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

Tech problem delays elective reform target

Concerns have been raised about NHS England watering down a key target for its controversial “advice and guidance” scheme, just weeks ahead of the October deadline.
The fears surround plans to create “single points of access” for all primary care requests, other than urgent suspected cancers, which trusts were set a target to introduce for 10 specialties by next month.
Instead of GPs routing referrals and A&G requests (where they get advice from a specialist) separately, the SPoA model is meant to send all requests via a single route, which NHSE believes will help reduce avoidable referrals and outpatient appointments.
However, upgrades to the e-Referral System have been delayed, and NHSE has been forced to allow trusts to go live with incomplete SPoA models.
Under an interim arrangement, A&G requests and referrals can enter the same SPoA service, but will arrive through separate e-RS routes, and will have to be managed on separate worklists, which experts said “appear to introduce fairly significant compromises”.
Interoperability problems with the e-RS, which make it harder to share clinical information and track patients through pathways, were also identified in a recent report by the Health Services Safety Investigations Body.
Read full story (paywalled)
Source: HSJ, 18 September 2026
Patient Safety Learning

Thousands of pregnant women in England are reporting domestic abuse. Midwives are struggling to cope

About 20,000 disclosures of domestic abuse are estimated to be made to maternity services in England every year, analysis has found.
The figures are likely to be an underestimate of the true scale of disclosures, according to experts, highlighting the role maternity professionals play in identifying abuse.
About 3.3% of maternity bookings made within NHS trusts across England involved a disclosure of current or non-recent domestic abuse.
Applying this proportion to national NHS maternity bookings activity suggests there are approximately 20,000 disclosures of domestic abuse made within maternity services in England every year.
Gill Walton, the chief executive of the Royal College of Midwives, said the findings “lay bare” something that midwives already know from their day-to-day practice.
“Midwives are often the only professional a pregnant woman sees regularly and alone, which makes them uniquely placed to spot the signs of domestic abuse and respond with care,” Walton said.
“But recognising a disclosure is only the first step – staff need proper, specialist training to know how to respond and services need the time and resources to follow through with support, so that no disclosure is ever a missed opportunity to protect a parent and their baby.
Experts have also called for midwives to receive adequate support and training on handling such domestic abuse disclosures, while also working long hours on busy maternity wards that can also face staff shortages.
“Midwives and other maternity staff play such a crucial role when it comes to reporting disclosures of domestic violence which are made to them. However, maternity staff also need better support so they know what the next steps are regarding what to do with these disclosures,” Veronica Oakeshott, the interim head of external affairs at Women’s Aid, said.
Read full story
Source: The Guardian, 20 September 2026
Patient Safety Learning

Adults with severe mental illness die 15 to 20 years earlier from diseases such as cancer

Adults with severe mental illness are nearly five times more likely than their peers to die from serious physical diseases before the age of 75, according to research.
The analysis of NHS data by the Rethink Mental Illness charity reveals that people with severe mental health problems die 15-20 years earlier than the wider adult population, largely due to preventable physical conditions.
Rethink’s calculations show that adults under 75 with serious mental ill health – defined as those referred to specialist secondary mental health services – are 6.3 times as likely to die from liver disease, 6 times more likely from respiratory illness, 3.8 times more likely from cardiovascular disease and 2.3 times as likely from cancer. They are also 14.6 times as likely to die due to suicide, compared with those who were not referred. Overall, they are 4.8 times more likely to die before the age of 75 than the general population.
For some conditions, these health inequalities are the starkest to date. For working-age adults living with a mental illness, the number of deaths from cardiovascular disease and cancer are at their highest levels since records began, each with more than 24,000 deaths in the 2022-2024 reporting period, the charity calculated.
Cancer, cardiovascular disease, liver disease and respiratory disease accounted for more than half (56.5%) of deaths for 18 to 74 year olds with severe mental health problems in England during this period.
The report identifies a number of factors driving this excess mortality, including poverty, poor housing, higher rates of smoking, weight gain from medication, physical inactivity, and fragmented care. But the authors conclude that “diagnostic overshadowing” – where physical symptoms are wrongly attributed to mental illness – means potential illnesses are not always properly investigated and treated.
Read full story
Source: The Guardian, 20 September 2026
Patient Safety Learning

Ministers hire economist to scrutinise cancer performance

Health economist Anita Charlesworth will independently co-chair a “reformed” National Cancer Board, seven months after the government’s cancer plan promised a body “accountable for delivery” of its commitments.
The plan, published on 4 February, said the board would be chaired jointly by the Department of Health and Social Care and an independent figure from the cancer community, and would publish annual progress reports and an in-depth review after three years.
Ms Charlesworth will co-chair with Mark Cubbon, Manchester University Foundation Trust chief executive and NHS England’s elective care, cancer, and diagnostics director.
DHSC said the board would scrutinise progress against the plan’s more than 100 commitments, identify which areas were falling behind and advise ministers on further action.
Its first task is a set of standards the NHS is missing. The 28-day faster diagnosis threshold rose to 80% at the start of 2026-27 and has not been met since; July’s 79.3% was the best of the four months so far.
Read full story (paywalled)
Source: HSJ, 21 September 2026
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Twenty women had breasts removed needlessly, says NHS trust

Twenty women underwent mastectomies unnecessarily while being treated for breast cancer, an NHS trust in north-east England has told the BBC.
They were among hundreds of patients who came to harm during treatment at the breast unit of the County Durham and Darlington Foundation Trust (CDDFT).
The admission comes in the wake of revelations about serious failures in the unit, as reported by the BBC last year.
Dozens of affected women and their families contacted us after we reported concerns about serious failings at the trust's breast cancer unit. These included:
A high number of mastectomies compared with other NHS trusts.
Operations that were carried out "too quickly".
Outsourcing of some treatment to private clinics run by the trust's breast cancer clinical lead - an arrangement that one independent expert said created "a clear conflict of interest.
Patients described the shock they had felt on being told a mastectomy (the removal of all or part of a breast) could have been avoided, as well as the psychological and physical pain that many still live with.
CDDFT is now carrying out an internal review of breast cancer cases between January 2023 and February 2025, alongside the cases of 640 former patients who contacted a dedicated helpline.
It says that cases have also been identified where cancer diagnoses were missed or delayed. Some of these patients subsequently saw their cancer spread.
Last year, BBC News reported that nearly £6m had been paid by the trust over six years to breast cancer diagnostic clinics and surgery companies run privately by Mr Amir Bhatti, who was CDDFT's clinical lead for breast services from 2013-24. Concern about this arrangement was raised in a 2025 review into the running of the trust carried out by governance specialist Mary Aubrey,
She said outsourcing patient appointments had created financial incentives which were potentially "a risk to clinical standards".
Mr Bhatti has now been suspended from carrying out clinical practice but is still employed by the trust on full pay.
Read full story
Source: BBC News, 18 September 2026
Related reading on the hub:
Report of the independent Inquiry into the issues raised by Paterson

Patient Safety Learning

USA: Pennsylvania asks CDC for emergency help as measles outbreak spreads

Pennsylvania is seeking emergency assistance from the US Centers for Disease Control and Prevention (CDC) as a major measles outbreak spreads across the state. The state warned the request could be withdrawn unless the federal agency publicly recognises four measles-associated deaths reported by the state.
The Pennsylvania department of health has begun the process of requesting CDC emergency support known as an Epi-Aid, according to a letter reviewed by the Guardian. The letter was first reported by Reuters on Thursday.
Debra Bogen, Pennsylvania’s secretary of health, outlined the condition in a letter sent on Wednesday to the CDC director, Erica Schwartz.
“The CDC’s choice not to publicly recognize ⁠the deaths undermines our response,” Bogen wrote. “For this reason, if CDC is unable to transparently and accurately communicate information about those measles-associated deaths, the department will respectfully rescind our request for a CDC Epi-Aid.”
The development comes amid an ongoing dispute involving Josh Shapiro, the state’s Democratic governor, and Robert F Kennedy Jr, the US health secretary, over the state’s handling of the outbreak and how measles-related deaths are being counted.
Read full story
Source: The Guardian, 17 September 2026
Patient Safety Learning

Major concerns raised about patient safety at Cardiff hospital

Major concerns have been raised about patient and staff safety on wards at a Welsh hospital in a damning report by the watchdog.
The investigation into two mental health wards at the University Hospital Llandough in Cardiff by Healthcare Inspectorate Wales (HIW) comes just months they published a similar report raising concerns about other mental health units at the hospital.
An unannounced inspection at the Meadow and Daffodil mental health rehabilitation services in June found mould, ceiling leaks, faulty showers and bathing facilities at the hospital. Inspectors also identified "significant concerns" regarding mandatory training compliance and were not satisfied that sufficient staff could manage risks safely.
HIW said "urgent action was required at the unit" to address immediate patient staff and safety concerns as a result. Progress across the health board will be monitored closely as a result of the recent inspections, the watchdog added.
Read full story
Source: Wales Online, 17 September 2026
Patient Safety Learning

Andy Burnham urged to set dementia waiting-time target

Prime Minister Andy Burnham is facing calls to set a national waiting-time target for dementia care in England.
An Alzheimer's Society proposal to set an 18‑week referral‑to‑treatment target has been backed by Professor Sir Mike Richards, England's former national cancer director, and Baroness Louise Casey, who's leading a major review of adult social care.
In a report, Alzheimer's Society and the King's Trust said a "cancer-style revolution" was needed to improve dementia care, which they described as being "stuck in the 20th century".
In a speech at Alzheimer's Society conference on Thursday, Social Care Minister Alison McGovern expressed support for the report, external.
She said: "The report that the Alzheimer's Society published today on going on the journey that we've been on with cancer, with Alzheimer's and dementia, I think that's spot on."
The minister said dementia had been "neglected for far too long".
She added: "And nowhere is this division between health and social care felt more sharply than by people living with dementia in their families, too often left to navigate a shattered system at the most difficult time in their lives."
Read full story
Source: BBC News, 17 September 2026
Further reading on the hub:
Making patient safety work for people living with dementia
Patient Safety Learning

Plan to limit NHS diagnoses of ADHD attacked as ‘rationing’ healthcare

Proposals to limit the number of patients being formally diagnosed with attention deficit hyperactivity disorder have been attacked as “rationing” healthcare and pushing children and adults to self-diagnosis via social media.
The comments came before a government review due next week, which is expected to say that patients with ADHD symptoms should not automatically be formally diagnosed, but should be “triaged” and offered support without the need for a formal diagnosis.
Details of this “needs-based” system, first revealed in the Times, would mean NHS services target those most acutely affected by ADHD, such as those at risk of self-harm or unable to work.
Less severely affected people may not be referred for a formal diagnosis to NHS clinics but would be offered help according to a “holistic” assessment of their needs, the report will say.
Proposals to limit the number of patients being formally diagnosed with attention deficit hyperactivity disorder have been attacked as “rationing” healthcare and pushing children and adults to self-diagnosis via social media.
The comments came before a government review due next week, which is expected to say that patients with ADHD symptoms should not automatically be formally diagnosed, but should be “triaged” and offered support without the need for a formal diagnosis.
Details of this “needs-based” system, first revealed in the Times, would mean NHS services target those most acutely affected by ADHD, such as those at risk of self-harm or unable to work.
Less severely affected people may not be referred for a formal diagnosis to NHS clinics but would be offered help according to a “holistic” assessment of their needs, the report will say.
The government’s independent review of mental health conditions, autism and ADHD was commissioned in December by the then health secretary, Wes Streeting, amid concerns over the sharp rise of people making sickness benefit claims due to mental health, autism and ADHD diagnoses.
Led by Prof Peter Fonagy, a clinical psychologist and psychoanalyst at University College London, the interim review concluded that the system forces children and adults to obtain a formal diagnosis in order to get support.
Official figures show that patients are waiting years to be assessed, with 800,000 on NHS waiting lists. Meanwhile, complaints about autism and ADHD services in England have more than tripled in five years.
Read full story
Source: The Guardian, 17 September 2026
Patient Safety Learning

Judge to examine trust’s care failings

Government has named a chair for its public inquiry into care and governance failings at a mental health trust – nine months after the probe was promised. 
Judge John Potter is to lead the inquiry into Tees, Esk and Wear Valley Foundation Trust, which will examine the deaths of teenagers Christine Harnett, Nadia Shariff, and Emily Moore, who died by suicide while in the trust’s care, in 2019 and 2020.
He is a retired circuit judge and former deputy judge of the Criminal Division of the Court of Appeal, with over 40 years of experience in public service, judicial leadership, and the administration of justice.
He said his first priority would be to meet and “listen to those affected”, who would be “central to the inquiry’s work” and terms of reference.
Its formal start date will be Monday.
Lawyers and the families have called for the inquiry’s scope to include all sites run by the trust, not just West Lane Hospital, where two of the teenagers died.
Read full story (paywalled)
Source: HSJ, 18 September 2026
Patient Safety Learning

NHS CEO will keep top-tier status

The NHS chief executive is set to have equal rank in government to the health department’s permanent secretary when NHS England is abolished – meaning a proposal to downgrade their status has been rejected by ministers.
The decision was made by health and social care secretary Yvette Cooper last week, after several weeks of deliberation over the choices she needs to make ahead of NHSE being scrapped, officials have been told.
Ms Cooper had decided the NHS CEO post will sit “alongside the permanent secretary” of the Department of Health and Social Care and with “equal rank” in government, the current NHSE CEO Sir Jim Mackey said at a staff meeting last week.
She wants a return to a departmental structure very close to that immediately before the creation of NHS England in 2012, Sir Jim said. This would include a distinct “NHS executive” group within the department, to run NHS-focused national work, led by the NHS CEO.
The decision means the NHS CEO will report directly to the health and social care secretary and, in central government, to the cabinet secretary, after NHSE is abolished, which is due to take place at the end of March.
Sam

Bristol research transforms Scottish infection control guidelines

The AERATOR (Aerosolisation and transmission of SARS-CoV-2 in healthcare settings) study took place during the COVID-19 pandemic. It aimed to understand whether so-called aerosol generating procedures, such as inserting a breathing tube, produced aerosols in significant numbers.
AERATOR was led by anaesthetic, intensive care, infectious disease and respiratory clinicians at Southmead Hospital and aerosol scientists at the University of Bristol. The study was supported by the National Institute for Health and Care Research Biomedical Centre (NIHR BRC) Bristol. 
Respiratory aerosols are tiny droplets produced when people breathe, talk and cough. They are the main way respiratory infections such as COVID-19 are transmitted. 
The team used PLUME (Portable low-background unit for measuring exhaled aerosol), a cutting-edge device to monitor aerosol production in real time in ultraclean theatre environments usually used for orthopaedic and neurosurgery. This enabled them to study aerosols in a healthcare setting for the first time. 
The study found that most of the aerosol generating procedures considered high risk produced less aerosol emission than coughing or talking. 
Based on this and other evidence, Public Services Delivery Scotland has published updated transmission-based precautions guidance. Reflecting the latest evidence on how respiratory infections spread, the guidance introduces a more consistent, risk-based approach to infection prevention and control across Scotland’s NHS Boards, care homes and wider health and care settings. 
The guidance moves on from procedure-focussed risk assessment to a more holistic consideration of the type of respiratory infection, the patient’s symptoms and the healthcare professional’s exposure and own risk factors. This has effectively ended the use of the term ‘aerosol generating procedure’ in risk assessments. It will lead to a major change in how personal protective equipment (PPE) is deployed in healthcare settings. 
Wales has followed Scotland’s lead and adopted the same risk-based approach. Whilst the English guidelines were the first to remove some of the procedures from the original aerosol generating procedures list, they are yet to drop the list completely.
Read full story
Source: NHS Bristol Foundation Trust, 14 September 2026
Patient Safety Learning

£2.5bn tech programme dubbed ‘unachievable’

Successful delivery of NHS England’s £2.5bn Frontline Productivity programme “appears to be unachievable” due to governance failures and political uncertainty, according to a government review.
A review of the programme carried out by the government in July gave the programme a “red” confidence rating and concluded that “successful delivery is unlikely under the current operating arrangements”.
The review, which has never been published, found that the programme’s ambition of devolving delivery to regions was undermined by “ongoing restructuring” and “the desire for greater control from the centre”.
It said that achieving the programme’s aims was “predicated on a model of region-led delivery that has been overtaken by events, not least the significant reductions in capacity at regional level”, and that the model therefore requires “rapid recalibration”.
In a response provided within the report, NHSE director of frontline productivity Dermot Ryan said the “red” rating was “warranted” and acknowledged the need to “reset the operating model”, but said this “falls outside my powers”.
Read full story (paywalled)
Source: HSJ, 16 September 2026
Patient Safety Learning

NHS winter planning: Penny Dash’s “groundhog day” comments are “admission of failure,” doctors say

NHS England chair Penny Dash has been criticised after suggesting that winter planning for the months ahead will be “exactly the same” as previous years, despite concerns by doctors that such planning has been ineffective.
Speaking at the King’s Fund on Tuesday 8 September, Dash, who took over as chair in April 2025, said, “We are about to have a paper come to the NHS England board on winter planning.
“This will be my sixth year as an NHS chair, with exactly the same paper on winter planning coming to the board. We can’t just keep going in the same way.”
Dash, previously chair of North West London Integrated Care Board (ICB), continued, “We know that we’ve got 40% of people turning up at A&E [hospital emergency departments] who don’t need to be in an A&E. We’ve got over 20% of emergency admissions who don’t need to be admitted to hospital.
“We’re just in groundhog day, trying to make an existing system, which is a suboptimal system, work better. So, we need to get on and do the redesign of urgent and emergency care.”
Dash’s comments—which follow the NHS’s busiest summer on record—have been met with incredulity among doctors.
Ian Higginson, president of the Royal College of Emergency Medicine, described Dash’s comments as an “admission of failure” and “immensely frustrating.”
Meanwhile, David Oliver, a consultant in geriatrics and acute general medicine and columnist for The BMJ, questioned what Dash as chair has “personally done to address the issues instead of wringing her hands.”
Oliver also pushed back on her claim that the issue lies in people coming into A&E unnecessarily.
“We know that the issue with long waits and overcrowding in A&E departments is not to do with people turning up there with minor injuries and illnesses.
“It is to do with patients who require admission to acute beds, because they are sick enough to need admission or because no alternative services are available for them, and there are not enough beds for them to be admitted to.”
Read full story
Source: BMJ, 11 September 2026
Patient Safety Learning

USA: Pennsylvania officials report fourth measles-associated death in 'surge' of cases

A fourth person has died from complications related to measles in Pennsylvania, say state officials, in an outbreak that has infected hundreds of people.
An 18-year-old died from acute encephalomyelitis, a rare and severe neurological complication of measles, the Mifflin County Coroner's Office in Pennsylvania said.
The Keystone state has seen over 600 cases of measles this year, primarily in Lancaster County.
The US eliminated measles in 2000 with the help of vaccines, but it has this year experienced the highest number of deaths from the virus since the 1990s.
Last year, three people - including two children - died from a measles outbreak in Texas that spread predominantly among the Mennonite community.
The rising number of cases has come as vaccine hesitancy in the US has increased in recent years, leading to lower immunisation rates.
In Pennsylvania, state and local officials have said the 18-year-old and a 40-year-old, both unvaccinated, died from measles-related complications over the past month.
Two infants have also died. US children typically do not receive their first MMR (measles, mumps, and rubella) vaccine until 12 months of age.
Read full story
Source: BBC News, 15 September 2026
Patient Safety Learning

"It makes you feel helpless": patients and doctors cast doubt on standard treatment for endometriosis

“It’s really frustrating to be in this cycle of continuous surgery. It makes you feel helpless,” says Natalie Greenwood, of a condition that affects her so badly she is “non-functioning most of the time because of the constant fatigue”.
Greenwood, 36, needs to have an operation every few years to limit the impact of the endometriosis that gives her chronic pelvic pain, as well as extreme tiredness and brain fog.
She says the trouble with depending on surgery is not just having an invasive procedure and then having to recover afterwards. It’s more that the benefit gained – the relief from persistent pain – is brief.
She is not alone in her lack of belief in surgery and hormonal medication being effective for chronic pelvic pain. A study has found that dual approach, which is the NHS’s usual way of treating the condition, does not improve quality of life for female patients.
Dr Jasmine Hearn, a reader in health psychology at Manchester Metropolitan University who co-led the research in the new study, said: “Sadly patients are often left struggling due to current pain management strategies not sufficiently alleviating pain.
“Chronic pelvic pain is often invisible but its impact can be profound. Our findings highlight that women with pelvic pain report poorer quality of life when they’ve had surgery and hormonal medication for pelvic pain and better quality of life when psychological support is part of treatment.”
Read full story
Source: The Guardian, 15 September 2026
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