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

New maternity inspection ‘unit’ demanded by government review

Ministers should create a new specialist unit to assess maternity services because the Care Quality Commission does not have the credibility to do so, a government review has concluded.
Baroness Valerie Amos’ national maternity and neonatal investigation, established by former health secretary Wes Streeting a year ago, published its final report, recommendations and 12 trust-level investigations today.
Among the eight national recommendations, it says ministers must establish a “specialist regulatory unit” to provide assessment for maternity and neonatal services.
The report said: “We do not consider that CQC has credibility as the regulator of maternity and neonatal care with clinical teams, executive teams, or families.” The Department of Health and Social Care’s oversight of the regulator has also been “insufficient”, with “limited evidence… that [it] has addressed the significant problems CQC continues to experience”.
Baroness Amos cited a recent example of a service being rated “good” despite serious safety concerns being raised with her team.
The report says officials should “work with CQC to improve its effectiveness immediately and start work to put in place a specialist regulatory unit…[which] must include clinicians from a range of professional backgrounds”.
Asked by HSJ, the review team said it intended for this to be a dedicated unit within the CQC.
Read full story (paywalled)
Source: HSJ, 30 June 2026
Patient Safety Learning

Maternity adviser quits in ‘normal birth’ dispute

The chair of several high-profile safety inquiries has resigned from the government’s national maternity review in a dispute over “normal birth ideology”, HSJ can reveal.
Bill Kirkup, who also investigated the Morecambe Bay and East Kent maternity scandals, stepped down from his position as expert adviser to the national maternity and neonatal investigation.
In a letter ahead of today’s publication of the national review, its chair Baroness Valerie Amos writes: “Dr Bill Kirkup has decided to step down from his role as one of the expert advisers to the NMNI.
“This was following discussions regarding the wording of the conclusions relating to normal birth ideology in the final report, where we were not able to reach agreement.”
However, HSJ understands Dr Kirkup’s position is that he resigned because of a disagreement of principle over the findings on normal birth, and not simply on the specific wording.
It appears he wanted a stronger line on the patient safety consequences of a normal birth ideology than Baroness Amos would agree to.
A “normal birth” ideology has been repeatedly referred to in various recent maternity scandals, prioritising spontaneous vaginal birth with minimal medical interventions as an ideal outcome.
Read full story (paywalled)
Source: HSJ, 29 June 2026
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UK’s first Maternity and Neonatal Commissioner to be appointed

Families across the country will see their maternity and neonatal care overhauled, as the Government takes urgent steps in response to Baroness Amos’ landmark independent investigation - including the creation of the UK’s first ever Maternity and Neonatal Commissioner. 
The new commissioner will provide independent leadership to hold the system to account, drive change and rebuild trust, co-chairing the National Maternity and Neonatal Taskforce with the Secretary of State. Crucially, the commissioner will ensure the voices of women are always heard by those at the heart of the system.
Baroness Amos examined the experiences of thousands of women, their families and staff, alongside local investigations of 12 trusts, and her report paints a stark picture.
It found a system that is fragmented, overly complex and too slow to learn, that women and families are not being listened to, there is a lack of accountability and answers when things go wrong, and that racism and discrimination are driving inequalities in care. Staff also reported feeling unheard.
A comprehensive National Action Plan will be published in December 2026, setting out priority actions and long-term reform to deliver safer, fairer care. This will be driven by the taskforce, bringing together families, clinicians and other experts with a clear focus on safety, equity and accountability.
Alongside structural reform, the Government is investing a further £41 million to tackle urgent safety risks in maternity and neonatal facilities, building on £145 million already committed since April 2025. This funding will address issues such as fire safety, ventilation issues and outdated infrastructure - creating safer environments for mothers and newborns.
Secretary of State for Health and Social Care, James Murray, said: 
"For too long women, babies and families have been failed by a system that didn’t listen. Their stories are heart-breaking and demand action. 
I am grateful to Baroness Amos for her work on this landmark review, which is a turning point. Appointing the UK’s first ever Maternity and Neonatal Commissioner will drive lasting change and make sure women and families are never ignored again.
For patients, the changes will mean more consistent, responsive care. New national standards for maternity triage will ensure women are assessed quickly, listened to properly and given safe, timely care from the moment they arrive. The aim is clear: to end the postcode lottery and ensure every family receives the same high standard of care."
Read press release
Source: Department of Health and Social Care, 30 June 2026
Patient Safety Learning

Regulators poised to strip back AI rules

Regulators are about to significantly strip back regulation of ambient voice technology (AVT) – one of the fastest-growing healthcare AI tools – HSJ has learned.
The Medicines and Healthcare products Regulatory Agency will make clear that some AVTs, also known as AI scribes, will no longer be classed as a medical device, according to several well-placed sources.
This would remove a key oversight mechanism for a rapidly developing area and a provider market that NHS leaders have likened to the Wild West.
National leaders are seeking to accelerate roll-out of the tech, which will potentially release huge amounts of medics’ time by automating entry into medical records and other admin.
Under guidance that HSJ understands is due to be published shortly by the MHRA, most suppliers would no longer need to seek medical device classification for their ambient scribes.
The regulator will stress that this is only required for AVTs with a “medical intended purpose” – effectively only advanced products which also profess to make medical diagnoses or have a therapeutic function.
The move would mark a major departure from NHS England policy over the past year.
NHSE’s national AVT registry, launched just five months ago to tackle what a national official called a “Wild West” market, requires suppliers to hold at least self-certified Class I accreditation (the lowest risk category of medical device registration).
And a year ago, NHSE warned trusts against adopting “non-compliant” AI technology, stating that tools must have at least Class I accreditation and Class IIa for enhanced “capabilities” such as “generative diagnoses, management plans or other medical referrals and calculations”.
Read full story (paywalled)
Source: HSJ, 29 June 2026
Patient Safety Learning

Risk of serious birth injuries is rising for women in England, data suggests

Women in England are at their highest risk of suffering a serious injury while giving birth since records began in 2020, NHS figures show.
The rate of women sustaining the most serious type of tear during childbirth rose to 31.1 in every 1,000 in January, February and March – the highest since monitoring started in 2020.
Similarly, the rate of women having a postpartum haemorrhage increased during 2025 to 31.2 in every 1,000 births – the highest annual rate over the five years data has been collected.
Helen Morgan, the Liberal Democrat health spokesperson, who obtained the figures from NHS England, said: “Behind these statistics are women going through unimaginable trauma, requiring surgery and in many cases months or even years of recovery. Some will never fully recover.
“This news … shows that we need to treat maternity services as a national crisis. The truth is that we will not reverse this dangerous, unacceptable trend – of rising blood loss and record severe tears – until we make safety a priority.”
NHS bosses and ministers are preparing for the publication on Tuesday of Lady Amos’s government-commissioned report into the state of childbirth care. It will add to the increasingly urgent clamour for a major transformation of often-inadequate childbirth care in order to make it safe.
The government intends to publish an action plan to transform maternity services by the end of the year. But pressure is intensifying for it to spell out its plans sooner.
The rate of third- and fourth-degree perineal tears has risen to 31.1 in 1,000, from 25 in 1,000 when figures were first published in June 2020.
The rate of postpartum haemorrhage – which involves the loss of 1.5 litres of blood – has increased similarly over that time, from 25.6 in 1,000 to last year’s 31.65 in 1,000. It was slightly lower – 31.2 in 1,000 – in early 2026.
The Department of Health and Social Care voiced unease at the birth injury trends.
“These are concerning findings, and as last week’s shocking report into maternity services at Nottingham university hospitals [trust] underlined, too many women are being failed by poor quality maternity care,” a spokesperson said.
Read full story
Source: The Guardian, 28 June 2026
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One person a week in England dies with undiagnosed TB, study finds

One person a week dies with undiagnosed and therefore untreated tuberculosis in England, a study has found.
British-born, older men were among those most likely to have TB diagnosed only after death, researchers said, suggesting healthcare workers could be overlooking the possibility of the disease in these patients.
Being diagnosed with TB postmortem should be considered a “never event” that prompts urgent investigations, they said, describing it as “the ultimate diagnostic delay”.
Tuberculosis rates in England are at a 10-year high, with 9.4 cases per 100,000 people in 2024. The rate is only just below the World Health Organization’s “low incidence country” threshold of 10 cases per 100,000 – a level expected to be breached when 2025 figures are published.
Most TB cases are diagnosed in people born outside the UK, with an average age of 36. But research published in the journal Thorax found that was not the case in those diagnosed after death, who tended to be older and British-born.
“As TB rates continue to rise, we need to keep asking: ‘Could this be TB?’, even in people who do not fit the usual risk profiles,” said Dr Eleanor Morgan, the study’s co-author and a resident doctor at Liverpool University hospitals NHS foundation trust.
“If England is to eliminate TB, reducing delays in diagnosis will be essential so that fewer people miss the opportunity to receive effective treatment.”
The researchers also found children aged under four were at higher risk, which they said could be linked to underdeveloped immune systems, non-specific symptoms, and challenges in getting samples from very young children for testing.
Read full story
Source: The Guardian, 29 June 2026
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Child mental health crisis as one million seek help for anxiety and autism in England

More than a million children in England are currently engaged with mental health services, a figure described as revealing the "sheer scale of distress young people are facing today". The Children’s Commissioner, Dame Rachel de Souza, has declared that the nation is "in no doubt that we are facing a crisis in young people’s mental health".
Her annual report, published on Monday, revealed that 1,048,965 children had active referrals to children and young people’s mental health services in the 12 months leading up to March 2025. This figure encompasses children who were referred for, awaiting, or receiving treatment during that period, though it excludes those already undergoing treatment at the start of the year.
The number of active referrals has almost doubled from 563,639 in 2018-19, with a 9.5% increase in the last year alone. While Dame Rachel noted there appeared to be "no straightforward answers" to the surge, data obtained from NHS England by her office indicates anxiety as the primary reason for referrals.
The report also exposed concerning waiting times, with a weighted average of 128 days for all children in the year ending March 2025. Of those still awaiting treatment at that point, 60,041 (16%) had been waiting for over two years, an increase from 14% the previous year, with waits exceeding a year described as "common".
Dame Rachel branded the figures "stark", stating: "Roughly one in 10 children have an active referral to mental health services in England, which clearly demonstrates the sheer scale of distress young people are facing today. These are not just numbers, but children whose lives have been put on hold for months and, in some cases, years waiting for support they urgently need."
Read full story (paywalled)
Source: The Independent, 29 June 2026
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Promised ‘neighbourhood health centres’ already met requirements

Nearly all the first wave of “neighbourhood health centres” (NHC) – currently being developed for launch by next year – were already doing the job required of the model, government documents reveal.
Ministers – who have used the centres as a high-profile symbol of delivering their 10-Year Health Plan – announced in March  that 27 would be opened by 2027.
The Department of Health and Social Care said at the time that the centres would mean “tens of thousands of patients… will benefit from improved healthcare on their doorstep”.
Government has previously accepted that many NHCs will be created from “upgrading, repurposing, or extending” existing NHS buildings. 
However, documents obtained by HSJ reveal for the first time that, for 22 of the 27, officials recorded they “could already be considered an NHC” when they were considered for acceptance to the programme.
An industry source, who wished to remain anonymous, told HSJ: “It’s an open secret in the sector that lots of these sites are already performing the function required of NHCs.”
They said most were community centres built under a national private finance scheme in the 2000s and “were designed to do exactly the same thing” at that time.
The source added that: “Labour seems to have taken a leaf out of the Tories’ [new hospital programme] playbook on a more modest scale.” This meant, they said, finding out “what projects were underway already” and then to “badge them up as a programme”.
Read full story (paywalled)
Source: HSJ, 29 June 2026
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NHS manager died after being ‘lost to follow up’

An NHS manager died after an urgent referral was “recategorised” and a triage time of six weeks was arranged instead.
Mr Paul Harries was scheduled to undergo a scan in July 2022 as the result of a 2020 test showing an abdominal aortic aneurysm (AAA) was increasing in size. However, he did not attend and was then “lost to follow-up”, according to a coroner’s report into his death.
In February 2023, Mr Harries attended accident and emergency department for an unrelated reason. A scan showed the AAA had grown even larger. However, his GP was not informed of this finding until April 2024. 
The GP made an urgent referral to the vascular surgery team at the Royal Sussex County Hospital in Brighton. However, the surgeon who was sent the referral rated Mr Harries as “amber”, meaning he would be triaged within six weeks and be seen within 40.
A scan in May 2024 showed the AAA was “difficult to measure”, and Mr Harries was given an outpatient appointment in October of that year. However, he died at his home in Brighton two weeks before the appointment.
His family contacted the hospital in February 2025, raising concerns that he had not been followed up appropriately, and an inquest opened in September last year after a patient safety incident investigation was concluded.
West Sussex, Brighton and Hove coroner Joseph Turner said that the changes made by the hospital since his death “do not appear to fully resolve the observed weaknesses” that saw an urgent GP referral not resulting in appropriate action by the hospital. 
He said that the hospital remained reliant on three separate referral systems, and the emergency department had an inconsistent approach to reporting incidental findings in existing conditions to GPs.
Read full story (paywalled)
Source: HSJ, 29 June 2026
Patient Safety Learning

Healthcare worker exposure to hazardous medicinal products

Luke Akehurst MP took to the floor of the House of Commons to call for a Westminster debate on protecting healthcare workers from hazardous medicinal products (HMPs).

Mr Akehurst pointed to BBC footage broadcast last month showing a nurse handling a potentially dangerous new cancer drug without the correct protective equipment considering it's classification as a Cat1B-Reprotoxic substance, a stark illustration of a problem that affects healthcare workers across the country every day. The current regulation is failing to properly protect healthcare workers properly.

Since formally launching the Protecting Healthcare Workers: Safer Handling of Hazardous Medicinal Products campaign in January 2026, the Safer Healthcare and Biosafety Network has been working to ensure this issue receives the attention it deserves.

Mr Akehurst's question to the Work and Pensions Minister earlier this year marked the first ever mention of HMPs in Parliament, and Thursday's Business Question was the next step.

Their goal remains clear: national legislation, enforceable safety standards, and the widespread adoption of closed-system transfer devices for all healthcare workers handling HMPs.

Watch the full clip of Mr Akehurst's question here: https://lnkd.in/eGQz95Y9
Patient Safety Learning

Calls grow over compensation for victims of pelvic mesh and sodium valproate scandals

The government is under renewed pressure to decide on compensation for individuals who have suffered avoidable harm from pelvic mesh and the epilepsy drug sodium valproate.
More than two years after the Hughes Report called for a two-stage redress scheme, its author, Professor Henrietta Hughes, England’s patient safety commissioner, has expressed disappointment over the "continued absence of visible and timely progress".
Campaigners insist compensation "is not optional and is long overdue".
Transvaginal mesh implants, used for pelvic organ prolapse and incontinence after childbirth between 1998 and 2020, have caused debilitating harm, leading in some cases to women having their bladders or bowels removed.
The Hughes report had suggested victims should start to receive interim compensation payments from 2025.
It said an interim award of £25,000 was the “median amount patients said would be appropriate”.
However, Prof Hughes said the Government has still not given a “substantive response” to her recommendations.
She has written to No 10 for more information under the Medicines and Medical Devices Act, with a response deadline set for 16 July.
Kath Sansom, founder of campaign group Sling the Mesh, said the “evidence has been undeniable about the thousands of women living with devastating, irreversible injuries caused by treatments they trusted”.
“These women did everything right. They trusted their doctors. And for that trust, they’ve paid with their health, their jobs, their savings, and for some their marriages, but moreover their sense of self,” she added.
“This is not good enough. They should not be forced to fight through the courts for justice over a piece of plastic mesh that has shattered their lives.
“The Government must act now. Full, fair and urgent financial compensation is not optional, it is long overdue.”
Read full story
Source: The Independent, 26 June 2026
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Mackey: We’ll change exec contracts to ensure accountability for failings

NHS executives could have their contracts rewritten to ensure they can be held to account for any actions taken while working for previous employers, NHS England’s chief executive has said.
Sir Jim Mackey’s intervention came after it was revealed that many executives called to give evidence to the inquiry into the Nottingham maternity care scandal had refused to do so. Inquiry chair Donna Ockenden said this had left “gaps” in the inquiry’s knowledge of how patients were failed.
Ms Ockenden’s review revealed all current Nottingham University Hospitals Trust staff approached to give evidence did so. However, 29 others, including “relatively recent former executives” did not. Meanwhile just five of 14  integrated care board and clinical commissioning group managers contacted agreed to speak to the review.
The Nottingham Maternity Families Group said those who had refused “to engage constructively and with candour in this review process” had provided “further proof you are unfit to keep mothers and babies safe”. The statement added: ”Questions need to be asked by senior leaders and regulators whether you are fit to work for our NHS.”
Sir Jim told a conference held by the The Institute for Public Policy Research think tank today that: “Everybody needs to be accountable for their actions. We’re looking at changes we can make to leaders’ contracts. A lot of people often leave and then it’s very difficult to hold them accountable for what happened on their watch. We’re going to try and make some changes to make… [it] more easy to hold them to account.”
Read full story (paywalled)
Source: HSJ, 25 June 2026
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Another major trust sacks staff over snooping

Members of staff from yet another NHS trust have been sacked for inappropriately viewing patient medical records, HSJ can reveal. 
Cambridge University Hospitals Foundation Trust told staff last week it had dismissed five staff and has since told HSJ the patients whose records were viewed had been told, as had the Information Commissioner’s Office.     
The trust said the dismissals had taken place in recent months. Sky News has reported CUH is also investigating why 40 members of staff accessed files belonging to a three-year-old attacked by a crocodile in a zoo last week.
The latest snooping revelations come just days after the ICO declared that the number of cases of NHS staff viewing patients’ records without legitimate reasons had become a “worrying trend”.   
ICO boss Paul Arnold made his remarks just hours after HSJ revealed more than 1,400 reports of “unauthorised access” to patient data had been disclosed to the watchdog since 2019. 
This also follows staff inappropriately accessing the records of the victims of the 2024 Southport attack, as revealed by HSJ last month, and similar intrusions happening to the records of the Nottingham stabbing victims in 2023. 
Read full story (paywalled)
Source: HSJ, 26 June 2026
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‘Infection control becomes almost impossible’: four doctors on the NHS heatwave crisis

Hospitals in England are declaring critical incidents with radiotherapy machines, MRI scanners, cooling units and IT systems failing owing to the extreme heat.
Four doctors have described their experiences on the frontline that they say feels unsafe and dangerous for patients amid the worst NHS heatwave crisis in years.
“On Wednesday, I led a ward round on an AMU [acute medical unit]. The office I started from was shared with eight other staff members, and the wall-mounted thermometer read 36C [96.8F]. No spare fan, and certainly no air conditioning, was available.
“Out of seven patients reviewed, four of them had adverse effects due to the extreme heat. These included falls due to postural hypotension, and multiple pre-renal AKIs [acute kidney injuries]."
“This heatwave has pushed patient care into concerning territory. In the heat, corridor care has become more serious and more unsafe.
“We are now ‘reverse parking’ patients opposite one another because there is simply nowhere else to put them. Privacy and dignity disappear instantly. We are breaking bad news in corridors with other patients listening because there’s no room to go anywhere else.
“We are resuscitating patients in corridors after cardiac arrest. This should never happen in a modern health system."
Read full story
Source: The Guardian, 25 June 2026
Patient Safety Learning

Trusts must recheck 10 years’ worth of mortuary records

Trusts must check records stretching back to 2016 to ensure any failings that have taken place in their mortuaries have been reported to the regulator.
Reportable incidents can include accidental damage to a body, and disposal or retention of organs against family wishes.
The move by the Human Tissue Authority (HTA) follows revelations of poor practice involving neo-natal bodies at Nottingham University Hospitals Trust (NUH) and the arrest of two men.  The Nottingham maternity review found “multiple failings” to report incidents to the HTA.
The HTA inspected NUH in March this year. The inspection “identified a critical shortfall relating to serious and long-running failure to report incidents to the HTA”. Inspectors found eight bodies “showing advanced deterioration” which had not been transferred to a freezer because of the lack of sufficient capacity at Queen’s Medical Centre. The deceased were routinely stored in bags in a refrigerated area because of the lack of freezer space, it added.
A review of incidents found on the trust’s internal systems showed that 73 had not been reported to the HTA of the last 10 years. It also found 10 “shortfalls” in procedures and processes – three of which were critical.
Read full story (paywalled)
Source: HSJ, 24 June 2026
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Children in poorer countries are six times higher risk of dying after emergency surgery

Children who need life saving emergency surgery after a serious injury are almost six times more likely to die if in poorer countries than in wealthier ones, according to an international study led by the University of Cambridge.
The research, published in The Lancet Child & Adolescent Health, analysed 237 children aged 18 and under who underwent trauma laparotomy – emergency surgery for severe abdominal injuries – in 85 hospitals across 32 countries.
Traumatic injuries, including those caused by road traffic accidents and violence, are among the leading causes of death and disability in children and adolescents worldwide.
This study looked at children who needed emergency surgery for severe abdominal injuries, comparing their care and outcomes across hospitals around the world.
Overall, 8% of children in the study died within 30 days of surgery.
After taking account of differences between patients and settings, children treated in countries with lower levels of development were almost six times more likely to die than those treated in countries with higher levels of development.
The study found major differences in the care children received, which are likely to be important in understanding why outcomes were worse in poorer countries.
Children often faced longer delays before reaching hospital and before receiving surgery.
They were also less likely to receive a blood transfusion, have a CT scan, receive medicine used to reduce bleeding, or be operated on by a consultant surgeon.
Children also made up a larger share of these cases in poorer countries than in wealthier ones.
This suggests that poorer countries may face a double challenge: more children needing emergency surgery after trauma, and less access to the care needed to treat them.
Read full story
Source: Surgery, 15 June 2026
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