Skip to content

News

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

Best and worst-performing NHS Trusts in England named

New league tables rating the performance of NHS trusts in England have been published for the first time, external, with specialist hospitals taking the top slots.
Number one is Moorfields Eye Hospital NHS Foundation Trust, followed by the Royal National Orthopaedic Hospital NHS Trust and cancer centre the Christie NHS Foundation Trust.
At the bottom is Queen Elizabeth Hospital in King's Lynn, which has had major problems with its buildings because of structural weaknesses and the need for props to hold up ceilings.
Health Secretary Wes Streeting said the tables would help inform the public and allow them to exercise choice - but trusts have questioned whether they were using the right metrics.
The rankings score NHS trusts on seven different areas including waiting times for operations, cancer treatment, time spent in A&E and ambulance response times.
Their finances are also assessed, and it is possible that a hospital rated highly for clinical care will be marked down if they are running up a larger than expected deficit.
They are then sorted into four categories, the first of which reflecting the best performers and the last listing the worst.
The public will be able to use the league tables check the performance of their local hospital, ambulance service or mental health trust.
Read full story
Source: BBC News, 9 September 2025
Patient Safety Learning

Review finds nine infant deaths at trust ‘potentially avoidable’

A trust has apologised after an external review into maternity failures concluded that nine neonatal deaths may have been avoidable.
Gloucestershire Hospitals Foundation Trust announced in 2024 that its board had commissioned external reviews into deaths at its maternity services.
This followed an “inadequate” rating from the Care Quality Commission and a subsequent BBC Panorama investigation which raised concerns over cultural and staffing issues.
The reviews, which examined seven maternal deaths between 2017 and 2023 and 44 neonatal deaths between 2020 and 2023, found that nine of the neonatal deaths warranted further investigation due to “missed opportunities” in care that “could have potentially changed the outcome”.
Concerns included “incomplete risk assessments” during pregnancy, particularly around reduced foetal movements, and “misinterpreting” foetal heartbeat monitoring during labour and “delaying calling for senior review”.
Read full story (paywalled)
Source: HSJ, 8 September 2025
Patient Safety Learning

Gap in crisis services risks future deaths

Only 10 integrated care boards have set up a mental health crisis text service, leaving a “gap” in service provision that could risk future deaths, a coroner has warned.
Joanne Kearsley, senior coroner for Manchester North, raised this concern in a Prevention of Future Deaths report relating to 27-year-old Jessica Smithson, who died by suicide last August. 
During the inquest, the coroner discovered that before her death Ms Smithson, who was under the care of Pennine Care Foundation Trust, contacted Shout, a mental health crisis text message service, after making an allegation of sexual assault to Greater Manchester Police.
Ms Kearsley noted that Shout receives 1,500 to 2,000 crisis texts per day and is contacting police forces with, on average, 28 cases per day where there is an immediate risk to life.
The coroner found that the text crisis service did not know Ms Smithson’s name or location but had an arrangement with the Metropolitan Police, who have the power to try to locate anyone who is at “real immediate risk”.
It was found the service did not contact the police but should have done, although Ms Smithson’s death would not have been averted even if contact was made, Ms Kearsley said.
However, Greater Manchester ICB is one of about 30 ICBs which have not commissioned a local crisis text service, and the coroner warned that this created a “gap” across much of the country, which is being filled by more informal services run by charities. These are not connected to local healthcare providers, and have different policies if someone’s life is at risk, resulting in a “lack of consistency”. 
The coroner warned: “As they are not linked into local NHS trusts, [these [providers] have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.”
Read full story
Source: HSJ, 5 September 2025
Patient Safety Learning

Women in UK with polycystic ovarian syndrome facing widespread failures in treatment, report finds

Women living with polycystic ovarian syndrome (PCOS) face prolonged delays in diagnosis and limited access to treatment, according to a report by a parliamentary group.
More than a third of women with the condition had to wait longer than four years for a PCOS diagnosis, according to the report, and after diagnosis almost two-fifths (38%) of respondents were not provided with any resources.
Published by the all-party parliamentary group on PCOS, the report consists of oral evidence sessions, a survey of more than 2,000 patients on their experiences, as well as freedom of information requests to all 42 Integrated Care Boards (ICBs) in England.
Only 3% of patients with the condition felt supported by healthcare providers, with almost a third (28%) feeling dismissed or not taken seriously.
“PCOS affects one in eight women and those assigned female at birth, yet for too long it has been sidelined in policy, overlooked in funding, and misunderstood in practice,” said Michelle Welsh, Labour MP for Sherwood Forest and chair of the APPG on PCOS. “This report sets out a clear and urgent case for reform. If we are serious about improving women’s health, we must act now to break the cycle,” she said.
Stark inequalities were also highlighted by the report, with women from Black and Asian backgrounds being up to 2.5 times more likely to be diagnosed with the condition, and those from ethnic minority backgrounds more likely to present with more severe symptoms such as insulin resistance.
Dr Itunu Johnson-Sogbetun, GP and founder of the Royal College of GPs’ Women’s Health Special Interest Group, said the report reflected “what many of us with PCOS already know from lived experience: care is fragmented, diagnosis is delayed, and long-term risks are too often ignored.”
She said: “PCOS is a multisystem condition, yet the NHS frequently treats it narrowly as a fertility or gynaecological issue. The report rightly highlights the postcode lottery of care, the lack of national pathways, and the absence of coordinated support for the metabolic, cardiovascular, and psychological complications that come with PCOS.”
Read full story
Source: The Guardian, 7 September 2025
Patient Safety Learning

Private menopause tests risk undermining NHS care, doctors say

Expensive, over-the-counter hormone tests for menopause are clinically useless and risk undermining women’s healthcare, senior doctors have warned.
The testing kits, offered by private clinics and available to buy for self-testing, claim to offer tailored insights through measuring hormone levels. But they have been described by experts as misleading and medically unnecessary.
“There are lots of private healthcare and telehealth clinics offering tests and increasing numbers of medically untrained, self-proclaimed ‘experts’ giving advice on social media and podcasts to get these tests done,” said Dr Stephanie Sterry, who recently co-wrote an editorial for the BMJ titled Menopause Misinformation is Harming Care.
“Unfortunately, these tests are not evidence-based,” she added. “They’re not giving us any new information or making treatment more effective. All they are doing is encouraging women to spend hundreds of pounds on tests that don’t make any difference to the treatment they should be given.”
Read full story
Source: The Guardian, 7 September 2025
Patient Safety Learning

Spending freeze imposed after NHSE identifies £300m budget hole

The government has ordered a spending freeze and told the NHS to absorb the £300m cost of the most recent resident doctors’ strikes from existing budgets, HSJ  has learned.
The Department of Health and Social Care has told all arm’s-length bodies to pause any uncommitted spending outside a small number of essential priorities, according to an internal NHS England document.
The paper reveals for the first time the estimated £300m bill for July’s industrial action, which it says “cannot be easily covered”.
It says NHSE is also preparing to impose fixed prices for commissioner-funded drugs, and offer “incentives” for local systems to spend less than planned this year, to help “support the overall NHS position”.
The NHSE paper, written by NHSE deputy chief financial officer Nicci Briggs, states: “The resident doctors’ industrial action has introduced extra challenge that cannot be easily covered within the Spending Review settlement. Initial analysis indicates that industrial action has already cost the NHS approximately £300m.
“It is in this context that the DHSC has introduced an admin or programme [resource department expenditure limit] (revenue) spending moratorium with immediate effect… [it] sets out that new, uncommitted spend cannot now go ahead unless it is considered an exception.”
Read full story
Source: HSJ, 5 September 2025
Patient Safety Learning

Thousands of opioid deaths missed off official figures

More than 13,000 heroin and opioid deaths have been missed off official statistics in England and Wales, raising concerns about the impact on the government's approach to tackling addiction.
Research from King's College London, shared exclusively with BBC News, found that there were 39,232 opioid-related deaths between 2011 and 2022, more than 50% higher than previously known.
The error has been blamed on the government's official statistics body not having access to correct data and it is understood ministers are now working with coroners to improve the reporting of deaths.
A former senior civil servant said fewer people might have died if drug policies had been based on accurate statistics.
The number of opioid deaths per million people in England and Wales has almost doubled since 2012, but this new study means the scale of the problem is likely to be even greater.
Researchers from the National Programme on Substance Use Mortality at King's used data from coroners' reports to calculate a more accurate estimate of opioid-related deaths.
Read full story
Source: BBC News, 16 September 2025
Patient Safety Learning

Calls for halt to mesh surgery after surgeon struck off

Calls are being made for an immediate suspension of rectopexy bowel mesh surgery after the surgeon who pioneered the procedure was struck off.
Bristol surgeon Tony Dixon was removed from the medical register for serious misconduct, including performing unnecessary surgeries and fabricating patient records.
Patient safety campaigners and MPs say there is now growing concern over the credibility of his research, which underpins the procedure used to treat bowel conditions.
Kath Sansom, founder of the patient-led campaign group Sling the Mesh, said: "The government must suspend rectopexy mesh procedures immediately and launch a full review."
The National Institute for Health and Care Excellence there are "well‑recognised, serious but infrequent complications" with this type of surgery.
But Ms Sansom said: "Women have suffered horrific complications - pain, mesh erosion where it slices into nearby organs and tissues, nerve damage - and many were never warned.
"Our rectopexy members suffer some of the most horrific life-changing complications, including a high number now living with stoma bags as a result."
Mr Dixon pioneered the LVMR (laparoscopic ventral mesh rectopexy) procedure and promoted it through a series of studies.
But two separate tribunals found him to have performed operations on five patients without obtaining informed consent and that one of these procedures was not clinically indicated.
They also found that he failed to provide post operative care and to have dishonestly created patient records long after he was involved in their care.
Read full story
Source: BBC News, 4 September 2025
 
Patient Safety Learning

Error leaves 55,000 diabetes patients needing new tests

Errors by machines used to diagnose diabetes mean at least 55,000 people in England will need further blood tests, a BBC investigation has discovered.
Some patients have been wrongly diagnosed with type 2 diabetes and even prescribed medication they don't need - and there could be more people affected, say NHS England.
NHSE has confirmed 16 hospital trusts use the machines, made by Trinity Biotech, which have produced inaccurate test results.
In a statement, Trinity Biotech says it is working closely with the UK health regulator and has contacted all hospitals which use the machines.
The BBC first reported in September 2024 that 11,000 patients faced re-testing after a machine at Luton and Dunstable Hospital issued incorrect diabetes results.
NHS England now say type 2 diabetes diagnoses rose by 10,000 in 2024, 4% more than expected.
The procedure, known as the haemoglobin A1C test, measures average blood sugar levels which are used to diagnose type 2 diabetes and monitor the condition.
According to the medicines and healthcare regulator (MHRA), issues with the tests on these machines was first reported in April 2024.
Read full story
Source: BBC News, 5 September 2025
Patient Safety Learning

RFK Jr accused of ‘reckless disregard for science and the truth’ in Senate hearing

The US health secretary, Robert F Kennedy Jr, faced the Senate finance committee in a tense and combative hearing on Thursday, during which lawmakers questioned his remarks expressing vaccine skepticism, claims that the scientific community is deeply politicized and the ongoing turmoil plaguing the Centers for Disease Control and Prevention (CDC).
In a hearing lasting more than three hours and ostensibly about the Trump administration’s healthcare agenda, Kennedy defended his leadership at the Department of Health and Human Services (HHS), claiming that his time at the agency will be focused on “unbiased, politics-free, transparent, evidence-based science in the public interest”.
Senate Democrats on the committee began the hearing calling for Kennedy’s resignation. “Robert Kennedy’s primary interest is taking vaccines away from Americans,” ranking member Ron Wyden, a Democratic senator from Oregon, said in his opening remarks. “People are hurt by his reckless disregard for science and the truth in this effort. I hope the very least, Robert Kennedy has the decency to tell the truth this morning.”
Raphael Warnock, also a Democrat, called Kennedy a “hazard to the health of the American people”, repeating calls for him to step down or for Donald Trump to fire him.
Last week, Kennedy fired the CDC director, Susan Monarez, less than a month after she was confirmed to her position. She is now mounting a legal case challenging her removal.
Shortly after Monarez’s termination, several leading public health officials at the CDC resigned from their positions, citing frustration with Kennedy’s approach to vaccines and his management style.
Read full story
Source: The Guardian, 4 September 2025
Patient Safety Learning

New technology for diabetic pregnant women will reduce risk of miscarriage and stillbirth

Thousands of pregnant women with type 1 diabetes are to be given a special artificial pancreas to reduce the risk of stillbirth and miscarriage.
Mothers-to-be with the condition have higher risks as pregnancy hormones can make it harder for them to regulate their blood glucose levels.
Now, expectant mothers in England will be offered a “game-changing” specialised tool to help them manage their blood glucose levels effectively.
The new tool, also known as a hybrid closed loop system, will be offered to the 2,000 women with type 1 diabetes who fall pregnant each year.
It will be also offered to women who have type 1 diabetes and are planning a pregnancy, NHS England said.
The technology, which is linked to a mobile phone app, delivers the precise insulin dosages a woman requires before and during pregnancy.
Unlike other artificial pancreases, this allows pregnant women to set a glucose target to the lower level required to achieve better outcomes in pregnancy, NHS England said.
It also allows remote monitoring by health workers which means fewer check-ups for mothers-to-be.
Read full story
Source: The Independent, 5 September 2025
Related reading on the hub:
Diabetes tech: Do national aspirations and local practice align? Diabetes technology is life-changing, but we need to be prepared when it fails - A blog by Andrew Stroud How safe are closed loop artificial pancreas systems?
Patient Safety Learning

Less than half of England has NHS access to jab months after roll-out, distressing patients and GPs

Less than half of England has access to tirzepatide (Mounjaro) through general practices, despite the NHS roll-out of the weight-loss jab having officially started over two months ago, The BMJ can disclose.
Just 18 of 42 commissioning bodies across the country confirmed that they had started prescribing tirzepatide in line with NHS England’s primary care roll-out plan.
The data, obtained through a freedom of information request, also show that, despite NHS England stating it expects 70% of eligible patients to come forward for treatment, only a fraction of integrated care boards (ICBs) have enough funding for that.
Experts warned that the lack of funding and poor communication to the public about the roll-out were resulting in “distress and uncertainty both in patients and primary care” and had left ICBs in a difficult financial situation.
Four ICBs reported that the NHS funding they had received covered just 25% or less of their eligible patients, with Coventry and Warwickshire faring the worst. That ICB told The BMJ it had received funding to cover just 376 patients, despite identifying 1795 eligible patients in the first year, meaning it can cover only 21% of its patients.
Because of the large number of people who could benefit from tirzepatide—an estimated 3.4 million—and the drug’s price, NHS England and its spending watchdog, the National Institute for Health and Care Excellence (NICE), agreed that the injections would be rolled out in phases over 12 years.
Jonathan Hazlehurst, consultant endocrinologist and academic clinical lecturer at the University of Birmingham, said that although the central funding from NHS England was “extremely welcome” the roll-out had so far been “significantly underfunded.”
He said, “That clearly drives up distress and uncertainty both in patients and primary care and runs the risk of inequity in access to treatment, and that’s my biggest concern.”
Read full story
Source: The BMJ, 4 September 2025
Patient Safety Learning

Trust orders review after racism complaints

One of the country’s biggest trusts has ordered a review following staff accusations of racism and bullying, including an official complaint against a board member, HSJ can reveal.
Mike Baker, Leeds Teaching Hospitals Trust’s senior independent director, has commissioned The Employers Network for Equality and Inclusion to review its diversity and inclusion policies in response to a number of incidents.
This review, started in June, is taking place while the trust separately investigates an official complaint of bullying and racism made against one of its directors, HSJ understands. The specific nature of the complaint against the director, who HSJ has decided not to name, is unclear.
The complaint is among a number of issues that the trust has dealt with during the past 18 months, including staff receiving an “anonymous” email describing “distressing experiences” of employees from a minority ethnic background.
In June 2024, an emergency department worker at one of LTHT’s hospitals was accused of unprofessional conduct for the way they responded to being racially abused on shift, and later faced disciplinary action.
A group of more than 40 medical consultants working in the trust’s emergency departments signed a letter voicing their support for the worker, who they described as a “dedicated and incredibly well-liked team player”.
In the letter, seen by HSJ, the consultants said the disciplinary actions faced by the worker appeared “unjust and disproportionate” given the circumstances of the incident, which raised “serious questions” about the “handling of workplace harassment and the rights of staff members to maintain their dignity and safety”.
Read full story (paywalled)
Source: HSJ, 4 September 2025
Patient Safety Learning

'My son's constipation wasn't taken seriously until he reached crisis point'

A mother who feared her two-year-old son's untreated constipation could have killed him is calling for access to children's continence services to be made a national priority.
Elissa Novak said Ivan was constantly vomiting, losing weight and in severe pain when it was at its worst, and a doctor said 2kg of his 10kg (22lb) body weight was estimated to be stool.
The number of children aged up to 16 admitted to English hospitals suffering with constipation, among other symptoms, is at a 10-year high, with more than 44,000 admissions in 2023-24, according to NHS figures.
Children are being failed by the absence of dedicated bladder and bowel services in some parts of the country, an expert said.
About 1.5 million children in the UK suffer with constipation, according to the charity Bladder and Bowel UK.
As many children returned to school this week, charities have told the BBC they are seeing a spike in calls to their helplines.
"It's a huge problem and many healthcare professionals don't consider it a serious issue in children," said Davina Richardson, a children's specialist nurse with the charity.
"Discussing wee and poo is very un-British. It's not something that we as a culture do."
Read full story
Source: BBC News, 4 September 2025
Related reading on the hub:
National primary care clinical pathway for constipation in children  
Patient Safety Learning

Opticians to treat common eye problems under new government plans

High street optometrists are set to gain expanded powers to treat common and emergency eye conditions under new government proposals.
The changes aim to shift more healthcare into community settings and alleviate pressure on general practitioners.
Under the proposed rules, optometrists and contact lens opticians would assume a significantly broader role in diagnosing patients and prescribing essential medications.
This includes drugs for issues such as dry eye, severe allergies, and bacterial conjunctivitis. They would be authorised to sign off on prescription-only medicines in emergencies or for prescriptions to be filled at local pharmacies.
Among the specific medications that could be prescribed is acetylcysteine, used to manage tear film abnormalities in dry eye cases where standard treatments are ineffective.
Dr Paramdeep Bilkhu, clinical adviser at the College of Optometrists, said: “Enabling optometrists to supply a wider range of prescription-only medicines will ensure more patients receive effective treatment for many common minor eye conditions at their local optical practice, without having to be referred to a prescriber or wait for a GP appointment.
“If these proposals are agreed and implemented, optometrists can continue to play a key role in reducing the burden on A&E departments and GPs, who often lack the specialist ophthalmic training and equipment needed to handle most eye conditions.
“By expanding the number of medicines that all optometrists can supply to patients, optometrists’ core skills will be better utilised to improve patient outcomes and experiences, particularly where commissioned acute eye care services are available.
“We urge our members, all healthcare professionals and the public to support these proposals to improve eye care in the community.”
Read full story
Source: The Independent, 4 September 2025
Patient Safety Learning

Ministers pressed for promised ‘independent workforce plan’

Government must deliver on its manifesto commitment to “regular, independent workforce planning” for health and social care, royal colleges and others warned Wes Streeting today.
Some 74 health and care organisations today wrote to the health and social care secretary urging him to engage with them on his 10-year NHS workforce plan.
It is due to be published this year but government and NHS England are yet to begin detailed discussions with the sector. 
The government’s 10-Year Health Plan says there will be fewer staff than proposed in the 2023 long-term workforce plan. It says there will need to be more flexible working and changes to staff roles, to increase productivity – moves likely to be unpopular with some professionals.
The wide-ranging groups that have written the letter – which include most royal colleges – warned a “robust stakeholder engagement process” was crucial if the plan is to be “thorough [and] credible”, and to get support from the sector. There should be an accompanying implementation plan, they say.
“We remain supportive of a regularly refreshed, credible national workforce plan for the NHS with independently verified modelling,” the letter adds. “We are clear that funding will need to be attached to any priorities that the plan sets.”
Read full story (paywalled)
HSJ, 3 September 2025
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.