Patient Safety Learning

Doctors at one of England’s remotest hospitals have been given a “crash course” in birth emergencies after its maternity unit was shut and as fears grow that the safety of women and babies may be put at risk. From Tuesday, the maternity service at North Devon district hospital (NDDH) in Barnstaple has been suspended indefinitely owing to staff shortages, leaving many pregnant women facing a journey of at least an hour and a half when they go into labour. A doctor at the hospital has now revealed that emergency staff at the NDDH have been given training in dealing with difficult births if mothers cannot get to Exeter. The doctor, who asked not to be named, said: “I’m hoping that we won’t see such emergencies and women will birth their babies without a problem and both will be fine, but there is a potential that we will see women who can’t make it to a maternity unit who have to be diverted to the hospital. “There’s been a crash course in learning how to deal with emergencies such as shoulder dystocia or postpartum haemorrhage. It’s been an intense time and we’re all pretty shocked. We’re capable but they’ve thrown us into a potentially very serious situation. There’s a physical risk to the public. “The emergency department and its staff are familiar with dealing with emergencies without the direct help of specialities but it’s the unfamiliarity of an obstetric emergency or neonatal collapse and having no one nearby on site to assist that is confronting.” Read full story Source: The Guardian, 11 August 2026

Wes Streeting and the government’s maternity adviser are urging a safety body to consider investigating the NHS’s handling of a “severe yet poorly recognised” condition which can cause “life-changing harm”. The former health secretary and Michelle Welsh have written to the Health Services Safety Investigations Body about hospitals failing to listen to women experiencing Placenta Accreta Spectrum. The move follows around 100 women launching the Action for Accreta campaign earlier this year. They warned about the failures in care for patients experiencing PAS, a serious pregnancy complication where the placenta attaches too deeply into the uterine wall. One harmed mother shared how her baby had suffered a stroke at birth, and another explained her child now has cerebral palsy, with many hospitals failing to diagnose until it was too late. Campaign founder Amisha Adhia was turned away from five specialist hospitals, while others shared permanent injuries to their bladders or bowels, and around a third of women surveyed underwent emergency hysterectomies. Mr Streeting, who is Ms Adhia’s local MP in Ilford North, and Ms Welsh warned that women experiencing the condition were not listened to despite raising concerns and asking for help. Read full story Source: HSJ, 12 August 2026

The Trump administration is dismantling the US Agency for Healthcare Research and Quality (AHRQ), an organisation credited with major improvements in hospital safety, including preventing thousands of deaths and saving billions in healthcare costs. In this Guardian article, Robert B Shpiner, an internist and clinical professor of medicine at the David Geffen School of Medicine at UCLA, describes how grants have been abruptly cancelled, staff dismissed, and core patient‑safety programmes halted despite congressional funding, leaving critical research—such as maternal health, infection prevention, diagnostic safety, and rural telehealth—without support. He warns that replacing evidence‑based safety work with vague promises about AI and “new priorities” will quietly increase preventable harm in hospitals, eroding decades of progress in patient safety.

Interoperability in healthcare – the ability of health systems and stakeholders to securely exchange and use data – remains a longstanding yet underachieved goal in the digitalisation of health systems. This paper analyses international practices across OECD countries to support efficient, equitable, and impactful data use and sharing. Drawing on interviews, a survey, desk research, and expert consultations, the report highlights both the barriers and leading practices at the level of people, policy, processes, and technology. The paper outlines opportunities at local, regional, national, and cross-border levels of health data exchange, focusing on stakeholder engagement, individual empowerment, global governance to guide interoperability efforts, collaboration, and the need for legislative foundations. The full value of interoperability is estimated to be between 2.7% and 6.6% of health expenditure annually as per OECD country estimates. Realising it requires a shift from implementation of health information systems to meet the needs of individual facilities towards implementation within an integrated digital health ecosystem centred around the patient. This shift can enable data to follow patients across the care continuum and allow for timelier reuse of data for public benefit, with protections. While technical challenges have historically been prioritised, findings suggest that interoperability is inherently a people (e.g. governance, trust, adoption) and l

Donald Trump has signed an executive order with plans for sweeping changes to the childhood vaccination schedule that attempts to override the authority of the US Centers for Disease Control and Prevention (CDC). It is an attempt to undergird the changes made earlier this year to CDC vaccination recommendations, which were halted by a federal judge. The CDC is the federal agency tasked with recommending vaccines, not the White House. The order would also require that the measles, mumps and rubella vaccine be broken into three separate shots, once it becomes available in the US. And it would recommend that all shots be given at separate medical visits, a frequent point Trump has made despite the safety, ease and lower costs of giving vaccines together. On a press call, a White House official said the order draws on a Department of Health and Human Services (HHS) scientific assessment published in January 2026, which examined “comparisons of the U.S. to other peer-developed nations” and looked at “where there is consensus amongst our peers on recommendations for immunizations for children”. The official said the number of recommended childhood immunizations would drop “down to 11 diseases”, compared with 18 at the end of 2024. Only six of the 17 vaccines currently routinely recommended for all children in the US would continue to have full recommendations: measles, mumps, rubella (MMR), diphtheria, tetanus, pertussis (DTaP), polio, Hib, pneumococcal disease, HPV and varicella. “Together, there could be a possibility they’re quite lethal,” Trump said of the MMR vaccine at the signing of the order on Monday. He opened the event by calling the executive order a new “gold standard” for childhood vaccination recommendations, referring to “autism in particular.” Later, he added, “Decades ago, children received only a small fraction of the vaccines required today.” He claimed, without providing evidence, that people then “were much healthier” and that “high rates of autism now observed did not exist.” However, he did add: “We do not know exactly what the cause is with respect to autism.” Read full story Source: The Guardian, 10 August 2026

Errors in intravitreal fluorinated gas selection or dilution can result in unintended expansile concentrations, causing irreversible visual loss. This study aimed to quantify the problem using national incident reporting, published literature and a UK surgeon survey, developing expert consensus recommendations on safe storage, handling and intraocular use.

In edition 15 of her newsletter, Judy Walker reports early findings from her PSIRF implementation survey, showing most organisations believe PSIRF is largely embedded, though wider use of After Action Review (AAR) beyond patient safety remains limited. Using Normalization Process Theory, Judy highlights that broader AAR use signals organisational maturity, reflecting deliberate appraisal and extension of AAR into wider learning and improvement work 

The UK has become the first country in Europe to approve a new once-a-day pill to aid weight loss and treat type 2 diabetes. Orforglipron, known as Foundayo and made by pharmaceutical giant Eli Lilly, was authorised by the Medicines and Healthcare products Regulatory Agency (MHRA) on Monday. Orforglipron is a GLP-1 receptor agonist, a type of medication which helps lower blood sugar levels, slows the digestion of food and can reduce appetite. Alongside a reduced-calorie diet and increased physical activity, orforglipron is licensed for people with a body mass index (BMI) of 30 or above, or those with a BMI of between 27 and 30 and at least one weight-related condition. It can also be used to improve blood sugars in patients with poorly controlled type 2 diabetes. The pill is taken once a day, at any time, with no food or water restrictions. The most common side effects for those taking orforglipron are nausea, constipation, diarrhoea, vomiting, dyspepsia (indigestion), and abdominal pain. Read full story Source: The Independent, 10 August 2026

England is “on the cusp” of becoming one of the first countries globally to eradicate hepatitis C, health officials have said. Efforts such as A&E blood tests, GP registration testing, and free home test kits have helped identify individuals who were previously undiagnosed. Global health leaders have set out plans aimed at eliminating viral hepatitis across the world by 2030. NHS England stated that the nation is among a small number of countries worldwide to have already beaten the World Health Organisation benchmark of treating 80% of all known cases. It added that deaths associated with the virus have fallen by 36% over the past 10 years. Hepatitis C is transmitted via contact with infected blood. Many people have no symptoms but if it is not treated it can cause serious, and potentially life-threatening, liver damage. A treatment course of antiviral drugs for eight to 12 weeks cures more than 95% of cases. NHS England said that since 2015, more than 100,000 people have been diagnosed and treated for hepatitis C. Read full story Source: The Independent, 11 August 2026

Patient safety and public health have been upgraded to a ministerial responsibility, the Department of Health and Social Care has announced. They will now be covered by a minister of state, Dame Diana Johnson, after previously being the responsibility of a junior minister, according to a list of responsibilities published today. The Kingston upon Hull North and Cottingham MP will also cover neighbourhood health, general practice and health inequalities. In contrast, three responsibilities – dentistry, eyecare and men’s health – have been moved to more junior ministers. Alison McGovern, who represents Birkenhead, has been appointed the minister for social care, where she will also cover hospital discharge, SEND (special educational needs and disabilities) and mental health. The latter was previously covered by junior minister Baroness Merron. Andy Burnham has pledged to fix England’s “broken” social care system, asking Baroness Casey to bring forward an ongoing review. Read full story (paywalled) Source: HSJ, 10 August 2026

Professor Brian Edwards summarises the final day of evidence in the inquiry into mental health services in Essex, focusing on expert testimony, systemic failings and anticipated next steps. An interim report is expected in October.

California lawmakers are pushing to stop AI from being used as a full-on therapist as interest in chatbot-based mental healthcare has skyrocketed in recent years. Under Senate Bill 903, companies would be banned from advertising chatbots as therapy, and AI systems themselves would not be allowed to make therapeutic decisions without review from a licensed professional. The bill would also require patients’ permission for health providers to use AI to record therapy sessions or triage care. “AI has many upsides, and the possibility to improve the lives of Californians across the state, but only if we ensure it is used responsibly,” state Senator Steve Padilla of San Diego, author of the legislation, said earlier this year when introducing the measure. “AI algorithms are not fit to take over the job of human therapists, who have skills and training that AI is incapable of replicating,” he added. “We must act and place guardrails that prevent AI algorithms from being deployed in a way that is potentially harmful to patients.” Critics of the bill say it will stifle legitimate uses of AI and could harm the ability of health providers to use AI tools to direct patients toward treatment. Read full story Source: The Independent, 10 August 2026

Dame Diana Johnson DBE MP has today been confirmed as the new UK Government minister who will have a portfolio responsibility for patient safety. She was previously Minister of State at the Department for Work and Pensions between 6 September 2025 and 21 July 2026, and Minister of State in the Home Office between 8 July 2024 and 6 September 2025. She was elected as the MP for Kingston upon Hull North and Cottingham at the general election in July 2024 and has represented Hull North, as Hull’s first female MP, since May 2005. Diana was Chair of the Home Affairs Select Committee from 2021 until 2024. Under the Labour government between 2005 and 2010 Diana was a Parliamentary Under-Secretary of State in the Department of Children, Schools and Families and a government whip. Between 2010 and 2015 Diana held a number of front bench roles including in the shadow Home Office team. She was named backbencher of the year in 2018 for her work to secure a public inquiry into the NHS contaminated blood scandal. Diana served as a Commissioner on the Commonwealth War Graves Commission from 2019 to 2024. In 2020 Diana received a Damehood for her political and charitable work. Read more here. Source: Department of Health and Social Care, 10 August 2026

This article from Roger Kline examines an employment tribunal judgment involving Mr Jug Johal, a long‑serving NHS estates director who was unfairly dismissed following what the tribunal found to be a predetermined, biased, and procedurally flawed process led by senior leaders. Roger argues that the Johal case is not an isolated failure but a symptom of deeper NHS cultural and governance problems: predetermined investigations, recycled leaders, weak accountability, compromised HR processes, and systemic risks for minority ethnic staff and whistleblowers. He calls for meaningful reform rather than repeated promises to 'learn'.

A disgraced former solicitor who abandoned his clients with no reasonable explanation has been ordered to repay £92,000 and hit with indemnity costs, after a judge found he seriously abused the court’s process. Darren Hanison was on record to represent six women who brought vaginal mesh claims against the NHS, as part of a larger cohort of 305 claimants linked to the proceedings. Hanison failed to lodge the papers ahead of a hearing in 2022 which caused it to be relisted. Hanison’s firm, Fortitude Law, was shut down by the Solicitors Regulation Authority in 2023 over his suspected dishonesty. In February this year he was struck off by the Solicitors Disciplinary Tribunal after facing 17 allegations including dishonesty, misleading clients, poor service and serious regulatory breaches. At a hearing to deal with costs issues relating to the mesh claims, the defendants in the six linked claims requested that Hanison repay £92,000 in various payments made on account. They also asked that the former solicitor should pay the costs of the aborted hearing in 2022, as well as costs associated with the detailed assessment proceedings for the six claims. Read full story Source: The Law Society Gazette, 6 August 2026

New guidance and supporting scoring rubric for anyone using the Learning Response Review and Improvement Tool (LRRIT) as part of PSIRF or other approaches for learning from patient safety incidents. The scoring rubric provides evidence level discriminators and evidence indicators to assist with more explicit and consistent review of learning response reports. Free to download from NHS Education for Scotland.

For mother-to-be Harriet Knight, the suspension of maternity services at one of England’s most remote hospitals means having to face horribly stark choices. “The next closest maternity unit is a full two hours away and we have a family history of labour taking under two hours from start to finish,” said Knight. “So we have the option of potentially giving birth in a layby on the north Devon link road as we try to get there or opting for free-birthing at home with no access to maternity care.” Mothers in labour will have to trek to Exeter or Taunton, at least an hour and a half away, but usually more, especially at this time of year when the roads are thick with holiday traffic. “It feels there is no safe option at the moment,” said Knight, who is 34 weeks pregnant. “We live in one of the most rural places in the country and this has left pregnant mothers in north Devon in a really scary situation. It feels like a complete failure by the hospital trust.” One option she and her partner are considering is spending all their savings on temporary accommodation in Exeter as her due day approaches. “Moving out may be the only thing we can do to keep us safe,” Knight said. Hannah Rulton, who is expecting her third baby in November, is to undergo a caesarean section because during her second labour she and her child suffered severe shoulder dystocia, an obstetric emergency in which the baby’s head is delivered, but the shoulder gets stuck behind the mother’s pubic bone. “He was stuck for 11 minutes. Both my son and I very nearly died. The trauma of that birth has never left us. Every appointment during this pregnancy has brought back memories,” she said. “I have been told there is a significant chance of shoulder dystocia occurring again and what now keeps me awake at night is the fear of going into labour before my planned surgery. The thought of making that journey knowing I have a history of one of the most time-critical obstetric emergencies imaginable is absolutely terrifying." Read full story Source: The Guardian, 10 August 2026

Police are sending people in mental health crisis to prison when they should be in a secure hospital, with “devastating consequences”, inspectors have warned. West Midlands Police introduced a local version of the national “Right Care Right Person” policy without consultation or agreement from partner agencies, including the NHS, inspectors found. Under this approach, the force stopped asking “liaison and diversion” mental health services to arrange assessments before sending detainees to court, including where it identified serious mental illness. It appears to have begun last year and involves about nine prisoners each month. HM Inspectorate of Prisons told HSJ: “The crucial diversion function in custody is being overridden by criminal justice imperatives when the core purpose of liaison and diversion is to prevent vulnerable, acutely mentally unwell detainees entering the criminal justice system.” NHS England has expressed “serious concerns” and an inspectors’ report said that, along with senior managers at the prison, NHSE had raised the issue with the police. Despite a warning from the prisons inspector in the autumn, as of June there was “no progress at all” in stopping the police sending “the most mentally unwell men to Birmingham without prior assessment or diversion”, the inspectorate has reported. Read full story (paywalled) Source: HSJ, 10 August 2026

The Liberal Democrats have urged Andy Burnham to stop the "bonfire of patient safety" as part of the government's plans to modernise the NHS. Healthwatch England (HWE), an independent body which represents the views of patients at their local health and social care providers, is set to be scrapped under the NHS Modernisation Bill. The Health Service Safety Investigation Bureau (HSSIB), which carries out patient safety investigations, is also being abolished. The government says its changes will strip back bureaucracy and improve patient safety. The Lib Dems warned it risks another Stafford Hospital scandal – where years of abuse and neglect led to hundreds of unnecessary patient deaths. Under the government proposals, Healthwatch's responsibilities will be transferred to integrated care boards (ICBs) and local authorities, meaning they would have to respond to feedback about their own services, rather than being challenged by an independent body. Separately, HSSIB's functions will be transferred to the government-run Care Quality Commission (CQC), which the Lib Dems argue raises concerns there is no guarantee that staff who raise safety concerns are given anonymity. Other measures include the abolition of NHS England in a bid to centralise the running of health and social care services under the Department of Health and Social Care (DHSC). Read full story Source: BBC News, 10 August 2026 Related reading on the hub: The King’s Speech 2026: Six key takeaways for patient safety (Patient Safety Learning) Perspectives on the NHS Modernisation Bill

Clive Flashman is Chief Digital Officer at Patient Safety Learning. In this blog, he considers questions posed by participants at a recent panel discussion exploring the patient safety risks associated with the application of artificial intelligence (AI) technologies in healthcare. It covers: What boards need to understand before approving AI deployment. What safe AI looks like in practice. How governance and incident reporting need to evolve. What patients themselves can do to protect their own safety when AI is involved in their care.

In this blog, Darren Kilroy shares the challenges he experienced of moving a Trust to a new electronic patient record (EPR) system. He shares the safety issues that this change brought, what he learnt from the experience and suggestions of actions to address the identified safety risks.

The impact of incivility in terms of individual and team performance in clinical environments is increasingly acknowledged and supported by a growing evidence base. However, clinical environments are not just areas where patient care is delivered, they are also rich, key learning arenas for healthcare professionals. To date, the potential impact of incivility in clinical environments on healthcare professional learning and development has not been comprehensively explored. This article provides an overview of the physiological mechanisms that inhibit learning and memory recall in individuals experiencing or observing incivility and social stress. It establishes a clear need for focus on the impact of incivility on clinical learners and educators and further evidence for the need for clinical environments in which civility is firmly rooted into the pervading culture.