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

GPs asked to report patient harm after trust failed to send over 14k discharge letters

A hospital trust has failed to send over 14,000 discharge letters to GPs due to ‘a failure’ in the process, Pulse has learnt.
University Hospitals of Leicester (UHL) told Pulse it discovered that 14,443 discharge letters were not digitally sent to GP practices between March 2023 and March 2024.  
The trust said that an audit of a ‘random selection’ of 120 patient records covering the period has been conducted to ‘check for any potential patient harm’.
GPs were not asked to go through the backlog but they were asked to contact the trust if they have ‘any concerns’ that patients have ‘come to harm as a result’ of the practice not receiving a hospital letter during the affected period.
GPs with concerns have been sent information on how to get in touch with the trust, UHL said.
This is the latest in a series of similar incidents uncovered by Pulse during the past two years, which led to chaos for GP practices having to deal with backlogs and to anxiety for patients whose clinical information could have been missed.
Leicester, Leicestershire and Rutland (LLR) LMC chief executive officer Dr Grant Ingrams said that the LMC and the trust agreed that the additional workload of having to check thousands of letters ‘would be disproportionate for practices’.
He said: ‘For example, it would not just be reconciliation of medication, but the practice would then need to look through every clinical interaction since the date of discharge (within and external to the practice) to check if there had been any subsequent changes.’
He said that the backlog ‘could cause some issues with patients’, mainly because the practice would not have received a final message to say why a patient had been in hospital.
Read full story
Source: Pulse, 26 September 2025
Patient Safety Learning

Labour ‘on course to miss’ key NHS pledge on waiting times

Labour is unlikely to meet its key election pledge on tackling NHS waiting lists, analysis has suggested.
Sir Keir Starmer was elected after promising that 92% of routine operations and appointments would be carried out within 18 weeks by 2029.
However, a major report by the Health Foundation think tank said that, at the current rate of progress, Labour would “fall short of delivering on its headline pledge”.
The overall hospital waiting list stands at 7.4 million, down from 7.6 million when Labour took office. But it has risen for the past two months, and currently only 61 per cent of patients are seen within the 18-week target.
The report said that based on current trends, the overall waiting list will be 4.7 million at the time of the next general election in four years’ time. This would be the lowest figure since 2021, but not low enough to meet the election pledge.
It also warned that further disruption, such as another wave of junior doctors strikes, could make it even harder to lower waiting lists.
Dr Francesca Cavallaro, a senior analytical manager at the Health Foundation, said: “The scale of the challenge remains significant, and even getting close to meeting the target would be a considerable achievement. This will require not just more activity, but smarter use of resources and continued investment in the NHS workforce and infrastructure. And there are several factors that could hold back progress, including if future referrals rise faster than expected and the potential impact of further industrial action."
Read full story (paywalled)
Source: The Times, 25 September 2025
Patient Safety Learning

Misinformation warning as vaccine uptake drops

Yorkshire has recorded one of the sharpest drops in childhood vaccination rates in England, with uptake in Bradford among the worst nationally.
NHS data shows the proportion of two year olds in the region who have received their first dose of the vaccine fell from 92.8% in 2018-19 to 90.1% in 2023-24.
Health authorities warn that coverage needs to reach 95% to prevent outbreaks of the viruses.
Andrew Taylor, interim director of public health at Bradford Council, said the authority was working hard to address the issue, adding that misinformation was partly to blame.
"We really do want to improve the rates of immunisation," he said.
"It is disappointing to see that we're lower in this latest period than we really wanted, because we're putting in a lot of work to encourage people."
He said there was a growing feeling of reticence around vaccinations, saying people were becoming "more hesitant than they used to" and criticised those in the public eye who cast doubt on vaccine safety.
"Any politician, as far as I'm concerned, who promotes ideas that vaccinations don't work is actually putting the public at risk and should think very carefully before they spread that [message]."
Read full story
Source: BBC News, 26 September 2025
Patient Safety Learning

Government steps in to ‘accelerate’ AI in the NHS

AI regulation will be clarified by a major commission to help the NHS and investors “accelerate uptake”, the government has announced.
Science and technology minister Liz Kendall said the commission aims to make the NHS “the most artifical intelligence-enabled healthcare system in the world”, promising to end “regulatory uncertainty currently holding the tech back”.
The announcement specifically mentioned ambient voice technology, a relatively simple form of AI, that recently reported impressive time savings during a trial at NHS trusts.
The Commission will produce a “new regulatory rulebook for AI in healthcare” next year, superseding the current rules.
Read full story (paywalled)
Source: HSJ, 26 September 2025
Related reading on the hub:
Balancing promise and risk: AI hallucinations, confabulations and omissions in healthcare Patient safety and the role of AI in a cautiously optimistic future: A blog by Ian Fearnley
Patient Safety Learning

WHO rejects Trump’s claims of link between Tylenol and autism

The World Health Organization (WHO) is pushing back against contested claims by the Trump administration that acetaminophen use during pregnancy heightens the risk of autism, further underscoring that no scientific consensus supports such a connection.
“Extensive research, including large-scale studies over the past decade, has found no consistent association,” the agency said in a Wednesday statement.
“[The] WHO recommends that all women continue to follow advice of their doctors or health workers, who can help assess individual circumstances and recommend necessary medicines.”
The concern had escalated earlier in the week when Donald Trump, alongside senior health officials including Robert F Kennedy Jr, issued a warning about acetaminophen, the active ingredient in Tylenol, alleging it contributes to rising autism rates. The announcement also included plans for a new study examining potential links between childhood vaccines and autism.
“Taking Tylenol is not good … all pregnant women should talk to their doctors about limiting the use of this medication while pregnant,” Trump said on Monday.
WHO stressed that all medications should be used with caution during pregnancy, especially in the early stages, but pointed out that previous studies raising alarms about acetaminophen were flawed and have since been discredited.
The organization also reaffirmed its stance on vaccines and said that “large, high-quality studies from many countries have all reached the same conclusion” – that vaccines do not cause autism. It emphasized that over the past five decades, global immunization efforts guided by the agency have prevented at least 154 million deaths.
The vaccine schedule “remains essential for the health and wellbeing of every child and every community”, it said.
Read full story
Source: The Guardian, 24 September 2025
Patient Safety Learning

Unsafe abortions and no antenatal care: aid cuts hit women hardest in one of Africa’s poorest countries

Ablue, burgundy and white patterned wrapper hides the swell of Joanna Banda’s belly. Eight months pregnant, she has had just three of the five antenatal appointments she should have had. She is unlikely to attend her final three either, as she still has to save 3,000 kwacha (£1.28) for a bicycle to take her six miles on rutted dirt tracks to the nearest health centre when she goes into labour.
In remote villages in Malawi, pregnant women such as 22-year-old Banda, who has one child after losing her first soon after giving birth, are struggling to get the medical care they need.
In January, US aid cuts abruptly ended a rural healthcare outreach programme that was starting to reduce the number of local women dying in childbirth.
Momentum Tikweze Umoyo, a five-year $28m (£20m) programme aimed at cutting maternal and infant mortality rates in five of Malawi’s 28 districts, was meant to last until 2027.
It is just one of the many casualties of Donald Trump’s decision to suspend foreign aid just hours after taking office in January, risking the lives of some of the world’s poorest, most vulnerable people. In July, Congress approved $9bn in cuts to aid and public broadcasting. Last month, the US president said he would be cancelling $4.9bn in aid already approved by Congress.
Kafulatira, where Banda lives, was once regularly visited by a mobile clinic, but villagers now have to walk 11 miles to the nearest health centre. 
A mobile clinic used to visit the community every month or so, providing a private space for women to get screening for cervical and other cancers, HIV tests and treatment, and vaccinations for children. It also provided antenatal checkups and family-planning services, including contraception.
“The outreach clinics were helping a lot, because we could access services right here in the village,” Mulirani Gerard says through a translator. “Since last year, we had been waiting for the team to come, so we were just wondering what had happened.” No one told villagers why their healthcare had been cut.

Read full story
Source: The Guardian, 25 September 2025
Patient Safety Learning

Disabled children facing ‘national crisis’ as thousands wait months for wheelchairs

Thousands of children are facing long waits for vital wheelchairs as NHS rejections rise, and the UK’s only charity has been forced to stop taking new patients due to a surge in demand.
Whizz Kids, the UK’s leading charity for specialist wheelchair services, has warned patients are facing a “national crisis” after unprecedented pressure on its services has forced it to close to new referrals for the first time in over three decades.
The charity’s leaders said demand has risen 12.5% year on year because more children are being rejected by the NHS for specialist wheelchairs, which cost on average £4,800, due to cost concerns.
One of those children, Charlie Drinkwater, who has spina bifida and growth hormone deficiency, has been denied a specialist chair by the NHS for the past five years.
Although she is eight years old, she is the size of a two-year-old, and so she needs a specialist chair, which could cost up to £4,500. However, due to budget constraints, the NHS does not provide chairs for under-five-year-olds, according to Whizz Kids. The NHS would only offer her a buggy, despite being eight years old.
Now, having grown out of the first chair provided by the charity, and having again been rejected by the NHS, Charlie’s childhood is on hold while she waits for a new one.
She told The Independent: “I’m excited for my new chair because it’s going to be pink. But it makes me sad when it takes a long time.”
Read full story
Source: The Independent, 25 September 2025
Patient Safety Learning

Head nurse describes 'chaotic' night baby died

The night a baby died with an undiagnosed heart condition in a Kent hospital was "quite chaotic", a court has been told.
Head nurse Ronald Carrido was giving evidence at an inquest into the death of seven month-old Tommy Kneebone on 21 January, 2023, at Tunbridge Wells Hospital in Pembury, Kent.
Mr Carrido told the inquest he called for consultant help "when there was no improvement in Tommy, when he was deteriorating".
The boy's mother, Shanice Kneebone, previously told Kent and Medway Coroner's Court in Maidstone that "no-one took her concerns seriously" at the hospital.
At the hearing on Wednesday, his parents also heard from the consultant on duty that night.
Breaking down in tears, Doctor Chhaya Patankar told the inquest when she went into his room at 19:00 GMT, Tommy looked at her with "such bright, beautiful eyes".
The paediatric consultant said she examined Tommy, listened to his heartbeat and checked his liver.
He "responded like any baby would do," she said.
Dr Patankar said the baby had mild respiratory distress, which "fitted with" what she had been told.
"But there was a lack of the broader picture," she said.
Read full story
Source: BBC News, 24 September 2025
Patient Safety Learning

Women who miss first breast cancer screening at ‘40% higher risk’ of dying from the disease

Women who miss their first breast cancer screening appointment have a 40% higher risk of dying from the disease, according to a new study.
Experts at the Karolinska Institute in Sweden analysed data for about half a million women across Sweden, with the findings published in the British Medical Journal. The women all received their first screening invitation between 1991 and 2020 and were monitored for up to 25 years.
After taking into account social, economic, reproductive, and health-related factors, the researchers found almost one in three (32%) women did not attend their first mammogram appointment.
Not attending a first screening was linked with a significantly higher risk of breast cancer death – 9.9 deaths per 1,000 women over 25 years – compared with seven in those screened.
These women were also less likely to attend subsequent screenings and were more likely to be diagnosed with advanced stage breast cancer than those who were screened.
In contrast, the 25-year breast cancer rate was similar between groups. This suggests that the higher death risk among those not attending a first appointment reflects delayed detection rather than increased incidence of the disease, the team said.
The researchers wrote: “First screening non-participants had a 40% higher breast cancer mortality risk than participants, persisting over 25 years.
“If early screening behaviour is predictive of later stage diagnosis and mortality risk, it could provide a valuable opportunity to identify populations at high risk decades before adverse outcomes occur.”
Read full story
Source: The Guardian, 24 September 2025
Patient Safety Learning

‘Lack of curiosity’ contributed to stillbirths, review finds

An area with high stillbirth rates has found there were “significant” gaps in maternity care in more than one in five cases, in a newly published review.
The review of stillbirths across the Black Country was commissioned by its local maternity and neonatal system (LMNS), following an increase in rates since 2020. 
The review, dated March 2024, has just been published by the integrated care board, after repeated requests from HSJ  and others.
It states that stillbirths and neonatal deaths were both continuing to increase in 2023, but “this is at a more significant rate for stillbirths”.
More than a fifth (22.5%) of the reviews identified “significant modifiable factors” – where different management might have saved the baby’s life – and 42.5% found “minor modifiable factors”, which are issues that may have contributed but are unlikely to have changed the outcome.
The review, carried out by a panel of senior local clinicians, sets out a wide range of shortcomings in the cases, and recommendations.
It gives several examples where there is a failure to pursue apparent concerns and warning signs during pregnancy.
Under issues with “risk assessment”, the report says: “There was a concern that there appeared to be a lack of professional curiosity. Particularly in relation to medical problems that occurred during the pregnancy and the discord between the plans for pregnancy care and the implications of the medical problems and their effect on the pregnancy and care.”
Read full story (paywalled)
Source: HSJ, 25 September 2025
Patient Safety Learning

‘Fuzzy’ NHS management standards to be revised

The NHS’s first proposed skills framework for managers has too much “fuzzy language” and needs to be simplified, the NHS England board has decided.
It is meant to give clinical and non-clinical NHS management its first “code of practice, defined set of standards and competencies [and] a national development curriculum” and to “elevate NHS management and leadership as a recognised professional discipline”.
It should “work alongside” the government’s proposed management regulation and “any potential future accreditation [system]”, a board paper said.
It responds to recommendations from a 2019 review of the “fit and proper person test” by Tom Kark KC, and the 2022 Messenger review of NHS leadership, as well as renewed support for management standards and accountability after Lucy Letby’s conviction for murdering babies in Chester.
But NHSE chair Penny Dash told the NHSE board meeting that officials needed to “tighten up” the current document and its language, and include clearer methods for measuring leaders’ performance.
She said: “I have to say I had a bit of a personal problem with some of the language in here. This one on self-effectiveness [says], ‘keep safe’.
“What does that mean? Does that mean I walk slowly down the corridor? We keep using that word, I wouldn’t know what that meant.
“We’ve also got things in here like ‘patient-centred care’, I don’t know what that means. We’ve got a whole lot of really good patient experience metrics, which we could be aspiring to, so we’ve got a bit too much fuzzy language in here.
“I think we need to be much clearer on the sorts of things we have been talking about [at the board] today, like ‘do we have a group of managers who can really think about resource allocation?’
“We do refer to that but I’m not sure it’s quite tight enough.”
Read full story (paywalled)
Source: HSJ, 24 September 2025
Patient Safety Learning

NHS trust wrongly claimed £5m for maternity care

An NHS trust at the centre of concerns over its poor maternity services has had to repay almost £5m after wrongly claiming it provided safe care to mothers and their babies.
Leeds Teaching Hospitals NHS Trust was paid the money after saying its services met safe standards of care and staffing.
But a subsequent investigation by the health service's litigation arm, NHS Resolution, found the trust had not met the standards and asked for the money to be repaid to the NHS.
The trust received the money under a programme called the Maternity Incentive Scheme, which is run by NHS Resolution to encourage the health service to provide good maternity care.
Hospitals are asked to judge their performance against a range of standards, including listening to patients' concerns, staffing levels and properly investigating deaths.
If a trust meets all 10 safety measures, it can get a rebate on its insurance premiums as well as a share of the money paid by trusts that do not meet all the goals.
For the past two years, the Leeds trust reported it had met all 10 standards and was paid £4,887,084 from the scheme.
But the regulator, the Care Quality Commission (CQC), published a damning report in June about maternity services at the trust. Care was rated as inadequate, the lowest level, and it warned that women and babies were being exposed to "significant risk".
The report prompted NHS Resolution to ask Leeds to re-examine its submissions to the Maternity Incentive Scheme. The subsequent review found not all safety standards had been met, forcing the trust to repay all the money it had received.
Read full story
Source: BBC News, 24 September 2025
Patient Safety Learning

Pharmacies to offer toddler flu spray vaccination

Thousands of pharmacies in England will offer free NHS flu spray doses to toddlers for the first time this year.
The vaccination is given via a child's nose and two and three-year-olds could previously access them at their GP surgery.
Around 4,000 pharmacies have signed up to deliver the vaccine to 1.2 million eligible toddlers from 1 October.
Both walk-in and booked flu vaccine appointments will be available as part of the NHS drive to increase vaccine uptake nationally.
NHS England stats show that last winter, there were more than 300,000 hospital bed days taken up by patients with flu – almost double the previous winter.
It's a situation Health Minister Ashley Dalton said "we cannot afford a repeat of" this year.
The hope is that by vaccinating young children, they are not only protected from catching flu, but they will also not pass the virus on to others.
Read full story
Source: BBC News, 24 September 2025
Patient Safety Learning

Home-birth system is a ‘risk to patient safety’, audit finds

The current home-birth system in Ireland creates a “risk to patient safety”, an internal health audit has found.
The Health Service Executive (HSE) audit reached this finding as there is no agreed maximum safe travel time to the nearest maternity unit or self-employed community midwife (SECM).
In February 2022, the home-birth service was moved from community operations to acute operations and is now integrated into the 19 maternity services nationwide.
In light of this, the HSE conducted an audit to establish the “adequacy and effectiveness of governance and risk management” of the home-birth service.
The auditors examined three sites – Cork University Maternity Hospital, Rotunda Maternity Hospital and the Coombe Maternity Hospital – and reviewed 30 midwifery notes relating to home births that occurred from March 1st, 2023, until February 29th, 2024.
It found weaknesses in the system of governance across all three sites that the audit said created a “significant risk that the system will fail to meet its objectives”.
According to the audit report, there is “no national governance structure in place” for home births as acute operations no longer has oversight due to the reorganisation of the HSE into the six health regions.
Read full story
Source: Irish Times, 23 September 2025
Patient Safety Learning

Patients complain about disruption following new EPR in Sheffield

Patients have complained about disruption to outpatients bookings and waiting lists following the introduction of  a new electronic patient record (EPR) system at Sheffield Teaching Hospitals NHS Foundation Trust.
The trust went live with its £85 million Oracle Cerner EPR in July 2025, following an eight month delay to deal with “outstanding issues” around system and organisational readiness.
Following the go live, Clive Betts, MP for Sheffield South East, wrote to Kirsten Major, chief executive of the trust, stating that constituents had “serious concerns about an ongoing failure in the hospital’s digital patient records system that has persisted for a number of weeks”.
“According to these reports – which specifically mention cardiology and potentially other departments – the trust’s electronic system has been ‘down’ or malfunctioning in a way that waiting list data and patient records have gone missing or become inaccessible.
“In one case a patient was informed by staff that the cardiology department no longer knows who is on their waiting list due to this system issue.
“Understandably, this situation is causing anxiety to patients who are unsure if they remain in the queue for treatment or have ‘fallen off’ the list through no fault of their own,” the letter says.
Responding to the concerns, Major told Digital Health News: “A change of this magnitude and scale is bound to have some initial issues to resolve and we have had disruption to some of our outpatient appointment booking processes and correspondence.
“We picked this up very quickly and thanks to the amazing work of our staff many of the clinics affected have already been corrected, and we have a programme of work to complete the remainder as quickly as possible to limit any impact on existing waiting times.
“Our clinical teams are continuing to triage and prioritise the most urgent appointments as normal, and all patients will be contacted as soon as their appointment is ready to be scheduled in line with the waiting time for that clinic or service.”
Read full story
Source: Digital Health News, 24 September 2025
Related reading on the hub:
EPR systems and concerns about patient safety (Patient Safety Learning)
Patient Safety Learning

MHRA confirms taking paracetamol during pregnancy remains safe and there is no evidence it causes autism in children

Following the announcement by US President Donald Trump that US physicians will soon be advised not to prescribe paracetamol (known as Tylenol in the US) to pregnant women, Dr Alison Cave, Chief Safety Officer at the Medicines and Healthcare products Regulatory Agency (MHRA), said:
"Patient safety is our top priority. There is no evidence that taking paracetamol during pregnancy causes autism in children.   
"Paracetamol remains the recommended pain relief option for pregnant women when used as directed. Pregnant women should continue to follow existing NHS guidance and speak to their healthcare professional if they have questions about any medication during pregnancy. Untreated pain and fever can pose risks to the unborn baby, so it is important to manage these symptoms with the recommended treatment. 
"Our advice on medicines in pregnancy is based on rigorous assessment of the best available scientific evidence.  Any new evidence that could affect our recommendations would be carefully evaluated by our independent scientific experts. 
"We continuously monitor the safety of all medicines, including those used during pregnancy, through robust monitoring and surveillance. We encourage anyone to report any suspected side effects to us via the Yellow Card scheme."
Read full press release
Source: MHRA, 23 September 2025
MHRA factsheet on taking paracetamol while pregnant:
Factsheet - Paracetamol and Pregnancy.docx
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