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

USA: Physician group sues Trump admin to reverse agencies' health web page, data blackout

A physician advocacy group filed a lawsuit Tuesday against federal agencies over last week’s purge of health information web pages and public health data sets, which they said harms patient care and medical research.
The complaint, filed in the District of Columbia’s federal court by Doctors for America, outlines a “dangerous gap in the scientific data” that health experts use to spot disease outbreaks and better speak with their patients.
It lists the Office of Personnel Management, the Centers for Disease Control and Prevention (CDC), the FDA and the Department of Health and Human Services as defendants.
Last Friday, the agencies began scrubbing critical data and pages from their websites that were related to LGBTQIA+ issues to comply with President Donald Trump’s executive order to strike “gender ideology” from the federal government. Per a New York Times analysis, more than 8,000 pages were removed in total—including more than 3,000 from the CDC—alongside numerous online data sets.
Though some pages have come back online with a notice that they are being modified to comply with Trump’s order, other pages including those relating to the Youth Risk Behavioral Surveillance System, HIV data and recruiting underrepresented populations in clinical studies remain down as of Tuesday, per the complaint (PDF).
“For example, DFA members had relied daily on CDC webpages with guidelines on ‘PrEP for the Prevention of HIV Infection in the U.S.’ and ‘U.S. Medical Eligibility Criteria for Contraceptive Use,’” the group wrote in its complaint. “DFA members used those webpages, and other removed pages, to guide how they treat patients, particularly patients with other medical conditions that must be taken into account to safely recommend and prescribe treatment options.”
“Federal public health agencies must reinstate these resources in full to protect our patients,” Reshma Ramachandran, M.D., a member of the board of directors for DFA, said in a release.
Read full story
Source: Fierce Healthcare, 4 February 2025
Patient Safety Learning

Killer evaded medication over needle fear, report says

Triple killer Valdo Calocane was not forced to take his anti-psychotic medication because he did not like needles, a major review of his NHS care has revealed.
The NHS England report identified numerous failings that show "the system got it wrong" with Calocane, who stabbed to death Barnaby Webber, Grace O'Malley-Kumar and Ian Coates in Nottingham in June 2023.
It laid out how Calocane, who has paranoid schizophrenia, had no contact with mental health services or his GP for about nine months prior to the killings - and was discharged after failing to engage with them.
The NHS said it had taken the decision to publish the report in full, in line with the wishes of the families, and "given the level of detail already in the public domain".
The independent review, by Theemis Consulting, looked into the treatment given to Calocane by Nottinghamshire Healthcare NHS Foundation Trust prior to the killings, as well as the interactions the NHS had with other agencies involved in his care.
The key findings of the report include:
Calocane's risk "was not fully understood, managed, documented or communicated". There were missed opportunities to take more assertive action towards Calocane's care. The voice of Calocane's family "was not effectively considered to support the dynamic evaluation of risk" during his treatment. Other patients under the care of the same trust, some of whom had been discharged, had also perpetrated acts of "serious violence" across 15 incidents between 2019 and 2023. Calocane had no contact with mental health services or his GP for about nine months prior to the killings. Read full story
Source: BBC News, 5 February 2025
Patient Safety Learning

End of life care ‘not working’ for dying people or their families, say campaigners

The UK spends £11.7bn on people’s health in the last year of their life, largely on hospital care even though most would rather die at home or in a hospice.
The stark disparity is “robbing many tens of thousands of dying people of the chance to remain where they want to be in the final chapter of their life”, according to Marie Curie. A report from the charity has revealed that, in all, Britain spends £22bn a year on health care, social care and welfare benefits for people who will be dead within 12 months.
Of the £11.7bn spent on health needs, £9.6bn (81%) goes to hospitals and out of that, more than two-thirds, £6.6bn, is used to provide emergency care such as in A&E.
The findings come as MPs consider how to introduce assisted dying for people with a terminal condition who have less than six months to live. The Labour MP Kim Leadbeater’s private member’s bill has prompted widespread agreement that end of life care needs a dramatic expansion.
“Through inadequate community care for people in the final year of life, we are currently robbing many tens of thousands of dying people of the chance to remain where they want to be in the final chapter of their life. It is inexcusable and it cannot be ignored any longer,” said Dr Sam Royston, Marie Curie’s executive director of research and policy.
“No one wants to be calling an ambulance in the middle of the night because they can’t get the support they need at home, or facing long stays in hospital when they don’t want or need to be there, but that is the shocking reality for far too many dying people.”
Read full story
Source: The Guardian, 5 February 2025
Patient Safety Learning

Celebrity butt-lift injector who left women with sepsis exposed by BBC

A self-styled "beauty consultant", whose celebrity client list includes Katie Price, is offering potentially dangerous cosmetic procedures to clients and handing over medication illegally - a BBC investigation has discovered.
Ricky Sawyer specialises in liquid Brazilian butt-lifts (BBLs) - which involves injecting dermal filler into buttocks to lift them and make them look bigger.
BBC News has spoken to five of his clients who needed emergency hospital treatment after their procedures. We have also been shown the testimonies of more than 30 women who say they have been left with serious complications such as sepsis and necrosis (tissue death).
Several local authorities have banned Mr Sawyer from practising in their areas.
Uundercover filming captured Mr Sawyer handing out antibiotics without a valid prescription - a criminal offence. He is not qualified to prescribe and the pills were not labelled for a specific patient.
He also offered to inject increasing doses of local anaesthetic without a prescriber present - again illegal - and did not ask for our reporter's weight, thus putting her at risk of an overdose.
Reviewing the footage, plastic surgeon Dalvi Humzah, who sits on the Joint Committee of Cosmetic Practitioners, said Mr Sawyer's actions were "shocking", "very dangerous", and putting patients at a huge risk of infection and potentially fatal complications.
"Putting that volume in, in one sitting, is really dangerous," said Mr Humzah. "The buttocks are such a large area that if they become infected it can overwhelm the body and could end in sepsis - or even death."
Read full story
Source: BBC News, 4 February 2025
Patient Safety Learning

Thomas Kingston's family calls for antidepressant prescription change

The parents of Thomas Kingston have warned about the side effects of antidepressants after he took his own life.
Mr Kingston died from a head injury in February last year at his parents' home in the Cotswolds. A gun was found near his body.
The 45-year-old had stopped taking his medication, which had been prescribed by a GP at the Royal Mews Surgery in the days leading up to his death.
His parents, Martin and Jill Kingston, are now calling for a change in how patients are prescribed selective serotonin reuptake inhibitors (SSRI) - a widely used type of antidepressant.
Martin Kingston told BBC Radio 4's Today programme he believes both the patient and the people close to them should be told more explicitly about the potential side effects of the medication, including what can happen if they stop taking it.
The couple want patients to sign a document confirming they've been told about the difficulties of going on and coming off the medication. This could include the patient being told that "it's an extreme case, but it could lead to suicide", Mrs Kingston says.
"We'd really like to see that a person, a spouse, a partner, a parent, a close friend, somebody, was going to walk with them through it. Maybe they should be at that signing time."
Recording a narrative conclusion at an inquest into his death in December, Katy Skerrett, senior coroner for Gloucestershire, said Thomas Kingston had taken his own life.
"The evidence of his wife, family and business partner all supports his lack of suicidal intent," she said at the inquest. "He was suffering adverse effects of medication he had recently been prescribed."
In a prevention of future deaths report, made in January, Ms Skerrett said action must be taken over the risk to patients prescribed SSRIs. She questioned whether there was adequate communication of the risks associated with such medication.
Read full story
Source: BBC News, 4 January 2025
Related reading on the hub:
The question that will save lives: Interview with Katinka Blackford Newman, founder of Antidepressant Risks Long-lasting sexual dysfunction after taking antidepressants: Lack of recognition harmful to patients Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect?
Patient Safety Learning

US hospitals suspend healthcare for transgender youth after Trump order

In the wake of Donald Trump’s executive order threatening to withhold federal funding from hospitals that offer gender-affirming care to individuals under the age of 19, several major hospitals across the US have stopped providing such treatments.
The 28 January executive order directed federal departments and agencies to ensure that hospitals and medical institutions receiving federal research or education grants stop providing puberty blockers, hormone therapy or surgical procedures to transgender youth under the age of 19.
“It is the policy of the United States that it will not fund, sponsor, promote, assist or support the so-called ‘transition’ of a child from one sex to another and it will rigorously enforce all laws that prohibit or limit these destructive and life-altering procedures,” the order reads.
In response, several hospitals around the country have stopped providing gender-affirming care procedures for those under 19 while they evaluate and assess the order.
A spokesperson for Denver Health in Colorado told the Associated Press that the hospital had stopped providing gender-affirming surgeries for individuals under the age of 19, to comply with the executive order and continue receiving federal funding.
In a statement posted to its website, Denver Health said that it was “working to understand and comply with the full implications of the broadly worded order” and that “guidance on changes to medical care is being handled privately so that we can best support our patients and their families”.
The Denver hospital said it was “deeply concerned for the health and safety of our gender diverse patients under the age of 19”.
“We recognize this order will impact gender-diverse youth, including increased risk of depression, anxiety and suicidality,” the hospital stated.
Read full story
Source: The Guardian, 3 February 2025
Patient Safety Learning

Dozens of safety probes kept secret by trusts

Trusts are still keeping reports that reveal serious patient safety concerns secret, HSJ has discovered.
So-called “invited reviews” are often commissioned by trusts’ management from a medical royal college, when they are trying to deal with concerns about safety, quality or staffing in a particular service — or, in some cases, about individual doctors.
The providers are meant to publish a summary of the findings where they uncover safety or quality issues, but HSJ has established this is still routinely not happening.
Using the Freedom of Information Act, HSJ traced at least 49 reviews commissioned since April 2020. Only six had been published by the trust in a meaningful way, despite many others surfacing concerns about care.
Morecambe Bay inquiry chair Bill Kirkup told HSJ: “It is disappointing to see so many trusts continuing to treat invited reviews as confidential, despite clear recommendations. These are public services, and there should be transparency. Some detail may need to be redacted to maintain individual confidentiality, but I can see no justification for wholesale failure to disclose information that is in the public interest.”
Patient Safety Learning chief executive Helen Hughes added: “These reviews have the potential to unearth patient safety insights that are applicable far beyond the organisations they are focused on. Currently however, this learning is not shared widely in a consistent way to inform our understanding of patient safety risks and the need for improvements across the system.”
She said “privacy, personal sensitivity, and legal reasons… should not present an insurmountable barrier to extracting system-wide learning”.
Read full story (paywalled)
Source: HSJ, 4 February 2025
Patient Safety Learning

New trial to speed up breast cancer screening for 700,000 women

Health secretary Wes Streeting has announced a landmark trial that will harness artificial intelligence to help catch breast cancer cases earlier, potentially helping the tens of thousands of women diagnosed with the disease each year.
Nearly 700,000 women through 30 testing sites around the country will take part in the trial, which will use AI to assist radiologists in mammogram screening to identify changes in breast tissue which could be a possible sign of breast cancer.
At the moment mammograms require the expertise of two radiologists, but the Department of Health and Social Care said the AI technology will mean only one specialist will be needed to conduct the screening process safely and efficiently.
If successful the trial could free up radiologists and other specialists to conduct more testing which could help reduce waiting lists.
Read full story
Source: The Independent, 4 February 2025
Patient Safety Learning

Families urge NHS to publish full report into Nottingham killer Valdo Calocane

Families of the victims of Nottingham knife killer Valdo Calocane have urged NHS England to rethink a decision not to publish a report into the care he received in full.
Calocane was sentenced to an indefinite hospital order after killing 19-year-old students Barnaby Webber and Grace O'Malley-Kumar, and 65-year-old caretaker Ian Coates, before attempting to kill three others, in a spate of attacks in Nottingham in June 2023.
Prosecutors accepted his not guilty pleas to murder after medical evidence showed he had paranoid schizophrenia. He was later sentenced for manslaughter by reason of diminished responsibility and attempted murder.
A summary of the independent mental health homicide report is due to be made publicly available later this week, but the full version will be kept confidential due to “data protection legislation relating to patient information”.
Speaking on behalf of the families ahead of the NHS England (NHSE) report's publication, adviser Radd Seiger said: “The families have already reached out to NHSE to strongly urge them to publish the findings in full.
“They believe it is very much in the public interest and in the interests of safety to do so. NHSE have thus far refused.”
An NHS England spokesperson said: “Independent mental health homicide reports are commissioned by NHS England and published in line with the requirements of confidentiality and data protection legislation relating to patient information.”
In August, a damning report by the Care Quality Commission into the care previously received by Calocane found the trust’s mental health unit “minimised or omitted” key details of the serious risk he posed to others.
The watchdog laid out “gross, systematic failures”. It found that risk assessments had played down Calocane’s refusal to take his medication and his persistent symptoms of psychosis, and that he was released after undergoing eight separate risk assessments.
Read full story
Source: The Independent, 4 February 2025
Patient Safety Learning

UK online pharmacies face stricter rules for sales of weight-loss jabs

Access to weight-loss jabs through online pharmacies is to be tightened up as part of a crackdown on inappropriate prescriptions – although some experts say even more must be done.
Weight-loss injections such as Wegovy, which contains the drug semaglutide, and Mounjaro, which contains the drug tirzepatide, have boomed in popularity after trials showed they can help people lose significant amounts of weight, with many people seeking private prescriptions.
However, concerns have been raised that the medications are being inappropriately prescribed through online pharmacies to people who do not meet the criteria for them.
A Guardian investigation previously revealed some online pharmacies operating in the UK have approved and dispatched private prescriptions of the jabs to people of a healthy weight, as well as to those who have lied about their weight to meet criteria for a prescription.
Now the general pharmaceutical council (GPhC), which regulates pharmacists, pharmacy technicians and pharmacy premises in England, Scotland and Wales, has said it is tightening the rules.
The changes mean pharmacies can no longer base decisions about online prescribing of weight-loss jabs – or other high-risk medications such as antimicrobials, laxatives and opioids – on the information provided in an online questionnaire alone, as some online pharmacies have done previously. Instead, such information must be verified independently.
Read full story
Source: The Guardian, 4 February 2025
Patient Safety Learning

NHS 111 firm admits fault for not sending ambulance to baby who later died

A private call handling firm operating the NHS 111 non-emergency service has admitted it was at fault for failing to send an ambulance to a baby boy who died shortly after falling ill, an inquest has heard.
Ben Condon, who was born premature, died aged two months at Bristol children’s hospital in April 2015 after developing a respiratory illness.
A first inquest into his death ruled that Ben died as a result of acute respiratory distress syndrome, human metapneumovirus and prematurity but the conclusion was quashed by high court judges.
On Monday, a fresh inquest opened into Ben’s death and heard that when the child went home to Weston-super-Mare, North Somerset, with his parents he developed a cold.
His father, Allyn Condon, rang the non-emergency 111 service – run at the time by Care UK – at about 6pm on 10 April.
The call handler referred Ben for an out-of-hours telephone call-back appointment with a GP within two hours rather than send an ambulance, a decision the coroner said was affected by “bias” as the handler was aware of “external pressures” facing ambulances.
The court heard that by 7.45pm when Condon and his wife, Jenny, had not received the call from the GP, they took their son to the Weston general hospital.
Reading from a written statement, the assistant coroner Robert Sowersby said Care UK had apologised to the Condon family and the adviser was taken off calls for nearly three weeks and received further training.
“Care UK admitted it was at fault for having not sent an ambulance after the call,” Sowersby said. “It said that changes in the recordings of telephone calls needed to be made and apologised for their failings.
“Care UK identified in the root cause analysis that the health adviser failed to actively listen and failed to accept the responses provided and there was a failure to select the appropriate pathway responses.”
Read full story
Source: The Guardian, 3 February 2025
Patient Safety Learning

Nurse and leadership training face ‘devastating’ cuts

Trusts are urging the government to exempt NHS-related roles from controversial plans to axe funding for higher-level apprenticeships.
The government announced plans in September to replace the existing scheme for funding apprenticeships with a “growth and skills levy”. The new levy is intended to support investment “in younger workers” and shorter schemes, which means national funding for “level 7” apprenticeships, the equivalent of a master’s degree, will be reduced.
Trusts typically use the level 7 apprenticeship levy to fund training for various advanced clinical roles, such as district nurses and advanced clinical practitioners.
The apprenticeships are also used by trusts to fund a range of leadership training programmes, such as the NHS Leadership Academy’s Elizabeth Garrett Anderson and Rosalind Franklin programmes.
In an open letter addressed to Wes Streeting, seen by HSJ, trust leaders said the proposed changes “risk devastating critical training pathways for NHS roles”.
The letter said employers would face “considerable financial barriers” if they had to cover the cost of the apprentice schemes, likely to lead to a “significant decline” in uptake. The proposals also threatened to “undermine” the NHS’s capacity to meet the NHS Long Term Workforce Plan, it said.
It continued: “Without central support, the NHS cannot sustain these training pathways. The ripple effects will compromise workforce development, weaken healthcare provision, and exacerbate the already critical recruitment and retention challenges facing the NHS.”
Read full story (paywalled)
Source: HSJ, 3 February 2025
Patient Safety Learning

NHS eye care delays put complex cases at risk

Patients with complex eye conditions risk losing their sight due to delays in NHS treatment, medical experts and campaigners have warned. They say the system is under strain as independent providers prioritise simpler and more lucrative procedures.
Dr Ben Burton, the president of the Royal College of Ophthalmologists, said NHS ophthalmology services are "on the brink of collapse".
Labour MP and former surgeon Dr Peter Prinsley warned that some regions could become "ophthalmic deserts" due to inadequate coverage.
The crisis is partly driven by a rise in fees paid by the NHS to independent providers for cataract surgery in recent years, according to Prinsley. The speed of basic cataract procedures means several can be carried out in a day by consultants, which has proven lucrative, he added.
This has led to increasing numbers of NHS consultants taking on more private work, including setting up clinics near hospitals which can carry out work for the NHS, he told the Press Association (PA). It means fewer NHS appointments are available for patients with more complex conditions, such as glaucoma or macular degeneration.
Burton said the problem was reaching a crisis point, telling PA: "We're heading off a cliff, it's not sustainable, and it's not safe. It's been something I think somebody needs to take a step back on and see the bigger picture of."
Read full story
Source: Medscape UK, 3 March 2025
Patient Safety Learning

New York Blood Center Enterprises hit by ransomware attack

A cyber attack has forced a US non-profit blood donor centre to postpone appointments despite declaring blood shortages just one week earlier. 
New York Blood Center Enterprises announced that it had “identified suspicious activity” affecting its IT systems on on 26 January 2025.
In a statement, published on 29 January, it said: “We immediately engaged third-party cybersecurity experts to investigate and confirmed that the suspicious activity is a result of a ransomware incident.
“We took immediate steps to help contain the threat and are working diligently with these experts to restore our systems as quickly and as safely as possible. Law enforcement has been notified.”
On 1 February and 2 February 17 blood drives were cancelled as a result of the cyber attack.
The centre, which is the largest independent blood supplier in the New York City area, confirmed that although it is still accepting blood donations, “processing times may be longer than normal”.
There is no estimated timetable for fully restoring its operations.
The attack echoes the ransomware attack on NHS pathology provider Synnovis in June 2024, which led to NHS Blood and Transplant urgently calling for donations of O Positive and O Negative blood to boost stocks.
Read full story
Source: Digital Health, 3 February 2025
Sam

The new mpox vaccination sites opening across England after new cases found

Twelve new mpox vaccination sites have opened across England, after another case of a strain of the virus was found in the UK.
Health officials announced the new sites so every region in the country will be able to offer jabs to those at a higher risk of getting the infection.
Previously, vaccines were only available to eligible people at sites across London, Brighton in East Sussex, and Manchester.
Now, new locations in areas including Birmingham, Nottingham, Sheffield, Sunderland, Leeds, Liverpool and Bristol will open vaccination services.
The NHS offers the mpox vaccine to those deemed a higher risk of catching the virus, such as men who have sex with other men and have multiple partners.
Steve Russell, NHS national director for vaccination and screening, said: “The NHS is fully prepared to respond to mpox and the latest cases of clade 1b, with local services pulling out all the stops to vaccinate those eligible since it first became present in England, and tens of thousands in priority groups already coming forward and getting protected.
“While the risk to the public remains low, it is important that eligible people across England are able to access mpox vaccines easily, which is why we are now offering the jabs at even more sites across the country in line with supply.
“So, if you meet the eligibility criteria please come forward and get protected, simply search on the NHS website to find the vaccination site closest to you.”
Read full story
Source: Independent, 3 February 2025
Patient Safety Learning

More than 500,000 in England waited at least two months for vital cancer care

More than half a million people in England have had to wait longer than two months for essential cancer treatment, analysis of latest NHS figures has shown.
It has led experts to suggest thousands more patients will die unnecessarily unless the NHS gets to grips quickly with the delays.
Analysis of new NHS figures by Radiotherapy UK shows that in the decade to November 2024, 506,335 cancer patients in England waited more than 62 days for treatment.
International research shows that every four weeks of delay in cancer treatment increases the risk of death by up to 10%. But the NHS has not met its target for 85% of cancer patients to start treatment within 62 days since December 2015 – currently, only 69% begin treatment within the two-month target.
The Department of Health and Social Care is due to relaunch the government’s cancer plan on Tuesday, to coincide with World Cancer Day.
Some experts fear the government’s cancer plan will lack teeth and contribute to more deaths, after NHS England scrapped the target to diagnose 75% of cancers at stage 1 or 2 and the health secretary, Wes Streeting, told the Health Service Journal that the government could not commit to meeting national cancer targets by the end of this parliament.
Prof Pat Price, chair of Radiotherapy UK and a leading oncologist, said: “The last decade of leadership in cancer has normalised dangerous delays and unacceptably low ambitions. These delays will cost thousands of lives. We need a brave and bold cancer plan or even more lives will be lost needlessly in the next decade. Incremental change will fail. We need strategies to supercharge both early diagnosis and treatment.”
Read full story
Source: The Guardian, 3 February 2025
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