Patient Safety Learning

This report is an interim publication as part of the Health Services Safety Investigation Body (HSSIB)’s focus on electronic patient record systems – electronic referrals for ongoing care. This report examines the patient safety risks associated with advice and guidance (A&G) services between general practice and secondary specialist care. A&G services enable clinicians in general practice to seek specialist advice about a patient’s care, either before or instead of referring them to hospital for specialist assessment. A&G is often undertaken via the NHS electronic referral service (e-RS), a digital platform also used for referring patients to NHS hospitals. The use of A&G services has increased significantly in recent years. Concerns were raised with HSSIB that further plans for expansion and prioritisation of A&G, including as part of single point of access (SPoA), created risks to patient safety. SPoA is a model where all A&G requests and elective referrals (other than those for urgent suspected cancer) are directed into a single digital entry point at specialty level within secondary care

A coroner has warned that more people could die because of a shortage of dietitians for psychiatric inpatients, after the death of a woman whose nutritional needs went unmet. Rachel Redman, assistant coroner for East Sussex, issued a Prevention of Future Deaths report to NHS England and the Department of Health and Social Care after the death of 69-year-old Neeshat Dalal in December 2022. It was published this month with both responses. Ms Dalal was sectioned under section 2 of the Mental Health Act for severe depression and struggling to eat and drink. She was admitted to Sussex Partnership Foundation Trust’s Heathfield Ward at Eastbourne District General Hospital. She collapsed during her third round of electroconvulsive therapy and died the following day of a heart attack. A jury inquest found staff had given inadequate consideration to whether she was physically unable to eat and drink, rather than refusing food as a means of ending her life. Her nutritional needs “were not appropriately met”, it found, and she needed a dietitian and a more timely gastroenterology referral. The jury also criticised East Sussex Healthcare Trust over vasopressor use and a delay in moving her to high dependency care. Ms Redman’s single matter of concern was funding for “appropriately qualified dieticians” to meet the nutritional needs of psychiatric inpatients at the trust and “in other trusts where such support does not already exist”. She said she had heard evidence from the trust’s clinical director that “SPFT’s lack of funding for a dietetic resource extends to trusts nationwide and that this is not a local problem experienced by this trust alone”. Read full story (paywalled) Source: HSJ, 19 August 2026

A deaf woman was given the wrong vaccine because she was not provided with a British Sign Language (BSL) interpreter at her doctor's surgery, a report says. The Parliamentary and Health Service Ombudsman (PHSO) said disabled people were being let down by inaccessible communications. It said the patient, Samantha, had booked a flu jab but was instead given a Covid vaccine after staff failed to show her a BSL video which would have highlighted the error. She said the experience had had a "profound impact" on her. The Department of Health and Social Care said the "deeply upsetting stories" were "completely unacceptable" and NHS and social care organisations had a duty to make services accessible. PHSO said public services were legally required to support people with their accessible communication needs, which might be due to a disability, neurodivergence or English not being their first language. Samantha had booked her flu and Covid jabs for separate weeks and showed a nurse a note on her phone which said she was there for the "flu jab only", the PHSO said. Despite that, the practice said it believed it had correctly established Samantha wanted the Covid vaccine and had got her consent through her grandmother, even though she had early-stage dementia and was not in the treatment room. Following an investigation, the PHSO recommended the surgery should apologise and pay Samantha £450. It has also since signed a contract with a sign language interpreting company. Read full story Source: BBC News, 19 August 2026

A trust has called for “tangible improvements” in behaviour from some of its senior clinicians, after an external review reported bullying, harassment, and racism. East Sussex Healthcare Trust commissioned an external review earlier this year following concerns being raised. The full review has not been released, but a summary found that women, non-consultant doctors, and staff from ethnic minorities reported harm. Some staff reported “shouting and abuse” of non-white medical consultants in meetings, and that trainees were “manipulated and coerced” to raise complaints about staff with minority ethnic backgrounds. The findings were first reported by the BBC. In a statement to HSJ on Monday, chief medical officer Simon Merritt said he expected “tangible improvements in psychological safety, fairness, and leadership behaviours”. “Bullying, harassment, racism, sexism or any other form of discrimination has no place in our trust. Our values of kindness, inclusivity, and integrity are not optional,” he said. Read full story (paywalled) Source: HSJ, 18 August 2026

A watchdog has called for a pause in the rollout of NHS England’s “advice and guidance” policy to protect safety, and linked it to two patient deaths, HSJ can reveal. The Health Services Safety Investigations Body (HSSIB) ordered a rapid review of the initiative, whose expansion is under way and forms a key part of NHSE’s waiting list reduction plan. It said: “HSSIB recommends that NHS England/Department of Health and Social Care undertakes a rapid evaluation of [A&G] processes… “Completing this evaluation and addressing findings before further expansion of advice and guidance processes, including as part of single point of access, would ensure risks to patient safety have been identified, assessed, and managed.” A&G encourages GPs to seek specialist advice from secondary care clinicians, either before or instead of referring a patient. HSSIB’s findings, from a review it has carried out in recent months and shared exclusively with HSJ, include strong support for A&G where it is working well. But its report says poorly designed or badly monitored implementation elsewhere is contributing to harm. This includes delayed and missed diagnoses, including in cancer care. In one case it cites, a GP’s A&G request about a patient with a history of epilepsy went unanswered by a neurology team for over a month; a subsequent urgent referral then went unanswered for a further six weeks. While waiting to be triaged, the patient had a seizure at home and died of a cardiac arrest. Read full story (paywalled) Source: HSJ, 18 August 2026

Inpatient observations are a cornerstone of risk management and practice in mental health care units in the UK, despite questions about their effectiveness in keeping people safe and evidence highlighting their financial cost, resource burden, and impact on patient privacy and dignity. Observations themselves may exacerbate mental health symptoms and increase risk to patients and those around them. Drawing upon ethnographic data collected across three wards in two NHS Trusts in England, this study explored staff and service users’ perceptions and experience of observations, how observations are routinely conducted, and the organisational social, and cultural influences shaping their use.

In his latest blog, hub topic lead Martin Fletcher discusses the factors that contribute to a better and more ‘worthwhile’ experience of a regulatory complaints process. He highlights the importance of regular, clear communication and setting expectations early to reduce anxiety, build trust and help participants understand what the regulator can and cannot do.

Healthcare is full of brilliant, dedicated people but the conditions we work in often mean we fall short of the care we want to give. Mistakes aren’t usually the result of bad individuals; they are the predictable outcome of poorly designed systems and cultures that don’t make safety easy. When staff don’t feel supported or listened to, it is almost impossible for them to deliver safe care. This book was written for the entire multidisciplinary team—doctors, nurses, allied health professionals, managers, educators, students, indeed anyone and everyone involved in delivering or improving care—and is an essential guide to recognising the human and organisational factors that shape our actions and learning how to do better. It draws a straight line from staff well-being and psychological safety, connecting these directly to the techniques needed to deliver safe and effective patient care.

In February this year, Beth Harris sat in the day surgery waiting room of her local hospital and tried to steady her nerves. She was there for a hysteroscopy, in this case to remove a fibroid. A thin surgical instrument with a lens, a light, a blade and an irrigation system for pumping saline solution would be inserted through her vagina and cervix, into her womb. The saline solution would widen the womb and the fibroid would be shaved away. Her hospital had advised taking paracetamol or ibuprofen an hour before the appointment, which Harris had done. However, the appointment was for 1pm, and by 4pm, she was still waiting in her hospital gown, surrounded by other patients. Hysteroscopies are common procedures – classed by the NHS as “high volume low complexity”. In 2021, 71,000 took place in England alone. This was Harris’s third. “I’d been shocked by how painful the first two were,” she says. They had been “diagnostic” only – examinations of the inside of the womb – because years of breast cancer medication had led her womb lining to thicken. When she learned that she had a fibroid that needed removing, Harris’s first question was: “Will it be painful?” Her gynaecologist assured her that she would be given local anaesthetic and “wouldn’t feel anything”. He compared it to “going to the dentist”. When Harris was finally called in, there were several people in the theatre. “There was the gynaecologist, nurses, an anaesthetist behind me, although he didn’t do anything. They were talking to each other throughout – no one was sitting with me. It was very casual.” The gynaecologist administered local anaesthetic – a small injection near the cervix – but there was no pause to see if it had worked. “There was no gap, no questions,” she says. “The injection itself was painful, but the procedure, with this spinning blade inside you, was unbelievable. The pressure, the pushing of the machine, the manipulation – it was barbaric. I’ve never experienced anything like it in my life. I felt as if I’d been assaulted. By the end, I was crying my eyes out.” A nurse led her, sobbing, to the recovery room. “There was no dignity, no privacy,” says Harris. “I said to her: ‘There must be a better way of doing this.’” Katharine Tylko, a founder member of the campaign group Hysteroscopy Action (HA), has been saying the same thing for 16 years. HA was formed in 2010 to demand that all hysteroscopy patients are fully informed about the procedure, including the risk of severe pain, and given a full range of pain relief choices – local anaesthesia, gas and air, conscious sedation, epidural, and, for those who need it, general anaesthetic. “In short, we want parity with colonoscopy patients, half of whom are men,” says Tylko. In April, the renewed Women’s Health Strategy set out by the then health secretary Wes Streeting seemed a major breakthrough. Action 7 of the strategy called for informed consent and a choice of pain relief for hysteroscopies. “We were thrilled,” says Tylko, “but there’s been nothing since. Just silence.” Read full story Source: The Guardian, 16 August 2026 Further reading on the hub: Painful hysteroscopy community thread From pain gaslighting to gender biases in women’s accounts of hysteroscopy: A qualitative reflexive thematic analysis (20 April 2026) My experience of an outpatient hysteroscopy procedure

A scientist involved in the development of Scotland's super-hospital has claimed his concerns over patient safety were repeatedly ignored. Dr Michael Bradnam told the Scottish Hospitals Inquiry he had spent 15 years raising issues with ventilation systems, electrical safety and humidity control at the Queen Elizabeth University Hospital (QEUH) campus in Glasgow. In a late submission to the probe, launched in the wake of a series of patient deaths, Bradnam said there had been no "formal responses" to his complaints. NHS Greater Glasgow and Clyde (NHSGGC) said it was reviewing the evidence, but that patient safety remained its "utmost concern". The inquiry was launched in 2019 to examine mistakes made in the planning, design and construction of the QEUH campus, which includes the Royal Hospital for Children (RHC), following concerns about unusual infections and the deaths of four patients. Scotland's independent public prosecution and death investigation authority is looking into seven deaths for potential links to the environment at the hospital. Read full story Source: BBC News, 16 August 2026

The proportion of acute trusts with an overall Care Quality Commission rating that disagrees with at least one of their main hospital sites has tripled over the past decade, analysis reveals. HSJ looked at instances where an acute trust’s “overall” or “well-led” rating disagreed with the overall rating of at least one of its main hospital sites – either higher or lower. The gap – which rose from 9.2% in 2016 to 29.8% in 2026 – is a result of big delays in the CQC issuing new trust overall ratings. It poses a risk that patients or others looking at the trust rating, which is often displayed on providers’ websites and premises, will misinterpret the care quality on offer. It is also frustrating some leaders who feel their trust’s ageing rating is out of kilter with improvements they have made. Penny Dash highlighted the problem in her 2024 review of CQC’s effectiveness, naming Manchester University Foundation Trust as an example of a trust rated “good” since 2019, despite its hospitals being downgraded in 2023. MUFT’s trust-level rating remains “good” now, two years on from the review. Read full story (paywalled) Source: HSJ, 17 August 2026

Poor understanding and a failure in a trust’s virtual ward process contributed to the death of a 19-year-old man, a coroner has found. The failure to refer to the virtual ward team, and misunderstanding about the team’s suitability, caused or contributed to the death of Isaac Arrowsmith, who was treated by East Cheshire Trust earlier this year. According to a Prevention of Future Deaths notice, Mr Arrowsmith had haemoglobin Rainier disease – a condition that increases the risk of blood clots. He attended hospital four times between 19 December 2025 and 1 January 2026 with chest pain and after coughing up blood, and was discharged each time, with clinicians concluding he had a chest infection or pneumonia. On his third attendance on 31 December, a doctor decided to send Mr Arrowsmith home. He decided he should be under the care of the respiratory virtual ward team, for follow-up in 48 hours. However, no referral was made to the virtual ward team that day. The coroner found that, had the referral been made and the VW team considered it, the team would have rejected it and advised that Mr Arrowsmith should remain in hospital, because it was not appropriate for the virtual ward. Instead, the patient deteriorated at home on 2 January and could not be resuscitated by paramedics. The coroner concluded that, had he been admitted to hospital, “he would have been in hospital at the time of his deterioration on 2 January and would have been successfully resuscitated”. Read full story (paywalled) Source: HSJ, 17 August 2026

In June 2014, the Department of Health’s Chief Medical Officer requested a report from MHRA as the regulator of medical devices, to advise on whether the risk/benefit assessment remains correct for vaginal mesh implants. This was in light of the recent decision taken by the Scottish Parliament to ask Health Boards to consider the suspension of these devices. This is a summary of the evidence on the benefits and risks of vaginal mesh implants.

Unreported removals from the referral-to-treatment (RTT) waiting list increased in June, reaching levels normally associated with “validation sprints”. The surge was big enough to stop the waiting list from growing, but not nearly enough to put the headline figures on track for “18 weeks” recovery. Over the past five years (and since the covid shutdowns), unreported removals from the RTT waiting list have averaged 14%of total removals. Unreported removals comprise any change in the waiting list that cannot be explained by the other data. When they increase suddenly, it is usually a sign that NHS trusts have stepped up efforts to remove patients who are on the waiting list in error (for instance, because they were treated some time ago, but were not correctly removed from the waiting list). In June, unreported removals increased to 16.1%, which is well above the 14% average and close to levels seen in the recent “validation sprints” sponsored by NHSE (for instance, 17.1% in March, and 16.5 and 16.2%, respectively, in April and May last year). Read full story (paywalled) Source: HSJ, 14 August 2026

Isaac Arrowsmith, age 19, had a background medical condition of haemoglobin Rainier disease which put him at higher risk of developing blood clots. On 19 December 2025, Isaac was taken to Macclesfield District General Hospital by ambulance with chest pain and finding it difficult to breathe. His symptoms were largely consistent with either a chest infection or a pulmonary embolism. He was assessed and diagnosed with pneumonia, before being discharged home with antibiotics. No testing was done to exclude a pulmonary embolism. He reattended later that day as he had begun coughing up blood and was again discharged. On 31 December Isaac saw his GP who felt that a chest infection did not fully explain his ongoing symptoms, particularly given his background medical condition, and referred him for further tests. Before these could be undertaken, Isaac attended hospital again, as he was now coughing up more significant amounts of blood. He was assessed and again was felt to have a chest infection, but the doctor wanted additional investigations to assist given his lack of improvement despite treatment. A decision was made to send Isaac home, under the care of the respiratory virtual ward team for follow up in 48 hours. No referral was made to the virtual ward team that day and, had it been, it would not have been accepted and Isaac would have been admitted to hospital. Later that evening Isaac attended hospital for the fourth time as he again was coughing up further am

This information is for families and friends of an adult who is experiencing a mental health crisis.    It can be frightening seeing someone you love in a mental health crisis. Your voice is crucial.    You can describe what you are seeing, what has changed, what worries you and what you believe may happen if nothing changes.   Professionals bring clinical expertise. Families bring expertise of knowing the person. Keeping people safe and helping their recovery requires both.  If you are with someone in a mental health crisis you have the right to ask for help to keep the person safe. It’s OK to keep asking and negotiating until you feel confident that appropriate support is in place.  This guide from Making Families Count will help you feel more informed, more confident, and less alone. 

Mary McClinton, 69, arrived at Virginia Mason Medical Center one day in November 2004 for a complex but routine procedure. She had been diagnosed with a brain aneurysm, and doctors planned to place a stent in an artery and then inject dye into her bloodstream for an imaging test. The procedure appeared to go according to plan, but she awoke in terrible pain. The team worked feverishly to determine what had happened and how they could help her, but she never recovered. Mrs. McClinton never left the hospital. Nineteen days after the procedure, she died. At first, the team was mystified as to what had happened to cause her death. After carefully reviewing every step along the way they finally found the culprit. A topical disinfectant solution, chlorhexedine, had been mistaken for the injectable dye. In fact, the disinfectant, injectable dye, and a saline solution - three visually identical clear liquids - were all placed in unlabeled stainless steel bowls in the procedure room. At some point, the disinfectant - highly toxic if used internally - was drawn up into the syringe meant for the dye. A tragic, fatal, and wholly preventable mistake. At that moment in time, late 2004, Virginia Mason was a couple of years into its journey to apply the Toyota Production System to its own work through the Virginia Mason Production System. This approach is all about constantly examining and improving processes - and the system is intended to prevent dangerous errors completely.

“System reforms” are needed to fix the “patchwork” of policies aimed at preventing hospital admissions and speeding up discharge, the health and social care secretary has said. Yvette Cooper said improvements could be made “even within existing resources and even within existing systems” if organisations worked together. She said: “Where I do think there are system reforms that are needed [are of the] patchwork process of, how do you solve the fact that there are people in acute hospitals who shouldn’t be in there? “We’ve had layer upon layer of different patchwork attempts to think, ‘okay, this is how we’ll prevent people going into hospital. Okay, this is how we’ll get people out faster.’ Maybe into intermediate care, maybe into some NHS-funded, maybe some local council funded, and it’s all a mess. “And actually you could do that in a much more effective way… even within existing resources, even within existing systems, there’s a lot of things that, actually, if everybody came together, we could make improvements.” Read full story (paywalled) Source: HSJ, 13 August 2026

This guidance has been developed in partnership between the Scottish Public Services Ombudsman (Independent National Whistleblowing Officer) and Healthcare Improvement Scotland. This work follows Healthcare Improvement Scotland’s NHS Greater Glasgow & Clyde Emergency Department Review (March 2025), which recommended the development of clear and unambiguous guidance on national processes for raising concerns under Whistleblowing and the Public Interest Disclosure Act, with the aim to help NHS boards strengthen their arrangements and improve staff understanding. Speaking up is essential to safe, high-quality care. Staff, contractors, volunteers and students are often the first to notice when something may not be right. It is vital they feel confident, supported and clear about what to do next. Awareness of how to raise concerns, and confidence in using existing processes, is not always consistent. For some, it can feel unclear or difficult to know where to go. This guidance is designed to make speaking up simpler, clearer and easier to navigate. It sets out: what speaking up means when and how to raise a concern the different routes available for advice and action. The aim is to remove uncertainty and make it easier for people to speak up. Everyone who delivers NHS services in Scotland should feel assured that their voice matters, and that there are clear, confidential and supportive routes available to them.

This new prioritised list provides a national, evidence-informed framework to guide where development of Clinical Quality Registry (CQRs) can deliver the greatest impact on patient outcomes and the health system in Australia. It highlights 75 diseases, categorised under clinical domains, where variation in care, outcomes, and disease burden indicate the greatest opportunity to deliver measurable improvements.

This Health Services Safety Investigations Body (HSSIB) report is the third in a series considering the self-administration of insulin by people with diabetes mellitus (diabetes) in community settings. Each report in the series has a focus on specific groups of people who, due to their circumstances, may be at increased risk of harm because of the way they self-administer insulin. HSSIB identified incidents where people with a learning disability and diabetes (requiring insulin) had been harmed when they had not been supported to administer their insulin safely. Incidents included where patients had not administered their insulin, or had administered it incorrectly. Many people with diabetes administer their own insulin to manage their blood sugar levels, either by injection or using an insulin pump. Insulin pumps can be standalone meaning the person has to adjust all settings manually, or can be a combined monitor/pump device where some of the insulin delivery is automated (a hybrid closed loop system). However, a disability or impairment may affect someone’s ability to safely administer their own insulin if they are not supported. This can lead to short-term and long-term health problems, which can be life threatening.

In their latest podcast, Niall and Roy speak with maternity review Chair, Dr Bill Kirkup following his resignation as an expert advisor to the latest government review of childbirth headed by Lady Amos. His key reason for quitting was around natural childbirth with Dr Kirkup opposing attempts as he saw it to shut down debate on the issue. But in the podcast he is adamant that while debating the place of so called natural childbirth is essential, it is not the only issue. Instead he focuses on the current training system which sets professionals off to work for different objectives which are in opposition to each other. And that he insists that is never going to produce good, safe practice.  And he backs those who have argued there have been adverse consequences of midwives no longer needing to be trained first as nurses. He says that also means they are often going into midwifery straight from school with no experience of anything outside of the educational system and no experience of the healthcare system. With the best will in the world he suggests it is probably not surprising that ‘some get ideas that are not helpful’

The NHS is under enormous pressure to expand access to mental health support. Rising demand and lengthening waiting lists mean services are having to deliver more care with limited or no growth in capacity. Against this backdrop, recent HSJ reporting on unregistered practitioners in NHS mental health services raises important questions about workforce shortages, standards, transparency and public confidence in evidence-based care. This debate matters because psychological therapies, such as cognitive behavioural therapy (CBT), are not generic emotional support; they are specialised clinical interventions recommended by the National Institute for Health and Care Excellence for a wide range of mental health conditions. Delivering them safely and effectively requires appropriate training, supervision and professional accountability.

Pregnant women who took an epilepsy drug and say they were not warned of possible birth defects, feel a mix of "guilt" and "anger," one mother has said. Sodium valproate, which is also used to treat bipolar disorder, external, can cause physical harm in the womb and children can be born with a cleft palate and spina bifida, external as well as neurodevelopmental disorders. The medicine now carries warnings about use during pregnancy, but Susan Jamison, now 60, said she was not told about the possible consequences when she was expecting babies in 1990s. A 2020 review recommended compensation to those affected, and a subsequent report in 2024 said there was an "urgent" need for redress for those harmed. It is thought thousands of children in the UK have been left with disabilities caused by valproate since the 1970s. Of the estimated 20,000 people across the UK, external affected about 500 to 600 are in Northern Ireland. "All the women feel guilty," said Susan. "The government knew that it [sodium valproate] caused problems and it was still continued to be licensed for usage for pregnant women," she said. In June, England's first patient safety commissioner, Dr Henrietta Hughes, wrote to then Prime Minister Sir Keir Starmer, external expressing disappointment that there had not been a "substantive response" from the government to the calls for redress. She has still not received a response to her 16 July deadline. Back living in Northern Ireland, it was only after the 2020 publication of the Cumberlege Report, , externalthat Susan says she got "closure". But six years on from the initial report, families are waiting for redress. "I'm angry. Parents are not getting any younger and we need to set out a care path for our children. It needs to be sorted quickly," Susan said. "If I am no longer here Anna will have proper housing and medical care which she will need all her life," she added. Read full story Source: BBC News, 12 August 2026