Skip to content

News

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

Martha’s rule may have saved more than 500 lives in England since 2024

More than 500 people have received potentially life-saving care thanks to Martha’s rule, which gives hospital patients the right to seek a second opinion about their health.
They were moved to intensive care or a specialist unit after they, a loved one or a member of NHS staff triggered the patient safety mechanism, which the NHS in England began using in 2024.
Martha’s rule lets patients, relatives and staff call a helpline run by the hospital if they are worried about the person’s condition or treatment and ask for a “rapid review” of their care.
In the 18 months between September 2024 and February 2026, a total of 524 adults and children about whom concerns had been raised were moved to an intensive care or high-dependency unit, a specialist hospital or a specialist ward at the hospital where they were already an inpatient.
Wes Streeting, the health secretary, said the figures proved that Martha’s rule is “already having a life-saving impact”. It has been widely hailed as a major advance in patient safety.
Martha’s rule is named after Martha Mills, who died aged 13 in 2021 after her family’s concerns that she was deteriorating went unheeded by staff at King’s College hospital in London.
NHS England’s latest data on how Martha’s rule is operating shows that 12,301 calls were made to Martha’s rule helplines during those 18 months. About one in three – 4,047 – helped to identify a patient whose health was getting worse. Three-quarters of them (2,967) were made either by a patient and their carer or by the patient themselves. Hospital staff made the other 1,080.
Read full story
Source: The Guardian, 1 May 2026
Further reading on the hub:
Embedding Martha's Rule into practice—Lessons from the national pilot Martha's Rule - Merope Mills (Martha’s mother) explains Martha’s story (31 March 2026
Sam

Advice and guidance ‘adding to backlogs’, say consultants

Many medical consultants report a “mixed” experience with the advice and guidance model, saying it is “under-resourced and adding to existing backlogs”, according to research by an integrated care board.
Cheshire and Merseyside ICB surveyed around 300 GPs and medical consultants about their views on the A&G model, which NHS England has said must be significantly expanded this year.
A&G allows GPs to seek pre-referral advice from specialist clinicians working in secondary care, and is designed in part to reduce referrals.
The ramping up of the model in recent months has been controversial among GPs, but the ICB’s survey found 54% said A&G worked “mostly well” or “very well” for them. 36% said their experience was mixed, and 10% “bad”.
However, consultants were more wary: the majority – 51% – said their experience was “mixed”; 18% said it was “bad”; while 31% said it worked “well”.
The ICB’s feedback report says consultants complained about having “no job-planned time” to provide the A&G, as well as “growing volumes, limited admin support, and difficulty accessing GP records”. This was “leaving A&G under-resourced and adding to existing backlogs”.
Consultants also complained of “inappropriate use”, with A&G “sometimes used by [allied health professionals], trainees, and PAs for queries that should go via a GP first”. The findings added: “Many requests lack adequate history or a clear clinical question.”
Although GPs were more positive, they also highlighted problems. They said A&G responses from secondary care could be “brief, contradictory, dismissive, or written by non-consultants, with some specialties slow or unresponsive”.
They also highlighted that “consultants may advise referral but cannot convert A&G directly, forcing GPs to re-refer – sometimes only to be rejected again, creating duplication and patient frustration”.
Read full story (paywalled)
Source: HSJ, 1 May 2026
Patient Safety Learning

NHSE intervenes at governance crisis trust

NHS England has formally intervened over governance failures at a trust whose chair resigned after “exceeding her authority” by suspending its chief executive.
NHS England told East Kent Hospitals University Foundation Trust it was taking action because of “leadership and board instability and the impact of recent events on the working relationship between the wider board members and the council of governors”.
It was “imperative that a strong and stable board and executive leadership team [are] in place… to set direction, manage and respond to the range and scale of the issues currently faced”, according to a letter on Tuesday from regional director Anne Eden.
NHSE told the trust to “ensure that the board is equipped with the right leadership skills, experience and capacity to oversee all elements of organisational governance, financial delivery, quality of care and operational delivery”.
Read full story (paywalled)
Source: HSJ, 29 April 2026
Patient Safety Learning

GPs lose half an hour every day battling ‘clunky’ IT

GPs waste half an hour every day navigating “clunky” IT systems that mean patients’ details get lost or bounced around between doctors, a survey suggests.
The Royal College of General Practitioners said the NHS lost the equivalent of £410 per GP per day because doctors had to spend time on “avoidable” bureaucracy instead of seeing patients.
Overall, GPs said they spent a quarter of their working hours on administrative tasks such as issuing sick notes or chasing information from other parts of the NHS. 
One of the biggest frustrations, according to the survey of more than 2,000 GPs, was the “inefficient” IT systems used for referring patients to hospital specialists for further tests. The college highlighted the loss of patient details and family doctors having to pick up the pieces.
The report said: “The majority of GP participants reported spending 25-30 minutes per day completing tasks relating to a referral or follow-up activities, including manual data entry, re-issuing prescriptions and re-sending referrals, including those which had been lost, bounced back or rejected because of inconsistent and ‘clunky’ pathways.”
GPs described having to act as a “safety net” for the rest of the NHS, dealing with follow-up work from the rest of the system and other “pointless” tasks creating a “hidden workload”.
Read full story (paywalled)
Source: The Times, 29 April 2026
Patient Safety Learning

Stabbing ‘could have been avoided’ with better care

A mental health trust discharged a patient without reviewing his risk level, a month before he went on to stab a man.
Kent and Medway Mental Health Trust then carried out a “flawed” internal investigation, according to a Parliamentary and Health Service Ombudsman report published today.
It comes amid ongoing response to the killing of three people in Nottingham by Valdo Calocane in 2023, who had also been in the care of mental health teams. The public inquiry about this incident is ongoing.
Providers have been asked to review their services, and there are concerns about a lack of capacity.
In the Kent and Medway case, the PHSO said the trust should compensate the patient’s mother, because caring for her 31-year-old son left her with lasting trauma. The man – who has not been named – was diagnosed with schizophrenia after the attack.
He had been detained in hospital but was discharged in June 2020 to a community mental health team, who were responsible for assessing his risk and providing care. He was discharged by the trust in October 2020, without having had a face-to-face appointment since June, and without a risk assessment or care plan in place.
The following month, he stabbed a man, who survived, and was later convicted and detained in a medium secure unit under the Mental Health Act.
PHSO chief executive Rebecca Hilsenrath said: “It highlights the stark consequences of poor mental health care, not just for patients, but also for their families, carers and even strangers.”
She said the patient’s mother endured a “frightening and distressing situation” for more than a year while her requests for help went largely unanswered, leaving her fearing for her safety.
Read full story (paywalled)
Source: HSJ, 30 April 2026
Patient Safety Learning

Trial of non-invasive endometriosis scan boosts hopes for quicker diagnosis

A non-invasive scan for endometriosis has shown promising results in a trial, boosting hopes for far quicker diagnosis.
The trial, which included 19 women with the condition, suggests that an experimental radiotracer, called maraciclatide, can “light up” endometriosis on a scan. The current need for a surgical investigation is seen as a major obstacle to timely diagnosis, with women in England typically waiting nearly a decade.
Prof Krina Zondervan, head of department at the Nuffield Department of Women’s and Reproductive Health (NDWRH) at the University of Oxford, and co-lead on the study, said: “The most prevalent subtype of endometriosis currently evades reliable detection, leaving women no choice for diagnosis other than invasive surgery. If these results are confirmed in larger phase 3 studies, imaging with maraciclatide could transform clinical research and practice and potentially empower the development of treatments for women across the globe.”
Research by the charity Endometriosis UK suggests women in England currently wait an average of 9 years 4 months – rising to 11 years for women from ethnic minority communities. Wes Streeting, the health secretary, highlighted the problem in the government’s renewed Women’s Health Strategy, earlier this month. Endometriosis can progress, leading to more severe physical symptoms and restricting the ability to make informed choices around fertility.
Read full story
Source: The Guardian, 29 April 2026
Patient Safety Learning

Knee surgery for cartilage damage does not benefit patients, study suggests

A common knee surgery for cartilage damage does not benefit patients and may lead to worse outcomes, a 10-year trial suggests.
The study tracked outcomes for patients treated for a meniscus tear, who were given a partial meniscectomy, one of the most common orthopaedic surgeries. Their trajectories were compared with patients who had randomly been assigned to receive “sham surgery”, in which no procedure was carried out.
Patients who had undergone the surgery, which involves trimming frayed meniscus tissue, did not appear to benefit and scored worse on a range of measures designed to measure knee function, pain and progression of symptoms.
Prof Teppo Järvinen, an orthopaedic surgeon and researcher at the University of Helsinki who led the study, said: “Our findings suggest that this may be an example of what is known as a medical reversal, where broadly used therapy proves ineffective or even harmful.”
“We now know that these meniscal tears are very frequently found in patients with no symptoms,” said Järvinen. “Over the past 20 years, evidence has accumulated to suggest that most of these findings on MRI are purely incidental.”
Read full story
Source: The Guardian, 29 April 2026
Patient Safety Learning

Stress from racism may help explain why black women more likely to die in childbirth, study finds

Stress from racism and deprivation could explain why black women are more likely to die during childbirth, a study has found.
Researchers reviewed 44 existing studies that examined three physiological pathways associated with worse pregnancy outcomes: oxidative stress, inflammation, and uteroplacental vascular resistance, and found black women had higher levels of the three metrics.
Such physiological differences are not the result of genetic differences, according to the researchers, but rather suggest that socioenvironmental stressors such as systemic racism and deprivation, which are known to have a measurable biological effect, may influence the body’s ability to function healthily during pregnancy.
Grace Amedor, of the University of Cambridge, the first author of the peer-reviewed study published in the journal Trends in Endocrinology and Metabolism, said: “Pregnancy and childbirth put great stress on a woman’s body. Black women may experience additional strain due to factors including systemic racism, socioeconomic disadvantage and environmental stressors.
“During pregnancy, this strain may affect key biological processes in ways that increase the risk of conditions such as pre-eclampsia. I was surprised that although this disparity had been known for a long time, there was little research into the potential underlying physiological reasons.
“It’s important that we don’t stop trying to tackle the root causes that lead to worse pregnancy outcomes in black women, which are the socioeconomic disparities and the systemic racism they can experience throughout their lives.”
Read full story
Source: The Guardian, 29 April 2026
Patient Safety Learning

Thousands of UK stroke patients ‘left facing a life of disability’ after being denied crucial treatment

Thousands of stroke victims are being denied access to a crucial, life-altering treatment, a charity has warned.
The Stroke Association has highlighted "stark inequalities" in whether patients receive a thrombectomy – a procedure that removes a blood clot from a blocked blood vessel in the brain.
Getting this treatment in the hours after stroke symptoms start can save a person’s life or reduce the risk of life-long disability, as it reduces brain damage caused by a clot.
Analysis by the Stroke Association reveals that 1,222 patients missed out on a thrombectomy between October and December last year, despite the procedure needing to be carried out within the first 24 hours.
The charity attributes these disparities to the fact that some parts of the country lack access to round-the-clock thrombectomy services.
NHS plans, introduced in 2019, had set ambitious targets to expand thrombectomy provision from just 1% to 10% of stroke patients, predicting this would enable 1,600 more individuals to live independently each year.
But the Stroke Association said that this critical target remains unmet
Read full story
Source: The Independent, 29 April 2026
Patient Safety Learning

Early care scheme could prevent thousands of miscarriages a year

After going through two devastating miscarriages, Lisa Varey could not believe what she was thinking.
She knew she would have to miscarry again before she could get the help she needed. Only when you have had three miscarriages do you normally qualify for specialist NHS help in England. One in five pregnancies end in miscarriage, most before 14 weeks.
After her second miscarriage, Lisa was invited on to a pilot project at Birmingham Women and Children's Hospital, which experts believe will prevent thousands of miscarriages every year by offering earlier checks and advice.
As part of the project, women who had suffered one miscarriage were given a one-to-one consultation with a specialist nurse to discuss lifestyle changes - including reducing alcohol consumption and giving up smoking - and using the hormone progesterone, which can help prevent miscarriage.
After a second miscarriage, women were tested for anaemia and abnormal thyroid function, which can affect pregnancy outcomes. They were also offered early scans to reassure them the pregnancy was advancing normally.
Following a third miscarriage, the pathway joins up with what the NHS currently offers - including a referral to a recurrent miscarriage clinic, further blood tests and a pelvic ultrasound.
Tests showed Lisa would benefit from taking the hormone progesterone to help maintain her pregnancy and a regular aspirin tablet to increase the chances of a healthy birth.
Lisa is now pregnant and in the last weeks of her second trimester. She breaks down in tears as she speaks about how much difference the project's help has made.
"There's so much support for pregnant women, but it didn't always feel like there was any support for women who were no longer pregnant. We're having to go through that journey of just feeling very sad."
Professor Arri Coomarasamy, head of miscarriage research at Tommy's, says the three miscarriage wait is an unacceptable anomaly.
"We don't do that with any other medical condition. If somebody has a heart attack, we don't say have your third heart attack and then we will see if there is anything we can do," he says.
He says the findings of the study, if rolled out across the NHS, could also save the NHS money. The pilot suggests the extra costs of staff and training are outweighed by the money saved having fewer women miscarry.
Read full story
Source: BBC News, 29 April 2026
Patient Safety Learning

Precautionary recall of antidepressant medication due to manufacturing error

The Medicines and Health products Regulatory Agency (MHRA) has advised healthcare professionals to stop supplying the affected batch of Sertraline 100mg and return all remaining stock to their suppliers.
Amarox Limited is recalling one batch of Sertraline 100mg film-coated tablets as a precautionary measure due to a manufacturing error that led to two antidepressant medicines being packaged incorrectly.  
The recall follows a patient complaint which helped identify that a pack of Sertraline 100mg film-coated tablets contained one blister strip of Citalopram 40mg film-coated tablets inside the sealed carton.   
Sertraline and citalopram are both selective serotonin reuptake inhibitors (SSRIs) used to treat depression, anxiety disorders, and related mental health conditions by boosting brain serotonin.  
Both SSRI medications are produced by the same manufacturer, at the same site, and the error appears to have occurred during secondary packaging of the blister strips into the cartons.   
Patients who believe they have already taken any Citalopram 40mg tablets by mistake or are experiencing side effects, are advised to seek medical advice immediately. 
Read full press release
Source: MHRA, 28 April 2026
Patient Safety Learning

NHSE home birth proposals spark major safety fears

NHS England is considering allowing midwives to “withdraw” services from women deemed to be giving birth at home against professional advice, HSJ has learned.
The Royal College of Midwives has warned that if this advice is introduced, it risks “push[ing] women towards giving birth entirely alone, [presenting] far greater risk to mother and baby”.
The disagreement comes as NHS services urgently seek clarity from system leaders on how they should best support home births and some high-risk pregnancies.
However, the advice would also cover how services should respond to other care and treatment requests that are considered “highly unsafe or unreasonable”.
NHS England’s discussions about the potential new advice were revealed in a letter responding to a coroner’s Prevention of Future Deaths report.
The letter is dated 24 December, but it was only published last month, and HSJ understands a definitive decision about the advice has not yet been made.
The letter said: “We will build on work already started, looking to clarify whether NHS health professionals providing maternity services may withdraw midwifery services from women birthing at home against professional advice and/or from women making requests with regards to care/treatment that are considered highly unsafe or unreasonable.”
It added: “In developing [better home birth resources], NHSE and its partners will consider the ethical responsibility and proportionality of offering women an NHS home birth, while taking into account that women have a legal right to choose what healthcare they receive.
“In addition, some women who cannot be supported to birth at home due to the level of risk may choose to give birth unassisted, which carries a higher risk.”
The report prompted chief midwifery officer Kate Brintworth to order all trusts to “urgently” review the safety of home birth services in November.
Read full story (paywalled)
Source: HSJ, 28 April 2026
Patient Safety Learning

Care home manager struck off over 'horrific' restraining of disabled person

A care home manager in Ayrshire has been struck off after inappropriately and unnecessarily restraining a disabled person for a vaccine injection.
A tribunal hearing heard that Janette Donnelly's use of force was "horrific" and resulted in scenes of chaos at Millport Care Centre on 19 February 2021.
The jab ended up being administered through the resident's clothes, following which Donnelly told a colleague that she would not report that it had been injected that way.
The Nursing and Midwifery Council ruled her actions were a significant departure from the standards expected of nurses and she had repeatedly given a "dishonest and self serving" account of the day to justify her actions.
A registered NHS nurse had visited the care home on the day to administer the Covid-19 vaccine to people staying there.
The resident, described in the hearing as Service User A, had a learning disability and at times restraints were used to allow her to be fed, but these were only meant to be for brief periods of time.
She was due to receive her second vaccination but two attempts to do so in the building's dining room earlier that day had not gone ahead.
Instead, the vaccine was given in the resident's bedroom while she was being held on the floor Donnelly and two other staff members. Evidence to the panel said the woman was shouting, screaming and struggling.
One witness stated that she would never forget the sight she was confronted with, that it was a "horrific" scene, and that Donnelly had restrained the person's head with her hands.
Donnelly told the NHS nurse to carry out the injection through the resident's clothing.
After this happened the colleague said to Donnelly, "please don't tell anyone I've administered the vaccine in this way", to which Donnelly said "of course I won't".
Donnelly claimed she was unaware the vaccine had been given through the clothing, which the panel did not agree with. It ruled her actions in not reporting this were dishonest.
The panel also ruled that the vaccine did not have to be given on that day, and the nurse could have visited at another time.
It concluded that Donnelly's actions "placed Service User A at a risk of physical harm, and both Service User A and your colleagues at a risk of emotional harm".
Read full story
Source: BBC News, 27 April 2026
Patient Safety Learning

Spiralling cost of mental health patients stuck in acute hospitals revealed

Hospital trusts are spending millions of pounds a year on expensive temporary staff to look after mental health patients stranded in emergency departments and acute wards, HSJ has learnt.
Figures released to HSJ by 70 acute trusts showed several trusts in cities spent more than £1m each during 2025 on additional agency staffing to care for patients waiting for mental health treatment, and with no physical care need.
Across 70 trusts that provided data, the cost was £19m last year, equating to about 16,000 additional staff. Many are hiring specialist mental health nurses, who come at an even greater agency cost premium than general nurses.
It is the latest sign of the rise in serious mental illness and strained capacity in mental health services – and the knock-on costs elsewhere.
Several trusts have said it is contributing to their financial problems. 
A University Hospital Southampton Foundation Trust board report last month said: “The number of mental health patients attending… creates a significant additional cost, including utilising specialist agency to ensure we have sufficiently skilled staff capacity to care for these patients safely often including additional security costs.”
Read full story (paywalled)
Source: HSJ, 27 April 2026
Patient Safety Learning

Trusts name first joint CEO

A chief executive has been appointed to lead ambulance services for a population of about nine million, in a new group of two trusts.
Simon Ashton is currently the hospital chief executive of Newham University Hospital, which is part of Barts Health Trust.
He will become the first joint CEO of South East Coast and South Central ambulance service foundation trusts.
They have begun forming a group and together will be bigger than all other English ambulance trusts except London.
The trusts recruited together, and the appointment had to be confirmed by both their councils of governors. They have said they do not plan to merge, but are working together on areas including workforce planning, digital, clinical collaboration, service resilience, and staff wellbeing.
Read full story (paywalled)
Source: HSJ, 24 April 2026
Patient Safety Learning

Motivation gap grows between bank and substantive staff

NHS bank staff motivation and engagement have increased in a new national survey, in contrast to falling scores among other colleagues.
The results also revealed a widening gap between the proportion who look forward to work and are enthusiastic about their job, compared to their peers.
The 2025 staff survey for bank workers showed motivation rose slightly to just under 7.5 out of 10. This fell to below 6.9 – the worst score in recent years – for substantive staff in results released last month.
The overall engagement score – which also covers involvement and advocacy – had a small rise to 6.93 for bank staff last year, compared to a historic low of 6.75 reported by substantive staff. 
The results showed bank staff were more likely to look forward to going to work at 67% of respondents compared to 52% of substantive staff, with the gap in scores over 3 percentage points wider than in 2023.
However, nearly one in four bank-only workers said they had experienced physical violence within the past 12 months, which has declined slightly from 25% the year before.
This is still significantly higher than the 15% reported by their substantive colleagues and varied by ethnic background.
The report said: “For female white bank workers, the proportion experiencing violence at work from patients or the public has decreased compared to last year and, at 22%, is at a three-year low.
“The proportion of male white workers experiencing at least one incident of physical violence from patients or the public has also decreased, whereas male workers from all other ethnic groups have seen an increase in experiences of violence this year, with more than three in ten … experiencing such behaviour in 2025.”
Read full story (paywalled)
Source: HSJ, 27 April 2026
 
Patient Safety Learning
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.