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

ME care reforms promised after woman’s tragic death

The government has pledged to overhaul care for hundreds of thousands of people living with chronic fatigue syndrome, acknowledging that many "struggle" to access appropriate support.
The Department of Health and Social Care (DHSC) stated its intention to publish a new plan, asserting it is "committed to changing attitudes and transforming care" for individuals with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS).
The pledge comes in the wake of Maeve Boothby-O’Neill’s death at just 27.
She had suffered with ME for a decade before dying at her home in Exeter in October 2021 from severe malnutrition.
Her inquest revealed she had been admitted to the Royal Devon and Exeter Hospital three times in the year of her death for malnutrition treatment.
Deborah Archer, now an area coroner for Devon, Plymouth and Torbay, concluded Miss Boothby-O’Neill had died from natural causes “because of severe myalgic encephalomyelitis (ME)”.
Last year she wrote to the Government to highlight a lack of specialist beds, “extremely limited” training for doctors and lack of available funding for research and treatment of the condition.
On Tuesday, the Government said that it has created a plan which “outlines clear steps to improve care for patients, by investing in research and offering access to care in the community”.
But Action for ME said that the plan “does not go far enough”.
Sonya Chowdhury, chief executive of the charity, said: “We appreciate the time DHSC has put into the delivery plan and their engagement with us and the ME community throughout.
“However, the plan simply does not go far enough. We are at the stage now where we need more than rhetoric, we need to take a strategic approach if we want a different outcome. What is proposed in the plan will not offer this.
“We must have a funded, dedicated research hub to leverage our world-leading life sciences sector to unlock treatments and ultimately cures for ME.
Read full story
Source: The Independent, 22 July 2025
Related reading on the hub:
Exploring the barriers that impact access to NHS care for people with ME and Long Covid Improving healthcare services for people with ME and Long Covid: Patients share their challenges, and the actions needed
Patient Safety Learning

Coroner warning over incompatible NHS systems

A coroner has warned NHS bosses that delays to the availability of mental health assessments between different teams due to outdated IT systems could lead to future deaths.
Prof Paul Marks, senior coroner for Hull and East Riding, issued a prevention of future deaths report following an inquest into the death of John Kirkman, who took his own life.
Prof Marks said healthcare teams could encounter problems accessing "vital" information about patients as a result of incompatible computer programmes and this could lead to delays in care.
A spokesperson for NHS England expressed their "deepest sympathies" to Mr Kirkman's family and said the organisation would "carefully consider" the report.
The report, sent to the chief executive of NHS England, said the organisation should take action, "possibly by reviewing the compatibility of IT systems".
The document said Mr Kirkman, who was 36, had a long history of paranoid schizophrenia and took his own life on 27 December 2023.
During the inquest, the coroner said the evidence revealed matters that caused him concern.
Prof Marks said that if a mental health screening assessment was carried out in one part of the country, the results and conclusions may not be immediately available elsewhere when a further assessment is carried out, due to the use of different IT systems.
"Absence of vital background information could result in an incorrect prioritisation for onward referral, as it did in this case," he said.
The lack of availability of clinical information and data may "adversely influence subsequent assessments", he said.
Read full story
Source: BBC News, 19 July 2025
Patient Safety Learning

Breast cancer breakthrough as new test could revolutionise treatment

A new test for breast cancer patients has been developed which can predict whether or not their cancer is likely to return just two weeks after they start treatment.
Experts said thousands of breast cancer patients could be spared unnecessary treatment as a result.
The new test has been devised by scientists to detect the likelihood of cancer reoccurring in patients with a type of breast cancer known as oestrogen receptor positive, human epidermal growth factor receptor 2 positive – which accounts for around 200,000 cases of cancer each year around the globe.
Writing in the journal eBioMedicine, experts said the test means that some patients will be able to “de-escalate” their treatment while it could also help identify those who need “more intensive therapeutic strategies”.
The test, which was developed by scientists at The Institute for Cancer Research, London, correctly identifies the 6% of patients at highest risk of relapse.
Dr Simon Vincent, chief scientific officer at Breast Cancer Now, which part-funded the study, said: “These findings add to the growing evidence that genomic testing can play a powerful role in helping to predict the risk of a woman’s breast cancer coming back, particularly in people with ER-positive, HER2-positive breast cancer.
“There’s potential for women to benefit hugely from this research in the future, with it ensuring they avoid undergoing unnecessary treatment and leading to more personalised treatment plans, so that women receive the most effective therapy for their specific type of breast cancer.”
Read full story
Source: The Independent, 19 July 2025
Patient Safety Learning

Premature babies to be immunised against winter virus

Thousands of premature babies in the UK can now be protected against a common winter virus which can cause a dangerous lung infection, and sometimes kill.
The injection will provide them "with a protective bubble" against RSV (respiratory syncytial virus) in time for the colder months, NHS medics said.
Most babies are protected via vaccination late in pregnancy, but babies born before 32 weeks are more vulnerable to life-threatening infections from the virus.
From late September, 9,000 babies and young children at risk across the UK will be offered a dose of the drug nirsevimab through the NHS.
RSV usually causes coughs and colds, but can make some children very ill with breathing problems, pneumonia and a lung infection called bronchiolitis.
According to NHS England, premature babies are three times more likely to go to hospital with RSV and are 10 times more likely to need intensive care compared with full-term babies.
Every year around 30,000 children in the UK aged under five need hospital care because of the virus, and around 30 don't survive.
The drug offers six months' protection in a single dose, and is more than 80% effective.
Neo-natal clinics will deliver the injection to premature babies. Families of vulnerable infants with heart or lung conditions or weakened immune systems will be advised by their medical teams how to get the jab before this winter.
"It will offer a long-lasting defence, helping to avoid unnecessary hospitalisations and serious illness, giving babies the best possible start in life and shielding them from harm," said Dr Claire Fuller, co-national medical director for NHS England.
Read full story
Source: BBC News, 19 July 2025
Patient Safety Learning

Patients lost sight due to poor care, trust admits

Multiple glaucoma patients have suffered significant harm, including loss of sight, after treatment guidelines were not followed by more than one member of staff over a number of years at the same trust, HSJ has learned.
George Eliot Hospital Trust has admitted that a locum consultant followed “incorrect processes” when treating patients, which led to “significant harm” to eight people.
Fresh concerns have also been raised about a separate optometrist treating glaucoma patients at GEH, and possible harm caused again because of processes not being followed. However, the trust does not yet know how many patients were harmed as a result of this case.
The developments have prompted the Royal College of Ophthalmologists’ review service to plan a visit to the trust next month, the trust confirmed.
Trust board papers from May revealed its quality assurance committee was made aware of concerns last year where patients were discharged without National Institute for Health and Care Excellence guidance having been followed. It discovered some patients returned with “permanent visual damage”, which led to a review of notes regarding one locum consultant. The individual no longer works at the organisation.
Read full story (paywalled)
Source: HSJ, 21 July 2025
Patient Safety Learning

Half of black women in UK who raise concerns during labour did not receive suitable help, study finds

Almost half of pregnant black women raised concerns to healthcare professionals during labour, with half saying that their concerns were also not properly addressed, according to the largest report of its kind.
Black women in the UK are up to four times more likely to die during childbirth compared with their white counterparts, and are also more likely to experience serious birth complications and perinatal mental health illnesses.
Five X More, an organisation dedicated to improving black maternal health outcomes, confirmed these findings through a study of the maternity experiences of more than 1,000 black and mixed-race people who were pregnant between July 2021 and March 2025.
The report found that more than half (54%) of respondents experienced challenges with healthcare professionals, and that just under a quarter (23%) of black women did not receive pain relief when they requested it. And of these women, 40% said they were given no explanation as to why that was the case.
Furthermore, 45% of respondents raised concerns during their labour and of these, under half (49%) said their concerns were not properly addressed.
Tinuke Awe and Clotilde Abe, the co-founders of Five X More, said that the report shows that the maternity system is failing black women, and that it is also a “call to action” to address these disparities.
“Black women deserve better care and communication. The statistics around black women dying in and around pregnancy and having adverse outcomes have been around for decades now. Black women deserve to be treated with dignity at every stage of their maternity journey and the burden cannot keep falling on them to make the system work,” they said.
“While we’re still seeing the same issues we raised years ago, such as systemic failings, being ignored in pain, and poor understanding of conditions affecting black women, new themes are also emerging like the emotional toll of self-advocacy and the impact of not having consistent or trusted care.”
Read full story
Source: The Guardian, 21 July 2025
Related reading on the hub:
Five X More campaign: Improving maternal mortality rates and health outcomes for black women
Patient Safety Learning

Superbugs could kill millions more and cost $2tn a year by 2050, models show

Superbugs could cause millions more people to die worldwide and cost the global economy just under $2tn a year by 2050, modelling shows.
A UK government-funded study shows that without concerted action, increased rates of antimicrobial resistance (AMR) could lead to global annual GDP losses of $1.7tn over the next quarter of a century.
The research, by the Center for Global Development thinktank, found the US, UK and EU economies would be among the hardest hit, prompting accusations that recent swingeing aid cuts are self-defeating.
On Thursday, the UK government announced it was axing funding for the Fleming fund, which combats AMR in low- and middle-income countries, as part of wider aid cuts. The Trump administration has confirmed $9bn in cuts to its foreign aid budget, while a number of European countries have also reduced spending on overseas aid.
Anthony McDonnell, the lead author of the research and a policy fellow at the Center for Global Development, said: “When we conducted our research on the economic impacts of antimicrobial resistance, it was anticipated that resistance rates would continue to follow historical trends.
“However, the sudden cuts to Official Development Assistance by the US, which has cut its aid spend by roughly 80%; the UK, which has announced aid cuts from 0.5% to 0.3% of gross national income; and substantial reductions by France, Germany, and others, could drive up resistance rates in line with the most pessimistic scenario in our research.
“Even countries that have been successful in keeping AMR rates under control cannot afford to be complacent. Unless AMR programmes are protected from aid cuts, resistance rates across the world will likely increase at a rate in line with the worst-affected countries.
“This would result in millions more people dying worldwide, including across G7 nations. Investing in treatment for bacterial infections now will save lives and deliver billions in long-term economic returns.”
Read full story
Source: The Guardian, 20 July 2025
Patient Safety Learning

More than 30 poisoned after suspected fake Botox

Thirty-eight cases of botulism poisoning have been recorded in England in the last six weeks after the suspected use of unlicensed Botox-like products in cosmetic procedures, the UK Health Security Agency (UKHSA) said.
Botulism is a rare but life-threatening condition caused by toxins produced by Clostridium botulinum bacteria, a key ingredient in the injection.
Cases have been recorded in the East, East Midlands and the North East regions.
The UKHSA urged those seeking treatments to obtain proof that their Botox practitioner was qualified and that their products were licensed.
According to the UKHSA, the evidence so far suggests clinics involved in the cases have used unlicensed Botox-like products.
In the most recent cases, recorded in East England and the East Midlands, patients had difficulty swallowing, slurred speech and breathing difficulties requiring respiratory support.
Other symptoms of botulism can include droopy eyelids, double vision and weak facial muscles.
Dr Gauri Godbole, of UKHSA, said botulism related to aesthetic procedures was rare but could be serious. She added that symptoms could take up to four weeks to develop and urged anyone who suspected they were suffering to contact the NHS 111 service.
Botox can only be prescribed after a consultation between you and a healthcare professional, such as a doctor or nurse.
While the person signing the prescription doesn't have to give the injection, they should ensure the person injecting is qualified to do so.
Dr Alison Cave, chief safety officer at the Medicines & Healthcare products Regulatory Agency, said: "Buying botulinum toxin in any other circumstances significantly increases the risk of getting a product which is either falsified or not licensed for use in the UK.
"This means that there are no safeguards to ensure products meet the MHRA's standards for quality and safety."
Read full story
Source: BBC News, 18 July 2025
Patient Safety Learning

Trust reviewing 9,000 patients lost from waiting list

A trust has launched an independent investigation examining nearly 9,000 patients who were “lost to first appointment or follow up”, with some waiting up to five years, HSJ can reveal.
The 8,849 patients were meant to be seen by an ear, nose and throat service that is run by Medway Foundation Trust but also operates out of the Darent Valley Hospital in Dartford.
The majority of the patients involved come from the areas served by the Darent Valley Hospital rather than the Medway towns and Swale, which are served by Medway Maritime Hospital. They include patients from North Kent and the London boroughs of Greenwich and Bexley.
HSJ understands that 4,279 patients have not had a first appointment after being referred into the ENT services, and 4,570 were left waiting for a follow-up appointment. Around 20% of the patients involved are children and the remainder adults, with a small number having waited as long as five years for an appointment.
Medway FT has now tried to contact all patients as part of a validation process and is sending duty of candour letters to them.
Read full story (paywalled)
Source: HSJ, 18 July 2025
Patient Safety Learning

UK health service AI tool generated a set of false diagnoses for one patient that led to him being wrongly invited to a diabetes screening appointment

AI use in healthcare has the potential to save time, money, and lives. But when technology that is known to occasionally lie is introduced into patient care, it also raises serious risks.
One London-based patient recently experienced just how serious those risks can be after receiving a letter inviting him to a diabetic eye screening—a standard annual check-up for people with diabetes in the UK. The problem: He had never been diagnosed with diabetes or shown any signs of the condition.
After opening the appointment letter late one evening, the patient, a healthy man in his mid-20’s, told Fortune he had briefly worried that he had been unknowingly diagnosed with the condition, before concluding the letter must just be an admin error. The next day, at a pre-scheduled routine blood test, a nurse questioned the diagnosis and, when the patient confirmed he wasn’t diabetic, the pair reviewed his medical history.
“He showed me the notes on the system, and they were AI-generated summaries. It was at that point I realized something weird was going on,” the patient, who asked for anonymity to discuss private health information, told Fortune.
After requesting and reviewing his medical records in full, the patient noticed the entry that had introduced the diabetes diagnosis was listed as a summary that had been “generated by Annie AI.” The record appeared around the same time he had attended the hospital for a severe case of tonsillitis. However, the record in question made no mention of tonsillitis. Instead, it said he had presented with chest pain and shortness of breath, attributed to a “likely angina due to coronary artery disease.” In reality, he had none of those symptoms.
A representative for the NHS, Dr. Matthew Noble, told Fortune the GP practice responsible for the oversight employs a “limited use of supervised AI” and the error was a “one-off case of human error.” He said that a medical summariser had initially spotted the mistake in the patient’s record but had been distracted and “inadvertently saved the original version rather than the updated version [they] had been working on.”
However, the fictitious AI-generated record appears to have had downstream consequences, with the patient’s invitation to attend a diabetic eye screening appointment presumedly based on the erroneous summary. 
Read full story
Source: Fortune, 20 July 2025
Patient Safety Learning

NHS facing ‘absolutely shocking’ £27bn bill for maternity failings in England

The NHS is facing an “absolutely shocking” £27bn bill for maternity failings in England, the Guardian can reveal, after a series of hospital scandals triggered a record level of legal claims.
Hundreds of babies and women have died or suffered life-altering conditions as a result of botched care in NHS trusts across the country in recent years, prompting the government to launch a “rapid” national inquiry.
Analysis of NHS figures shows the potential bill for maternity negligence in England since 2019 has reached £27.4bn – far more than the health service’s roughly £18bn budget for newborns in that time.
The number of families taking legal action against the NHS for obstetrics errors rose to a record of nearly 1,400 a year in 2023, double the number in 2007, according to figures released under the Freedom of Information (FoI) Act.
Labour MP Paulette Hamilton, the acting chair of the Commons health and social care select committee, said the figures were “absolutely shocking” and represented a “devastatingly high number of deaths and injuries of mothers and babies”.
She added: “The words ‘eye-watering’ come nowhere near to describing the enormous financial cost of these cases to the NHS, arising from failings within its own provision of care.”
Read full story
Source: The Guardian, 20 July 2025
Patient Safety Learning

NHS bosses who silence whistleblowers to be banned from health service

NHS managers who silence whistleblowers will be banned from working in other senior health service roles, the government has announced.
The Department of Health and Social Care (DHSC) is bringing forward a raft of proposals it says will ensure those who commit serious misconduct cannot simply work elsewhere in the NHS in senior management positions.
It said legislation will be put forward to parliament next year to introduce professional standards and regulation of NHS managers.
Currently, there is no regulatory framework for the tens of thousands of clinical and non-clinical NHS managers, as there is for doctors and nurses.
Health Secretary Wes Streeting said the reforms would "slam the door in the face of unsuitable managers".
Mr Streeting added: "I'm determined to create a culture of honesty and openness in the NHS where whistleblowers are protected, and that demands tough enforcement.
"We've got to create the conditions where staff are free to come forward and sound the alarm when things go wrong. Protecting the reputation of the NHS should never be put before protecting patient safety.
"Most NHS leaders are doing a fantastic job, but we need to stop the revolving door that allows managers sacked for misconduct or incompetence to be quietly moved to another well-paid role in another part of the NHS."
Read full story
Source: Sky News, 20 July 2025
Related reading on the hub:
Speaking up for patient safety: A new interview series about raising concerns and whistleblowing
Patient Safety Learning

Bodies of Nottingham mother and daughter found almost four months after 999 call

A woman who was found dead alongside her “entirely dependent” teenage daughter had called 999 saying she “could not move” almost four months before her body was found but no ambulance was sent to her, an inquest has heard.
Alphonsine Djiako Leuga, 47, suffered from sickle cell anaemia and died from pneumonia, and her 18-year-old daughter, Loraine Choulla, had learning difficulties and Down’s syndrome, relying on her mother for food and hydration.
Nottingham coroner’s court heard that Leuga called 999 on 2 February last year saying she was cold and could not move, and gave details of her address before hanging up.
The hearing was told that during the call Leuga groaned, requested an ambulance, and said: “I need help to my daughter” and: “I’m in the bed, I feel cold and can’t move” before cutting off the line.
She also gave details of her address in Radford, Nottingham, where her body and that of her daughter were found on 21 May last year, almost four months later.
Giving evidence at an inquest into their deaths, East Midlands ambulance service’s head of patient safety, Susan Jevons, said the call should have been referred to the control room dispatch officers.
She said attempts had been made to call Leuga back and that “the call should have been left for an ambulance to attend once we had got the address, which we had.
“The ambulance didn’t go to the address because the emergency medical adviser, thinking it was an abandoned call, closed the call down. So it wasn’t visible to anybody within the emergency operations centre.”
The coroner said she would have to consider the possibility that sending an ambulance to the address “might have been the difference between life or death” for Choulla.
Read full story
Source: The Guardian, 21 July 2025
Patient Safety Learning

Three-fold difference in app use by ICS revealed

The share of patients routinely contacting their GP practice using the NHS App is only 6 per cent, and varies more than three-fold between systems, new figures suggest.
The annual GP patient survey found the proportion of patients who used the NHS App the last time they contacted their practice increased nationally by two percentage points on last year, but was still only 6%.
It has increased year-on-year in every integrated care system, by as much as five percentage points (see table below). But there is significant variation.
It comes as the government places the NHS App at the centre of its health reform strategy, aiming to make it a “single front door” to NHS services. It follows rapid take-up in recent years, accelerated by Covid-19. 
Nationally, more people used their practice’s own website than the App (14%). For many practices, there is more functionality for messaging on their website.
But phone was by far largest way people tried to make contact, on 62%. Fourteen per cent visited in person, and the remainder used a different website or app, or “another way”. 
Read full story (paywalled)
Source: HSJ, 11 July 2025
Patient Safety Learning

How hard will UK aid cuts hit projects helping women and girls?

The scale of UK cuts to foreign aid means virtually all projects currently being funded in developing countries will be affected. But the cuts are tipped to fall particularly heavily on projects specifically for women and girls.
“The depth of the cuts means that there will definitely be cuts for nearly every programme,” said Ian Mitchell, a senior policy fellow at the Center for Global Development of Prime Minister Keir Starmer’s slashing of international aid from 0.5 to 0.3 per cent of Gross National Income (GNI).
Among the programmes that could be at risk is the UK-funded Women’s Integrated Sexual Health (WISH) initiative, which provides sexual and reproductive health services across 12 countries in West and Central Africa. The programme has reached 2.6 million people - mostly women in rural communities with no other options.
In the Democratic Republic of Congo, for example, where fewer than 15% of women use contraception, the WISH initiative has introduced access to family planning options and information, for some women for the first time.
The programme has averted an estimated 33,000 maternal deaths and prevented 100,000 children from losing their mothers, according to MSI Reproductive Choices, one of the world’s biggest providers of contraception and abortion services.
Family planning is often not seen as life-saving - certainly by the current US administration - but an unintended pregnancy in a country with high maternal mortality and no access to safe abortion can spell death, and does for tens of thousands each year.
Read full story
Source: The Independent, 18 July 2025
Patient Safety Learning

Patients in England’s most deprived areas wait longer for NHS treatment, data reveals

Patients from the most deprived areas of England face longer waits for NHS treatment and make up a higher proportion of those waiting for care, according to figures.
Data released by NHS England on Thursday provides a breakdown of the health service’s waiting lists by ethnicity and deprivation levels for the first time. It shows that people in the most deprived areas of England and people from ethnic minority backgrounds make up a disproportionate and growing proportion of those waiting for NHS treatment.
An average of 3.1% of patients living in the most deprived areas had been waiting more than a year to begin treatment as of June, compared with 2.7% of the least deprived.
The deprivation gap is even wider in certain regions of England, with 2.4% of patients in the most deprived areas in London waiting over a year for treatment, compared with about 4.9% of the most deprived in the east of England.
Patients from an Asian or British Asian background were more likely to be waiting longer than 18 weeks for treatment than any other group, and the east of England and south-west England were regions with the largest ethnicity gap for people waiting more than a year to begin hospital treatment.
Women made up a disproportionate percentage of those on the waiting list for NHS treatment, at 57%, while also being more likely to be waiting more than 18 and 52 weeks than men. People of a working age (between 19 and 64) are also more likely to wait over a year to start treatment, at 3%, compared with 2.5% of those over 65.
Read full story
Source: The Guardian, 17 July 2025
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