Monday, in the prosecution brought by the Care Quality Commission.
Adele O’Sullivan, Kahlani Rawson and Quinn Parker all died shortly after being born in 2021 within the same short period of time.
It is the largest fine for a trust from a CQC prosecution over maternity failings, although similar penalties have been issued for other care failures.
According to BBC reporting, Nottingham Magistrates’ Court heard the fine was reduced from an initial £5.5m, and district judge Grace Leong accepted the defence’s request that the fine be payable in two halves, one half by 31 March 2026 and the second half by 31 March 2027.
NUH has already been fined £800,000 after admitting failings in the care of Wynter Andrews, who died in 2019, which was only the second time the regulator has brought a case against an NHS maternity service, and the highest fine ever given for failings of this nature.
The trust is also at the centre of the NHS’s largest ever maternity investigation, which is ongoing and expected to cover around 2,500 cases.
Read full story
Source: HSJ, 12 February 2025
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