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

I've woken from endometriosis operations to find the surgery hasn't been done

Kelly O'Shea says she has woken from more than one operation to be told adequate resources were not available to do the procedure she needed.
The 32-year-old, who lives with chronic pain, felt there was no alternative but to pay £20,000 for the endometriosis treatment she needed, out of frustration and desperation.
It comes as gynaecologists warn specialist centres in Wales dealing with complex cases of endometriosis are in jeopardy and a national service must be commissioned.
The deputy minister for women's health in Wales said the current set up was "not sustainable" and is discussing options for a regional or national service to be established.
Changes are being introduced by national accreditation body British Society for Gynaecological Endoscopy (BSGE) highlighting the resource challenges faced by hospitals in Wales.
Clinical staff say it has been made worse because of the funding differences between England and Wales.
They say unless more resources are found to increase capacity and dedicate teams to endometriosis care, BSGE-accreditation requirements will not be met, which would lead to a downgrading of services, a potential skills exodus and large numbers of patients being sent to England for care.
At a recent cross-party Senedd group on women's health, gynaecologists said Wales either needed a nationally commissioned service or an overhaul of the funding model to better reflect the true cost of the specialist care.
Read full story
Source: BBC News, 12 October 2026
Patient Safety Learning

US maternity wards face wave of closures as Medicaid cuts kick in

Maternity wards across the United States are facing a wave of closures as cuts to federal Medicaid funding take effect, experts have warned.
According to analysis by the non-profit Protect Our Care, 52 maternity wards have closed since the HR1 bill was announced in July 2025, with a further eight having announced their upcoming closure.
The bill, which will fully come into effect in the new year, will result in many adults covered through Medicaid having to meet new work requirements and being subject to more frequent eligibility checks, while there will be less federal funding for states for Medicaid.
Hospitals which have already permanently closed their maternity wards include the Centra Southside Community hospital in Virginia and St Mary’s Sacred Heart hospital in rural north-east Georgia, which both cited upcoming federal policy changes to Medicaid as a reason.
Experts are expecting to see more closures of maternity units in the run-up to and after the federal changes to Medicaid come into effect in the new year.
“We’re deeply concerned that these changes already have and will continue to worsen an already serious maternity care crisis,” said Erin Jones, senior director of legislative and strategic counsel of the non-profit March of Dimes. “Reduced funding and restrictions on how states finance Medicaid will put additional pressure on state budgets and hospitals, increasing the risk that communities lose essential maternity services and specialized providers close to home.”
Read full story
Source: The Guardian, 11 October 2026
Patient Safety Learning

Patient safety tsar backs call for review of ex-soldier’s death

Calls are continuing for a fresh investigation into the death of former UN peacekeeper Ryan Wallace.
Scotland’s Patient Safety Commissioner, Karen Titchener, backs politicians who say lessons should be learned from Ryan’s death as the case raises questions about how patients with complex and unexplained illnesses are supported.
The intervention comes amid growing criticism of NHS Forth Valley’s refusal to carry out a Significant Adverse Event Review ­following Ryan’s decision to end his life at a clinic in Switzerland on 18 August.
NHS Forth Valley insists concern raised by Ryan and his family were investigated through its complaints ­process and later upheld by the Scottish Public Services Ombudsman.
But his widow, Marianne Wallace, argues that investigation only examined events and concerns raised at that time.
She said: “Their investigation did not examine the years that followed when Ryan’s health continued to deteriorate, he was given a succession of different diagnoses and treatment plans, and we felt forced to spent more than £60,000 on private healthcare as we searched for answers.”
Scottish Conservative Shadow Health Secretary Miles Briggs last week called on the health board to commission an investigation voluntarily, despite there being no requirement to do so because Ryan died outside Scotland.
Titchener said: “I can’t comment on the details of his care, and it isn’t my role to investigate this individual case, but his story raises questions. The whole system should want to understand what happens when someone lives for years with unexplained symptoms, conflicting diagnoses, and complex medication, and feels they need to look elsewhere for answers.
“A complaint process tells us whether individual decisions were reasonable at the time. It doesn’t always tell us what we could learn from the whole journey. Learning shouldn’t stop because a complaint has been closed.”
Read full story
Source: The Sunday Post, 11 October 2026
Patient Safety Learning

GP who entered incorrect data in death certificates suspended for 10 months

A GP who entered incorrect data while completing death certifications will be suspended for 10 months, a fitness-to-practise tribunal has ruled.
At the time of the events that led to the suspension, Dr Lea Cramsie was practising as a salaried GP for a practice in Glasgow which provided care to people living in nursing homes, according to documents released by the Medical Practitioners Tribunal Service (MPTS).
The MPTS said that the allegations were related to Dr Cramsie completing medical certificates of cause of death and ticking the box to confirm the deaths had been reported to the procurator fiscal ‘when she knew they had not’; this would exclude the deaths from being selected for review by the Death Certification Review Service. The documents said that the allegations related to ‘31 occasions’.
In Scotland, the procurator fiscal has a duty to investigate certain deaths, such as those which are sudden, suspicious, accidental or unexplained, with specific guidance for GPs on when a death should be reported.
The initial concerns were raised with the GMC on 26 June this year by the deputy medical director for primary care for NHS Greater Glasgow and Clyde.
The referral to the GMC was further to a local investigation by the health board which arose from ‘concerns that had been raised around death certificate completion’.
The GMC acknowledged that Dr Cramsie had described herself as ‘dealing with what she considered to be a disproportionate workload of death certificates’. The regulator submitted that Dr Cramsie’s workload ‘might provide some explanation for the misconduct’, but that the evidence from other practice members did not suggest that the workload was considered ‘unusually onerous’.
Read full story
Source: Pulse, 9 October 2026
Patient Safety Learning

Trust under manslaughter investigation over four deaths

An ongoing potential corporate manslaughter investigation is looking into the deaths of four patients, a court has heard today.
Police have been investigating allegations of neglect and mistreatment of patients on the stroke unit at Blackpool Victoria Hospital since 2018.
Since then, two staff members have been jailed for poisoning patients, and a murder inquiry launched into the death of patient Valerie Kneale after a violent sexual assault.
The investigation, known as Operation Bermuda, was also expanded to cover potential gross negligence or corporate manslaughter charges in 2023.
In an update to Blackpool and Fylde coroner’s court, the patients were named as 86-year-old Margaret Mary Hamilton and Geoffrey Duckworth, 81-year-old Peter Whittaker, and 75-year-old Joan Walker.
Detective chief inspector Mark Dickinson also told the court that the Care Quality Commission had investigated the deaths of the four patients but decided not to prosecute the trust.
DCI Dickinson said Operation Bermuda was originally launched to investigate allegations that patients on the stroke ward were being sedated with the drug Zopiclone without any clinical need.
DCI Dickinson said: “The investigation also identified other patients believed to have received poor care. Likewise, in the case of four patients, potential causal links were identified between the care they received and their death.”
Read full story (paywalled)
Source: HSJ, 9 October 2026
Patient Safety Learning

Independent review into Scotland's maternity services gets underway

Along-awaited review aimed at identifying “systemic changes” to Scotland’s crisis-hit maternity services has begun.
The nine month-long nationwide review will examine how care can be improved for women, babies, and families across the country.
The independent review is being chaired by the maternal and child health expert, Professor Christine McCourt, who is expected to submit her findings and recommendations in July 2027.
The Scottish government said the review will take a “whole-system approach,” drawing on data, evidence and the direct experiences of women, families and staff at every level of care.
However, some bereaved families have voiced misgivings about the scope of the review, and warned that it was in danger of becoming an “absolute insult” as a result.
Read full article.
Source: The Scotsman, 5 October 2026
Mark Hughes

£33.2 million to protect public from future epidemics and pandemics

Lives could be saved and the public better protected against future epidemic and pandemic threats through a £33.2 million UK Government investment in vaccines against some of the world’s deadliest infectious diseases.
This investment will help scientists to develop, test and deploy vaccines faster when new health threats emerge, both supporting people in low and middle-income countries (LMICs) and, in turn, protecting the UK by strengthening pandemic preparedness and improving resilience to future epidemic and pandemic threats.
The programme has already demonstrated the value of investing, having supported development of the Oxford/AstraZeneca COVID-19 vaccine. This latest investment will help researchers respond more quickly to future threats.
Supported by the UK Vaccine Network and delivered through Innovate UK, the funding will target diseases including Ebola, plague, Marburg, Lassa fever, Nipah virus, chikungunya and Mayaro.
Eight projects will advance promising vaccines, clinical trials and technologies that can make vaccine design and manufacture faster and more effective.
The new awards will build the research, clinical trial and technical capability needed to develop, test and deploy vaccines at speed. They will also help make vaccines affordable, accessible and ready for use in countries at greatest risk.
Read full article.
Source: Department of Health and Social Care, 8 October 2026
Mark Hughes

ADHD and autism at risk of over-diagnosis, says government review

There is a risk of people being over-diagnosed with ADHD and autism, an official review in England has found.
Experts said a rise in diagnoses over the past 25 years meant cases now appear to be outstripping the expected number in the population for some younger age groups.
The review called for tougher regulation of private firms offering assessments for the NHS, saying they had concerns about quality and consistency, and a ban on advertising.
It concluded economic uncertainty combined with social media was driving an increase in mental health problems among young people and said there needed to be better support in place for all conditions.
It is likely to feed into government policies on everything from NHS services and benefits to support for young people who are not in education, employment or training.
Read full article.
Source: BBC News, 9 October 2026
Mark Hughes

New global roadmap launched to tackle hypertension in pregnancy, a leading cause of maternal and newborn deaths

The World Health Organization (WHO) and partners have launched a new global roadmap to tackle hypertensive disorders of pregnancy, including pre-eclampsia, which affect millions of women every year. These disorders remain among the leading causes of death and serious illness for pregnant women and their babies, with tragic long-term impact on their families.
Hypertensive disorders complicate an estimated 10–15% of pregnancies worldwide. They account for around 16% of maternal deaths globally, resulting in an estimated 42 000 deaths each year, as well as more than 500 000 stillbirths and newborn deaths.
In many countries, women still lack reliable access to basic blood-pressure measurement, urine protein testing and essential medicines, including aspirin, antihypertensives and magnesium sulfate. Weak referral systems, shortages of trained health workers and limited emergency obstetric services can further delay life-saving care.
Launched at the Society for Maternal-Fetal Medicine Global Conference, the Global roadmap for hypertensive disorders of pregnancy from 2026 to 2035 and beyond sets out coordinated actions across research and innovation, global clinical guidance, access to medicines and diagnostics, implementation, advocacy and accountability.
The roadmap highlights a striking innovation gap between the scale of the problem and the lack of medicines specifically developed and approved by regulators for the prevention or treatment of pre-eclampsia or eclampsia. Research investment has largely focused on diagnostics, with chronic underinvestment in new preventive and treatment options.
Read full article.
Source: World Health Organization, 8 October 2026
Mark Hughes

At least 20% of baby deaths ‘potentially avoidable’

At least a fifth of baby deaths last year may have been preventable, with this estimate considered “a minimum”, an analysis of thousands of care reviews has concluded.
The findings were set out in the latest annual report into 2025 Perinatal Mortality Review Tool investigations, published today by MBRRACE-UK.
The report comes amid intense scrutiny of maternity services following the publication of the national maternity and neonatal investigation and Donna Ockenden’s Nottingham review this summer.
Read full article (paywalled).
Source: Health Service Journal, 9 October 2026
Mark Hughes

£80m dementia challenge to test AI and digital tools

Nine digital technologies for dementia diagnosis, including AI-enabled clinical decision support, remote cognitive assessments and faster MRI scans, will undergo real-world testing in NHS settings.
Diagnosis for dementia can take more than a year, with around 60% diagnosed within 18 weeks of referral.
The Dementia Challenge, backed by up to £80 million through UK Research and Innovation’s (UKRI) Research and Development Missions Accelerator Programme (R&D MAP), aims to increase the proportion of people diagnosed with dementia within 18 weeks of referral to 92%.
Read full article.
Source: Digital Health, 8 October 2026
Mark Hughes

'I was blamed for my baby's death, now NHS needs to change'

When Poppy Russell died in April 2021 at the Princess Royal Hospital in Telford shortly after birth, her parents were left bereft. What followed made matters harder to bear - her mother was blamed for the death.
An inquest would later conclude that Poppy's death was preventable.
But instead of walking away from the trust that had failed them, Neil and Katie Russell are now working with it to bring compassionate care back into the NHS.
"We could have very easily been consumed by hate and anger and rage at what happened – and those feelings are still there," said Katie.
"But if no change comes from what happened to Poppy, then what's the point?"
During her pregnancy her mother told midwives that she had tokophobia, a fear of natural birth and wanted a caesarean section.
Katie said she was repeatedly told however that she "couldn't just ask for a c-section."
When she went into labour, Katie was induced and then "we were left in a room for long periods of time where I had no care," she explained.
"Finally, when we got into the labour suite, I wasn't monitored appropriately and they missed signs that Poppy was in distress."
In a bitter irony, Poppy had to be delivered by emergency caesarean. By then however, she had developed a hypoxic brain injury and died later the same day.
An inquest into her death found that had Poppy been born an hour earlier, she would have survived.
The Shrewsbury and Telford NHS Trust (SaTH), which ran the hospital, subsequently blamed Katie for her daughter's death.
They said she had refused foetal monitoring; the inquest concluded that was untrue.
"The trust left us in an appalling position," said Neil Russell.
"Not only were they found to have neglected our care, but in the months and years following, we uncovered that members of staff had tried to cover it up.
“Losing your daughter is one thing, but then to find that there was a cavalcade of lies was almost as bad."
Following the inquest in 2023 the trust said: "We recognise there were failings in the care we provided and we are truly sorry."
Read full story
Source: BBC News, 8 October 2026
Patient Safety Learning

NHS bosses admit defeat on 18-week pledge

NHS chiefs have told ministers that their top health manifesto pledge - to restore the 18-week elective target by 2029 - is “not going to happen”, as a new analysis confirms the service is significantly off track.
The intervention by the NHS Alliance, which represents the large majority of trusts and integrated care boards, follows experts questioning whether ministers should abandon the 18-week pledge last month. Health and social care secretary Yvette Cooper has highlighted other priorities, such as maternity and early years, since her arrival in July.
The Health Foundation’s analysis published today projects the NHS will fall “a long way short” of the 2029 target if current trends continue, with the 92nd percentile wait nearly twice the 18-week standard by the end of the Parliament (see chart below).
Responding to the think tank’s findings, NHS Alliance acute lead Matthew Hopkins said it was time for “an honest conversation” about the target, and to “acknowledge [meeting it] this Parliament is not going to happen”.
He said: “Now with a change of prime minister and secretary of state, attention is turning to reform of social care, maternity and early years, and frailty services. We can’t have everything, everywhere all at once.
“Let’s be honest about where we can get to with the resources available, so there is a clear understanding of what can and cannot be achieved.”
Read full story (paywalled)
Source: HSJ, 8 October 2026
Patient Safety Learning

Hospitals seek ‘pause’ on ambulance handover rule

An ambulance trust is “not assured” the 45-minute limit on hospital handovers can be consistently delivered this winter, after repeated requests from hospitals to “pause” it.
East Midlands Ambulance Service Trust’s winter plan, presented to its board last month, says support is needed for “a zero tolerance to pausing the process”, given “current requests for pauses”.
Under the “release to respond” protocol, crews hand over their patient and leave after 45 minutes at hospital. NHS England’s urgent and emergency care plan for 2025/26 said the maximum, which 17 trusts were missing last summer, should “now be delivered without exception, including in the winter months”.
Anna Parry, managing director of the Association of Ambulance Chief Executives, said: “There may be exceptional circumstances in which the protocol needs to be temporarily paused or suspended, for example where there are specific clinical safety concerns, during a declared incident or where there is exceptional system failure. However, these should be strictly governed, escalation-based exceptions, agreed between ambulance and acute trusts, rather than becoming a routine response to operational pressure.”
She said any suspension should only be considered after actions to reduce pressure within the hospital had been exhausted.
Sarah Noonan, chief operating officer of University Hospitals of Northamptonshire, the group formed by Kettering General and Northampton General, said: “Only when our emergency departments and inpatient services are at full capacity may we need to temporarily hold ambulance crews, while recognising the impact this can have on patients waiting for an ambulance in the community.”
Read full story (paywalled)
Source: HSJ, 8 October 2026
Patient Safety Learning

Two in three housebound patients had no medication review for more than two years

A proactive pharmacist home visit service for housebound patients found that 30% had not received a medication review for more than five years, while 64% had not received a medicines review for more than two years.
This was despite 66% of the patients involved living with five or more long-term conditions and 70% being at risk of medication-related harm.
In some cases, “patients had gone more than 20 years or had never had a documented medication review”, the lead pharmacist for the project told delegates at the Royal College of Pharmacy’s Delivering a Healthier Wales conference, held in Cardiff on 25 September 2026.
However, a pharmacist home-visiting project has enabled more than half of its patients to reduce their medication, improving rates of falls and hospital visits.
Tracey Witherall, lead pharmacist for Aneurin Bevan Health Board’s Primary and Community Care Academy, shared an update on the Home Visit Project. This has run since summer 2024 and supports 349 housebound patients aged between 23 years and 103 years, with an average age of 80 years.
The project was developed as part of efforts to improve access to care for the area’s most vulnerable patients, who are often frail, with high levels of polypharmacy and multimorbidity, Witherall said.
“Visiting patients’ houses allows me to identify medication adherence issues and safeguarding issues, alongside other challenges such as loneliness, bereavement, poor mental health, housing problems, and unmet care needs.
“All of these factors impact how patients manage and take their medication, and increases the risk of falls, worsens their long-term conditions and can result in avoidable hospital admissions.”
Read full story
Source: The Pharmaceutical Journal. 5 October 2026
Patient Safety Learning

New York governor declares state of emergency after spike in measles cases

The New York governor, Kathy Hochul, declared a state of emergency on Monday in response to a dramatic spike in measles cases in the state.
Hochul’s administration said the emergency declaration was in response to a “growing number of measles cases across rural areas of New York and neighbouring states”, including Pennsylvania, which has been grappling with a deadly outbreak that is its largest in more than three decades.
The declaration expands the pool of people who can administer vaccines against measles and allows more individuals to order testing.
It comes as there have been 108 confirmed cases of measles in New York so far for the year, up from just one reported case in 2023. In Pennsylvania, which neighbours New York, five people have died after contracting the disease, and there have been 198 hospitalisations.
The state surpassed 1,000 measles cases on Monday while Ohio has also seen an increase.
“After reviewing the latest data on measles cases in New York state, I am declaring a State Disaster Emergency to strengthen our ongoing efforts to confront this disease,” Hochul said.
“No one should get seriously ill or die from a vaccine-preventable disease. That is why I have taken steps to increase the number of health professionals who can vaccinate and test. These emergency measures will protect New Yorkers and support our community partners as they work tirelessly to address the spread of this disease.”
Read full story
Source: The Guardian, 6 October 2026
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