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

Hospital whistleblowers 'still penalised', staff claim

Two porters who won an employment tribunal against the Countess of Chester Hospital Trust said their victory shows whistleblowers are "still penalised".
Last month, the trust said its culture had "improved" after the Thirlwall Inquiry found former bosses had "intended to punish" doctors who raised concerns about nurse Lucy Letby.
A tribunal this year found porters John Crayton and Thomas Jones had been "inappropriately interrogated" after raising concerns about the way deceased patients were transported. The pair said the ruling showed they had been "unlawfully victimised".
The trust said it accepted the tribunal's findings but "encourages all colleagues to speak up".
The porters raised concerns in 2024 that they were having to transport "exposed" bodies that were not in body bags, which they said posed an infection risk.
They said there was no protection for their forearms because of the trust's policy that staff had to be bare below the elbows.
Crayton claimed there was a risk of "psychological damage" from transporting bodies showing "signs of a traumatic death".
The tribunal in Manchester found the pair had been "inappropriately interrogated" by their line manager after a senior mortuary worker identified them as the possible authors of a whistleblowing complaint submitted anonymously through the trust's Freedom to Speak Up policy.
It heard their line manager questioned them and other porters in an attempt to "get to the bottom of who had broken the chain of command".
Read full story
Source: BBC News, 1 October 2026
Further reading on the hub:
Speaking up for patient safety: A new interview series about raising concerns and whistleblowing
Key themes emerging from our ‘Speaking up for patient safety’ interview series
Patient Safety Learning

Patients missing out on drugs due to NHS cost-cutting, claims minister

The NHS’s success in driving down the cost of drugs has meant fewer medicines are available for patients, a government minister has admitted.
Chris McDonald, minister for science, innovation and investment at the Department and Health and Social Care and the Department for Business, Innovation, Science and Trade, said: ”If you do an international comparison, the NHS runs extremely lean… it does a huge amount with its budget.
“But the consequence of that is, we’ve heard the NHS is world leading in driving down the cost of pharmaceuticals, and as a result there are a number of pharmaceuticals we don’t have available on the NHS.”
The NHS has historically been regarded as a world leader in pushing down the cost of medicines, although industry groups have said the UK lags behind other comparable nations in access to new ones.
The government has committed to doubling the NHS spend on new medicines to 0.6 per cent of GDP by 2036, as part of a wider UK-US trade deal. The share of the NHS budget going on drugs will also rise from 10 per cent to 12 per cent, according to the agreement.
Under the plans, the cost-effectiveness threshold used by NICE (the National Institute for Health and Care Excellence) to evaluate whether to adopt new medicines has been lowered, meaning more drugs will be approved.
The move has been welcomed by industry but has faced criticism from MPs and think tanks over concerns that it will divert funding from existing NHS services.
Read full story (paywalled)
Source: HSJ, 30 September 2026
Patient Safety Learning

NHS admits 'failing families' over stillbirths

An NHS trust has apologised after an independent review found that eight babies might have survived with better maternity care, admitting it has "failed families".
The stillbirths all occurred at the East Kent Hospitals NHS Trust's hospitals between June 2025 and March 2026.
An independent review ordered by the trust found systemic issues lay at the heart of the failures. These included failures to manage high risk pregnancies, provide appropriate triage, identify foetal growth concerns, and make appropriate use of interpreter services.
Since the report, a further seven stillbirths have occurred, including three last month. A review into those deaths has now been ordered.
All the stillbirths occurred after 34 weeks gestation.
Papers for a board meeting on Thursday contained a report by the acting CEO of the trust, Dr Des Holden, who apologised to the families involved.
Dr Holden wrote: "On behalf of the board, and personally, I am very sorry and apologise to the women and families, and their communities, where failings in our care are at the heart of these devastating outcomes."
The board papers contained a further report, headed Response to the Independent Stillbirth Review, which said four cases were assessed as having care deficiencies likely to have affected the outcome for the baby.
In a further four cases, care issues were identified that may have contributed to the outcome.
The review found "recurrent and systemic weaknesses in the management of high-risk pregnancy, foetal surveillance, maternity triage, escalation and organisational learning", documents said.
Read full story
Source: BBC News, 30 September 2026
Patient Safety Learning

Healthy Babies programme to be expanded across England

The government is rolling out a Healthy Babies programme to every local authority in England, as part of its efforts to expand a Sure Start-type system of help for deprived children and families.
It aims to support parents with infant feeding, their mental health and building strong bonds with their babies, alongside health visits, midwifery care and wider services.
The scheme seeks to follow the principles of Sure Start, a network of centres offering integrated services for the under-fives and their families, launched in 1998 under a Labour government. Sure Start was seen as one of that government’s major successes, with one study saying it generated longer-term savings worth twice the system’s cost.
But much of that scheme was dismantled amid massive spending cuts by the Conservatives. The new policy of family hubs will commit £500m to opening 1,000 centres from April 2027.
Announcing the expansion of the Healthy Babies programme at the Labour conference in Liverpool, Yvette Cooper, the Health and Social Care secretary, is expected to say that the programme will reach up to 1,000 family hubs over the next two years.
Since the election the Labour government has opened new family hubs across England, but more than half of local authorities have hubs without Healthy Babies services.
“Something is missing in half of communities … the Healthy Babies services – mental health support for mums and dad, the feeding and bonding support for your new baby. That changes now,” Cooper will say.
“We will bring back the Sure Start health services into every family centre. One of the Labour party’s greatest achievements, restored to families throughout the land.”
Read full story
Source: The Guardian, 30 September 2026
Patient Safety Learning

Patients face risk of harm as hospital group splits

Details of the serious concerns raised by the Care Quality Commission about the collapsing Humber Health Partnership hospital group have been uncovered by HSJ.
The regulator served section 29A warning notices on group members Hull University Teaching Hospitals Trust and Northern Lincolnshire and Goole Foundation Trust in July in response to ongoing patient safety concerns.
The warning notices, which have now been seen by HSJ, show the CQC is unhappy with the rate of progress achieved by the group. This was “insufficient due to the scale of work required”, and meant “patients remained at risk of harm”.
A review of serious incidents undertaken by the watchdog found “limited evidence” that learning was taking place, with the same factors “repeatedly” identified. These included staffing pressures and inconsistent policies, particularly on medicines management.
The group was also criticised for its poor record on infection control. The CQC said these failings were “part of a longer-term pattern, with little evidence of improvement over time”.
Read full story (paywalled)
Source: HSJ, 29 September 2026
Patient Safety Learning

Public inquiries a costly ‘knee jerk’, warns chair

The chair of a major public inquiry has admitted they are often “hugely expensive”, time-consuming, and popular with politicians who are keen to pass the buck to the next minister.
Tom Kark KC, who recently completed the Muckamore Abbey Hospital Inquiry into serious abuse at a Belfast mental health unit, told HSJ’s Patient Safety Congress in Telford today that such probes address a clear public need, but typically do not give bereaved families closure.
He also questioned why once the chair’s job is finished, they relinquish any power over their recommendations, and how they are implemented.
The leading lawyer, who was also chief counsel to the Mid Staffordshire public inquiry and carried out a review of the Fit and Proper Person Test (FPPT), warned in addition that the government’s plan to regulate managers must not become a “weapon or a stick to punish poor performance”.
Mr Kark told the event: “When something goes wrong, particularly in the NHS… there is very often a knee-jerk reaction to set up a public inquiry. Politicians in general quite like public inquiries because generally, by the time a public inquiry is reported, that [politician] has gone, and it’s the next one’s problem.
“There is certainly a problem about the timing of public inquiries and how long they take. We [Muckamore] actually took four years, and we were regarded as being extremely rapid… and that tells you something.”
Read full story (paywalled)
Source: HSJ, 29 September 2026
Patient Safety Learning

US response to UN pandemic talks ‘severely weakens’ global planning, says leading health expert

The United States government’s decision to block a major global declaration on pandemic preparedness “severely weakens” the effort, and signals intent to disrupt international cooperation, says Prof Lawrence Gostin, a leading expert on global health law from Georgetown University.
The United Nations general assembly had been due to adopt a political declaration on pandemic prevention, preparedness and response on 25 September after a high-level meeting on the subject.
The document would have seen countries agree to work together in solidarity to tackle global health threats and express concerns that the world remains unready to deal with future pandemics.
However, the US delegate said it was “not in a position” to support the text, blocking its adoption by consensus – the UN process whereby negotiated documents are assumed to be agreed unless there is an objection.
Dr Erica Schwartz, the director of the Centers for Disease Control and Prevention, said critical issues remained unresolved, referring to “the inclusion of divisive ideologies that lack definitional consensus” and references within the document to ongoing, WHO-led negotiations over the fair sharing of vaccines and drugs between countries in any future pandemic.
It is understood that the Trump administration was unhappy with mentions of equity and universal access to sexual and reproductive healthcare services. Earlier this year, President Trump signed executive orders expanding a “global gag” rule that bans US aid recipients from work related to abortion to also include bans on diversity, equity and inclusion initiatives and what it called “gender ideology”.
Read full story
Source: The Guardian, 28 September 2026
Patient Safety Learning

HSJ Patient Safety Awards 2026: Winners revealed

The winners of the HSJ Patient Safety Awards 2026 were announced last night, recognising outstanding efforts to make care safer.
This year’s event attracted 427 entries, with 217 shortlisted across 25 categories.
Categories included the Improving Medicines Safety Award, the Urgent and Emergency Care Safety Initiative of the Year, the Maternity, Midwifery and Neonatal Safety Initiative of the Year, and Patient Safety Team of the Year.
The 25 awards span three broad areas: clinical and specialist excellence, organisation-wide change, and service and system innovation. They also include awards for digital clinical safety, surgical care, the use of data and analytics, and patient involvement.
Opening the event, HSJ editor Alastair McLellan said patient safety had returned to the top of the health agenda over the past year, but warned the debate had focused overwhelmingly on maternity services.
He said safety in emergency departments and acute wards was receiving less attention, with debate instead dominated by access and waiting times. He noted that long accident and emergency department waits, particularly those of more than eight hours, were strongly associated with increased mortality.
Mr McLellan also praised those shortlisted for achieving improvements despite the pressures facing the NHS. He said work to prevent patient harm was not always welcomed amid unprecedented demand and the drive to recover performance, adding that the finalists’ achievements showed “what is possible in even the most unpromising situations”.
Read full story (paywalled)
Source: HSJ, 29 September 2026
Patient Safety Learning

Hospitals in England hit by shortages of common drugs such as paracetamol

Hospitals are being hit by shortages of key drugs used to provide pain relief, prevent blood clots and tackle high blood pressure.
Dozens of NHS trusts in England have encountered scarcities of aspirin, the painkiller co-codamol – a combination of paracetamol and codeine – and ramipril, a blood pressure tablet.
Nine trusts have had problems getting enough supplies of two of those three common medications, while one ran short of all three.
The shortages underline how precarious the health service’s supply chains for basic medicines have become in recent years as a result of trade disputes, global conflict and manufacturing problems.
Pharmacists have said supply problems have become a “national crisis” and in some cases have left patients unable to access their usual medications for weeks at a time.
Hospitals’ drug supply problems have emerged in freedom of information requests by Dr Rodolfo Catena, an expert in global health supplies at University College London, about stock levels of the three drugs. Sixty of the 184 trusts from which he sought figures responded.
The most widespread shortage involved aspirin, which is used to reduce pain and the risk of blood clots. Twenty-six (62%) of the 42 trusts that responded about it had experienced disruption to their supplies between last December and March this year.
Thirteen (31%) of the 42 trusts that replied on co-codamol had run short of that drug, which helps relieve muscle pain, period pain and toothache. York and Scarborough NHS trust’s supplies had been disrupted since May 2025, and Royal Wolverhampton NHS trust had trouble getting enough co-codamol for the 10 months between October 2025 and August this year.
Read full story
Source: The Guardian, 29 September 2026
Related reading on the hub:
Creon shortages: “It’s just another thing patients with cystic fibrosis could do without”
Medication supply issues: A pharmacist’s perspective
Medicines shortages: minimising the impact on patients (a blog by Catherine Picton)
Patient Safety Learning

Safety leaders ‘battling challenging political narrative’

NHS England’s patient safety chief has said the service is having to “battle against a narrative” that it has not improved safety.
Aidan Fowler, NHSE’s national director for patient safety, told HSJ’s Patient Safety Congress in Telford today that the narrative, which he described as “really challenging”, “sometimes says we haven’t made progress on patient safety when we know we have”.
He said ministers had “understandably” wanted to suggest “everything that happened [during] the last government was terrible, and that includes some of the work that people here have done”.
Dr Fowler said there “has been progress”, but this meant they “have to keep restating that, making the argument again”, which could “feel like quite hard work”.
The NHS Patient Safety Strategy was launched in 2019, and the new NHS quality strategy published this summer suggested it would need another refresh in the near future.
Dr Fowler admitted that some of this work, which has included changing the way the NHS responds to incidents through the Patient Safety Incident Response Framework, “is not very sexy”, so people have not heard about it.
He added: “I get that if you try and explain to all our patients what PSIRF is, they’re going to struggle with [it], I understand that.
“But I think that stuff has been foundational and important. We’ve created some bits of work that I think are really important, and we have made a difference.”
The national director also stressed there was “of course much more to do”, and that improvement was a “continuous process”.
Read full story (paywalled)
Source: HSJ, 28 September 2026
Patient Safety Learning

Urgent warning issued over cardiac death risk

A coroner has issued an urgent warning that the failure to implement an emergency cardiac pathway could result in more deaths.
Malcolm Budd, aged 65, was admitted to Royal Derby Hospital, part of University Hospitals of Derby and Burton Trust, in February with a suspected aortic dissection.
This is a medical emergency in which a tear happens in the inner layer of the aorta, the body’s main artery. For a severe ‘Type A’ dissection – which requires emergency surgery – mortality increases by up to 2 per cent each hour without treatment.
However, Mr Budd was not transferred to the specialist cardiac centre at Glenfield Hospital, part of University Hospitals of Leicester Trust, until almost 8.30pm, eight hours after he was first admitted to Royal Derby.
NHS England published a Standard Operating Procedure and a toolkit which aimed to standardise and improve aortic dissection pathways in 2022. This has been implemented in other parts of the country but not the East Midlands.
Dianne Hocking, assistant coroner for Leicester City and South Leicestershire, has now issued a Prevention of Future Deaths (PFD) notice in relation to this issue. The PFD was issued before the inquest into Mr Budd’s death begins next month due to the urgency of the coroner’s concerns.
Read full story (paywalled)
Source: HSJ, 28 September 2026
Patient Safety Learning

Three in four UK GPs ‘too busy to talk to their patients in depth’

A friendly chat with your GP about your life, health and happiness was once a key part of the UK’s family doctor service.
But most GPs no longer have time to have pastoral conversations, because they are too busy dealing with the country’s rising tide of illness, research reveals.
Three out of four family doctors are now too time-pressed to talk to patients in depth about how they might stop smoking, lose weight or get more sleep, the Royal College of GPs has found.
Intense demands and 10-minute appointment slots mean they also miss opportunities to discuss taking more exercise or review their medications to see if they still need to be on them.
An RCGP survey of 2,316 GPs across the UK found that 75% had too little time to offer preventative healthcare, such as offering lifestyle advice and giving advice on vaccinations. The results have raised concern about the government’s drive for the NHS – especially GPs – to do more to prevent people getting ill in the first place. One health expert called them alarming.
The college’s president, Prof Victoria Tzortziou Brown, who is a GP in east London, said: “General practice is dealing with enormous demand, so in a busy consultation we inevitably have to prioritise the problems that most need our attention that day.
“We will always act on symptoms or findings that need investigation or treatment. What can be squeezed out is the time to step back and look more holistically at how we can help that patient stay well in the long term.
“That might mean having a proper conversation with someone who smokes. We will of course advise patients about stopping smoking. But in a busy consultation there may not be enough time to explore in depth whether they want to stop, what has made it difficult in the past, what concerns they have and what support or treatment might work best for them.
“It is often the depth of those conversations, rather than simply identifying a risk and giving brief advice, that requires time.”
Read full story
Source: The Guardian, 27 September 2026
Patient Safety Learning

Ten NHS staff removed over Noah Woods data breach

Ten NHS staff have been removed from duty or suspended after a data breach involving the digital medical records of three-year-old Noah Woods.
Launching an "urgent" investigation, Dr Martin Mansfield, deputy chief medical officer at East Suffolk and North Essex NHS Foundation Trust, said that any unauthorised access of patient data was "completely unacceptable".
The trust has apologised "unreservedly" to Noah's family and said disciplinary action would be taken if needed.
A major search for Noah was carried out in the village of Brantham, Suffolk, after the child went missing on 15 September. His body was found the next day in a nearby pond by police divers.
A spokesperson for the trust said 10 employees had been "removed from active duty or suspended whilst investigations are concluded".
It comes after Sir Jim Mackey, the chief executive of NHS England, wrote to every trust on Friday, ordering stronger measures to tackle data breaches.
"We have seen too many cases of people abusing that trust, and enough is enough," said Sir Jim.
"Anyone who thinks they can satisfy their curiosity by looking at a patient's record should know this: they will be found out, they may lose their career and could end up with a criminal record."
Read full story
Source: BBC News, 27 September 2026
Patient Safety Learning

BMA reveals “shocking” accounts of unsafe substitution of doctors which put patients at risk

The BMA has published a series of “disturbing” reports warning that patient safety is being repeatedly put at risk when those patients are looked after by less-qualified advanced practitioners (APs,) rather than doctors.  
Earlier this year the BMA revealed that nearly three quarters of doctors reported that advanced practitioners, staff who originally trained as nurses, paramedics, pharmacists, midwives or other professional roles, are routinely replacing doctors in their workplaces. In FOI responses to the BMA, half of hospitals in the UK admitted to using advanced practitioners to cover doctor rota gaps and including these staff on doctors’ rotas. The BMA believes this places staff without the necessary medical training in difficult and inappropriate positions with clear risks to patient safety.
With concerns rising over the deployment of advanced practitioner roles, the BMA launched a new tool in January for doctors to share their experiences directly. Doctors have since reported hundreds of patient safety incidents. These include a case where an advanced practitioner failed to arrange vital testing and referral for a child with meningitis and another in which advanced practitioners missed a cancer diagnosis, resulting in a patient “losing out on 6 weeks of time to get her affairs in order before dying.”
Responding to the accounts now made public, Dr Tom Dolphin, chair of BMA council, said:
“These are shocking accounts of patients being let down by the system. Patients are being put at risk of harm or even death because hospital managers are putting advanced practitioners and others into roles that should be filled by doctors, as this report and multiple inquests suggest.
"We have made clear, over and over, that there are times when patients must be seen by a doctor and this testimony lays out why in extensive, excruciating detail. Patients with missed diagnoses, patients with severe conditions given nothing but mild pain relief and sent on their way, and patients facing end of life conditions being offered totally substandard care: they all deserved so much better
Read full story
Source: BMA, 22 September 2026
Patient Safety Learning

NHS bodies in England impose two-year minimum wait for ADHD and autism assessments

NHS bodies are forcing people with suspected attention deficit hyperactivity disorder and autism to wait at least two years before they can be assessed as they struggle to meet surging demand for diagnoses of neurodiversity.
Four NHS integrated care boards (ICBs) covering large regions of England have adopted the approach because they cannot afford the cost of the number of assessments that people are seeking.
Patient groups are warning that the “scandalous” delays such policies involve may damage children’s chances of succeeding at school, deny people the help they need to manage their lives, and increase the risk of suicide. The charity ADHD UK denounced minimum waits as “heartless and dangerous”.
In all, 15 ICBs, which between them cover 19 million people, have brought in various ways of rationing assessments for ADHD and autism to try to balance their books. These include limiting the number of assessments the ICBs will pay for in any given year and using “clinical prioritisation” criteria to restrict assessment to those with the most serious signs of neurodiversity.
Read full article.
Source: The Guardian, 25 September 2026
Mark Hughes

Health minister apologises after patients harmed by neurologist

A final report into the care provided by neurologist Michael Watt finds some patients were misdiagnosed and received inappropriate treatment. 
Northern Ireland health minister Robbie Butler has apologised for failings in the care of patients treated by consultant neurologist Michael Watt. A final report into the cases has now been published by the Regulation and Quality Improvement Authority (RQIA). 
It found that patients were harmed in some cases by delayed or incorrect diagnoses, inappropriate treatment and failures in communication and support.
The report reinforces significant failings identified in an earlier review published in 2022.
The RQIA said poor diagnostic practice, inadequate communication, isolated clinical decision-making and weak multidisciplinary oversight meant standards of care “frequently fell below expectations”.
Read full article.
Source: Healthcare Today, 25 September 2026
Mark Hughes
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

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