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

‘Serious leadership failures’ found at major trust

A major trust has been accused of presiding over “serious and systemic failures in leadership” and rated inadequate in the well led domain by the Care Quality Commission. 
Mid and South Essex Foundation Trust, which was previously rated “requires improvement” in 2022 for the leadership domain, said it accepted the regulator’s findings.   
The CQC said: “Many described a culture where poor behaviours went unchallenged, and where financial pressures were perceived to take priority over quality and safety.
“Staff across all three hospital sites told us they felt disconnected from senior leaders, undervalued, and unable to raise concerns without fear.”   
However, the report, which followed an inspection in May, also said leaders had demonstrated “integrity and compassion” and “the scale of the challenge facing the trust required continued energy, enthusiasm, and tenacity”. 
It added: “The assessment team noted signs of fatigue and pressure, which may impact leaders’ ability to lead effectively during a period of significant organisational change.” 
Read full story (paywalled)
Source: HSJ, 5 November 2025
Patient Safety Learning

‘A national scandal’: Hundreds of victims of cancer-linked pregnancy drug call for public inquiry

At aged 50, Susie Martin has already undergone her fair share of health procedures. She has endured dozens of surgeries - once going through five procedures in a single year - and will need to have screening for the rest of her life.
She believes it’s all because of a drug her mother was given by medics during pregnancy.
Ms Martin is one of the hundreds of victims of a “silent scandal” involving the pregnancy drug diethylstilbestrol - a synthetic form of the female hormone oestrogen, commonly known as DES, which has been linked to cancer. Like many others, she says the drug, also known as DES, caused her to develop a lifelong gynaecological condition. She now lives in fear for her health, facing tests each year to ensure she hasn’t developed cancer.
A campaign group of more than 300 people, including Ms Martin and her mother Jennifer Bradley, is calling on the government to launch a public inquiry to address what it describes as a national scandal.
Clare Fletcher, partner at the Broudie Jackson Canter solicitors, which represents the group, said: “This is the silent scandal, with victims suffering in pain for decades with limited medical support and no government recognition for what they have been through.
“It is one of the most devastating pharmaceutical failures in UK history and the people whose lives have been marred by it deserve answers.”
Read full story
Source: The Independent, 4 November 2025
Patient Safety Learning

‘It’s like the NHS would rather pay a hospital bill over a cheap jab’

Independent readers expressed frustration and disbelief over the government’s decision to restrict free Covid booster jabs to a smaller group of people, describing the move as “a national scandal”.
Many shared stories of being denied the vaccine despite chronic or respiratory illnesses, saying the policy risks leaving vulnerable people like Ella Halpern-Matthews – who has caught Covid three times since losing eligibility – without adequate protection.
Several said they had been forced to pay privately for the jab, effectively creating what they saw as a two-tier health system.
One reader remarked that it felt “as if the NHS would rather pay the hospital bill than for a cheap jab”, while others highlighted the inconsistency of vaccinating care home residents but not staff, and the false economy of cutting the rollout.
Some questioned why countries such as France and Germany continue to offer free or low-cost boosters to wider groups, while the UK “quietly withdrew” access.
Overall, readers urged the government to review eligibility urgently – calling for clearer communication, fairer access, and stronger protection for those still at risk.
Read full story
Source: The Independent, 3 November 2025
Patient Safety Learning

Women must be warned of home birth risks and have access to skilled

Women must be given clearer warnings on the potentially fatal dangers of giving birth at home and should only be aided by experienced midwives, experts have said.
Maternity services worldwide are dealing with an increase in the number of women with more complex pregnancies. Many are choosing to have their baby in a familiar environment, in the comfort and privacy of their own home. Some choose a home birth because having their first baby in hospital was “deeply traumatic” and they are reluctant to repeat the experience.
But access to safe, reliable and unrestricted home birth services is patchy, and varies enormously depending on where you live, experts say. Healthcare services in lots of countries struggle to offer home birth services because of staffing shortages, inconsistent training or local policy limitations. Some have dedicated home birth teams, while others rely on overstretched community staff.
The Guardian has spoken to leading doctors, academics and pregnancy experts about home births after a coroner’s court in Rochdale, England, ruled that a mother and daughter died following a home birth owing to “a gross failure to provide basic medical care”.
Jennifer Cahill, 34, died at North Manchester general hospital hours after suffering a haemorrhage while giving birth at home in Prestwich on 3 June 2024. Her baby, Agnes Lily, was delivered not breathing, with the umbilical cord wrapped around her neck. She died at the same hospital as her mother a few days later.
In England and Wales, about one in 50 births take place at home. However, they are recommended only for low-risk pregnancies. Cahill’s pregnancy was considered high-risk because she had suffered a postpartum haemorrhage after giving birth to her first child in 2021.
Because of this, she was advised to have her second baby in hospital. But her husband, Rob, told the court the dangers of a home birth had not been fully explained. Phrases such as “out of guidance” were favoured, rather than “against medical advice”, and the risk of death was not explicitly raised, the inquest was told.
“This is an unbearably sad case of two avoidable deaths,” said Kim Thomas, chief executive of the Birth Trauma Association, one of the first charities in the world to support women and families who have experienced traumatic births. “We often hear from women who, having had a deeply traumatic first birth in hospital, are reluctant to give birth in hospital again. Some choose not to have another baby, while others opt for home birth.
“Unfortunately, for women like Jennifer Cahill, who had experienced numerous complications in her previous birth, a home birth can be particularly risky. Several things seem to have gone wrong in this case. It seems staff were reluctant to spell out the risks to Mrs Cahill, so she was not able to make a fully informed decision.”
Read full story
Source: The Guardian, 4 November 2025
Patient Safety Learning

Hundreds of lung cancer patients harmed after long waits

Hundreds of lung cancer patients are coming to harm while waiting longer than the 62-day benchmark for starting treatment, according to unpublished data collated by HSJ which ministers have called “shocking”.
The figures, obtained from Freedom of Information requests, also suggest the true figure could be even higher, because around 30% of the 104 relevant trusts did not provide data. A leading expert also warned the findings were likely “a conservative estimate” of the level of harm.
The figures are understood to represent the first time the number of harm reviews relating to lung cancer patient long waits across all English trusts has been quantified.
The findings come as scrutiny around the NHS’s record on cancer is set to intensify in the coming months, with the government set to publish a new National Cancer Plan.
Lung cancer is the leading cause of cancer death in the UK, which has some of the worst survival rates in Europe for the condition, with only about 10 per cent of patients living longer than 10 years. There are around 49,300 cases of lung cancer diagnosed in the UK each year, accounting for 13 per cent of all new cancers.
The 71 responding trusts contacted by HSJ revealed they had carried out 4,574 harm reviews following lung cancer patients breaching the constitutional 62-day target for starting treatment in the two years between 1 January 2023 and 31 December 2024.
Read full story (paywalled)
Source: HSJ, 4 November 2025
Patient Safety Learning

USA: Doctors issue warning about ‘autism drug’ endorsed by Trump administration

A drug endorsed by the Donald Trump administration which allegedly treats against a rare disorder that causes autism-like symptoms has triggered a surge in demand from parents, despite a lack of data supporting its use.
More parents in the U.S. are asking for leucovorin, believing it could unlock speech and social connection in their autistic children.
Paediatricians and specialists caution the science on leucovorin in autistic people as the data is limited and does not support widespread use.
In the month since Food and Drug Administration Commissioner Marty Makary promoted the decades-old drug from GSK, saying it could help hundreds of thousands of autistic children, doctors and researchers say they have been inundated by parents seeking information.
“My Facebook feed is flooded with parents swearing that leucovorin works,” said Dr. David Mandell, a professor of psychiatry and autism researcher at the University of Pennsylvania.
Mandell and other scientists and doctors say Trump’s endorsement, without requiring large, randomized clinical trials, leaves practitioners facing emotional pleas from families while lacking data, guidance or confidence to prescribe the drug responsibly.
Read full story
Source: The Guardian, 1 November 2025
Patient Safety Learning

Patient safety concerns must be raised and acted on, GMC warns as it launches review of key guidance

Doctors, physician associates (PAs) and anaesthesia associates (AAs) must speak up if they spot patient safety concerns, and healthcare leaders must act when issues are raised with them, the General Medical Council (GMC) says as it launches a review of key guidance.
The GMC is seeking views on two pieces of its guidance, Raising and acting on concerns about patient safety and Leadership and management. Both pieces of guidance play crucial roles in setting positive workplace culture standards that prioritise patient safety. They make clear the regulator’s expectations on when and how concerns should be raised, as well as how those in management positions should respond.
The regulator is ensuring the guidance reflects developments across the UK’s healthcare systems, and wider social changes, while remaining clear, relevant and helpful. It will be the first significant updates since they were published in 2012.
Earlier this year results from the GMC’s annual national training survey revealed that more than one in five trainee doctors were hesitant about escalating concerns about patient care, and GMC Chief Executive Charlie Massey warned, in a speech in September, that maternity services were at risk from harmful cultures that put ‘cover-up over candour’ and ‘obfuscation over honesty’.
Professor Pushpinder Mangat, Medical Director and Director of Education and Standards at the GMC, said:
"Our guidance is there to provide support and confidence, as well as practical help, for people to speak up when necessary. But speaking up is no good in isolation. Leaders and managers have a duty to act when concerns are raised with them.
‘Whenever we update guidance, it is important we hear views from a range of respondents. Their voices and real-life experiences will be instrumental in ensuring our guidance is clear, relevant, and helpful, and reflects the needs of everyone it affects."
Read full story
Source: GMC, 3 November 2025
Patient Safety Learning

MHRA calls on public to report side effects and suspected fakes during #MedSafetyWeek

The Medicines and Healthcare products Regulatory Agency (MHRA) is urging the public to help keep medicines, medical devices, vaccines and blood products safe by reporting any side effects, device incidents and suspected fake medical products, as part of #MedSafetyWeek (3–9 November).  
The global campaign is marking its tenth year, bringing together more than 130 regulators and health organisations across 117 countries with one shared message: everyone has a role to play in medicine safety. 
Reporting matters more than ever 
With more people using medicines and medical devices than ever before – from weight loss treatments to wearable monitors – safety reporting is a key part of protecting public health.  
An estimated 2.5 million people in the UK are now using weight loss medicines, many bought online and delivered by post. Thousands use glucose sensors or blood-pressure monitors in the comfort of their own homes. As medicines and medical devices play a bigger role in daily life, including to prevent illness rather than treat it, public reporting of safety concerns is more important than ever. 
Professor Anthony Harnden, MHRA Chair, said:  
“Healthcare has changed significantly over the past decade, alongside advances in science and technology. Medicines and medical devices are part of everyday life for millions of people, and many are accessed in new ways, including online.  
“If you experience a side effect, notice a device isn’t working properly, or suspect a fake medical product, please tell us via the MHRA’s Yellow Card scheme. Your report could protect others – and it only takes minutes.” 
Read full story
Source: MHRA, 3 November 2025
Patient Safety Learning

NHS trials AI prostate cancer tool that could ‘massively improve’ treatment

A new study is set to investigate how AI could significantly improve doctors’ decisions regarding prostate cancer treatment.
While diagnostic methods for the disease have become safer and more precise, medical professionals still face considerable challenges in accurately assessing its aggressiveness in individual patients.
This difficulty can lead to some men undergoing invasive procedures such as surgery or radiotherapy, when a less aggressive monitoring approach might have been more appropriate.
The crucial Vanguard Path study, spearheaded by researchers at the University of Oxford, is being funded with a £1.9m grant from the charity Prostate Cancer UK to address this vital issue.
Experts will first test the technology – called ArteraAI Prostate Biopsy Assay – on prostate biopsy samples from men who have already been diagnosed and treated for the disease and have at least five years of follow-up data.
The study will compare how well the predictions made by the AI tool match what happened to patients in the real world.
It will then be tested in real clinics on biopsies from men as they are diagnosed, with a focus on cases in which doctors find it hard to decide the best course of treatment.
Read full story
Source: The Independent, 3 November 2025
Patient Safety Learning

Thousands of poorest Scots to receive free weight-loss jabs in trial

Thousands of people from some of Scotland's most deprived areas are to be offered free weight-loss jabs as part of government-funded research.
Up to 5,000 people in Scotland will take the injections as part of the multi-million pound study being led by Glasgow University.
The findings will provide insight into the lives of people living with obesity and health inequalities across the UK.
If successful, it could lead to a wider rollout of the injections throughout the country.
The UK government has provided an initial £650,000 for the Scotland CardioMetabolic Impact Study (SCoMIS).
As a leading cause of long-term illness such as heart disease and cancer, tackling obesity will help millions live longer healthier lives and reduce the pressure on health services, potentially saving the NHS billions annually.
UK Health Innovation Minister Dr Zubir Ahmed said: "As a practicing NHS surgeon and Glasgow MP, I know firsthand the impact of the obesity crisis that plagues Scotland – and the litany of health problems it leads to.
"More than 1 in 3 adults in Scotland's most deprived areas are living with obesity. The UK government is committed to tackling inequality wherever it finds it in our country.
"It's why this landmark UK government investment is targeting help where it's needed most in Scotland and meeting people where they are and backing helping the NHS services they trust to treat them."
Read full story
Source: BBC News, 1 November 2025
Patient Safety Learning

‘Everything is either anxiety or your period’: Readers share experiences of being dismissed by NHS GPs

Too often, young people with serious illnesses are dismissed or told they’re “too young” to be sick – and Independent readers have been sharing their own experiences of being ignored by the NHS.
Readers shared experiences of being dismissed by healthcare professionals, and speculated whether that was down to age, gender, or assumptions about their symptoms.
One reader’s story mirrored the challenges faced by patients like 19-year-old Milli Tanner, who went to 13 GP appointments and A&E visits over two years before being diagnosed with stage 3 bowel cancer. She was initially told her symptoms were caused by piles, IBS, or her age, and faced long waits for urgent testing before finally receiving a diagnosis.
Readers highlighted the emotional and physical toll of such dismissal, with one sharing being misdiagnosed for three years despite a private MRI showing multiple active MS lesions.
Another described how a family’s Lynch Syndrome history was overlooked, contributing to preventable deaths from bowel and uterine cancer.
Overall, Independent readers stressed that listening, taking symptoms seriously, and empowering patients are crucial to prevent young people from being failed by the system.
Read full story
Source: The Independent, 2 November 2025
Patient Safety Learning

UK’s unregulated pregnancy scan clinics putting lives in danger, say experts

High street clinics offering pregnancy scans could be putting unborn babies and their mothers in danger through a lack of properly trained staff, UK experts have warned.
According to the Society for Radiographers (SoR), high street clinics have seen a huge growth in numbers. However, hospital specialists say they have seen cases of missed health problems, misdiagnosed conditions, and situations in which women were erroneously told their babies were malformed or had died.
“I had a lady referred for a potential miscarriage from a clinic and when I scanned her they’d measured a bleed in the womb and they completely missed a very early pregnancy sac with a baby inside it,” said Katie Thompson, a hospital sonographer and president of the SoR.
“Potentially, if they were at a private clinic that could offer a miscarriage service, then they could have been given some medication to bring on a miscarriage on a pregnancy that was actually not miscarrying,” she said.
The SoR says it has also seen cases in which private clinics have wrongly told women they have an ectopic pregnancy – a potentially life-threatening condition – or conversely missed an ectopic pregnancy, while they have also misdiagnosed problems with the cervix and missed abnormalities in babies that should have been picked up.
Elaine Brooks, a former hospital sonographer and Midlands regional officer for the SoR, said some people attended their 20-week hospital scan after having had a private “sexing” scan a week or two before.
“And then they come for their NHS scan and there’s quite a large abnormality that should have been picked up – something like spina bifida, polycystic kidneys or fluid-filled ventricles in the head – things that you wouldn’t expect to have developed in a week,” she said.
The revelations come amid calls from the SoR for sonographers to have a “protected” job title – meaning it can be used only by qualified practitioners registered with a regulatory body. This is already the case for titles such as radiographer, dietician and speech and language therapist.
“At the moment, absolutely anybody can go and buy an ultrasound machine and set up a practice without any qualifications whatsoever. And that has happened,” said Thompson. “There has been somebody that bought a machine and started scanning in her front room because after having a baby, she thought it’d be a nice thing to do.”
Read full story
Source: The Guardian, 3 November 2025
Patient Safety Learning

Trusts ‘need help to cut through AI noise’

NHS Providers and IBM have set up an AI productivity centre to help trusts save money when adopting new technology.
The membership group for NHS trusts, which formally agreed to merge with NHS Confederation last week, is working with the global IT firm to accelerate uptake of AI across providers and build understanding among senior leaders.
The masterclasses for members will also cover shared learning on adoption, data privacy and security, and the responsible use of AI.
NHS Providers chief executive Daniel Elkeles said: “Trusts need help to cut through all the noise surrounding AI. From questions about what makes the biggest impact on improving productivity and risk management, to safe and effective adoption that tangibly improves quality of care and staff experience, that’s where we can step in and support our members.
“We need to get much better in the NHS at targeting its use at processes and tasks that enable us to unlock productivity that’s either cash releasing or enables more patients to be treated with the same resource.”
Read full story (paywalled)
Source: HSJ, 3 November 2025
Patient Safety Learning

FDA warnings and reports of ‘internal bra’ complications may lead to a surge in breast mesh lawsuits

Breast mesh implants promoted as “internal bra” supports have become the subject of legal and regulatory scrutiny. Not cleared for this use by the FDA, the mesh implants have been linked to higher rates of infections, reoperation and implant failure.
The “internal bra” technique uses synthetic or biologic mesh in combination with other breast surgeries to lift breasts and enhance results. In November 2023, the FDA released a safety communication emphasizing that no surgical mesh products are cleared or approved for use in breast surgeries. Despite this, mesh products have seen increased off-label use for internal bra techniques in breast surgeries with implants.
There are approximately 100,000 breast reconstruction surgeries per year and more than 300,000 breast augmentation surgeries per year in the US. The use of breast mesh in these procedures could put people at risk of higher complication rates.
Read full article.
Source: Drugwatch, 30 October 2025
Mark Hughes

NHS Lothian faces Scottish Government intervention after damning 'culture of mistrust' report on Edinburgh Royal Infirmary

NHS Lothian will face increased intervention from the Scottish Government, the health secretary has said, after a damning review found a “culture of mistrust” had led to patients being harmed at one of Scotland’s busiest maternity units.
The decision comes as the director of NHS Lothian apologised after a report from Healthcare Improvement Scotland (HIS) found “serious concerns” about staffing shortages for maternity care at Edinburgh Royal Infirmary.
Health Secretary Neil Gray announced in the wake of the report the health board had been escalated to level three on the NHS support framework, meaning “significantly enhanced support” would now be provided. He said a Scottish Maternity and Neonatal Taskforce would be set up, to listen to “women’s experiences of maternity services”, as he said he was “deeply disappointed and concerned” by the HIS report.
Read full article.
Source: The Scotsman, 29 October 2025
Mark Hughes

Left lying in excrement for 20 hours and scenes ‘like war films’: The elderly patients neglected in NHS hospitals

Elderly patients have been left languishing in their own excrement and puddles of urine for hours on end in NHS hospitals, a major charity has said.
Corridor care is a “crisis in plain sight” in A&Es across the country, charity Age UK warned ministers, as it described “truly shocking” incidents of poor care of elderly people waiting days on end for attention.
In a new report, The Longest Wait, Age UK revealed “heartbreaking” incidents of poor care, including a woman dying from a heart attack after being left to wait; a patient who was “lost” after being put on a disused corridor; and a man left hooked up to an IV drip in a chair for 20 hours, who soiled himself because he was unable to get to the toilet.
Age UK warned that many patients are unwilling to go to A&E, even if they are in a life-threatening situation, because of their past experiences.
It called on the government to “urgently” tackle corridor care as it warned that older people are disproportionately affected.
Read full article.
Source: The Independent, 31 October 2025
Related reading
Corridor care and patient safety - a series of blogs shining a light on some of the key patient safety issues surrounding corridor care
Mark Hughes
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

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