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

Trust leadership criticised for ‘nepotism’ and disinterest in race discrimination

Staff at a struggling trust believe that executives do not take racial discrimination seriously enough and that “nepotism is rife”, according to an external review. 
The review studied the recruitment and career progression of Black, Asian and ethnic minority staff at Milton Keynes University Hospital Trust. It was commissioned by CEO Joe Harrison following the publication of the annual NHS staff survey in March 2024.
This found that 11.4% of MKUH staff had faced discrimination, compared to the national average of 8.09%. Of those, 69.86% had faced discrimination on racial grounds. The national average was 51.77%.
The review was carried out in July last year, and the trust refused requests from HSJ to share its findings. These were finally revealed when it was discussed at a trust board meeting last week. A second report into the lived experience of minority ethnic staff is still being withheld by the trust.
Other findings from the report included the belief among BAME staff that “the pace of improvement” on tackling racial discrimination was too slow and that they did not have equal career progression opportunities.
Read full story (paywalled)
Source: HSJ, 18 July 2025
Patient Safety Learning

Behaviour of NHS leaders toward whistleblowers ‘shocking’, says Francis

NHS leaders continue to exhibit “shocking” behaviour when confronted with concerns raised by whisteblowers, according to Sir Robert Francis.
The veteran patient safety expert – currently interim chair of the Infected Blood Compensation Authority – was speaking at the Whistleblowers UK conference last week. 
He said the NHS still lacked a “system that gives proper justice to those who have been victimised” after raising concerns.
“There remain terrible issues,” he said. ”No one is being held accountable. We will get nowhere on this issue unless there is a consensus to make it perfectly normal, and indeed expected, to speak up if you are worried about something. Recruitment and training have to be on the basis of these values.
“When things go wrong people need to say that and take responsibility. What happens when they don’t do that? Very little, I’m afraid. The behaviour on the part of some senior people is shocking. They don’t end up being disciplined. That is something that needs to change.”
The barrister said a systemic problem was that trusts often treated a whistleblower’s concerns as a disciplinary or HR matter, rather than a clinical issue that needed to be investigated. This meant safety problems were often not examined until HR matters had been concluded.
He said: “The problem with so many cases is that there is no authoritative internal and impartial investigation of the facts. This needs to happen at the earliest stage.
“Safety concerns raised should be treated as incidents to be investigated, not HR issues to be ‘managed’.”
Read full story (paywalled)
Source: HSJ, 17 July 2025
Related reading on the hub:
Key themes emerging from our ‘Speaking up for patient safety’ interview series The whistleblower playbook  
Patient Safety Learning

NHSE admits ‘really poor’ management and HR

Persistently poor management and HR processes have been reported to NHS England’s board today.
The Freedom to Speak Up Guardian’s report from this month’s NHSE board meeting highlighted “reportedly poor experiences” of grievance processes. It also reported “an unusually large number of staff who appear to be stranded” without a suitable substantive role, in some cases after they had raised concerns or relationships had broken down in their team.
The report – authored by NHSE medical director Sir Stephen Powis and Tom Grimes, deputy director for FTSU and organisational health – said there had been a 60 per cent rise in FTSU concerns raised in 2024-25 compared to the previous year in NHSE. The service is dealing with 32 cases which are more than a year old.
It pointed out that NHSE did not carry out a staff survey in 2024, but its results for 2023 showed only 53 per cent of staff felt safe to speak up about concerns, compared with an average of 62 per cent across the NHS.
Only 36% thought NHSE would do something if concerns were raised. “We are not able to say whether this changed [since 2023] but we fully recognise that staff continue to experience barriers to speaking up,” the report added.
The strongest themes raised in concerns in 2024-25 were bullying and harassment by line managers, senior leaders and within teams; cultural leadership including lack of empowerment and collaboration; adherence to HR policies; and recruitment practices.
Read full story (paywalled)
Source: HSJ, 17 July 2025
Related reading on the hub:
Key themes emerging from our ‘Speaking up for patient safety’ interview series
Patient Safety Learning

'Over-complex' NHS led to man's death

An "over-complex" NHS system played a "major" role in the death of a 79-year-old man, a coroner has said.
Thomas Mallinson died on 23 November at Cumberland Infirmary in Carlisle following a lack of "effective response or treatment" from health services for four days, according to assistant coroner for Cumbria Dr Nicholas Shaw.
He said the case was an example of how "over-complexity has lost sight of a man's urgent care needs".
The coroner issued a future deaths report on Tuesday, outlining the various treatment delays that Mr Mallinson faced.
Dr Shaw said the 79-year-old became unwell on 17 November with vomiting and diarrhoea.
The following day, his wife called to request a GP appointment but was told there were none available that day and to call 111 instead.
Following the 111 call, an ambulance was sent and Mr Mallinson was found to be healthy enough and told to call again if his symptoms persisted.
Still feeling ill the next day, Mr Mallinson attended a telephone GP appointment and was prescribed anti-diarrhoeal medicine.
On the fourth day, Mr Mallinson continued to get weaker and so his wife called 111 again. She was told he would get a GP appointment the same day and to wait for a call back.
Dr Shaw said that call never came.
Mr Mallinson's wife then called 999 just before midnight. She was told by North West Ambulance Service (NWAS) that a doctor from Cumbria Health, the out-of-hours provider, would call back within two hours.
Mr Mallinson's wife waited up until 04:00 GMT, but that call also never came.
On the fifth day, following a night of "continuous vomiting and diarrhoea", Mr Mallinson's wife called the GP and was offered an afternoon appointment.
She then called 999 again and an ambulance was sent.
Mr Mallinson was taken to hospital immediately, where he was found to have symptoms including hypothermia and failing kidneys.
He died in hospital two days later, the coroner said, adding that if Mr Mallinson had received treatment in a "timely manner" he most likely would have survived.
Read full story
Source: BBC News, 17 July 2025
Patient Safety Learning

Large numbers of medical trainees uncomfortable raising concerns with senior colleagues

More than a quarter of medical trainees in some specialties reported feeling apprehensive or hesitant about escalating a patient to the supervising clinician, a “deeply troubling” finding that the General Medical Council says could put patient safety at risk.
This year’s GMC national training survey was completed by around 50 637 doctors in training and 21 289 trainers. For the first time the survey asked about escalation of care.
Among doctors in training, 21% reported feeling uncomfortable raising concerns with their senior colleagues. The figure was even higher among trainees in certain specialties—with 26% of trainees in emergency medicine, 27% in obstetrics and gynaecology, and 29% in surgery.
Read full story (paywalled)
Source: BMJ, 15 July 2025
Patient Safety Learning

Calls for urgent regulation of weight loss surgery tourism after 28 Britons die from medical complications in Turkey

Medical tourism for weight loss is rising in popularity, with around 5,000 Britons a year travelling overseas for cut-price surgery.
But experts have warned the industry is putting patients' lives at risk and is in urgent need of regulation.
Botched surgery can lead to infections “leakage, sepsis, and even death,” a report by the BMJ highlights.
At least 28 British people had died between 2019 and March 2024, due to complications from elective medical procedures performed in Turkey figures provided by the Foreign Office revealed.
Dr Jessica McGirr of the Obesity Research and Care Group RCSI University of Medicine and Health Sciences, Dublin, Ireland and Imperial College London highlight that although cheaper often these packages do not cover care after the operation or long-term nutritional or psychological support that you would be offered in the UK.
An inquest into 40-year-old Hayley Butler, a dog groomer from Norwich who died of organ failure after a sleeve gastrectomy at the Ozel Gozde Hospital in Izmir, revealed the surgery “had not been done properly”.
A doctor Tanveer Adil, who works at Luton & Dunstable Hospital, explained she died as a result of the procedure and the "lack of safety netting" afterwards.
Read full story
Source: The Independent, 16 July 2025
Patient Safety Learning

Hospital ‘finally says sorry’ over care in brain death tragedy

The hospital which treated a young woman who died unexpectedly four years ago has said her care fell below their usual “high standards” – but the admission is “a complete cop out”, her mother said.
Gaia Young, 25, was admitted to University College London Hospital (UCLH) in July 2021 when she was taken ill following a bike ride, and died 17 hours later.
Doctors know that Gaia died from a cerebral oedema – a brain swelling – but even after an inquest the underlying cause of her sudden illness remained unexplained.
Her mother, Lady Dorit Young, has continued to fight and campaign for the hospital to take accountability for what she says are failings in its care.
She described the hospital’s latest statement, a partial apology via a short comment in a news article, as “pathetic”, adding: “It came completely out of the blue. I didn’t even notice it at first, then I was extremely furious. Why, four years after Gaia died, why now? Why did they let us do all this work and fight and push? I think it’s cruel.
“They could have done it at court, in the inquest. They could have said it to me in person, but the fact that they put it into a rather unknown publication, it’s very sneaky, it’s pretty shameful. It’s a complete cop out.”
The UCLH comment was made in response to an article called “Failing the dead: How medical ignorance is killing Britain’s coroner service”, by journalist Angela Walker in online political magazine The Lead.
Read full story
Source: Islington Tribune, 14 July 2024
Further reading on the hub:
Treated with callous disrespect: A bereaved mother’s tale of institutional apathy from the Coroner Service  The hospital told me to GO HOME, but my daughter was critically sick. A bereaved mother’s 11 patient safety lessons
Sam

Family of woman who died after misdiagnosis by 'substitute doctor' criticise govt review

The parents of a woman who died after her blood clot was misdiagnosed by someone who she thought was a doctor have called a government-ordered review "a missed opportunity".
Marion and Brendan Chesterton have welcomed many of the recommendations in Professor Gillian Leng's review of the role that physician associates (PAs) perform in the NHS, but say "they don't go far enough".
Emily, 30, died in November 2022 after suffering a pulmonary embolism. She went to see her GP at a north London surgery twice in the weeks before her death - and on both occasions was seen by a physician associate who missed the blood clot and instead prescribed propranolol for anxiety.
The actress from Salford had told her worried parents that she had been seen by a doctor, but she had not.
Her father Brendan told Sky News: "If she come out and said I've seen someone called the physician's associate I'm sure we would have insisted that, you know, let's go back and insist that you see a doctor. She never knew."
Read full story
Source: Sky News, 14 July 2025
Sam

Ambulance staff being 'pushed beyond breaking point' as 2.7m hours of overtime revealed

Scottish ambulance staff have worked more than 2.7 million hours of overtime, costing taxpayers almost £74 million - with concerns raised the pressures are “pushing already exhausted staff beyond breaking point”.
The statistics come amid separate analysis of cancer waiting times showing patients waited a year for treatment to begin and a warning from a senior doctor that “the Scottish NHS is struggling to provide the care patients need, when they need it”.
New statistics revealed under freedom of information legislation, showed 2,718,922 hours of overtime were worked by paramedics, ambulance technicians, care assistants and specialist nurses between 2020 and 2024.
Scottish Conservative health spokesman, Dr Sandesh Gulhane, said the situation was “completely unacceptable”, and claimed the ambulance service was being “kept afloat” by overtime.
He added: “This will be pushing already exhausted staff beyond breaking point and is completely unsustainable.
“Relying on overstretched staff to plug gaps in shift will be putting staff as well as patients at serious risk.
“Ambulance crews have been left dangerously understaffed because of years of dire workforce planning by successive SNP health secretaries who are clueless to the scale of the emergency facing them.”
Read full story
Source: The Scotsman, 15 July 2025
Patient Safety Learning

‘Life-changing’ therapy now available for cystic fibrosis patients

Hundreds of people with cystic fibrosis are to be offered a new pill which has been hailed as “life changing” by health experts.
The National Institute for Health and Care Excellence (NICE) has given the green light for the NHS to give patients Alyftrek, a type of modulator therapy which works to tackle the underlying cause of cystic fibrosis (CF).
CF is caused by a faulty gene that affects the production of a protein called CFTR.
Modulator drugs work by helping to make the CFTR protein work effectively.
Helen Knight, director of medicines evaluation at NICE, said: “CFTR modulators are already revolutionising the way cystic fibrosis is treated so we’re pleased to be able to recommend Alyftrek, the latest of this type of treatment that has been shown to be effective, with significant benefits for people with the condition.”
Read full story
Source: The Independent, 15 July 2025
Patient Safety Learning

New at-home heart monitors to slash NHS hospital waiting lists

The NHS has started rolling out a new at-home heart monitor designed to detect heart rhythm problems.
Unlike traditional monitors that can require lengthy set-up by a trained physiologist, the innovative kit can be posted to patients for them to attach themselves at home and used to investigate conditions including atrial fibrillation, tachycardia or heart blocks.
The device itself is a small patch that adheres to the skin, while traditional devices see patients hooked up to numerous wires and monitors during hospital visits.
After the new tool is worn for a few days, patients simply post the monitor back, removing the necessity for appointments to fit and remove the equipment.
The collected data is then analysed by an artificial intelligence (AI) tool called Cardiologs, which generates a report for assessment by a physiologist or doctor.
Frimley Health NHS Foundation Trust is the first hospital in the country to roll out the device, with hopes that the device will soon be used across other NHS trusts.
Read full story
Source: The Independent, 14 July 2025
Patient Safety Learning

Weight loss surgery tourism needs urgent regulation, say UK experts

A booming trade in medical tourism for weight loss surgery is placing patients at risk and needs urgent regulation, experts have warned.
Despite the growing popularity of injections such as Mounjaro to treat obesity, the number of patients travelling to other countries for surgery is increasing, the latest analysis suggests.
And, with the wider medical tourism industry set to be worth about £300bn annually, with anticipated year-on-year growth of 25%, international regulation is urgently needed, according to a commentary in the journal BMJ Global Health.
“We are seeing this ongoing increase, linked to the globalisation of healthcare and long wait lists,” said Dr Jessica McGirr of the University of Medicine and Health Sciences in Dublin and Imperial College London, adding that many are being marketed bariatric surgery through “before and after” images on TikTok and Instagram.
“Incorrectly, surgery is often marketed from an aesthetic point of view,” McGirr said. “This is complex surgery for treatment of a chronic disease with potentially significant health complications.”
Read full story
Source: The Guardian, 15 July 2025
Patient Safety Learning

Why the UK is lagging behind other countries on measles vaccinations

The UK is the worst-performing G7 country for coverage of measles vaccines, as rates lag behind Europe, with experts warning declining health budgets and the spread of misinformation are putting children at risk.
Now, health officials in the UK have sounded the alarm over our waning vaccine coverage after a child with measles died in Liverpool.
On Monday, health secretary Wes Streeting said that the child’s death shows the nation needs to “redouble its efforts” to vaccinate more children and said improvements promised in the NHS’s 10-year plan, such as giving parents access to digital health records, could help.
One expert told The Independent a multitude of issues have impacted the UK’s measles vaccination rates, including declining public health budgets, lower access to GP services, and the increased circulation of misinformation on social media.
Speaking with The Independent, Adam Finn, Professor of Paediatrics at the University of Bristol, and a member of the government’s Joint Vaccinations and Immunisations Committee, explained there were several factors, including the fact that there has been a general decline in immunisation over the past 15 years, which had initially been ignored.
He said: “The public health authority officials favour the idea that it’s because there’s been a waning of resource in the health service to deliver the vaccine programme, so as primary care in particular has become more stretched the capacity to chase people up and go after the people that are otherwise not getting their act together has disappeared and that’s resulted in the vulnerable edge getting worse and worse.”
“The competing hypothesis, which is quite convenient for the politicians, is that it's mad internet misinformation, and in a sense, people are somehow to blame for believing it and that it’s not really a governmental problem, it's myth and legend, as it were.”
“My view is that those two things are not mutually exclusive.”
Read full story
Source: The Independent, 15 July 2025
Patient Safety Learning

We are entering 'golden age' of cancer treatment - and also facing a less gilded era too

Cancer treatment is becoming increasingly personalised and oncologists know their enemy in more intimate detail than ever before.
So the outgoing medical director of the NHS, Sir Stephen Powis, is not wrong: we are entering a "golden era" of cancer treatment, if we're not living in it already.
Cancer treatment is becoming increasingly personalised to the specific mutations in the cancer itself. Oncologists know their enemy in more intimate detail than ever before.
Tools like AI can sift through that detail to identify new vulnerabilities in cancer cells and techniques like gene editing allow scientists to design previously impossible new ways of exploiting them to slow, or reverse the spread of cancers.
But we're entering a parallel and less gilded era too.
Cancer is primarily a disease of ageing and our population is doing that rapidly.
It is also more common in those who eat and drink too much and exercise little - which is most of us - and explains why cancer rates are now, perhaps for the first time in human history, increasing in younger people too.
As Sir Stephen points out, prevention must play an important role in reducing that increasing burden. It already has for some: smoking-related lung cancer is declining, so too is cervical cancer thanks to HPV vaccination in schools.
But the bulk of cancers linked to poor diet, poor air quality, or poverty in general are not.
We're also failing to make sure everybody benefits from the incredible new treatments available and those yet to come.
Read full story
Source: Sky News, 14 July 2025
While people are now getting cancer diagnosed faster in the NHS, many start treatment too late. More than 30% of patients wait more than two months to see a cancer specialist following an "urgent" referral from their GP (well below the NHS target that has not been met since it was introduced in 2015).
Cancer survival is increasing, but so too is the disparity between those benefitting from the latest treatments and those who aren't.
Specialist treatment in some parts of the UK is far better than in others - often those in poorer places where cancer rates are higher.
And the latest, and best, cancer treatments - which are largely bespoke-tailored to the patient's needs - are increasingly expensive.
Patient Safety Learning

NHS cuts could lead to another Baby P or Victoria Climbie as safeguarding staff face axe, doctors warn

NHS cuts to key safety roles could trigger more abuse and child deaths, such as those of Baby P and Victoria Climbié, doctors and experts have warned.
Medical staff responsible for safeguarding in their area are legally required to flag concerns about vulnerable patients, but their roles are at risk of being axed as local NHS bodies scramble to make government-imposed cost savings, doctors have told The Independent.
Almost two dozen healthcare professionals, medical royal colleges, alongside children’s charity the NSPCC, have written to health secretary Wes Streeting urging him to protect the roles.
The letter to Mr Steeting, shared with The Independent, said: “The NHS has a crucial role to play in protecting children.
“Given the scale and pace of reform, we ask you to urgently send a clear message to the public and all those who work to protect babies. This should guarantee that keeping children safe will remain a priority for the NHS and that ICBs will be fully resourced to carry out their child safeguarding duties.”
Dr Peter Green, chair of the national network of designated health professionals and doctors for child safeguarding, told The Independent there was a risk that cases such as Baby P and Victoria Climbie will occur more frequently as a result of any cuts.
Dr Green said: “There is a clear risk of those cases significantly increasing. The risk of those cases is obviously going to increase by not having the [NHS’] oversight and learning when things go wrong.”
Read full story
Source: The Independent, 16 July 2025
Patient Safety Learning

'Confusion' over mortuary oversight still 'widespread' four years after necrophilia scandal

There is “widespread confusion” among which senior executive is accountable for mortuary services, with many CEOs blind to potential criminal liability, according to the final report into the abuse of dozens of deceased patients at an NHS trust.
The latest phase of the independent inquiry into the crimes of convicted sex offender David Fuller was released today. It is highly critical of the lack of oversight exercised by trust boards over the operation of their mortuaries despite the national profile of the scandal.
Maintenance supervisor Mr Fuller sexually violated 100 women’s and girls’ bodies in hospital mortuaries at Maidstone and Tunbridge Wells Trust over a 12 year period before his crimes were finally uncovered in 2020 when he was arrested and then convicted for two murders committed before he started to work for the NHS.
The inquiry was headed by Sir Jonathan Michael, former chief executive of Oxford University Hospitals Foundation Trust. The final report highlighted confusion among executives about who held accountability for mortuary services, but also stressed “this confusion was one aspect of the limited oversight of the performance of the mortuary service”.
The inquiry investigated the arrangements at 24 trusts in detail. It found many significant inconsistencies in who directors thought was accountable for mortuary services, with some at the same organisation saying it was the medical director and others the chief operating officer. 
Senior executives also believed their trusts’ safeguarding policies included the care of dead people, but failed to ensure that policies did so.
Read full story (paywalled)
Source: HSJ, 15 July 2025
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