Skip to content

News

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

Nurses at psychiatric unit called teens 'pathetic'

Former patients at Scotland's biggest children's psychiatric hospital have spoken out about a culture of cruelty among nursing staff.
Patients who were teenagers when they were admitted to Skye House, a specialist NHS unit in Glasgow, told BBC Disclosure some nurses called them "pathetic" and "disgusting" - and even mocked their suicide attempts.
"It was almost as if I was getting treated like an animal," one young patient, being treated for anorexia, said.
NHS Greater Glasgow and Clyde said it was "incredibly sorry" and has launched two inquiries into the allegations uncovered by the BBC's investigation.
Programme-makers spoke to 28 former patients while making BBC Disclosure's Kids on The Psychiatric Ward documentary.
One said the 24-bed psychiatric hospital, which sits in the grounds of Glasgow's Stobhill hospital, was like "hell".
"I'd say the culture of the nursing team was quite toxic. A lot of them, to be honest, were quite cruel a lot of the time," she added.
Read full story
Source: BBC News, 10 February 2025
Patient Safety Learning

Corridor care and no privacy: Inside A&E at the height of the NHS winter crisis

Trollies hem the corridor and surround the central nursing hub in the acute centre of Newham Hospital’s emergency department, lined up end-to-end in the humming ward.
Most are occupied: some patients are too ill to sit up, while others are monitored by security. Doctors and nurses are assessing patients as other staff and family members try to squeeze past in the crowded space.
Bright fluorescent lights beam down and dozens of monitors make incessant noise over the chatter of patients, families and hospital workers, with no privacy to speak of.
This is the reality of England’s NHS in winter, with a record 96% of hospital beds currently full.
Newham Hospital has to use corridors as care spaces, like many hospitals across England, because demand for care is so high (The Independent)
Anna Morgan, a consultant in emergency medicine and the clinical lead, says corridor care is an unavoidable necessity in an under-pressure department running at double its capacity.
“It is a very crowded, very busy department at the moment, for today and the last few days,” she tells The Independent. “This department was originally built with the idea of having about 250 patients, is what we’re told. And we quite regularly now get over 500 a day... so that is a challenge.”
Gemma Davies, the deputy associate director of nursing in urgent and emergency care, says private areas to carry out personal care or confidential conversations with patients are “at a premium”.
“So all the things that we would normally do in quite a controlled space, and having monitoring equipment, then becomes almost like ‘Move this to there, move that to there, move that’, and it’s almost like playing nursing Jenga with patients,” she says.
Read full story
Source: The Independent, 9 February 2025
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

Patients at risk without better protection for whistleblowers, says ex-NHS hospitals chief

Patient safety is at risk without better protection for NHS whistleblowers, according to a former health service chair who claims he was forced from his job after raising concerns about reviews into preventable baby deaths.
Maxwell Mclean, the former chair of the Bradford Teaching Hospitals NHS foundation trust, said his treatment made “an absolute mockery of the freedom to speak up” in the NHS.
“This isn’t just about me. This kind of failure to be held to account is a danger to our community,” said Mclean. “It is genuinely in the public interest that a chair is supported when they try to hold a trust’s CEO to account. Because the consequence if they don’t is a danger to patient safety.”
Mclean claims he raised a number of “alarming” issues at the trust, including significant delays investigating neonatal deaths and the neglect of a staff member who was formally reported to be at risk of suicide.
Mclean was chair of the trust for almost five years from 2019, following a 30-year career at West Yorkshire police. In 2021, he raised concerns about the length of time being taken to investigate the deaths of newborn children at the trust – he said some reviews were not concluded for 14 months, despite NHS England guidelines stating they should be done within 60 days.
This led to an independent investigation that corroborated some of his concerns. Mclean claimed that shortly after this review was completed he was forced to resign by the trust’s other board members. He is pursuing a whistleblowing claim at an employment tribunal in Leeds later this month.
“My contract was unlawfully terminated by a board that should not have met and did so in secret, so it was entirely against the constitution. And they were doing it in order to cover up very serious failings,” said Mclean, who is fundraising to help cover his legal costs.
“It has had a massive impact on my career. I have a reputation for thoroughness and fairness.”
Read full story
Source: The Guardian, 10 February 2025
Related content on the hub:
Patient Safety Learning's speaking up for patient safety interview series
Patient Safety Learning

Hospitals prosecuted over baby deaths

The trust at the centre of a maternity investigation is to be prosecuted by the Care Quality Commission over the deaths of three babies.
Nottingham University Hospitals Trust intends to plead guilty to the charges relating to care and treatment to the babies, it has said.
The trust is at the centre of the NHS’s largest ever maternity investigations, which is expected to cover around 2,500 cases. It has already been fined £800,000 after admitting failings in the care of Wynter Andrews, who died in 2019.
In a statement, the trust said: “We can confirm that the CQC is bringing charges against Nottingham University Hospitals Trust following an investigation into three deaths which occurred in our maternity services in 2021.
“We have co-operated with the CQC throughout their investigation, and intend to plead guilty to the charges when proceedings open.
“We are not able to comment any further at this stage.”
Read full story (paywalled)
Source: HSJ, 7 February 2025
Patient Safety Learning

CDC scientific report resumes publication after unprecedented pause

The Centers for Disease Control and Prevention (CDC) resumed publishing its weekly scientific report Thursday after an unprecedented pause, but information about the bird flu virus that was supposed to appear remained on hold even as the outbreak spreads.
Three studies about the H5N1 bird flu virus were scheduled to be released in the weekly Morbidity and Mortality Weekly Report on 23 January according to multiple CDC officials who spoke on the condition of anonymity out of fear of retaliation. But release of the results was abruptly halted when the Trump administration instructed federal health agencies to pause all external communications on 21 January.
The weekly document is the agency’s primary vehicle for disseminating public health information and recommendations. Health officials, clinicians and researchers are among those who rely on the studies for vital guidance. Until last month, the MMWR has been published without interruption since 1952, even during government shutdowns.
“Although I’m encouraged that the MMWR is being published again, I’m surprised and concerned that it doesn’t contain any reports on bird flu spreading in animals and people, the new strain of mpox spreading or other emerging health threats,” said Tom Frieden, a former CDC director for the Obama administration.
“If political decisions determine which health threats to highlight, we’ll all be less safe,” Frieden said. “I hope the new Administration will see the value in CDC publishing information on health threats every week, without political interference.”
Read full story (paywalled)
Source: Washington Post, 6 February 2025
Patient Safety Learning

Abandoned in the middle of clinical trials, because of a Trump order

The stop-work order on USAID-funded research has left thousands of people with experimental drugs and devices in their bodies, with no access to monitoring or care.
Zsanda Zondi received a startling phone call last Thursday, with orders to make her way to a health clinic in Vulindlela, South Africa, where she was participating in a research study that was testing a new device to prevent pregnancy and HIV infection.
The trial was shutting down, a nurse told her. The device, a silicone ring inserted into her vagina, needed to be removed right away.
The US Agency for International Development, which funded the study, has withdrawn financial support and has issued a stop-work order to all organisations around the globe that receive its money. The abrupt move followed an executive order by President Trump freezing all foreign aid for at least 90 days. Since then, the Trump administration has taken steps to dismantle the agency entirely.
Ms. Zondi’s trial is one of dozens that have been abruptly frozen, leaving people around the world with experimental drugs and medical products in their bodies, cut off from the researchers who were monitoring them, and generating waves of suspicion and fear.
In interviews, scientists — who are forbidden by the terms of the stop-work order to speak with the news media — described agonizing choices: violate the stop-work orders and continue to care for trial volunteers, or leave them alone to face potential side effects and harm.
In England, about 100 people have been inoculated with an experimental malaria vaccine in two clinical trials. Now, they no longer have access to the clinical trial staff if that vaccine were to cause an adverse reaction in their bodies. Had the trial not been frozen, the participants would be coming to a clinic routinely to be monitored for adverse physical effects, and to have blood and cell samples taken to see whether the vaccine was working. The participants are meant to be followed for two years to assess the vaccine’s safety.
An anonymous scientist who worked on the trial said: “It’s unethical to test anything in humans without taking it to the full completion of studies. You put them at risk for no good reason.”
Read full story (paywalled)
Source: New York Times, 6 February 2025
Patient Safety Learning

Woman’s life cut short by delayed lung cancer diagnosis

A hospital’s failure to diagnose a woman’s cancer denied her precious time with her family, England’s Health Ombudsman has found.
The Parliamentary and Health Service Ombudsman (PHSO) is urging hospitals to improve processes to avoid delays in diagnosis.
A woman underwent a CT scan at University Hospitals of Leicester NHS Trust towards the end of November 2017 to investigate a potential liver problem.
While nothing significant was found on her liver, the scan revealed a nodule – a small dense area - and a possible pulmonary embolism on her left lung.
In December, the woman was referred to a clinic to treat the pulmonary embolism. The consultant at the clinic wrote to her GP asking she be referred for another CT scan three months later to investigate the nodule. This was not done and a review in mid-April 2018 revealed the follow-up scan had not been carried out.
An urgent CT scan towards the end of May 2018 revealed the woman had lung cancer, of which she died aged 81 in February 2019.
The Ombudsman found the woman should have been diagnosed with lung cancer in December 2017, around six months earlier.
The Trust should not have passed the matter back to the woman’s GP and did not appropriately follow up the lung nodule’s finding.
Though PHSO cannot say exactly what would have happened, there is evidence the woman may have lived longer if the diagnosis had been made sooner.
Read full story
Source: PHSO, 6 February 2025
Patient Safety Learning

We aborted healthy babies after NHS mistakes, couples tell BBC

Two couples have told the BBC they went through with abortions after an NHS trust mistakenly told them their unborn babies had serious genetic conditions.
They say errors by doctors at the Nottingham University Hospitals NHS Trust led to them terminating their pregnancies.
Another family say a last-minute scan on the day they were due to have an abortion changed their minds and they are now the parents of a healthy nine-year-old boy.
The trust, which is currently at the centre of the largest maternity inquiry in the history of the NHS, said its foetal medicine teams strived to provide "compassionate and professional" care.
Ms Carly Wesson and her partner Carl Everson were expecting their first child in January 2019, when a 12-week scan indicated their baby had a high chance of having Down's Syndrome.
They were offered a test, known as chorionic villus sampling (CVS), to check if their baby had any genetic or chromosomal conditions.
Two days later, the foetal care team at City Hospital in Nottingham told them the initial results indicated their daughter had a rare genetic condition called Patau's Syndrome, which often results in miscarriage, stillbirth, or the baby dying shortly after birth.
Results from a more detailed analysis of the sample were due back two weeks later. The couple asked if it might show a different outcome, but they say their consultant advised them it would not. The couple decided to have an abortion.
Six weeks after the abortion, they were asked to attend a meeting at City Hospital, which they assumed was a routine follow-up.
"[The consultant] just walked in and the first thing she said was 'I have got something to tell you, your results have changed'," says Ms Wesson.
The second test, called a long term CVS culture, showed their daughter had no chromosomal abnormality.
When they asked if their daughter would have survived, Ms Wesson says the doctor told the couple: "Well, you could have miscarried anyway."
"That's always stuck with me - it was almost malicious," she says.
An investigation into the death carried out by the trust said the second test showed "all 50 cells studied had a normal chromosome compliment".
The first test result - which the couple say was the basis on which they decided to terminate the pregnancy - had been a false positive.
This is "a well-recognised hazard of early CVS results", the investigation found.
Read full story
Source: BBC News, 6 February 2025
Patient Safety Learning

Mesh victims still wait for financial compensation

Women harmed by pelvic mesh implants are still waiting for government compensation a year after a major report, external called for urgent action.
Patient safety commissioner Dr Henrietta Hughes, who made that recommendation, called it "an injustice" for the thousands of lives destroyed.
Some women were left in permanent pain, unable to walk, work or have sex, after the surgery to treat incontinence and pelvic organ prolapse.
The government says it remains "fully focused" on how best to support patients and prevent harm.
A Department of Health and Social Care official said: "Our sympathies are with those affected.
"This is a complex area of work and Health Minister Baroness Gillian Merron met with some of those affected before Christmas, and has committed to providing an update to the patient safety commissioner at the earliest opportunity."
Dr Hughes said: "It is very disappointing that women who have suffered so much harm are still waiting for redress.
"They need redress now and the government must act immediately."
Read full story
Source: BBC News, 7 February 2025
Patient Safety Learning

New push to stop sending patients ‘out of area’ after homicides

NHS England has told trust, system and regional leaders to push ahead with plans to eliminate out-of-area placements within three years, in response to an independent review into the care of a man who killed three people while being treated by a Nottinghamshire mental health trust.
NHSE’s mental health leaders wrote to trusts and systems last night after publication of the findings on Valdo Calocane’s treatment.
The review said that he was sent to two inpatient units outside his home area, including a spot-purchased independent sector bed, “due to a lack of local capacity” and despite his family being against it. The review suggested that if he was cared for locally, the admissions “may have been the opportunity to fully see” that he was disengaging with community services, and for services to change their approach.
Claire Murdoch, NHSE’s national director for mental health, learning disabilities and autism, and Adrian James, the national medical director for mental health and neurodiversity, told trust and ICB leaders they must discuss their “action plans” to improve treatment of mental health patients who need “intensive and assertive community treatment” by 30 June.
In particular, they said they should review their plans for “eliminating out-of-area placements in line with ICB three-year plans”; for “personalised assessment of risk across community and inpatient teams”; “joint discharge planning arrangements involving family”; multi-agency working; and information sharing.
Read full story (paywalled)
Source: HSJ, 6 February 2025
Patient Safety Learning

California warns hospitals not to withhold trans youth healthcare

As Donald Trump seeks to block transgender youth healthcare across the country, California’s attorney general has sent a clear message to providers, reminding them of their duty to provide gender-affirming treatment under the state’s nondiscrimination laws.
“The law requires [hospitals] to continue to provide gender-affirming care to our transgender community,” Rob Bonta, a Democrat who heads the California justice department, told the Guardian on Wednesday. “We will have the transgender community’s back. We will fight for their rights, for their protections, for their freedoms.”
His comments come a week after Trump issued an executive order decreeing that medical institutions that receive federal funding and grants do not provide gender-affirming care, including hormone therapy and puberty blockers, to youth under age 19.
In response, some hospitals have paused treatments, which are considered part of the standards of care for gender dysphoria endorsed by all major US medical associations. Trans patients, their families and civil rights groups have said the interruption of care could have dire consequences for patients’ physical and mental health. They’ve also argued that Trump’s order is unlawful, violating patients’ constitutional rights and parental rights, and that hospitals have no legal obligation to preemptively deny care, particularly while the policy is being challenged in court.
On Tuesday, Children’s Hospital Los Angeles (CHLA), a major local provider, said it was pausing the initiation of hormone treatments for trans youth. The hospital told the LA Times it was not starting new patients’ gender-affirming care while it evaluated Trump’s order “to fully understand its implications”, but said treatment for existing patients would continue.
On Wednesday, Bonta wrote a letter to CHLA warning that “withholding services from transgender individuals based on their gender identity or their diagnosis of gender dysphoria” would violate the state’s Unruh Civil Rights Act, a longstanding law that prohibits discrimination against LGBTQ+ people.
Read full story
Source: The Guardian, 5 February 2025
Patient Safety Learning

The life and death of Jen Bridges-Chalkley: why did a 17-year-old die waiting for NHS therapy?

When Sharren Bridges talks about her daughter’s last summer, in 2021, she chokes up and has to pause. In some ways, it was a good summer. Jen Bridges-Chalkley had a boyfriend and, like most parents of teenagers, Sharren would occasionally act as a taxi driver, taking them down to the local river to swim.
On 12 October 2021, Jen killed herself at her mother’s home. She was 17. At the inquest, which concluded in April 2024, the coroner said her suicide could have been avoided if she had received the support she needed “in a timely manner”. It was “a multi-agency failure”, he concluded in the report, which is a devastating document: 81 pages of missed opportunities, bad communication and poor decision-making.
“There was a failure of the agencies to work effectively together to ensure that Jen’s needs were met,” the coroner wrote. Safeguarding failure; failure by educational establishments; failure by child and adolescent mental health services (Camhs). “For much of the time between May 2018 and June 2020, she was on a waiting list for therapy from the psychology team and was awaiting assessment.” He concluded that Camhs had failed “properly to assess, diagnose and treat Jen … in order to manage her conditions and minimise her risk of suicide”.
Camhs is the NHS service for children with emotional, behavioural and mental health issues. Its staff includes psychiatrists, psychologists, nurses, therapists and social workers. It aims to provide support and treatment, including therapy, medication and in-hospital care. Sharren’s assessment of Camhs, provided in Jen’s case by Surrey and Borders Partnership NHS foundation trust, is simple: “It’s not fit for purpose.”
Sharren is angry when she speaks about Camhs. “Jen is a person, she’s my daughter, she’s my everything, and she’s not here any more because people didn’t do their job. They didn’t do their job when she was five, they didn’t do their job when she was 11, they didn’t do their job when she was 14, 15, 16, 17, and now she’s not going to get older than 17.”
In a statement, Graham Wareham, the chief executive of Surrey and Borders Partnership NHS foundation trust, said: “We remain deeply saddened by Jennifer’s tragic death and we have expressed our deepest condolences to her family. Our investigation into the support we provided Jennifer found that while we gave care and consideration into delivering a person-centred therapeutic approach to meet Jennifer’s mental health needs, we acknowledge that there were shortcomings.
Read full story
Source: The Guardian, 6 February 2025
Patient Safety Learning

One in five UK adults living with diabetes or pre-diabetes as diagnoses reach all-time high

One in five UK adults are living with diabetes or pre-diabetes as diagnoses have reached an all-time high, new data shows.
Charity Diabetes UK called this a “hidden health crisis” and urged the government to act immediately. Some 4.6 million people are now diagnosed with the condition, compared to 4.4 million a year ago.
This includes about 8% with type 1 diabetes, which happens when a person cannot produce insulin, a hormone that helps the body turn glucose into energy.
Some 90% have type 2 diabetes, which happens when the body does not use insulin properly, while 2% have different and rarer forms of the condition. A further 1.3 million are estimated to be living with undiagnosed type 2 diabetes.
The chief executive of the charity, Colette Marshall, said: “These latest figures highlight the hidden health crisis we’re facing in the UK and underline why the government must act now.
“There must be better care for the millions of people living with all types of diabetes, to support them to live well and fend off the risk of developing devastating complications.
“With more people developing pre-diabetes and type 2 diabetes at a younger age, it’s also critical that much more is done to find the missing millions who either have type 2 diabetes or pre-diabetes but are completely unaware of it. The sooner we can find and get them the care they need, the more harm we can prevent.”
Read full story
Source: The Independent, 6 February 2025
Patient Safety Learning

‘Basic’ gaps left trusts exposed to cyber attacks

Two recent cyber attacks that cost the NHS millions of pounds and led to patients’ data being published online could have been mitigated with basic security measures, an integrated care board has found.
Wirral University Teaching Hospitals Foundation Trust was hit by a “targeted” cyber attack in November, which lasted about nine days, then three other trusts in Merseyside were hit in early December in an unconnected incident.
WUTH was forced to take its Cerner electronic patient record system offline, while some activity was either cancelled or rescheduled, which the trust has confirmed amounted to a loss of around £3m. A report to its board said its cancer performance “will take months to recover”.
In an update to ICB executives, chief digital information officer John Llewellyn said: “The incidents above may have been mitigated if core cyber security standards had been adhered to… There are still significant gaps in compliance with basic security standards in multiple organisations which, in turn, lead to vulnerabilities for all organisations because of the interconnected/cross organisational patient flows, clinical services (such as pathology and imaging) and supporting digital infrastructure and clinical systems.
“These are just examples, however, and there are many other technical aspects to cyber risk that need to be shared, understood and proactively managed in order to manage and mitigate these as effectively as possible.”
Read full story (paywalled)
Source: HSJ, 6 February 2025
Patient Safety Learning

ICBs missing checks on vulnerable children

Integrated care boards are warning they are failing to carry out health checks for vulnerable children in care because of a lack of paediatricians and rising demand, HSJ  has found.
ICBs are required to commission initial health assessments within 20 working days of a child entering care, arranged by a local authority, then a review six to 12 months later.
HSJ  has identified several ICBs warning they are not or may not meet the requirement – citing workforce pressures, complex cases and rising demand.
Missing the checks for children in care risks harming their physical and mental health, school attainment and future wellbeing, according to paediatricians. 
A community paediatrician working in the South East told HSJ  delayed assessments could have significant long-term impact — delaying intervention in developmental concerns, alcohol and drug use, oral health, immunisation and medications.
“These children are incredibly vulnerable,” they said. “The quicker we get issues addressed, often putting them on SEN [special educational needs] or other support, the better they often do in school and in life.”
Read full story (paywalled)
Source: HSJ, 5 February 2025
Patient Safety Learning

Researchers rush to preserve federal health databases before they disappear from US government websites

A group of researchers and students at the Harvard T.H. Chan School of Public Health are scraping and downloading data related to health equity from U.S. government agency websites before they disappear. Their goal is to make the downloaded data publicly available through repositories such as the Harvard Dataverse.
The new Trump administration has at least temporality halted most communications from the Department of Health and Human Services and has begun taking down government websites, including many pages that include DEI initiatives. The Center for Disease Control and Prevention’s Youth Risk Behavior Survey site, which monitors health behaviors of high-school students, including sexual behavior, mental health and tobacco use, is no longer available.
Health researchers worry that more of their trusted federal health databases could disappear in the coming hours and days. It’s not clear whether the changes are permanent or the websites will once again become available.
“In my lifetime, in the United States I don’t know of another situation where researchers have been this concerned about losing access to data that they’ve had access to their whole career,” says Jonathan Gilmour, a data scientist at the Chan School who is researching human health impacts of climate change. “It’s dire.”
Read full story
Source: The Journalist's Resource, 31 January 2025
Sam
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.