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Patient Safety Learning

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  1. Patient Safety Learning
    Four hospital trusts have been assessed as having higher than expected rates of both stillbirth and neonatal deaths, according to HSJ analysis of a national safety audit.
    Only one of those trusts scoring highly on both measures is part of the ongoing national government maternity inquiry. That is University Hospitals of Leicester Trust.
    Three other trusts that are not part of Baroness Valerie Amos’ review were also rated “red” for these measures: South Tyneside and Sunderland, East Suffolk and North Essex, and Royal Devon University Healthcare Foundation Trusts.
    A red rating means their adjusted death rate was at least 5% cent higher than peers. 
    The four trusts are also red rated for “extended perinatal mortality” - which combines the two other metrics - including stillbirths after 24 weeks of pregnancy and “neonatal” deaths up to 28 days after birth.
    MBRRACE study author Brad Manktelow, from Leicester University, told HSJ the mortality rates reported are not definitive measures of care quality.
    But he added: “However, given the information that is available, the rates reported by MBRRACE-UK are robust and make an important contribution in highlighting those organisations where extra investigations should be targeted [to] improve the quality of perinatal and neonatal care in the UK.”
    Read full story (paywalled)
    Source: HSJ, 26 March 2026
  2. Patient Safety Learning
    Under-performing NHS bosses are being “quietly moved on” rather than being “named and shamed”, Wes Streeting has said.
    The health and social care secretary was speaking as he unveiled a new “intensive recovery programme” for struggling trusts.
    Speaking on the BBC’s Today programme, Mr Streeting said: “The reason why you haven’t seen headlines about individuals and their heads being on spikes, [with us] naming and shaming, is because I’m not in the business of humiliating people to try and look tough politically.
    “What I am in the business of doing is quietly, effectively and efficiently moving on poor performing senior leaders where they are not delivering the improvement that’s needed.
    “And that’s why today I’m also announcing the five trusts where we’ve had stubborn under-performance, where I’m sending in NHS veterans with experience of turnaround to drive improvement.”
    The five trusts are Mid and South Essex Foundation Trust, Hull University Teaching Hospitals Trust and Northern Lincolnshire and Goole FT (which together form the Humber Health Partnership Group), North Cumbria Integrated Care FT, and East Kent Hospitals Trust.
    Read full story (paywalled)
    Source: HSJ, 25 March 2026
  3. Patient Safety Learning
    Hundreds of children are in hospital unnecessarily on any given day because they do not have the right support to go home, according to an analysis of NHS England data.
    The discharge delays mean patients affected are missing out on childhood activities and youngsters needing hospital care are waiting for beds, the children’s commissioner’s report found.
    More than 260,000 young people spent three or more weeks of their childhood in hospital and 1,300 were there for more than a year.
    Medical advancements have meant more patients with complex or life-limiting conditions can live longer but community services such as children’s social care, housing, education and home nursing have not kept pace, it said.
    Dame Rachel de Souza, children’s commissioner for England, said in a statement: “For all the debate and attention given to hospitals, waiting times and social care, children are rarely mentioned.
    “Childhood is a short and precious time – so when a child spends months or even years confined to a hospital ward, not because they are too unwell to leave but because the right community support cannot be found, the system has failed.”
    De Souza said this is partly driven by a “lack of good data”.
    The NHS does not consistently record how many youngsters are medically fit to leave hospital but are remaining there as a result of factors external to the health service, the report said.
    Read full story
    Source: The Guardian, 23 March 2026
  4. Patient Safety Learning
    A hospital trust did not immediately alert health officials about a case of meningitis in Kent.
    A patient first presented to East Kent Hospitals University NHS Foundation Trust on the evening of Wednesday 11 March, a spokesperson said.
    But the trust waited until Friday 13 March, once a diagnosis had been confirmed, to notify the UK Health Security Agency (UKHSA), which manages an outbreak of such an illness.
    Dr Des Holden, acting chief executive of East Kent Hospitals University NHS Foundation Trust, said: “Our first patient presented on the evening of Wednesday 11 March.
    “We recognise there was an opportunity prior to diagnosis being confirmed on Friday 13 March to notify UKHSA".
    Health secretary Wes Streeting said that there was a 24-hour window in which hospitals were meant to raise a suspected case with the agency, and that staff had instead done so in 26 hours.
    He told LBC: “The patient came in on the Wednesday unwell. By mid-morning on Thursday, the staff suspected meningitis. Now at that stage, they had 24 hours within which they should have notified the UKHSA. They did so in 26 hours.
    “While I can reassure people that it appears in this case that that delay did not have a material impact – we have not found evidence of onward transmission to other people through that delay that we would otherwise have traced faster – nonetheless, we have that 24-hour standard for a reason, and I am taking this seriously.”
    Read full story
    Source: The Independent, 25 March 2026
  5. Patient Safety Learning
    Public satisfaction with the NHS has risen for the first time since 2019, but people remain deeply frustrated with stubbornly long waits to receive GP, A&E or hospital care according to the latest annual British Society Attitudes survey. 
    The proportion of voters in Britain satisfied with the way the NHS runs has increased from the record low of 21% seen last year to 26%. At the same time dissatisfaction with the health service fell 8% – the biggest drop since 1998 – although it remains high at 51%.
    However, delays in accessing care continue to cause public unhappiness. Most people are dissatisfied with the time it takes to get seen in A&E (66%), receive hospital care (63%) and get a GP appointment (58%). Only 14% are satisfied with A&E waiting times.
    Mark Dayan, head of public affairs at the Nuffield Trust, said: “These are still numbers that you would have thought were catastrophic in the 2010s. They’re still worse than they were even during the 90s, a period when the public was widely perceived to be very unhappy about the NHS.”
    Wes Streeting hailed the findings as proof that the NHS, which he said was “broken” when Labour won power in July 2024, was now “on the road to recovery”.
    The health secretary will cite them as evidence of progress in a speech on Wednesday in which he will set out plans to improve care at five badly performing health trusts.
    Mark Dayan, head of public affairs at the Nuffield Trust, said: “These are still numbers that you would have thought were catastrophic in the 2010s. They’re still worse than they were even during the 90s, a period when the public was widely perceived to be very unhappy about the NHS.”
    The rise in satisfaction “is a glimmer on the horizon, but the public mood remains dark”, he added.
    Read full story
    Source: The Guardian, 25 March 2026
  6. Patient Safety Learning
    Waiting time information in the NHS App has been overhauled after causing “confusion, anxiety and mistrust” among patients, HSJ has learned.
    NHS England changed the app’s waiting information page – which initially showed a mean average time – after it led to many patients calling hospitals to ask why they were waiting longer.
    Alongside the mean average referral-to-treatment time for their trust, a new metric has now been added to the page, which shows “eight in 10 patients are seen within X weeks”.
    A design history document, published by NHSE this month, admitted the previous version – introduced more than two years ago – was causing patients to believe they were seeing a personalised wait time, updated in real time.
    This caused “confusion, anxiety and mistrust” when the average date passed, but they had not been contacted or had an appointment.
    Many users also believed the waiting time referred to their initial appointment, rather than treatment.
    NHSE said the initial information caused “increased call volumes and burden on frontline staff” as patients called hospitals for clarification.
    Read full story (paywalled)
    Source: HSJ, 24 March 2026
  7. Patient Safety Learning
    A hospital trust has apologised to the parents of a three-year-old boy who died from severe bleeding after his artery was pierced by a trainee doctor during a routine procedure.
    Aarav Chopra, from Wolverhampton, died during a biopsy at Birmingham Children's Hospital in 2023, after his body had rejected an earlier liver transplant.
    A spokesperson for the NHS trust running the hospital said they had not met standards expected of them and changes were made to improve care in the future.
    "The strain it's put on us as a family has killed us," his mother Amrita Chopra said.
    "Because we took Aarav to a really good place, like he was in the best place for his care, and then they've basically killed him and that's how we see it.
    Aarav suffered a cardiac arrest triggered by a build-up of blood in his chest and neglect contributed to his death, a coroner concluded.
    An inquest last year concluded that Aarav's death was "contributed to by neglect" and found his death was preventable.
    A coroner's report called on the hospital to take action.
    They included confusion around the experience of a trainee doctor carrying out the biopsy, who was thought to be a year six trainee but was actually a year four, something the family didn't discover until much later.
    Kishore Chopra said they were never informed of a trainee being involved.
    Read full story
    Source: BBC News, 23 March 2026
  8. Patient Safety Learning
    Dying individuals across the UK are facing a "postcode lottery" in their final moments, according to a new report from MPs.
    The Health and Social Care Committee has declared palliative and end-of-life care services "inadequate", highlighting the "significant pressure" under which providers are currently operating.
    “It feels unthinkable that specialist care services for those who are close to passing away are somehow undervalued in the NHS.
    “And yet that is the heartbreaking reality that too many frightened patients and their families, including of young children, have to encounter during some of their most trying moments, when help is most needed,” said committee chairwoman Layla Moran.
    “These services are under significant pressure, with providers struggling to fund and commission the right care, and individuals entering a ‘postcode lottery’ of care in their most vulnerable moments at the end of life, the authors wrote.
    “These issues are further compounded by a workforce declining in numbers, a lack of access to and use of effective data, a poorly equipped social care system, and an unsustainable funding model.”
    The group has called for specific standards for how children’s palliative care should be provided; the need for 24/7 services throughout the country and a plan to strengthen the specialist workforce in the sector.
    Read full story
    Source: The Independent, 24 March 2026
  9. Patient Safety Learning
    As colon cancer rates are rising among people in their 20s and 30s, some adults in the US who are under 45 and experiencing worrying symptoms are struggling to get insurance coverage for colonoscopies, which can detect colon cancer.
    The Affordable Care Act (ACA) requires insurance companies to cover colonoscopies for people over 45 “because it’s been recommended by the US Preventive Services Task Force”, says Caitlin Murphy, a cancer epidemiologist and professor at the University of Chicago. The ACA requires preventive screenings, including pap smears, for example, to be completely covered.
    But, Murphy noted, for people “under 45, if you have symptoms like rectal bleeding, a colonoscopy would be considered a diagnostic test, and so it’s not going to be covered in the same way as a screening test would be”. She added that the cost of a diagnostic colonoscopy a given insurance plan will cover varies widely.
    Dominick, a 35-year-old software engineer living in Florida, learned about the distinction between preventative and diagnostic colonoscopy the hard way. His doctor recommended a colonoscopy after he experienced bowel movement changes, stomach pain and weight loss. At first, his insurance company said it would be covered. Then, three hours before the procedure was scheduled, he got a call saying the colonoscopy wouldn’t be covered because it was considered diagnostic.
    The out-of-pocket cost for Dominick’s colonoscopy was roughly $2,000, which he paid for with a credit card because he didn’t have the cash readily available. The procedure later revealed a precancerous polyp, which he had removed – he said it’s scary to think about what could have happened if he hadn’t been able to find a way to pay.
    Read full story
    Source: The Guardian, 23 March 2026
  10. Patient Safety Learning
    The Government is poised to introduce sweeping reforms aimed at making it significantly easier to dismiss doctors found to have engaged in racist or antisemitic conduct.
    The move, described as the biggest overhaul of the General Medical Council (GMC) in four decades, comes amid growing concerns over a perceived lack of swift action against medical professionals using discriminatory language.
    The Department of Health and Social Care has launched a consultation on legislative changes, citing "too many" recent instances of doctors, particularly on social media, using racist and antisemitic language without adequate regulatory response.
    The proposed reforms stem from a rapid review conducted by Lord Mann, commissioned last November to investigate antisemitism and other forms of racism within the health service.
    Among the initial recommendations from Lord Mann's review, which the government plans to consult on, are new powers for the GMC to challenge decisions made by the Medical Practitioners Tribunal Service (MPTS).
    Additionally, the Professional Standards Authority, which oversees all health regulators, will be granted enhanced powers to scrutinise and contest such decisions.
    Read full story
    Source: The Independent, 24 March 2026
  11. Patient Safety Learning
    A coroner has called for action after the death of baby Madison Bruce Smith, who died after he was placed in an "unsafe sleeping position" in his cot by an unregulated maternity nurse.
    The four-month-old grandson of football manager Steve Bruce was found unresponsive by his father, ex-Leeds United and Fulham striker Matt Smith, on the morning of 18 October 2024.
    Madison could not be resuscitated at the family home in Trafford, Greater Manchester, and was taken to Wythenshawe Hospital where he was pronounced dead by paramedics.
    Mr Smith and his wife, Bruce's daughter Amy, had employed Eva Clements through a company named Ruthie Maternity Services after their son had difficulties sleeping in the afternoons.
    They believed Ms Clements was skilled, fully trained and vetted, and that the company was a well-established maternity and sleep support service, but Stockport Coroner's Court heard that neither was regulated.
    In a short, narrative conclusion, senior coroner for south Manchester, Alison Mutch, said: "Madison died in circumstances where his cause of death could not be ascertained while asleep in his cot having been placed in a prone and unsafe sleeping position."
    She said the "purported expertise" of untrained people posed a risk to all children where those unregulated services were used.
    Issuing a prevention of future deaths report to the Secretary of State for Health, she said: "I hope the services can be regulated and, going forward, parents are not left in a situation where they believe they are employing someone who is qualified to advise them when they are clearly unqualified."
    Read full story
    Source: Sky News, 24 March 2026
  12. Patient Safety Learning
    Ambulance chiefs have been urged to take greater efforts to ensure their workforce is more diverse by NHS Alliance chair Lord Victor Adebowale.
    Lord Adebowale told the Ambulance Leadership Forum that it was “weird” to be in an environment which was so predominantly white.
    The NHS Alliance is the body formed by the union between NHS Providers and the NHS Confederation. 
    Its chair told the annual forum of ambulance chiefs: “I can’t believe how white you are”, noting most of the other meetings he went to had at least 5 per cent non-white participants.
    He praised the work ambulance trusts had been doing to improve the treatment of LGBT+ and neurodiverse staff but added the sector had a “problem” with racial diversity.
    Lord Adebowale said: “It is not sustainable, it’s not credible. So whatever you are doing it is not working fast enough.”
    Rates of Black, Asian and Minority Ethnic staff in ambulance trusts are lower than in other parts of the NHS. In part, this reflects a paramedic population that is predominately white, with overseas recruitment tending to focus on countries like Australia which have similar training.
    There is only one BAME CEO in the sector – North West Ambulance Service’s Salman Desai – and a sprinkling of executive directors. None of the 10 English ambulance trusts are led by a woman. 
    Read full story (paywalled)
    Source: HSJ, 23 March 2026
  13. Patient Safety Learning
    More than half of NHS staff using an electronic patient record system say it made their job harder and they lacked necessary training, a survey has found.
    The Health Foundation has published a report on staff experience of electronic patient records (EPR). A survey for the work found 53% said the introduction of an EPR had made their work more difficult.
    A third of respondents said they thought EPR systems were not currently working well, but that they could see there would be benefits in future.
    Common reported problems included differences between systems, making work more complicated, a lack of real-time support when issues occurred, and a lack of training to help staff use systems. The findings mirror the conclusions drawn in the 10-Year Health Plan that “Clinical systems often provide a poor and inefficient user experience requiring multiple clicks to set the next step in the care process.”
    Only 46% of the 1,725 respondents to the Health Foundation’s survey said they had received basic training on how to use their EPR system, while just 28% said they had received additional training on how to gain insights from EPR data.
    Alex Lawrence, an improvement fellow at the Health Foundation and one of the report’s authors, said that NHS staff “are experiencing barriers and… frustrations” with using EPRs, but that overall, they “do feel positively about these systems”.
    She said: “[Staff] either think that [EPRs] are delivering value now or they’re going to deliver value in the future. They think they have improved safety; they think they have improved care.
    “That positivity and that momentum is not going to last forever and needs to be capitalised on as soon as possible. The longer these frustrations continue, the more that positivity is going to be eroded, and at the moment, there’s a lot that could be done to improve these systems.”
    Read full story (paywalled)
    Source: HSJ, 24 March 2026
    Related reading on the hub:
    HSSIB Investigation Report: Patient safety issues associated with electronic patient record (EPR) systems – a thematic review Patient safety and electronic patient record systems: Patient Safety Learning’s response to HSSIB report Electronic patient record systems: Putting patient safety at the heart of implementation
  14. Patient Safety Learning
    Researchers at King’s College London have analysed coroners’ reports from across England, Wales and Northern Ireland to identify safety concerns linked to deaths involving fentanyl patches.
    Fentanyl is a highly potent and fast-acting synthetic opioid used to treat severe pain and is available in several forms, including injections, nasal sprays and skin patches. The study, which is published in the British Journal of Clinical Pharmacology, examined deaths associated with transdermal fentanyl patches between 1997 and 2024.
    While fentanyl can be an effective treatment for pain, it has also been linked to increasing numbers of drug-related deaths worldwide. In the UK, the Medicines and Healthcare products Regulatory Agency (MHRA) has issued several safety warnings about the risk of accidental exposure to fentanyl patches and the importance of safe disposal.
    To better understand the risks, the researchers conducted a systematic case series linking two national sources of coronial data, the National Programme on Substance Use Mortality (NPSUM,) and the Preventable Deaths Tracker, which collects coroners’ Prevention of Future Deaths (PFD) reports. By linking these datasets, the team created the first comprehensive overview of fentanyl patch-related deaths reported by coroners.
    The analysis identified 99 deaths involving fentanyl patches between 1997 and 2024. Coroners reported 77 safety events linked to these deaths, with the most common issues relating to adherence and usage (34%), administration errors (32%) and prescribing practices (6%).
    The study also highlights differences in how deaths are reported across the two datasets, suggesting that important safety information from coroners may not always be systematically captured or monitored.
    As part of the project, the team also developed a live online dashboard that tracks Prevention of Future Deaths reports involving fentanyl patches in real time. The researchers hope this tool will support regulators, policymakers and healthcare professionals in monitoring safety concerns and improving prescribing practices.
    Read full story
    Source: Kings College London, 18 March 2026
  15. Patient Safety Learning
    "It's barbaric. That's how bad the pain is, It's absolutely barbaric."
    A woman who waited 30 years to be diagnosed with endometriosis describes how she struggles in pain.
    Nichola Howells from Manchester started experiencing extremely heavy periods at the age of 14 but spent decades being "dismissed" by doctors and even gynecologists.
    The 47-year-old said it meant that by the time she was diagnosed she was "literally riddled" with the disease.
    Nichola is not alone, with many other women reporting they were not taken seriously by health professionals.
    The Department of Health and Social Care said it was trying to change things by investing in training and women's health hubs, adding that "waiting decades for an endometriosis diagnosis is unacceptable".
    In the UK, one in 10 women have endometriosis, according to the World Health Organisation.
    The average waiting time for a diagnosis has now reached nine years and four months, according to a new report by the charity Endometriosis UK.
    Nichola, who grew up in London, started taking contraception to try and manage the bleeding but as time went on her symptoms got worse.
    She said she was ignored or dismissed by health professionals, with one doctor telling her to "rid herself of her crippled mentality".
    By the time she was diagnosed, she had reached stage 4, with deep infiltrating endometriosis spread across her ligaments, intestine, pelvis, ovaries and uterus.
    She said: "Three decades is absolutely insane, to the point where I am literally riddled with endometriosis."
    Read full story
    Source: BBC News, 23 March 2026
  16. Patient Safety Learning
    The “substantial improvements” in a trust’s A&E performance praised by NHS England directors “may not be real” according to a paper prepared by its local health and care partnership.
    In a report submitted to the NHSE board meeting last month,  national director of UEC and operations Sarah-Jane Marsh and financial reset and accountability director Glen Burley claimed: “Local clinical and operational teams across the NHS have demonstrated how significant improvements and leaps in performance can be achieved.”
    They added: “The Princess Alexandra Hospital Trust have delivered substantial improvements in urgent and emergency care services for patients, and achieved a 23% improvement in 4-hour performance in December 2025, compared to the same month the previous year.”
    The latest version of the NHSE provider league table ranks PAHT 13th out of 123 relevant providers for its quarter three performance on the A&E standard. It was placed 55th in Q2 and 94th in Q1. 
    However, a performance analysis by the East and North Hertfordshire Health and Care Partnership submitted to the March board meeting of the neighbouring East and North Hertfordshire Teaching Trust questions the basis of the improvement in PAHT’s record.
    It states: “There was a significant improvement in the ranking of PAH between July and September. This was primarily due to a recording change in relation to [same day emergency care] patients…However, there are some inconsistencies between the PAH ECDS data and its A&E sitrep data, which means that this improvement in A&E performance may not be real.
    Read full story
    Source: HSJ, 23 March 2026
  17. Patient Safety Learning
    Scotland has become the first part of the UK to test newborn babies for Spinal Muscular Atrophy (SMA).
    The rare genetic condition causes progressive muscle weakness and, without treatment, can limit life expectancy to just two years.
    Babies can be identified as having SMA through a heel prick test and early treatment can prolong their lives. As part of a two-year pilot, this test will now be given to all babies born in Scotland.
    The test has come too late for Grayce Pearson, now three, from Milton, Glasgow, who was diagnosed with SMA when she was a baby.
    She lacks a protein vital for muscle development which affects everything from walking to swallowing and breathing.
    Her father Tony said: "Overnight she stopped kicking her legs and wasn't attempting to crawl. She wasn't trying to reach out for things."
    Getting a diagnosis is a race against time because as nerve cells die, treatment options and outcomes change.
    After raising concerns about her six-month-old baby's decline in movement, her mother Carrie said she was at first told she was just being an over-anxious mother.
    "A child just doesn't stop being able to physically move her legs altogether," she said.
    Grayce was eventually diagnosed with SMA type 2 - which is less severe than SMA type 1 - when was 14 months old.
    Carrie said: "Grayce's age when she was diagnosed, she couldn't get gene therapy, which would have been a one-off and she probably would have been making her milestones."
    Read full story
    Source: BBC News, 23 March 2026
  18. Patient Safety Learning
    The NHS “teetered on the brink of collapse” during the Covid pandemic, and only just coped thanks to the “superhuman” efforts of healthcare workers, an official inquiry has concluded.
    In a damning assessment of how the UK’s healthcare systems coped with the pandemic, the Covid-19 inquiry chair, Heather Hallett, said the impact was “devastating” due to the NHS being in a “parlous state” before the outbreak of the virus.
    She said Covid patients did not always receive the care they needed, with some diagnoses and treatments coming too late to save lives. “Healthcare systems coped with the pandemic, but only just,” said Lady Hallett, a former court of appeal judge. “On a number of occasions, they teetered on the brink of collapse and only coped thanks to the almost superhuman efforts of healthcare workers and all the staff who support them.
    “Workers carried the burden of caring for the sick in unprecedented numbers. They were obliged to work under intolerable pressure for months on end.”
    She said politicians, including the former health secretary Matt Hancock, refused to admit the NHS was “overwhelmed” during the pandemic, as they believed this to mean total collapse.
    “There was clearly overwhelm,” she said. “Patients could not be admitted to hospital and, in particular, into intensive care units. The pressure was, at times, intolerable. This continued for wave after wave of the virus.”
    Other findings of the report included:
    The NHS entered the pandemic with low bed numbers, high numbers of staff vacancies and high bed occupancy, meaning it was already in a “precarious position” and ill-prepared to deal with a pandemic. There was not enough PPE at the start of the pandemic, meaning healthcare workers had to put themselves and their families at risk to care for patients. Infection control in the early stages of the pandemic was flawed as it assumed Covid-19 was spread by physical contact, rather than being airborne. The “stay home, protect the NHS, save lives” public message may have inadvertently led to a decline in hospital attendance of life-threatening emergencies such as heart attacks. 80% of healthcare professionals said they acted in a way that conflicted with their values during the pandemic, with some saying they felt they were “playing God” as they were unable to give everyone the treatment they needed. Read full story
    Source: The Guardian, 19 March 2026
    Related reading on the hub:
    Presentation by David Osborn to the Safer Healthcare Biosafety Network How much of the £100 million spent by Government on evidence to the COVID-19 Inquiry was actually to cover up decisions which led to avoidable death? Covid-19 : A risk assessment too far? A blog by David Osborn
  19. Patient Safety Learning
    At least 58 babies at an NHS maternity unit might have survived with better care, a BBC investigation has found.
    The deaths included 32 stillbirths and 26 neonatal deaths - which is a death within 28 days - at Oxford University Hospitals Trust (OUH) between 2019 and 2024, according to a Freedom of Information request.
    Bereaved and harmed mothers have blamed missed chances, "arrogance" among some senior doctors and a "defensive culture".
    In a statement, OUH said it was sorry some mothers have had experiences that have left them feeling this way.
    It added the figures included mothers and babies who were referred to the trust for specialist care from across the region and every baby death was reviewed in detail to "fully understand what happened and whether improvements are required".
    Laura Cook, a partner at Medilaw, told the BBC: "They carry out a tick-box exercise with internal reviews to look like nothing could have been done, it forces families to go to lawyers who then find there's more to it... it puts families through hell.
    "What stands out with Oxford is its defensiveness, it's clear that reputation is of the upmost importance, it's not the same with other trusts."
    The trust said it recognises some families remain dissatisfied and it takes feedback seriously.
    Read full story
    Source: BBC News, 19 March 2026
  20. Patient Safety Learning
    Doctors have been issued new guidance stipulating they must not impose their personal views, beliefs, or values on others.
    The General Medical Council (GMC) has published the draft rules, currently open for consultation, which apply to all doctors, physician associates, and anaesthesia associates across the UK.
    The guidance explicitly states that medics should not treat colleagues poorly based on assumptions about their beliefs or due to disagreements with their views.
    It also makes clear that personal beliefs or values must not be imposed on patients.
    The doctors’ regulator clarified that these directives relate specifically to professional practice and do not cover healthcare workers expressing their beliefs or values outside of the workplace.
    This updated draft guidance follows a series of incidents involving healthcare professionals, both within and outside their professional duties.
    The regulator is seeking views on draft updates to its “personal beliefs and medical practice guidance”, which also includes information about conscientious objections to providing certain treatment or procedures – which could include abortions.
    The guidance states patients must be prioritised and that such an objection must not prevent a patient from being able to access the care or service they need.
    Read full story
    Source: The Independent, 19 March 2026
  21. Patient Safety Learning
    Health bosses cannot yet confirm whether a deadly meningitis outbreak has been contained, Kent's director of public health has said.
    An urgent public health alert was issued urging health workers to look out for signs of infection after 20 suspected cases were investigated by the UK Health Security Agency, including two people who had died.
    A vaccination programme targeting about 5,000 students began at the University of Kent, following an outbreak thought to have originated at a Canterbury nightclub.
    When asked whether the outbreak had been contained, Dr Anjan Ghosh, of Kent County Council, told BBC Radio 4's Today programme they were "not in a position yet to say that definitively".
    He added: "If you see the daily reporting that's going on, there are more and more cases being reported, but these cases all relate more or less to that same period of time when the initial exposure happened.
    "We are looking at what's called secondary transmission, so that's a case that's then transmitted to another couple of people. We need to rule that out before we can say it's definitely contained."
    Health chiefs have described the "explosive nature" of the outbreak as unprecedented.
    Read full story
    Source: BBC News, 18 March 2026
  22. Patient Safety Learning
    Pregnant women must be routinely included in clinical trials to help them access medicines and “prevent another thalidomide scandal”, doctors have said.
    At present, 99% cent of clinical trials exclude women who are pregnant or breastfeeding, according to experts at the British Pharmacological Society (BPS). Women are in the dark about the safety of thousands of common medications and many choose to “stop all their medication” immediately after becoming pregnant.
    The BPS gave the example of antidepressants, which are taken by eight million people in Britain but have not been trialled in pregnant women. As a result some people stop the drugs, which puts them at risk of postnatal depression and suicide, one of the leading causes of death in new mothers.
    The BPS is urging health officials to require pharmaceutical companies to “routinely include pregnant women, where safe and appropriate, in clinical research”. It said that companies should also monitor safety data for pregnant women taking approved drugs, and that doctors should balance the risk of potential harm to unborn babies with the danger to mothers of stopping or switching certain medications. 
    Read full story (paywalled)
    Source: The Times, 18 March 2026
  23. Patient Safety Learning
    Pharmacies are running out of stock for the meningitis B vaccine as concern rises and demand soars.
    The spike comes after the UK Health and Security Agency (UKHSA) confirmed it is now investigating 20 cases of meningitis in Kent during an “explosive” outbreak that has left two dead.
    Boots has implemented a queuing system for customers to enter the vaccination service page of its website, with a warning that demand for its menB jab is currently high.
    Superdrug has also created a waiting list for the vaccine, with a note on its website informing customers of a “national shortage” and adding “stock is limited”. It said it is “working with suppliers to secure more doses”.
    The high street pharmacy reported a 65-fold increase in demand compared to last week.
    Some pharmacies in Kent are also running out of supplies, according to Dr Leyla Hannbeck, CEO of the Independent Pharmacies Association.
    Read full story
    Source: The Independent, 18 March 2026
  24. Patient Safety Learning
    Women who develop maternal sepsis in sub-Saharan Africa are almost 150 times more likely to die than mothers in Britain, Europe and North America, according to new research – with a lack of clean water and sanitation contributing to 36 deaths a day.
    The analysis by WaterAid finds that the infection – one of the most dangerous complications of pregnancy and childbirth – is vastly more lethal in parts of Africa where maternity wards frequently lack clean water, toilets or basic hygiene facilities. These dangers made worse by devastating overseas aid cuts by the US and UK impacting swathes of the continent.
    Across sub-Saharan Africa, an estimated 4.7 million women develop maternal sepsis each year, equivalent to around one in every nine births. 
    Globally, about one in 1,100 cases of maternal sepsis results in death. In Africa, however, the fatality rate is dramatically higher with one death for every 350 cases. By comparison, mothers in Western Europe and North America face a vastly lower risk.
    Health experts say the disparity reflects the stark reality of maternity wards where even the most basic elements of safe childbirth are missing. WaterAid’s research suggests that three out of four births in healthcare facilities in sub-Saharan Africa take place in environments without adequate water, sanitation or hygiene - conditions that dramatically increase the risk of infection for both mothers and newborns.
    Read full story
    Source: The Independent, 18 March 2026
  25. Patient Safety Learning
    The first targets for neighbourhood health have been set in long-awaited government guidance.
    The neighbourhood health framework, published on Tuesday afternoon, gives several national targets related to GP, elective outpatient and community services.
    They include:
    At least 25% diversion rate from outpatient referrals through “single points of access” in at least 10 high‑volume specialties by next March; Reduce secondary care outpatient follow-up appointments by at least 10% by next March; A 10% reduction in acute outpatient appointments for under‑16s by March 2029; A new target date of March next year for GPs to see 90% of clinically urgent patients the same day – an objective first announced last autumn; A 10% reduction in non‑elective admissions and bed days for people with mid to severe frailty, care home residents and housebound patients by March 2029; A 10% increase in people identified as approaching end of life and a 10% reduction in their non‑elective admissions and bed days by March 2029; At least a 10% improvement in evidence‑based clinical outcomes for people with CVD, diabetes, COPD, mental health conditions and dementia; and A 10% cent increase in patients with diabetes receiving all eight recommended care‑process elements. In addition, the framework says that each area – “through” health and wellbeing boards – should agree local priorities and measures, which are likely to focus more on prevention and wider public services.
    Read full story (paywalled)
    Source: HSJ, 17 March 2026

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