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

Coroners reveal concerns over trust safety investigations

Trusts are beginning to run parallel safety investigations because a compulsory new national process does not meet the demands of coroners, HSJ has learned.
One provider said it had already established a separate process for deaths likely to result in an inquest, while others confirmed they were reviewing how they carry out investigations.
National officials admitted separate investigations might be required.
It follows the rollout in recent years of NHS England’s new “patient safety incident response framework” (PSIRF) for all NHS trusts, as well as other providers on the NHS standard contract.
It is meant to be a more “proportionate” process than the previous “serious incident framework”, with a focus on learning and engaging with those affected, rather than attributing blame. One consequence is that fewer incidents – including some deaths – are likely to receive a full investigation.
HSJ has uncovered seven cases – covering nine people – where coroners have issued Prevention of Future Deaths (PFD) reports which raised concerns that the PSIRF is producing inadequate reports or there had been no safety investigation at all.
Barking, Havering and Redbridge University Hospitals Trust has reverted to using root cause analysis as a parallel process for all cases that may be subject to a coroner inquest. This was required “to ensure the coroner received the necessary information, while maintaining the integrity of the PSIRF investigation”, the trust’s board heard last month. Chief medical officer Andrew Deaner said: “Nationally coroners were finding some issues with the PSIRF process.”
A Department of Health and Social Care spokesperson said: “Under the [PSIRF], all deaths thought likely to be down to problems in care must be subject to a patient safety incident investigation.” However, they added: “It is vital that NHS trusts continue to engage with coroners and work with them to ensure that coroners get the information they need.”
NHS England has also said it is aware some coroners had raised concerns, although it consulted the chief coroners’ office in developing the PSIRF. It acknowledged the methodology may differ from a coroner’s remit, and said NHS organisations could use other methods in addition.
The judiciary office and the Coroners’ Society did not want to comment.
Read full story (paywalled)
Source: HSJ, 29 July 2025
Patient Safety Learning

Lifestyle changes and vaccination ‘could prevent most liver cancer cases’

Three in five liver cancer cases globally could be prevented by reducing obesity and alcohol consumption and increasing uptake of the hepatitis vaccine, a study has found.

The Lancet Commission on liver cancer found that most cases were preventable if alcohol consumption, fatty liver disease and levels of viral hepatitis B and C were reduced.
The commission set out several recommendations for policymakers, which it estimated could reduce the incidence of liver cancer cases by 2% to 5% each year by 2050, preventing 9m to 17m new cases of liver cancer and saving 8 million to 15 million lives.
Prof Jian Zhou at Fudan University in China, who led the research, said: “Liver cancer is a growing health issue around the world. It is one of the most challenging cancers to treat, with five-year survival rates ranging from approximately 5% to 30%. We risk seeing close to a doubling of cases and deaths from liver cancer over the next quarter of a century without urgent action to reverse this trend.”
The commission author Prof Hashem B El-Serag of Baylor College of Medicine in the US said: “Liver cancer was once thought to occur mainly in patients with viral hepatitis or alcohol-related liver disease. However, today, rising rates of obesity are an increasing risk factor for liver cancer, primarily due to the increase in cases of excess fat around the liver.”
The commission’s recommendations included that governments boost HBV vaccination and implement universal screening for adults; introduce minimum alcohol unit pricing and sugar taxes along with warning labels; invest in early detection of liver damage and cancer; and improve palliative care for sufferers.
Read full story
Source: The Guardian, 28 July 2025
Patient Safety Learning

New study says self-test could prevent up to 1,000 cervical cancer cases a year

About a third of women are overdue for their appointment for life-saving cervical cancer screening – due to embarrassment, discomfort or simply not having enough time to attend.
But offering women an at-home self-test could prevent as many as 1,000 cases of cervical cancer every year, a study led by Queen Mary University of London with King’s College London found.
More than 3,000 women are diagnosed with cervical cancer each year in the UK. It has been estimated that the number would be 5,000 higher if it weren’t for cervical screening.
The number of women participating in cervical screening has been falling, and in 2024, only 66% of those eligible for screening were up to date.
In the study, published in the journal EClinicalMedicine, researchers recruited 13 GP practices in West London to find out the benefits of offering women a take-home test.
One group of GP practices made in-person kit offers to women who were at least six months overdue for their cervical screening, the other group did not. For the first group, when women attended their GP practice for any reason, their doctor or nurse was encouraged to offer them a self-sampling kit.
In the study, people who were 15 months overdue for cervical screening were randomised each month. Half received no special communication, a quarter were mailed a self-sampling kit, and a quarter were sent a letter offering a kit.
Of the 449 women opportunistically offered a kit in a GP appointment, 234 (52%) accepted and returned a sample.
However, the uptake of self-sampling after a postal offer was lower: 12% among those sent a kit, and just 5% for women sent a letter offering a kit.
Researchers estimate that if this approach were adopted across the NHS, 1,000 cases of cervical cancer could be prevented.
dings are directly relevant to current efforts to modernise cervical screening in England. Self-sampling gives women greater control over how and when they get screened.
“This study reinforces that many women welcome the option - particularly when it’s offered in person by a trusted healthcare professional. A simple change like this could have a major impact on preventing cervical cancer.”
Read full story
Source: The Guardian, 29 July 2025
Further reading on the hub:
Top picks: 9 resources about improving access to cervical screening
Patient Safety Learning

Children’s heart unit in ‘very precarious state’

A surgeon at one of England’s largest teaching trusts has had their practice restricted following the deaths of two children, amid a “worrying and significant deterioration” in mortality rates for its children’s heart service.
Leeds Teaching Hospitals Trust commissioned a review of its paediatric congenital cardiac service after the clinical team raised concerns about the surgeon’s performance as well as overall mortality rates, waiting lists, patient flow and culture.
The review found mortality rates at LTH were around three times the national average and had shown a “worrying and significant deterioration” over the past two years.
The findings have been published in the trust’s papers for its board meeting this week. It comes as its chair and CEO are leaving, and major problems have emerged in its maternity services. 
The service review was carried out by consultant cardiothoracic surgeon Massimo Caputo and paediatric intensive care consultant James Fraser, both of whom work at Bristol Royal Hospital for Children. They found that rates of significant complications, reoperation and protracted length of stay after surgery had increased since April 2023.
A separate review, by Andrew Parry, a paediatric cardiac surgeon in Bristol, looked into seven specific cases of particular concern that all involved the same surgeon – who the trust has declined to name. Two of the children died, and the remaining five continue to receive care from various specialities including congenital cardiac surgery.
Read full story (paywalled)
Source: HSJ, 29 July 2025
Patient Safety Learning

'My dad started spying on my mum' - the drugs causing sexual urges

When "Sarah" climbed up into the attic of her father's house - she was completely unprepared for what she would find.
Her father, "James", was a modest man who worked most of his life for the same company. He retired about 20 years ago when he was diagnosed with Parkinson's.
He had managed the tremors and balance difficulties caused by the disorder by taking a prescription drug called Ropinirole.
But during the Covid-19 pandemic, Sarah had grown increasingly alarmed about her father's secrecy and wanted to see what he had been spending his time doing.
In the loft, she discovered reams of handwritten notes and a dozen recording devices he had been using to bug his own home.
In writing and on tape he had documented innocent sounds his wife had made as she moved around the house, and while she slept, to try to prove she was having an affair. He had also catalogued details of numerous chat lines and porn websites he had been obsessively using.
It was only when Sarah took him to see his specialist nurse five years ago that she learned the medication her father was on could have such extreme side effects.
James lives in a specialist care home and Sarah says she has been told that he has sexually assaulted staff there.
"This medication has torn my family apart," says Sarah - whose name we have changed along with her father's.
James's case is one of 50 the BBC has now been contacted about, the majority concerning men being treated for movement disorders whose behaviour changed dramatically after being prescribed medication from a specific family of drugs.
The risk of impulsive behaviour side effects of dopamine agonist medication have long been known - but the BBC has discovered that doctors are still not warning all patients who have been prescribed the drugs for a variety of conditions.
In March we revealed how British drug company GSK had found a link between Ropinirole and what it called "deviant" sexual behaviour - including paedophilia - in 2003.
GSK told the BBC it had shared these findings with health authorities, included this safety advice in medication leaflets, and conducted extensive trials for the drug which has been prescribed for 17 million treatments.
But warnings about such behaviour were not included in leaflets until 2007 - and, even now, only specify "altered" sexual interest and "excessive" or "increased" libido as risks.
Safety advice about the medication's "toxic" side-effects needs to be strengthened immediately because their impact can be "devastating", according to the acting chair of the Health Select Committee, Labour MP Paulette Hamilton.
Read full story
Source: BBC News, 26 July 2025
Patient Safety Learning

Demand for weight loss drugs is becoming unsustainable, say pharmacists

Demand for weight loss drugs is becoming so “unsustainable” that demand may soon outstrip supply, pharmacists have warned.
The National Pharmacy Association (NPA) said supply problems could encourage people to turn to unregulated online sources, despite the risks involved.
The number of people in the UK using drugs such as Wegovy and Mounjaro has soared to well above a million, with most patients paying to get them privately.
During April, 1.6m packs of Mounjaro and Wegovy were bought in Britain, with the number thought to correlate closely with the number of people using them.
“Spiralling demand for weight loss medication risks going far beyond what is clinically deliverable”, the NPA said.
“Weight loss jabs are one of the biggest drug innovations this century but growing demand for weight loss treatment highlights the need to make sure this is appropriate for those who want it,” said Olivier Picard, the NPA’s chair.
“It’s clear from this polling that more people are interested in getting weight loss jabs than can benefit from weight loss medication.”
Supply of the medicines has been hit by shortages in some parts of the UK, including for higher doses of Mounjaro, the NPA said. Supply has been restricted to some pharmacies, which has stopped some new patients from going on to the drugs.
The Medicines and Healthcare products Regulatory Agency, the UK’s drugs watchdog, has warned patients to obtain the drugs only with a doctor’s prescription, and not from beauty parlours or websites.
Read full story
Source: The Guardian, 28 July 2025
Patient Safety Learning

Staff left “vulnerable” after concerns “ignored” by trust leadership

A culture in which staff felt “done to” and not able to raise concerns safely to a disconnected leadership have all contributed to “a longstanding sense of dissatisfaction” and “continuing” fears over care quality at one of the NHS’s largest teaching trusts, an NHS England review has discovered.
The review was undertaken by NHSE’s Maternity Safety Support Programme into care delivered by Leeds Teaching Hospitals Trust. Its publication comes a month after the Care Quality Commission downgraded maternity services at Leeds General Infirmary and St James University Hospital from “good” to “inadequate”.
The publication of the NHSE review in the trust’s board papers led to the trust chief executive Phil Wood to write to the organisation’s 20,000 staff, warning them that it and another investigation into the organisation’s paediatric congenital cardiac service would prove “challenging”.
The report describes the culture at LTH as “challenging” and exhibiting “a degree of negativity”. It was not viewed as “supportive”, and a “lack of communication” was a common theme. Many staff felt “they were ‘being done to’”.
The combination of these factors “led to escalation fatigue from the staff as they did not feel that their safety concerns were responded to in a productive and supportive way”.
Read full story (paywalled)
Source: HSJ, 28 July 2025
Patient Safety Learning

Trusts blaming cyber-attack risk for failing to share information

Four trusts have been warned by the UK’s information regulator over their failure to respond to freedom of information requests.
The Information Commissioner’s Office said it carried out an assessment across the NHS provider sector after receiving regular complaints over delays and backlogs. The review focused on compliance with the FOI Act, which grants the right to access information held by public authorities. 
The review has resulted in Nottingham University Hospitals Trust being served an enforcement notice over a “significantly low compliance rate” and a backlog of nearly 200 requests that were over a year old. The formal order is issued when an authority is considered as failing to comply with obligations.
The ICO said NUH had answered only 17% of requests within the statutory deadline compared to an average of 82%. 
ICO director of FOI Warren Seddon said most trusts were treating the laws with the “seriousness that is required”. But he added: “A small number still show significant room for improvement and that’s where we step in.”
Read full story (paywalled)
Source: HSJ, 28 July 2025
Patient Safety Learning

Mum who blames mesh implant for crippling pain blasts Government for continued use

A mum who blames a controversial plastic implant for her crippling pain has blasted the Scottish Government for continuing to use the products.
Roseanna Clarkin is one of a number of women who blame mesh products for life-changing complications.
In her case, it was used to treat an umbilical hernia in 2015.
Three years later, while the Scottish Government banned the use of trans vaginal mesh products, surgical mesh is still used for other procedures.
Studies suggest 5 to 20% of hernia operations result in mesh failure. A study in the British Medical Journal, said the rate could be 12 to 30%.
Campaigners have been calling for an independent review and patients including Roseanna want a ban on all surgical mesh and fixation devices.
Roseanna, 41, of Clydebank, said: “Vaginal mesh is banned but mesh is still used for other procedures. Ultimately, it’s the same mesh that can cause the same problems.”
In 2023, then First Minister Humza Yousaf said to suspend the use of hernia mesh would leave some people with limited or no treatment options.
Last year, Roseanna was diagnosed with a rectocele – a prolapse of the wall between the rectum and vagina – but was shocked doctors wanted to use mesh.
She said: “I was outraged. Mesh has caused ­devastating effects to my life and body. There was no way I was having any more.” 
Read full story
Source: The Sun, 23 July 2025
Sam

Top medical body concerned over RFK Jr’s reported plans to cut preventive health panel

A top US medical body has expressed “deep concern” to Robert F Kennedy Jr over news reports that the health secretary plans to overhaul a panel that determines which preventive health measures including cancer screenings should be covered by insurance companies.
The letter from the the American Medical Association comes after the Wall Street Journal reported on Friday that Kennedy plans to overhaul the 40-year old US Preventive Services Task Force because he regards them as too “woke”, according to sources familiar with the matter.
During his second term, Donald Trump has frequently raged against organisations and government departments that he considers too liberal – often without any evidence. The US president, and his cabinet members such as Kennedy, have also overseen huge cuts and job losses across the US government.
The taskforce is made up of a 16-member panel appointed by health and human services secretaries to serve four-year terms. In addition to cancer screenings, the taskforce issues recommendations for a variety of other screenings including osteoporosis, intimate partner violence, HIV prevention, as well as depression in children.
Writing in its letter to Kennedy on Sunday, the AMA defended the panel, saying: “As you know, USPSTF plays a critical, non-partisan role in guiding physicians’ efforts to prevent disease and improve the health of patients by helping to ensure access to evidence-based clinical preventive services.”
“As such, we urge you to retain the previously appointed members of the USPSTF and commit to the long-standing process of regular meetings to ensure their important work can be continued without disruption,” it added.
Read full story
Source: The Guardian, 27 July 2025
Patient Safety Learning

Impact of long NHS waits on patients revealed, plus who waits longest

People who wait longer for NHS treatment are significantly more likely to seek emergency care in the months after eventually receiving it, compared with those who are seen quickly.
People treated within 18 weeks of being on the waiting list made 18% fewer A&E visits per week in the three months following their treatment, compared to how often they visited A&E while waiting for treatment.
In contrast, people who waited over a year ended up making 31% more A&E visits in the three months following their care.
The Health Foundation, which carried out the research and shared the findings with the Sky News Data and Forensics Unit, say that the fact people need more emergency care after long waits for treatment "may indicate additional aftercare needs or decreased effectiveness of treatment following a longer wait".
They analysed detailed patient-level data that had previously not been available for research use.
It complements new NHS data published last week which revealed the make-up of the waiting list for the first time, in terms of the gender, age, ethnicity and deprivation status of the patients on it.
The Health Foundation explained that, as well as patients having to live with the "consequences of debilitating conditions for longer", long waits can also lead to "more complex, difficult and expensive treatment" being required.
They also "significantly increase consumption of pain relief medication". In some cases, while waiting, conditions for the patient become permanent and untreatable.
Read full story
Source: Sky News, 25 July 2025
Patient Safety Learning

First trusts picked to ‘host’ neighbourhood health

An integrated care board has become the first to select “integrators” to coordinate neighbourhood teams in four of its boroughs, each of which will be “hosted” by a trust.
South East London ICB said the arrangements – all of which are an alliance between several organisations – would not replace its “place-based care partnerships” in the boroughs. The integrators will “provide the core infrastructure to support effective integrated neighbourhood team working as it develops”.
London’s other four ICBs are still in the process of selecting organisations or partnership for each of their council areas, as agreed in a neighbourhood health operating model for the city published in May. 
The “host” for each integrator is likely to employ any dedicated staff and hold its funding, particularly if it takes on delegated commissioning budgets. The London model says integrator hosts must be of a ”scale sufficient to manage related budgets and provide required infrastructure, including around data sharing, workforce, estates and digital”.
As well as developing and coordinating community-based services, the integrators will help any GP practices which are “at risk of failure”, the plan said.
However, the concept of an integrator was not included in the 10-Year Health Plan, and it is unclear how it will fit with the government’s proposed neighbourhood provider contracts.
Read full story (paywalled)
Source: HSJ, 25 July 2025
Patient Safety Learning

Millions will die from infections as aid budget is cut

Antimicrobial resistance (AMR) is one of the gravest public health threats confronting the world, one projected to cause 39 million deaths by 2050 and a direct threat to the UK that demands urgent action, not shortsighted funding cuts.
The Fleming Fund has an effective surveillance tool to track resistant infections, supporting experts working in hundreds of laboratories in countries in Africa and Asia at the greatest danger from AMR. It is the perfect example of the UK aid budget being used to protect us all from health crises that respect no borders, which makes the government’s sudden decision to scrap it a shocking act of vandalism.
It is five months since the government announced its £5 billion cut to the UK’s overseas development budget, a 40% reduction taking spending to its lowest level this century, but only now are the grim consequences becoming clear. Projects to combat AMR are particularly vulnerable because they are funded by the Department of Health and Social Care which must slash almost two thirds from its share of the aid budget over the next two years, from £331 million to just £123 million. 
AMR evolves constantly across borders. When we abandon surveillance programmes we create blind spots that allow drug-resistant infections to spread unchecked. 
Read full story (paywalled)
Source: The Times, 21 July 2025
Patient Safety Learning

Surgeon named ‘Bravest in Britain’ who told insurers he had his legs amputated due to sepsis charged with fraud

A “brave” vascular surgeon who told insurers he had his legs amputated due to sepsis has been charged with fraud.
Neil Hopper, 49, who carried out hundreds of amputations before having his own legs removed below the knees, is accused of telling insurers that the leg injuries were the “result of sepsis and were not self-inflicted”, intending to make a gain.
He has also been charged with encouraging someone else to remove the body parts of others.
Mr Hopper, of Truro in Cornwall, appeared before Cornwall Magistrates’ Court in Bodmin on Wednesday, charged with two counts of fraud by false representation, and a charge of encouraging or assisting in the commission of grievous bodily harm.
It is alleged that between 3 June and 26 June 2019, Mr Hopper dishonestly made a false representation to insurers.
It is also alleged that between 21 August 2018 and 4 December 2020, Hopper bought videos from The EunuchMaker website showing the removal of limbs, which “encouraged [website ringleader] Marius Gustavson to remove body parts of third parties”.
He was remanded in custody until his next court appearance at Truro Crown Court on 26 August.
Read full story
Source: The Independent, 23 July 2025
Patient Safety Learning

21 US States sue CMS over new ACA restrictions

A coalition of 21 Democratic-led states are suing the US Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) over new Affordable Care Act (ACA) rules they allege would impose significant barriers to receiving health coverage.
The lawsuit, filed 17 July in the U.S. District Court for the District of Massachusetts, challenges a final rule that CMS introduced earlier this year to amend ACA marketplace regulations, which the plaintiffs argue will lead to millions of people losing access to health insurance, raise costs for states, and reduce the availability of essential health benefits.
The final rule is set to go into effect on 25 August and is projected by CMS to cause up to 1.8 million people to lose coverage. It aims to implement stricter verification requirements for eligibility, shorten open enrolment periods, and eliminate coverage for gender-affirming care as an essential health benefit. In the complaint, the 21 states argue that the changes violate the law and would harm consumers by increasing premiums and out-of-pocket costs, and by imposing burdensome new paperwork requirements that could deter people from enrolling.
The coalition argues that the rule is “arbitrary and capricious” and would place undue financial strain on state health programs, including Medicaid programs. The states also claim that the rule would increase costs by forcing them to provide more healthcare services to newly uninsured individuals, adding to Medicaid spending and costs for emergency care. The coalition, which includes California, Illinois and New York, is seeking preliminary relief to prevent the rule from taking effect as planned.
Read full story
Source: Becker's 18 July 2025
Patient Safety Learning

Urgent care clinics are pushing pain pills that do little to treat conditions, new study finds

Urgent care clinics are reportedly pushing pills that do little to treat patients’ medical conditions.
Researchers said that a substantial number of antibiotic, glucocorticoid, and opioid prescriptions were filled despite being deemed inappropriate given the patients' diagnoses — potentially resulting in harm.
Antibiotics are commonly used to treat infections, glucocorticoids are steroids that can treat arthritis and asthma, and opioids are prescribed to treat pain. America’s opioid epidemic, which has led to thousands of deaths, has been tied to an increase in painkiller prescriptions.
"Previous studies had shown that patients continue to receive antibiotics for diagnoses where they may not be indicated, such as for a viral respiratory infection, especially in urgent care settings,” Dr. Shirley Cohen-Mekelburg, an assistant professor at the University of Michigan Medical School, said in a statement. “Our findings reveal that this trend of inappropriate prescribing includes other classes of drugs — including glucocorticoids — and a variety of conditions.”
The reason for these findings, they suggest, is tied to the knowledge of clinic doctors, demand from patients, and a lack of an information system to support the clinicians’ decisions.
Read full story
Source: The Independent, 23 July 2025
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