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

Change prostate cancer treatment for black men to avoid ‘epidemic’, NHS urged

The NHS must change how black men are treated for prostate cancer to prevent “an epidemic of unnecessary deaths” in which twice as many die as white men, campaigners have warned.
Academics are seeking to raise awareness that one in four black men are getting this cancer, twice the rate of white men, which is one in eight, according to Prostate Cancer UK’s analysis of patient datasets for England. One in 12 black men are at risk of dying of this condition compared with one in 24 white men.
“We are living through an epidemic of unnecessary deaths of black men,” said Stafford Scott a community activist. “Prostate cancer is not colour blind. Not only is the death rate twice as high in black men as white men but we are being diagnosed late and so are coming into the system late.”
Scott, the director of the organisation Tottenham Rights, is teaming up with experts to launch a podcast series calling for fundamental changes in the NHS approach to prostate cancer and its high incidence among black men to prevent many more deaths.
This would reflect Prostate Cancer UK’s call to change “outdated NHS guidelines” so that GPs can be advised to start conversations with black men earlier and discuss with them taking prostate-specific antigen (PSA) blood tests to indicate cancer.
Approximately 55,300 new prostate cancer cases are diagnosed across the UK every year and this figure is projected to rise by 15% in the next 15 years.
Scott suggested that prostate cancer diagnosis and treatment could also be improved through broader NHS reforms, such as improving how it recruits and promotes black staff, including into leadership positions; partnering with black-led organisations to rebuild trust; improving transparency of health data; and increasing independent oversight of the NHS treatment black men receive.
“For too long, black men have been failed by the very system that is meant to keep us well. The result is a cycle of mistrust, late intervention, and preventable deaths,” he said.
Read full story
Source: The Guardian, 24 September 2025
Patient Safety Learning

‘Moral distress’ at trust’s ‘persistently underfunded’ neonates service

“Persistent underfunding” and staff shortages at a teaching trust’s neonatal service is likely to have harmed long-term development of newborn babies, an NHS England review has found.
A peer review of the service at Leeds Teaching Hospitals Trust, commissioned by NHSE, also found “burnout and moral distress” among its staff, linked to a lack of psychological support for them.
The review was one of two commissioned by LTHT to look at its neonatal and maternity care, following concerns. HSJ reported in February that MBRRACE-UK, the national mother and baby mortality audit, showed the trust had the highest extended perinatal mortality in the country in 2023, 2022 and 2021.
A summary of the neonatal review, published in LTHT’s September board papers, said: “This shortfall [in allied health professional staff] not only affects compliance with [National Institute for Health and Care Excellence] guidance for the neonatal follow-up programme but also results in non-compliance with the service specification for inpatient neonatal care.
“As a result, there is likely to be a negative impact on long-term neurodevelopmental outcomes for patients and reduced support for families.”
Read full story (paywalled)
Source: HSJ, 23 September 2025
Patient Safety Learning

Healthcare providers failed to inform most victims of medical error in Oregon, report says

Close to one-third of Oregonians have experience with medical errors like incorrectly prescribed medication or botched surgeries, but providers often failed to adequately inform them of their errors, according to a new report.  
The Oregon Patient Safety Commission released the findings this week in a 16-page state report on medical harm in the past five years, calling it “the first comprehensive review of post-pandemic patient safety data in Oregon.”
The Oregon Legislature created the agency in 2003 with the goal of providing an advocate for patient safety while incorporating the perspectives of medical providers, insurers and consumers.
The survey found that 30% of Oregonians have reported experiencing some form of medical harm in the past few years, whether that involved their own care or “someone close to them.” Medical harm is a broad category that can encompass a wide variety of improper practices or mistakes by doctors and medical providers, which may spiral into further inaccurate treatment plans.
The findings say that victims want to be informed about errors and receive an apology promptly, but that only about one in three receive such redress. When an error results in what the commission calls “serious health consequences,” researchers found Oregonians were less likely to get an apology.
 “The combination of transparency and apology after medical harm is what patients want and expect,” said TJ Sheehy, director of programs for the Oregon Patient Safety Commission, in a statement. “And while this can be challenging in practice, other studies show that providers do want to disclose when harm has occurred.”
Read full story
Source: Oregon Capital Insider, 22 September 2025
Patient Safety Learning

Trump administration slammed by scientists for claiming paracetamol use in pregnancy causes autism

UK experts have condemned “fearmongering” in the US amid reports surrounding an upcoming announcement from Donald Trump’s administration about a link between paracetamol use in pregnancy and autism.
Scientists have hit back, with one saying the claim “risks stigmatising families who have autistic children as having brought it on themselves”.
The Wall Street Journal reported that US health secretary Robert F Kennedy Jr is expected to say Tylenol – which is paracetamol in the UK – is a potential cause of autism.
In the UK, the NHS website says “paracetamol is the first choice of painkiller if you’re pregnant. It’s commonly taken during pregnancy and does not harm your baby”.
Dr Monique Botha, associate professor in social and developmental psychology at Durham University, said: “There are many studies which refute a link, but the most important was a Swedish study of 2.4 million births published in 2024 which used actual sibling data and found no relationship between exposure to paracetamol in utero and subsequent autism, ADHD or intellectual disability.
Dr Botha added: “There is no robust evidence or convincing studies to suggest there is any causal relationship and any conclusions being drawn to the contrary are often motivated, under-evidenced, and unsupported by the most robust methods to answering this question.
“I am exceptionally confident in saying that no relationship exists.
“Similarly, pain relief for pregnant women is woefully lacking and paracetamol is a much safer pain relief option during pregnancy than basically any other alternative and we need to take pain seriously for women, including whilst pregnant.
“The fearmongering will prevent women from accessing the appropriate care during pregnancy.
“Further, it risks stigmatising families who have autistic children as having brought it on themselves and reinvigorates the long pattern of maternal shame and blame as we’ve seen re-emerge repeatedly over the last 70 years where we try to pay the fault of autism at the mother’s door one way or another.”
Read full story
Source: The Independent, 23 September 2025
Patient Safety Learning

'National tragedy' as over 800 patients die amid 'extreme' A&E wait times

More than 800 patients died while enduring lengthy waits for admission to accident and emergency departments across Scotland last year, with the leading body of emergency medicine professionals warning of a “system in crisis.”
In what it described as a “national tragedy,” the Royal College of Emergency Medicine (RCEM) said there were an estimated 818 associated excess deaths related to stays of 12 hours or longer before being admitted to A&E departments.
The death toll - the equivalent of 16 people losing their lives every week - is up by almost a third compared to the 616 estimated deaths in 2023, a trend the RCEM said was “shocking.”
The new analysis by the college found that a record 76,510 patients waited 12 hours or more to be admitted, discharged, or transferred from A&E last year, some 20,432 higher than the figure in 2023. Of those patients, the majority - some 58,906 - were waiting to be admitted to a ward for further care.
Dr Fiona Hunter, vice president of RCEM Scotland, said: “The fact that the deaths of more than 800 patients have been lost due to a system in crisis is a national tragedy. Behind this statistic are stories of heartbreak. Because these are people. Mums, dads, brothers, sisters, grandparents - their deaths shattering the lives of families and friends.
“These are patients who are sick and need further care on a ward. So they are forced to endure extreme wait times for an inpatient bed to become available for them. Often, they will be experiencing this, counting the hours they have been in emergency departments, on a trolley in a corridor, cupboard, or simply any available floor space.”
Read full story
Source: The Scotsman, 23 September 2025
Patient Safety Learning

NHS risks missing ‘new era’ of Alzheimer’s treatment without major reforms, experts warn

The NHS is “simply not ready” for a new era of diagnosing and treating Alzheimer’s disease and is not “keeping pace with the science”, experts have warned.
New drugs and blood tests are set to transform Alzheimer’s care and diagnosis in the coming years, according to a group of 40 expert researchers.
Researchers also say medications donanemab and lecanemab, which are currently not approved for use by the NHS, slow the progression of Alzheimer’s as effectively as treatments for other conditions such as cancer, rheumatoid arthritis, and multiple sclerosis.
Writing in a series of papers published in The Lancet, they warn that without rapid reform, the potential of “major innovations” within Alzheimer’s research will not be realised.
Dr Richard Oakley, associate director of Research and Innovation at Alzheimer’s Society, said the series of papers published in The Lancet “mark the beginning of a new era in Alzheimer’s disease diagnosis and treatment”.
However, he added, “The painful truth is that the NHS is simply not ready and isn’t keeping pace with the science.
“We now run the very real risk that people living with dementia will miss out on the opportunity to benefit from these big breakthroughs.
“It’s vital that the UK government keeps its eye on the ball so people with dementia aren’t left behind. We want to see better access to early diagnosis so people don’t miss out on the narrow window of eligibility to benefit from treatments which can slow Alzheimer’s disease.
Read full story
Source: The Independent, 22 September 2025
Patient Safety Learning

Violence in GP surgeries driven by waiting times and drug refusals, global study shows

Violence and abuse by patients against staff in GP clinics is widespread globally and usually triggered by long waiting times and the refusal to prescribe requested drugs, research shows.
The findings are based on a 24-country study of the threats and aggression that family doctors, receptionists and other practice staff experience at work.
As many as nine out of 10 GP surgery personnel have suffered a physical or verbal assault during their career – in some cases the same proportion reported it over the previous 12 months.
The threatening behaviour can damage workers’ mental health, increase their stress levels and lead to them wanting to quit.
The research, by Shihning Chou, an associate professor of forensic psychology at the University of Nottingham, is the first to look at aggression against GP staff as a global phenomenon. She based her findings on an analysis of 50 previous studies from 24 countries, including the UK, China, Australia, Germany, Ireland, Kuwait and Barbados.
Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners, which represents family doctors in the UK, said: “That incidences of abuse against GPs and our teams are so widespread – and as this research shows, not just in the UK – is extremely distressing. It’s entirely unacceptable for anyone working in general practice to be at the receiving end of abuse of any kind, when they’re just trying to do their jobs.”
Some assaults are so distressing that GPs call the police or remove perpetrators from their practice list, she added.
Read full story
Source: The Guardian, 23 September 2025
Patient Safety Learning

Jessica Brady's legacy inspires new life-saving GP safety rule

Patients with a potentially deadly illness will be diagnosed sooner through a new life-saving patient safety initiative called Jess’ Rule that is being rolled out across the NHS in England today.
Jess’s Rule is named in memory of Jessica Brady, who died of cancer in December 2020 at the age of 27, and will help avoid tragic, preventable deaths as GPs are supported to catch potentially deadly illnesses sooner. 
In the five months leading up to her death, Jessica had more than twenty appointments with her GP practice but eventually had to seek private healthcare. She was later diagnosed with stage 4 adenocarcinoma. With such an advanced disease there was no available treatment. She was admitted into hospital where she died three weeks later.
The new initiative will ask GPs to think again if, after three appointments, they have been unable to offer a substantiated diagnosis, or the patient’s symptoms have escalated.
While many GP practices already use similar approaches in complex cases, Jess’s Rule will make this standard practice across the country, aiming to reduce health inequalities and ensuring everyone – no matter their age or background – receives the same high standard of care.
Designed in collaboration with the Chair of Royal College of General Practitioners (RCGP) and NHS England, Jess’s Rule will help to catch serious conditions earlier and support GPs with guidelines that bolster their clinical judgment, while encouraging them to reflect, review and rethink if they are uncertain about a patients’ condition.
Jess’s Rule could support GPs to ensure continuity of care for patients with persistent health concerns. This could involve arranging face-to-face consultations if previous appointments were remote, conducting thorough physical examinations, or ordering additional diagnostic tests.
It also encourages GPs to review patient records comprehensively, seek second opinions from colleagues, and consider specialist referrals when appropriate.
Read full story
Source: Department of Health and Social Care, 23 September 2025
Patient Safety Learning

The 16 trusts forced to retest thousands of patients

The full list of 16 trusts which are retesting tens of thousands of patients who may have been wrongly diagnosed with diabetes can be revealed by HSJ.
Concerns about over-diagnosis first emerged last year, linked to problems with a device used to monitor glucose levels. But NHS England has so far declined to identify all the trusts involved.
Now, HSJ  has checked accreditation certifications to confirm which trusts use the Premier Hb9210 HbA1c analyser, manufactured by Trinity Biotech, and can reveal the full list for the first time.
They include several trusts not previously linked with the issue in public: Calderdale and Huddersfield Foundation Trust; Mid and South Essex FT; Airedale Hospitals; University Hospital Bristol and Weston FT; Stockport FT and Hull University Teaching Hospital Trust.
They join nine others who are publicly known to have been impacted following HSJ’s coverage last year, or information posted online. These are Norfolk and Norwich University Hospitals FT; South Tees Hospitals FT; York and Scarborough FT; West Hertfordshire Teaching Hospitals Trust; Maidstone and Tunbridge Wells Trust; Barking, Redbridge and Havering University Hospitals Trust; Chesterfield Royal Hospital FT; and County Durham and Darlington FT.
The Medicines and Healthcare products Regulatory Agency said in a notice in July it had received reports of a positive bias in results which have resulted in patients being incorrectly diagnosed as pre-diabetic. It said the manufacturer would update its instructions to clarify frequency of preventative maintenance required.
Read full story (paywalled)
Source: HSJ, 23 September 2025
Patient Safety Learning

USA: Trump officials reportedly set to tie Tylenol to autism risk

Donald Trump’s administration is on Monday expected to tie pregnant women’s use of the popular medicine Tylenol – known as paracetamol elsewhere in the world – to a risk of autism, contrary to medical guidelines, the Washington Post has reported.
Trump officials are also expected to announce an effort to explore how the cancer and anemia drug leucovorin could purportedly and potentially treat autism, according to the Post report published Sunday, which cited four sources with knowledge of the plans who spoke on the condition of anonymity because the announcement had not been made.
Medical guidelines say it is safe for pregnant women to take Tylenol, the over-the-counter pain medication whose active ingredient is known as acetaminophen in the US and paracetamol elsewhere in the world. But, as the Post noted, federal health officials have been reviewing previous research – including an August review by researchers from Harvard University and Mount Sinai hospital – that suggested a possible link between Tylenol use early in pregnancy and an increased risk of autism in children.
Earlier in September, the Wall Street Journal reported that Trump’s health secretary Robert F Kennedy Jr planned to announce that use of Tylenol by pregnant women was potentially linked to autism, which is defined as a neurodevelopmental condition marked by social as well as communication difficulties and behaviors that are repetitive.
As the Post reported, some medical trials involving administering leucovorin to children with autism have shown “what some scientists describe as remarkable improvements in their ability to speak and understand others” – though those trials are considered early.
Kennedy has claimed that the US is in the grip of an “autism epidemic” fuelled by “environmental toxins”.
Read full story
Source: The Guardian, 21 September 2025
Patient Safety Learning

Racism and marginalisation led to ‘tragic outcomes’

“Racism and marginalisation” at Nottingham University Hospitals Trust meant families “felt pushed out” and resulted in “tragic outcomes”, according to the chair of the inquiry into its maternity services. 
Senior midwife Donna Ockenden told HSJ’s Patient Safety Congress that talking to the hospitals’ “wider community” found “significant evidence of racism, marginalisation… ignoring, turning the backs on” people.
“A whole community felt pushed out in the cold,” she said, and families had been confronting a “brick wall” when dealing with the maternity unit.
They met an attitude from staff that “you are not coming in here, we are not listening to you, you can’t be in labour, we know what we are doing, and you don’t,” Ms Ockenden said. “There were a number of really tragic outcomes, with babies being born in the wrong place without the correct equipment.”
Some 2,460 families’ cases are now formally included in the review, and there were a further 520 which could be learned from, she said. There are 850 current and former staff engaged, and Ms Ockenden said she was working closely with current trust leadership. She said several senior doctors had told her team they had raised safety issues at earlier stages.
Read full story (paywalled)
Source: HSJ, 22 September 2025
Patient Safety Learning

Calls to overhaul NHS spending to fund weight-loss jabs for millions

Ministers should overhaul the NHS spending watchdog to enable millions more people to be put on weight-loss jabs, Tony Blair’s think tank has said.
Experts are calling for the National Institute for Health and Care Excellence (Nice), which decides which drugs the NHS should buy, to start factoring in the wider economic benefits of medication rather than just their health effect.
The Tony Blair Institute for Global Change (TBI) has calculated that giving weight-loss jabs such as Mounjaro and Wegovy to 15 million eligible overweight adults would save the economy £52 billion in the long term. By cutting rates of illnesses such as heart disease, people would stay in work for longer, saving billions of pounds in benefit payments and increasing tax revenues.
There are 15 million obese adults in the UK who could benefit from weight-loss jabs but the NHS is embarking on a rollout of Mounjaro, offering it to just 220,000 people over three years. The NHS has said it cannot afford a mass introduction.
Dr Charlotte Refsum, the director of health policy at TBI, said Nice should consider “the wider economic benefit of medications because a healthy working-age population drives economic growth”. She added: “Prevention should be part of the Treasury’s growth agenda and Nice’s remit should be expanded to consider the macroeconomic benefits of medicines, including anti-obesity drugs.”
Read full story (paywalled)
Source: The Times, 19 September 2025
Patient Safety Learning

Student left in agony after untreated decay led to abscess that nearly caused sepsis

A student described as "traumatised" has been awarded a £26,000 settlement from her former dental practice after alleged negligence led to a severe abscess and a near-sepsis incident.
Katelyn De Blick, then 16 and from Keighley, West Yorkshire, sought treatment at her local Skipton Road Mydentist practice in summer 2021 for a cracked tooth. Instead of addressing underlying decay, the tooth was reportedly cleaned and covered with a sealant.
Weeks later, Ms De Blick returned to the practice experiencing "severe pain and a swollen jaw."
She was diagnosed with a potential infected abscess, given antibiotics, and advised to attend A&E if her condition worsened.
As the "throbbing, stabbing" pain and swelling persisted, Katelyn’s mother took her to Airedale General Hospital’s A&E department.
There, she was informed that the tooth required immediate removal and that the abscess posed a significant risk of causing sepsis.
She subsequently underwent surgery under general anaesthetic at Bradford Royal Infirmary. Medics removed the tooth and drained the abscess externally, leaving her with a "painful" open wound for several weeks and a lasting 50p-sized scar.
“The whole experience was traumatic.”
After being put in touch with the Dental Law Partnership, which completed further investigations and analysis, it was revealed Katelyn’s dentists failed to diagnose and treat decay for years.
The progression of the decay resulted in the infected abscess, the emergency hospital admission and the need for an operation and tooth removal, all of which “could have been easily avoided”.
“It was frustrating and devastating to hear that, if they had just taken a few more minutes to clean (the tooth), then I wouldn’t have had to go through all of this,” she said.
The Dental Law Partnership took on Katelyn’s case in 2021 and it was successfully settled in January 2025, when she was paid £26,000 in an out-of-court settlement.
Read full story
Source: The Independent, 22 September 2025
Sam

Ambulance staff arrested in deaths probe

Two ambulance workers in the South West have been arrested as part of a major investigation into six deaths, a trust and police have confirmed.
Wiltshire police today said a man in his 30s was arrested in June 2024 on suspicion of six counts of gross negligence manslaughter and four counts of ill-treatment or wilful neglect by a care worker, while a 59-year-old woman was arrested in March this year on suspicion of gross negligence manslaughter.
Both individuals, who have since been released on conditional bail, were employees of South West Ambulance Service Foundation Trust in 2023 when Wiltshire police began its investigation following an initial report.
SWASFT confirmed that both individuals were suspended “as soon as the trust became aware of any concerns” and that one of the two individuals “is no longer employed by the trust”.
Police said the arrests relate to an investigation into “several adult deaths in and around Wiltshire”.
SWASFT said it wanted to “reassure people that this is an isolated situation and there is no on-going risk to patients”.
Read full story (paywalled)
Source: HSJ, 19 September 2025
Patient Safety Learning

CEO blames IT system for diagnostics slump

A chief executive has blamed his trust’s electronic patient record for the collapse of its diagnostic performance.
Professor Clive Kay told his board at King’s College Hospital Foundation Trust that the implementation of Epic in October 2023 had contributed to the organisation dropping to the bottom tenth of national rankings for diagnostic waiting times.
At last week’s public meeting, Professor Kay said the trust had fallen from being ranked 11th-best nationally for diagnostic waits to 11th from the bottom.
“As good as Epic is, the radiology elements of Epic were really very challenging for colleagues,” he told his board.
Electronic patient record systems from USA-based Epic have a reputation for having a lot of functionality, but being particularly expensive.    
While the rollout did not affect the range of diagnostic tests the trust was able to carry out, it caused significant disruption, including data migration discrepancies that affected the accuracy and availability of migrated records, as well as a number of manual workarounds required.
While no patient harm has been identified, a review is underway which includes a structured harm assessment.
Read full story (paywalled)
Source: HSJ, 19 September 2025
Related reading on the hub:
Electronic patient record systems: Putting patient safety at the heart of implementation
 
Patient Safety Learning

Turkey dental work leaves woman in constant pain

A woman has said she is living in constant pain and is unable to breathe through her nose after having dental work in Turkey.
Leanne Abeyance, 41, from Telford, said she had been left with a painful, infected face and the implants could not be removed due to the infections.
Her dental work also caused a collapsed septum which she said the NHS would not fix as it was deemed a cosmetic procedure.
She spent £3,000 on the initial treatment, she said, and has since spent another £2,000 on private work at home to relieve the pain. The government has warned people about the risks of travelling abroad for cosmetic procedures.
"Every day I wake up and I can't breathe through my nose," Ms Abeyance, a DJ and producer, said.
She decided to travel to Antalya in April 2024 to get four dental implants after previously having veneers fitted in the country.
She said she had been quoted about £50,000 to get the work done in the UK but found a dental practice in Antalya which took £3,000 in cash up front.
The NHS guidance is that while being treated abroad might be cheaper than the UK, the risks need to be weighed against the savings.
It adds that patients should consult their NHS dentist first as standards vary in different countries.
Read full story
Source: BBC News, 17 September 2025
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