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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    This webinar will bring together global experts and practitioners to explore how Infection Prevention and Control (IPC) interventions can be implemented to improve safety in newborn and child care and help reduce avoidable harm. The webinar will focus on: Why infection prevention and control is essential for safe newborn and childcare. How Goal 4 can be implemented in practice at the point of care. What health care workers, leaders, managers, and policymakers can do to prevent health care–associated infections. This webinar series is co-hosted by the World Health Organization, the International Pediatric Association, and the Child Health Task Force. Register
  2. News Article
    NHS England is considering allowing midwives to “withdraw” services from women deemed to be giving birth at home against professional advice, HSJ has learned. The Royal College of Midwives has warned that if this advice is introduced, it risks “push[ing] women towards giving birth entirely alone, [presenting] far greater risk to mother and baby”. The disagreement comes as NHS services urgently seek clarity from system leaders on how they should best support home births and some high-risk pregnancies. However, the advice would also cover how services should respond to other care and treatment requests that are considered “highly unsafe or unreasonable”. NHS England’s discussions about the potential new advice were revealed in a letter responding to a coroner’s Prevention of Future Deaths report. The letter is dated 24 December, but it was only published last month, and HSJ understands a definitive decision about the advice has not yet been made. The letter said: “We will build on work already started, looking to clarify whether NHS health professionals providing maternity services may withdraw midwifery services from women birthing at home against professional advice and/or from women making requests with regards to care/treatment that are considered highly unsafe or unreasonable.” It added: “In developing [better home birth resources], NHSE and its partners will consider the ethical responsibility and proportionality of offering women an NHS home birth, while taking into account that women have a legal right to choose what healthcare they receive. “In addition, some women who cannot be supported to birth at home due to the level of risk may choose to give birth unassisted, which carries a higher risk.” The report prompted chief midwifery officer Kate Brintworth to order all trusts to “urgently” review the safety of home birth services in November. Read full story (paywalled) Source: HSJ, 28 April 2026
  3. News Article
    A care home manager in Ayrshire has been struck off after inappropriately and unnecessarily restraining a disabled person for a vaccine injection. A tribunal hearing heard that Janette Donnelly's use of force was "horrific" and resulted in scenes of chaos at Millport Care Centre on 19 February 2021. The jab ended up being administered through the resident's clothes, following which Donnelly told a colleague that she would not report that it had been injected that way. The Nursing and Midwifery Council ruled her actions were a significant departure from the standards expected of nurses and she had repeatedly given a "dishonest and self serving" account of the day to justify her actions. A registered NHS nurse had visited the care home on the day to administer the Covid-19 vaccine to people staying there. The resident, described in the hearing as Service User A, had a learning disability and at times restraints were used to allow her to be fed, but these were only meant to be for brief periods of time. She was due to receive her second vaccination but two attempts to do so in the building's dining room earlier that day had not gone ahead. Instead, the vaccine was given in the resident's bedroom while she was being held on the floor Donnelly and two other staff members. Evidence to the panel said the woman was shouting, screaming and struggling. One witness stated that she would never forget the sight she was confronted with, that it was a "horrific" scene, and that Donnelly had restrained the person's head with her hands. Donnelly told the NHS nurse to carry out the injection through the resident's clothing. After this happened the colleague said to Donnelly, "please don't tell anyone I've administered the vaccine in this way", to which Donnelly said "of course I won't". Donnelly claimed she was unaware the vaccine had been given through the clothing, which the panel did not agree with. It ruled her actions in not reporting this were dishonest. The panel also ruled that the vaccine did not have to be given on that day, and the nurse could have visited at another time. It concluded that Donnelly's actions "placed Service User A at a risk of physical harm, and both Service User A and your colleagues at a risk of emotional harm". Read full story Source: BBC News, 27 April 2026
  4. News Article
    Hospital trusts are spending millions of pounds a year on expensive temporary staff to look after mental health patients stranded in emergency departments and acute wards, HSJ has learnt. Figures released to HSJ by 70 acute trusts showed several trusts in cities spent more than £1m each during 2025 on additional agency staffing to care for patients waiting for mental health treatment, and with no physical care need. Across 70 trusts that provided data, the cost was £19m last year, equating to about 16,000 additional staff. Many are hiring specialist mental health nurses, who come at an even greater agency cost premium than general nurses. It is the latest sign of the rise in serious mental illness and strained capacity in mental health services – and the knock-on costs elsewhere. Several trusts have said it is contributing to their financial problems. A University Hospital Southampton Foundation Trust board report last month said: “The number of mental health patients attending… creates a significant additional cost, including utilising specialist agency to ensure we have sufficiently skilled staff capacity to care for these patients safely often including additional security costs.” Read full story (paywalled) Source: HSJ, 27 April 2026
  5. Content Article
    Despite its proven ability to deliver fast, cost-effective and impactful learning, After Action Reviews (AARs) remain significantly underutilised in healthcare contexts. This study describes the use of AAR to illustrate the strengths of this structured learning approach and to promote its wider use. The authors provide a narrative synthesis of the findings, drawing on field experience and document analysis from two AAR contexts: (1) The ‘micro’ context: in hospital settings to improve patient safety and team performance as experienced within the NHS in England. (2) The ‘macro’ context: in health system settings to enhance preparedness for public health emergencies as used by WHO. Findings include the following:(1) where good practice should be repeated, such as house-to-house vaccination, the provision of consistent messaging for all teams and early communication with family members; (2) where gaps should be closed such as knowledge about procedures to be followed if a patient disappears from a ward, full vaccination of all healthcare workers and community confidence in vaccination. The comparison of the similarities in the process in both contexts and the challenges experienced provides insight into the value of the approach and is designed to support other healthcare contexts to adopt the approach successfully
  6. Content Article
    Surgical implants, such as joint replacements, are used for many serious conditions. Innovation continues to supply new implants, including outputs of the soft robotics revolution. However, they carry risk of complications with potentially devastating consequences. This opinion paper provides the reflections of two surgical technologists on present challenges to safety, efficacy and broad implementation of medical implants. They highlight lack of familiarity with implant surgery in healthcare services, with concomitant risk. First-in-human application of new implants is not sufficiently standardised and regulated. IDEAL-D is a structured framework for medical devices (Idea, Development, Exploration, Assessment, Long-term study). Once CE-marked and approved for mainstream use, there are problems with the implementation. ‘Early adopter’ surgeons and centres face cultural inertia, lack of funding support and issues around training, especially learning curves. Patient selection may not be well-defined, and complications inaccurately reported, affecting implant dissemination detrimentally. The Cumberlege report showed how harmful this can be. There is need to standardise early clinical studies. Implementation of implantable devices requires changes to whole-team training, funding and post-implementation reporting. The IDEAL-D framework represents an important step, but other system-wide changes are required if implants are to achieve their intended clinical impact.
  7. Event
    until
    Nursing is central to patient safety, quality of care and the sustainability of health systems, yet its contribution is frequently undervalued in policy and practice). This seminar will present an overview of the existing international and UK evidence on the association between safe nurse staffing and patient and staff outcomes, including mortality, failure‑to‑rescue and quality of care. It will examine how inadequate staffing is linked to missed care, preventable harm, staff burnout and attrition, contributing to the widening workforce crisis across health and care systems. Attention will be paid to the gendered nature of the nursing workforce, with women comprising nearly nine in ten registrants in the UK, and how structural inequities, misrecognition and limited professional agency shape decision‑making about safety and workforce investment. Positioning nursing as a critical yet often invisible ‘safety net’, this session demonstrates that patient safety cannot be meaningfully addressed without nursing workforce evidence at its core. Speaker: Dr Kate Kirk, Associate Director of Nursing Workforce Academy, Royal College of Nursing and Prof Amanda Adegboye, Head of Workforce Research, Royal College of Nursing Register
  8. Content Article
    Despite being regarded as the gold standard, outpatient hysteroscopy (OPH) is associated with inconsistent outcomes and pain, while the clinical, organisational, and personal determinants shaping patient-centred experience remain poorly characterised. This study aimed to harness the authenticity and richness of naturally occurring online qualitative data to explore the clinical, organisational, and personal factors that shape women’s hysteroscopy experiences, offering vital insights for service improvement. The study found that five themes captured women’s specific hysteroscopy experiences: (1) Contingent Consent, (2) Unacknowledged Vulnerability, (3) Analgesia Roulette, (4) Gynaecological Pain Gaslighting, and (5) Gendered Pain Gap. These themes delineate a hysteroscopy pathway where consent is shaped by limited choices and misinformation, vulnerability is heightened by procedural exposure, pain relief is inconsistently applied, women's suffering is routinely dismissed, and gender biases reinforce unequal standards of care. This study identifies clinical blind-spots that contribute to perceptions of systemic neglect in women’s gynaecological health care, evidenced by inconsistent pain management, inadequate consent, and gendered biases in OPH. These findings present an opportunity to inform structural reforms that advance equitable, patient-centred gynaecological care and improve clinical accountability. Further reading on the hub: Painful hysteroscopy Community thread My experience of an outpatient hysteroscopy procedure Preventable negative hysteroscopy experience
  9. News Article
    A chief executive has been appointed to lead ambulance services for a population of about nine million, in a new group of two trusts. Simon Ashton is currently the hospital chief executive of Newham University Hospital, which is part of Barts Health Trust. He will become the first joint CEO of South East Coast and South Central ambulance service foundation trusts. They have begun forming a group and together will be bigger than all other English ambulance trusts except London. The trusts recruited together, and the appointment had to be confirmed by both their councils of governors. They have said they do not plan to merge, but are working together on areas including workforce planning, digital, clinical collaboration, service resilience, and staff wellbeing. Read full story (paywalled) Source: HSJ, 24 April 2026
  10. News Article
    NHS bank staff motivation and engagement have increased in a new national survey, in contrast to falling scores among other colleagues. The results also revealed a widening gap between the proportion who look forward to work and are enthusiastic about their job, compared to their peers. The 2025 staff survey for bank workers showed motivation rose slightly to just under 7.5 out of 10. This fell to below 6.9 – the worst score in recent years – for substantive staff in results released last month. The overall engagement score – which also covers involvement and advocacy – had a small rise to 6.93 for bank staff last year, compared to a historic low of 6.75 reported by substantive staff. The results showed bank staff were more likely to look forward to going to work at 67% of respondents compared to 52% of substantive staff, with the gap in scores over 3 percentage points wider than in 2023. However, nearly one in four bank-only workers said they had experienced physical violence within the past 12 months, which has declined slightly from 25% the year before. This is still significantly higher than the 15% reported by their substantive colleagues and varied by ethnic background. The report said: “For female white bank workers, the proportion experiencing violence at work from patients or the public has decreased compared to last year and, at 22%, is at a three-year low. “The proportion of male white workers experiencing at least one incident of physical violence from patients or the public has also decreased, whereas male workers from all other ethnic groups have seen an increase in experiences of violence this year, with more than three in ten … experiencing such behaviour in 2025.” Read full story (paywalled) Source: HSJ, 27 April 2026
  11. News Article
    New mothers who had hypertension in pregnancy could reduce their risk of heart attack, stroke and potentially early death through daily blood pressure checks at home, research suggests. Women who regularly monitored their blood pressure in the weeks after giving birth, and had doctors tailor their medication if needed, had better functioning arteries nine months later than those who received routine care, scientists found. When the medication was adjusted to account for blood pressure changes, the women ended up with less stiff arteries, an effect that researchers at the University of Oxford estimate could reduce the future risk of heart attack or stroke by 10%. Paul Leeson, a professor of cardiovascular medicine who led the study, said the findings suggested that the weeks after birth provided a “powerful and often overlooked opportunity” to protect women’s future health. Read full story Source: The Guardian, 27 April 2026
  12. Content Article
    This analysis from The Health Foundation examines how healthy life expectancy in the UK has changed over the past decade, how it varies across local areas and how these trends compare with other high-income countries. Healthy life expectancy – the average number of years a person would expect to live in good health based on current mortality rates and levels of self-reported good health – is a key measure of the population’s health, providing a more comprehensive picture of the UK’s health than life expectancy alone. Over the decade 2012–14 to 2022–24, healthy life expectancy in the UK fell by about 2 years, to 60.7 years for males and 60.9 years for females. England, Scotland and Wales all saw steep declines, while the fall in Northern Ireland was more modest. The vast majority of local areas in Great Britain saw a decline over the decade, with healthy life expectancy having now fallen below the state pension age of 66 years in more than 90% of areas. In more than 1 in 10 local areas, healthy life expectancy is below 55 years. Deep inequalities in healthy life expectancy between affluent and deprived areas have widened. The gap between the most and least deprived deciles in England is now 19.4 years for males and 20.3 years for females. At the UK level, life expectancy has remained broadly stable, indicating that the drop in healthy life expectancy is largely driven by self-reported health and cannot simply be explained by the impact of the COVID-19 pandemic. However, in the most deprived areas, life expectancy has still not recovered to pre-pandemic levels. Of 21 high-income countries, the UK is one of only five that saw healthy life expectancy fall between 2011 and 2021, and had the second steepest decline. As a result, the UK has fallen from 14th to 20th out of these countries – only the United States now has a lower healthy life expectancy. These findings reinforce growing evidence about declining health in the UK, particularly among the working-age population. Successive governments have failed to take the long-term action needed to address this, resulting in a growing economic and fiscal impact as well as a substantial human cost. A new approach is needed to rebuild the UK’s health that puts improving health on a par with delivering economic growth at the heart of government policy. This should be supported by cross-government action on the wider factors that shape people’s health, a shift to prevention and a new strategy to address economic and health inequalities.
  13. News Article
    The number of years people in the UK spend in good health is falling, according to a new report. Over the past decade healthy life expectancy (HLE) has dropped by around two years to just under 61 for both men and women. The UK is one of only five of the richest 21 countries to see HLE decline and its fall was the second steepest. The Health Foundation, which produced the analysis, said there was a significant economic cost to this trend and the findings should act as a watershed moment. It said poverty, poor housing and lifestyle factors such as obesity were to blame along with the impact of the Covid pandemic. The analysis, based on data from the Office for National Statistics between 2022-24 and 2012-2014, found those in the wealthiest 10% of areas could expect to have around 20 more years of good health than those in the poorest. Read full story Source: BBC News, 27 April 2026
  14. News Article
    Mental health patients in the UK are routinely coming to harm because of high caseloads, understaffing and overwhelming administrative work, according to a poll that found only a fifth of specialist nurses felt their workload was manageable. Prof Nicola Ranger, the general secretary of the Royal College of Nursing (RCN), said mental health nurses were caught in a “perfect storm” and unable to keep up with rising demand, with patients paying the price by missing out on crucial care. Half of the specialist nurses who responded to the RCN union’s UK-wide survey said mental health patients “frequently come to harm” because caseloads are too high, with a quarter feeling that time pressures lead to daily issues with patient deterioration, relapse or self-harm. Nearly two-thirds said their caseloads had risen “a lot” in the past three years, while excessive admin and a “tick box” culture were blamed for taking away valuable time for patient care. The poll also suggests that demand for services has grown more than twice as fast as the number of nurses in the field. Read full story Source: The Guardian, 27 April 2026
  15. News Article
    A trust whose maternity care is under scrutiny is launching a review of all stillbirths last year, it has confirmed to HSJ. Sandwell and West Birmingham Trust (SWBT) confirmed it was due to begin a review of all 2025 cases. This will include a “comprehensive” review of care provided to identify “themes and learning”. It will also examine the reviews that staff carried out at the time of the stillbirths – a process which uses the national perinatal mortality review tool (PMRT). There have been concerns about whether those reviews were carried out properly at SWBT. The new review will be led and hosted by SWBT, but with experts from NHS England, and clinicians from other trusts in the local maternity and neonatal system (LMNS), taking part. It is the latest in a string of reviews to examine maternity care at SWBT, including the ongoing national investigation by Baroness Amos. The trust’s perinatal mortality has been flagged multiple times as an outlier, but it improved in the most recent data. Read full story (paywalled) Source: HSJ, 24 April 2026
  16. News Article
    Trusts passing an “AI readiness” test before being allowed to use the technology is one of the ideas being considered by an influential government commission. The National Commission into the Regulation of AI in Healthcare, this week, published meeting minutes that gave clues about what new rules it might propose. The minutes said discussion papers “outlined proposals to accredit healthcare providers who can demonstrate high levels of ‘AI readiness’ so they can provide earlier access to AI systems and a pathway for deploying earlier-stage AI systems, which maintains healthcare professionals’ confidence.” It said “AI readiness” would mean healthcare providers being able to show they have “the systems, digital infrastructure, governance and risk frameworks and capabilities in place to deploy AI systems safely”. Digital maturity varies widely across NHS organisations. The national commission was set up in September to help clarify the confused regulation of approval, deployment and liability in relation to the tools. AI use cases in healthcare range from automating administrative work and ambient voice technology to interpreting test results. The national commission is chaired by Professor Alastair Denniston. Minutes said he “emphasised throughout the discussion that the proposals were intended to stimulate forward-looking discussions around the possible future regulatory frameworks but were not under active development”. Read full story (paywalled) Source: 24 April 2026
  17. Content Article
    Protocols, targets and pathways save lives. They give us essential structure to deliver safe, high‑volume care with finite resources, and they have transformed the NHS for the better. But as the healthcare experience becomes increasingly streamlined, Hannah Little, Assistant Chief Nursing Officer at North Bristol NHS Trust, asks: who are we leaving behind? One size rarely fits all We often hear about what healthcare can learn from efficiency‑led industries such as automotive manufacturing, where success is defined by pace, scale and uniform outcomes. And indeed, cross‑industry learning has benefited the NHS enormously. But context matters. People are not cars rolling off a production line. We are complex, diverse human beings with individual social, psychological and clinical needs. And I wonder how far we can push a target‑driven model before we start hearing louder public concern about the fact that, in healthcare, one size rarely fits all. Finding the sweet spot As a nurse, I see individuals deliver personalised care brilliantly. I see colleagues who instinctively adapt, interpret and flex protocols to truly meet the needs of their patients and families. What worries me is not the people—it’s systems that increasingly constrains them. There is a 'sweet spot' between regulation, targets and national mandate on one side, and freedom to innovate on the other. That tension is necessary: too much control and we lose space for creativity; too little and we invite unsafe variation. When the balance is right, systems evolve safely, testing change within a clear structure while allowing for the flexibility that person‑centred care requires. The weight of national targets Standards and strong governance are essential to quality. But how do we ensure they don’t swallow the space needed for anything else? Over recent decades, the weight of national targets has grown heavier. The NHS Oversight Framework was intended to bring much‑needed clarity—a more focused set of national priorities that would reduce noise and strengthen local autonomy. At the 2026 Patient Safety Forum, national leaders spoke about a welcome cultural shift away from over‑mandating and toward local devolution. But this shift appears to be landing alongside a net reduction in resource and ever higher stakes to deliver. So instead of fewer mandates and more autonomy, we may be facing fewer mandates and less capacity for innovation. This raises a critical question: after the targets are met, is there enough resource left for the other things that matter? The things that support sustained performance? Targets tend to serve the 80% who fit neatly onto the healthcare conveyor belt. Without additional support for those who don’t, we risk widening health inequalities. Equity requires adaptability to be hard-wired into pathways—and adaptability requires headroom. The trade-offs Are we comfortable with where we are now? Has the pendulum swung into the place we need for 2026? Everyone recognises that resources are limited. But when limited resources necessitate laser focus on a small number of priorities, are the trade‑offs services have to make the right ones for population health? What will we think, looking back in five to ten years? Will we feel confident that a model which rewards optimising delivery for the majority was worth potentially widening the gap for those who didn’t fit standard pathways? Unlike other industries (e.g. Apple, which famously narrowed its product line to recover focus), healthcare cannot simply do fewer things well. Complex populations do not disappear because they fall outside a national priority. When centrally governed targets narrow without a corresponding rise in local capacity, the burden of adapting care falls to already stretched individuals. And when that happens, quality, equity and outcomes inevitably feel the strain. So what is the solution? If we care about equity and the safety and health of whole populations, resource to adapt and personalise care needs to be preserved. We need open, honest analysis of the trade-offs being made at policy level. Do we have the right set of priorities? Are we incentivising organisations to only pick low‑hanging fruit? And crucially: are we preserving the resource required to deliver personalised, equitable care? Passionate individuals cannot carry this burden alone. Flexibility must be designed into the system, not left to chance. And perhaps the answer is not fewer targets—but targets that incentivise equity as much as efficiency. Call to action Policymakers and senior leaders must prioritise embedding flexibility within national frameworks for all sectors by protecting resource for personalised care, incentivising equity alongside efficiency and enabling local systems to adapt. Without deliberate action, we risk incentivising services that work well for many, but fail those most in need.
  18. News Article
    A former senior leader of the Countess of Chester Hospital Foundation Trust has been arrested on suspicion of perverting the course of justice. Cheshire Constabulary has said it will not give details, including the age or gender, of the individual. However, they are understood to be one of three former members of the senior leadership team at CoCH FT between 2015 and 2016 who were arrested last June on suspicion of gross negligence manslaughter. They were later bailed pending further enquiries. The force said the latest arrest had taken place as part of an ongoing investigation into potential corporate manslaughter and gross negligence manslaughter at the hospital where convicted murderer Lucy Letby used to work. A statement from Cheshire Constabulary said officers executed a search warrant at a property on Wednesday. Read full story (paywalled) Source: HSJ, 23 April 2026
  19. News Article
    A string of bureaucratic barriers are still holding up development of buildings for primary and community care, multiple NHS and industry organisations have warned. Concerns were raised in written evidence to the health and social care committee’s ongoing inquiry into what is needed from the NHS estate to deliver the government’s vision of a neighbourhood health service. Primary Health Properties PLC, the UK’s largest primary care property investor, said it has 19 planned developments of new health centres and around 20 upgrades to existing buildings serving more than 500,000 patients that are “currently stuck due to challenges with local NHS decision-making and agreeing a viable rent”. Rugby Primary Care Network also said the “health on the high street” concept had “completely stalled” in Rugby and was “costing thousands due to acquisition from private landlords”. Warwickshire District Council, meanwhile, said local community estate, including GP surgeries, was “antiquated and out of date”, adding: “What you have got for the most part isn’t good enough to do the job.” NHS organisations and industry sources have raised concerns in recent years over barriers to upgrading primary care premises. HSJ reported how debate over rent prices was contributing to an “untenable stalemate” back in 2024. The government is now seeking to develop and expand hundreds of primary and community facilities to create “neighbourhood health centres”, with some funded publicly and some by a new private finance programme. It issued guidance last week that asked ICBs to set out their planned schemes. Read full story Source: HSJ, 23 April 2026
  20. News Article
    A mother who lost her baby a week after an “unsafe” home birth that went against medical advice was failed by the NHS, an inquest has found. Poppy Hope Lomas was seven days old when she died at University College hospital in London on 26 October 2022 after complications during a home birth that, according to her mother, was encouraged by midwives at Barnet hospital. An inquest into Poppy’s death at Barnet coroner’s court concluded that she probably died from a lack of oxygen reaching her brain in the 30 minutes before she was born. The senior coroner Andrew Walker said the Royal Free London NHS foundation trust had agreed to support Poppy’s mother, Gemma Lomas, with an “unsafe home delivery that was against medical advice” and had failed to address “an accumulation of risk factors”. After the inquest concluded on Thursday, Lomas said outside the court: “Nothing will ever bring her back, but hearing the truth today acknowledged means everything to us. “We trusted the professionals who were guiding us,” she said, adding that she hoped lessons would be learned. She previously told the inquest that midwives had actively encouraged her to have a vaginal birth at home, despite the risks because she had given birth to her first daughter, Willow, by caesarean section in 2018. Guidance from the Royal College of Obstetricians and Gynaecologists says vaginal births after caesarean (VBACs) should take place in a “suitably staffed and equipped delivery suite” and “with resources available for immediate caesarean delivery”. “I was encouraged to do what we did,” Lomas said. “I would have never made decisions to harm myself or my baby in any capacity.” Read full story Source: The Guardian, 23 April 2026
  21. News Article
    Doctors are having to choose which "very sick people" they prioritise because of the pressures on Northern Ireland's emergency departments (ED), the Royal College of Emergency Medicine (RCEM) has said. Department of Health (DoH) statistics for the first three months of this year show that no ED achieved targets for seeing patients within the four-hour and 12-hour benchmarks. RCEM Northern Ireland said, so far, the figures for 2026 are "the worst they have ever been" and described the state of emergency departments in Northern Ireland as "utterly horrifying". The association's vice president, Dr Michael Perry, said the environment staff are working in was making their jobs very difficult. "We're basically pleading with our policy makers and our elected representatives in our government to allow us to do our jobs," he said. "Don't put us in this position where we have to choose out of two very sick people who we prioritise," Dr Perry told BBC Radio Ulster's Good Morning Ulster. Nursing staff turnover in Northern Ireland's emergency departments is "vast and it is largely to do with the environment that they work in", he continued. "I've had staff very distressed where something's happened, they have tried their best to deliver the best care that they can, but because of the environment they're being forced to work in something adverse has happened." Read full story Source: BBC News, 24 April 2026
  22. News Article
    About one in 10 operations in England are cancelled with less than 24 hours’ notice or postponed, according to research. A study of elective surgery at 91 English NHS trusts found that 10% of operations were cancelled the day before the planned surgery date; while 9% were postponed when patients had their pre-op appointment. If the study’s findings were replicated nationally, that would equate to approximately 300,000 cancellations or postponements. Yet nearly 40% of cancellations could be avoided, the authors concluded. Researchers for the National Institute for Health and Care Research Central London patient safety research collaboration, NHS England, University College London and the Royal College of Anaesthetists examined planned surgery data over seven days in November 2024. They found that the most common causes of cancellations were for medical reasons, patients not attending, operating lists overrunning and emergency admissions. But in 37.3% of cases, had these issues been identified as little as three to five days earlier, the operation could either have gone ahead, or another patient could have been offered the surgery slot, the study calculated. The study, published in the British Journal of Anaesthesia, also found that nearly two-thirds of operations postponed at the pre-op appointment were because patients needed further tests or specialist clinical review. The authors concluded that clinical pathways need overhauling, with more early screening, nimbler surgery scheduling and better communication. Read full story Source: The Guardian, 24 April 2026
  23. Content Article
    Letter from Sir James Mackey, Chief Executive, NHS England covering priorities and a look ahead for the new financial year. Key points Outpatient transformation – shifting away from traditional outpatient models through a major expansion of Advice and Guidance and a reduction in unnecessary follow‑ups. A step‑change in reducing hospital bed‑days for highest‑risk cohorts – with neighbourhoods playing a central role in implementing proactive care models for high‑risk groups. Scheduling and access reform for urgent care – making it easier for patients to book urgent care appointments in GP practices, urgent treatment centres, or other appropriate settings, reducing avoidable ED attendances. Technology‑enabled productivity improvements – expanding the deployment of Ambient Voice Technology and a suite of tools to improve theatre utilisation, discharge flow, RTT validation, community waiting lists, Advice and Guidance, electronic prescribing in all trusts, and crisis response. The NHS App – accelerating efforts to expand the role of the App as the digital front door into the NHS, supporting more convenient and effective triage and navigation for patients. Payment reform – realigning the payment system to the service changes you are seeking to deliver, including new payment models for urgent and emergency care. Quality – putting quality back at the heart of everything we do, including the publication of a new quality strategy, the development of modern service frameworks focused on cardiovascular disease, sepsis, serious mental illness, frailty and dementia, children and young people, and palliative and end-of-life care, and testing new delivery models for secondary prevention to tackle variations in the uptake of high-impact CVD and diabetes interventions. Capability building and a focus on our people – launching the new Leadership College, which will be the most radical change to leadership development and talent management that the NHS has seen in over a decade.
  24. Content Article
    The Health Services Safety Investigations Body (HSSIB) engaged with a wide range of stakeholders, including clinicians and national leads, to learn more about the issues surrounding learning from patient safety events in mental health settings and to identify areas where an investigation could focus to help improve patient safety. Although suicide has been the focus of extensive national work, it has persisted as a safety risk. The themes from incidents and complaints have remained the same over time. Evidence from the intelligence gathered suggests that greater insight into the challenges faced at an organisational level when a service user has attempted suicide, or taken their life, would be helpful. To support NHS organisations and local investigation staff, HSSIB identified an opportunity to model approaches to patient safety incidents investigations (PSIIs) under the NHS Patient Safety Incident Response Framework (PSIRF). Stakeholders told HSSIB that this would help to increase local learning and provide examples of how PSIRF tools can be used to improve investigations. HSSIB has also used this opportunity to identify learning that may help to improve how PSIRF can support staff in carrying out incident investigations. This investigation has used the PSII report template and PSIRF tools to investigate an attempted suicide in the community mental health setting. Findings and areas for improvement are listed for the organisations that were involved in this incident. However, the learning may be relevant to other organisations. Summary of key findings The investigation found that: The Service User’s attempt to end his life was not expected by the mental health staff supporting him. The change to his medication meant it was a potentially vulnerable time for the Service User's mental health. This was despite him having a safety plan for how to seek help if he felt overwhelmed and planned monitoring check-ins in line with local procedure. The Service User’s case was complex and challenging; his mental ill-health, drug and alcohol use are likely to have impacted on his ability to reason and make informed decisions. Therefore, sharing of information across and between healthcare services was important to facilitate personalised care planning. Limited sharing of, and lack of ready access to, information about the Service User and his past mental health history impacted on the CMHS’s ability to provide effective and timely care. The Service User needed a tailored approach with reasonable adjustments to maximise his engagement with mental health services; there was a delay in his needs being identified and acted on. There was limited understanding and awareness by some staff of whether mental health medication can be offered to service users with mental health issues and concurrent alcohol use. Staff worked in a service that was overstretched and they had to make decisions about managing service user needs, service demand, and risk and safety, within limited resources. The demand for CMHT services exceeded the available capacity, impacting both service users and staff. Staff did not have the dedicated time and space to process and deal with distress they encountered as part of their daily work caused by incidents of patient harm. There are challenges to delivering the national ambition to provide a community focused model of care, many of which the mental health trust has limited or no control over. Summary of areas for improvement The investigation identified four areas of improvement which the mental health trust could develop safety actions to address. Area of improvement 1: Making information about service users easily available and accessible across providers to support effective initial engagement and decision making. Area of improvement 2: Early exploration of adjustments that individual service users might need to engage in the triage and referral processes. Area of improvement 3: Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol. Area of improvement 4: Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.
  25. Content Article
    Postponing or cancelling elective surgical procedures can adversely affect the patient experience, clinical outcomes, and operational efficiency. The Postponement and Cancellations in Elective Care (PACE2024) study assessed the incidence and causes of postponement at preoperative assessment and cancellation within 24 h of planned surgery across the NHS in UK. Data from 78 NHS trusts from a 7-day survey in 2024 show reduced cancellation rates (now 9.9%) and postponements (8.7%) with improved theatre efficiency (74.7% of lists reported as running efficiently) since the Super-SNAP1 study in 2022. Postponements were most commonly attributable to a need for further investigation, and cancellations were most frequently associated with acute medical conditions and list overruns. Because nearly half of postponements involved additional testing or consultations, and acute medical conditions were the main driver of short-notice cancellations, earlier optimisation and robust preoperative assessment to meet fit to proceed criteria are needed. Proactive management of acute medical conditions and patient-initiated reasons for cancellation, optimised theatre scheduling to reduce list overruns, and enhanced preassessment pathways to ensure preparation for surgery could reduce disruption and improve theatre utilisation, with positive impacts on patient experience, workforce, and resource utilisation.
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