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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The 'Please, Write to Me' guidance from the Academy of Medical Royal Colleges provides information and advice to encourage and support healthcare professionals to communicate directly with patients in writing.  This guidance was first published in 2018. As a result, many clinicians began writing directly to patients in plain English following outpatient clinic consultations. This has since been recommended as best practice by professional and NHS bodies, the General Medial Council, and the UK Government. This update extends the guidance to include writing a section of discharge summaries directly to patients following a hospital admission. This guidance and governance safeguards should also be applied when developing and using AI systems to create clinical documents for use in training and practice.
  2. Content Article
    In 2010, the English NHS employed around 95,000 doctors. Five years later, it was 105,000; five years after that, 124,000; and last year, the total reached 154,000. That’s a 58% increase in 15 years (and 24% in the last five). The same analysis reveals a 22% increase in the number of nurses (300,000 to 367,000). However, the number of nurses went down during the coalition years. The increase since 2015 has been 33%. So, in 2010, there were – very roughly - 560 people per doctor and 180 per nurse. Today those numbers are – again very roughly – 380 and 160. respectively. So what happened to NHS performance, patient satisfaction, and doctor happiness over that period? Whatever the answer to the NHS’s woes is, it is clearly not simply “more doctors and nurses”, writes Alastair McLellan in this HSJ article.
  3. News Article
    Mental health patients in crisis are facing "inhumane" conditions due to legal ambiguities, an investigation has found. The Health Services Safety Investigations Body (HSSIB) revealed that A&E staff lack powers to prevent patients awaiting assessment or admission from leaving. This forces doctors into a difficult choice, described by the HSSIB as selecting the "least harmful way to break the law". One consultant psychiatrist highlighted the "dilemma is stark" of unlawfully holding someone, breaching human rights, or allowing them to go. Inspectors from the health safety watchdog saw a patient who had been locked in a single room, with only a toilet, for more than four days. “It was not safe for staff to be in the room with them and it was not safe for the door to be unlocked as the patient kept attempting to leave and was desperate to end their life,” a new interim HSSIB report said. “Staff described that the patient was not receiving any therapeutic intervention and it felt ‘cruel’ and ‘inhumane’ for them to be waiting so long for a bed when they were so mentally unwell.” Nichola Crust, senior safety investigator at HSSIB, said: “Unclear legal powers don’t just create operational complications for care. “They can have a devastating impact on patients, leaving them exposed to uncertainty, emotional distress and an increased risk of harm at a time when being as safe as possible is paramount. “Without clear legal frameworks, staff repeatedly told us that they are placed in an impossible position when trying to keep people safe.” Read full story Source: The Independent, 9 April 2026
  4. Content Article
    This Health Services Safety Investigations Body (HSSIB) report is intended for healthcare organisations, policymakers and the public to help improve patient safety in relation to safety issues identified for people experiencing a mental health crisis who come into contact with urgent and emergency care services. This report focuses on the significant legal, policy and safety gap in the care of people in emergency departments (EDs) in mental health crisis. During consultation on this report, concerns were shared with HSSIB about the current challenges in relation to the resourcing and configuration of mental health services that exacerbate challenges faced in the ED. This is the first of two reports. In October 2025 HSSIB launched two investigations that explore the safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services. This interim report was produced due to the early identification of a significant legal, policy and safety gap in the care of people in emergency departments (EDs) in mental health crisis. It is reported that around 3% of all ED attendances are mental health related. However, people experiencing mental health problems are twice as likely as other patients to remain in the ED for more than 12 hours. People in mental health crisis may need to be assessed for admission to a mental health hospital in line with the Mental Health Act 1983. Delays in these assessments being undertaken, and/or the lack of availability of mental health inpatient beds once a person has been recommended for admission, can lead to patients remaining in EDs for prolonged periods. Findings There is an absence of clear legal powers to lawfully prevent vulnerable individuals from leaving the ED while awaiting assessment or admission. This legal ambiguity exposes patients to increased risk of harm and/or being unlawfully deprived of their liberty, and places staff in a position of uncertainty when attempting to manage safety. For those requiring formal admission to a mental health hospital, an application under the Mental Health Act 1983 cannot be completed until a bed has been identified, which can take days. Staff and organisations reported they are often faced with choosing “the least harmful way to break the law” in order to try and keep patients safe. EDs are not designed to provide therapeutic mental health care and prolonged stays may worsen patients’ conditions and create challenges in maintaining a safe environment for everyone. HSSIB makes the following safety recommendations: HSSIB recommends that the Department of Health and Social Care urgently reviews the current legal framework and addresses the current legislative gaps in emergency care for people in mental health crisis and clarify the extension of legal powers for health professionals to hold someone in the emergency department. This will safeguard people who are currently arriving at the emergency department in a mental health crisis and the staff who care for them to support safe, consistent and legally compliant care. HSSIB recommends that the Care Quality Commission works with stakeholders to produce a position statement on existing legal powers, and the expectations for support for staff, for the care of people experiencing a mental health crisis in emergency departments (including mental health emergency departments and mental health crisis assessment services), who are not detained under a formal legal framework. This should include a review of current guidance and existing powers to help support safe, consistent, and legally compliant care in the absence of comprehensive legislation, while minimising harm and addressing the unique challenges of prolonged stays in the emergency department.
  5. News Article
    NHS England’s chair is leading a national review of mental health services and productivity, HSJ has learned. The work, being referred to as a “supply-side review”, is running alongside the more high-profile independent analysis of demand for MH and learning disability services commissioned by Wes Streeting last year. HSJ understands Dr Dash’s deep-dive is expected to be complete in the autumn, around the same time as the government review. Analysis has begun in recent months, including on spending, variation, productivity and the potential for “reinvesting” current funding, according to sources briefed on the project. The review has been referred to as “internal” and NHSE does not appear to be planning to publish it. It was initiated by the “quad” of senior officials across NHSE and the Department of Health and Social Care (Dr Dash herself, NHSE CEO Sir Jim Mackey, DHSC permanent secretary Samantha Jones, and DHSC lead non-exec director Alan Milburn). The review is also being overseen by an advisory group, with representation from mental health trusts, and others. Read full story (paywalled) Source: HSJ, 8 April 2026
  6. Content Article
    The UK Council for Psychotherapy (UKCP) has examined the National Institute for Health and Care Excellence (NICE) anxiety guideline in detail and the extent to which it had fallen behind was startling. This HSJ article argues that NICE’s anxiety guideline is outdated and no longer fit for purpose, having not been meaningfully updated since 2012. It relies on obsolete diagnostic frameworks such as DSM‑IV, omits newer standards like DSM‑V and ICD‑11, and contradicts NICE’s own depression guideline, creating confusion for clinicians treating common cases of comorbid anxiety and depression. A coalition of more than 50 organisations and individuals, including Mind and Rethink Mental Illness, and more than 20 parliamentarians, including Danny Chambers MP and Bell Ribeiro-Addy MP, have written to NICE calling for an urgent, wholesale review of the anxiety guideline. We are calling for the guideline to be brought into line with the depression guideline, to properly address access for marginalised groups, and to place genuine patient choice at its centre.
  7. News Article
    Health service staff have expressed alarm that engineers working for controversial tech company Palantir have been given NHS email accounts. Employees using NHS.net email accounts have access to a directory with the contact details of up 1.5 million staff. Sources believe Palantir staff were granted the same access. Palantir staff working on the introduction of its Federated Data Platform (FDP) for NHS England have also been given access to NHS SharePoint filesharing systems and internal Microsoft Teams groups. Hospital trusts and integrated care boards across the country are being encouraged to adopt FDP, which Palantir won a £300m contract to provide in 2023. NHS England says FDP allows NHS organisations to connect patient records historically held across different systems, allowing staff to manage waiting lists, allocate appointments, speed up diagnoses and personalise treatment more effectively. It is part of the government’s plan to “reinvent the NHS” through “radical shifts”, including moving systems from “analogue to digital”. The use of NHS email accounts and internal systems by private contractors is not unusual. However, Palantir’s association with AI-powered surveillance and war technology has made some staff, patients and human rights campaigners question the ethics and implications of allowing the spy-tech company to become embedded in the UK public sector. Rory Gibson, a resident doctor, said: “I – as a doctor – absolutely don’t want my personal email and number to be accessible to someone who works for Palantir on the NHS, and might next month be working on systems for drone strikes. NHS staff have not consented to sharing their email addresses with Palantir staff.” Read full story Source: The Guardian, 8 April 2026
  8. Content Article
    Psychological safety is an emergent property of conditions: not a programme, a metric, or an individual attribute. Those conditions are shaped primarily by structural power, collective responses, and the substrate of norms and history that precede any particular interaction. Because the costs of speaking up are disproportionately higher for those with the least power, psychological safety is first and foremost a matter of equity and rights, not performance optimisation. The work is therefore ecological and about changing the conditions for psychological safety to emerge, rather than exhorting people to speak up, and the work is never finished. Tom Geraghty shares 10 core principles. Fostering psychological safety is the right thing to do. Power and its unequal distribution is at the heart of this work. The cost of speaking up is not equally shared. Psychological safety is different for everyone. There is no such thing as too much psychological safety. How we respond shapes what follows. We change the environment and support the people, together. We all hold responsibility for psychological safety. Evidence includes experience. Psychological safety is always in flux.
  9. Content Article
    In hospitals, improvers and implementers use quality improvement science (QIS) and less frequently implementation research (IR) to improve healthcare and health outcomes. Narrowly defined quality improvement (QI) guided by QIS focuses on transforming systems of care to improve healthcare quality and delivery and IR focuses on developing approaches to close the gap between what is known (research findings) and what is practiced (by clinicians). However, QI regularly involves implementing evidence and IR consistently addresses organisational and setting-level factors. The disciplines share a common end goal, namely, to improve health outcomes, and work to understand and change the same actors in the same settings often encountering and addressing the same challenges. QIS has its origins in industry and IR in behavioural science and health services research. Despite overlap in purpose, the two sciences have evolved separately. Thought leaders in QIS and IR have argued the need for improved collaboration between the disciplines. The Veterans Health Administration’s Quality Enhancement Research Initiative has successfully employed QIS methods to implement evidence-based practices more rapidly into clinical practice, but similar formal collaborations between QIS and IR are not widespread in other health care systems. Acute care teams are well positioned to improve care delivery and implement the latest evidence. This paper provides an overview of QIS and IR; examine the key characteristics of QIS and IR, including strengths and limitations of each discipline; and present specific recommendations for integration and collaboration between the two approaches to improve the impact of QI and implementation efforts in the hospital setting.
  10. Content Article
    This paper from Mark Sujan and colleagues examines Erik Hollnagel’s impact on patient safety concepts and methods. Patient safety developed around linear models of error and compliance. Hollnagel’s work introduced a systems-based alternative. Resilience Engineering provided new conceptual foundations, reframing safety as a property of healthcare systems shaped by everyday performance variability and adaptive capacity. Concepts such as the Efficiency-Thoroughness Trade-Off (ETTO) and resilience potentials offered fresh ways of understanding how clinicians sustain safe care under pressure. Safety-II translated these insights into an accessible language, with terms such as work-as-imagined versus work-as-done, performance variability, and learning from what goes well. The rhetorical contrast with “Safety-I”, though contested, offered a provocative narrative that helped practitioners and policymakers reframe safety. The FRAM operationalised these ideas in investigations and improvement work, enabling healthcare teams to model interdependencies, illuminate system dynamics, and understand how everyday adaptations both sustain and threaten safe outcomes. Equally important has been Hollnagel’s role in cultivating healthcare-focused communities such as the Resilient Health Care Society, the Safety-II in Practice workshops, and the FRAMily. These communities have provided interpretive spaces for translating abstract principles into clinically meaningful insights, while guarding against superficial adoption and supporting sustained learning and capability development. Hollnagel’s enduring contribution is not a fixed doctrine nor a set of prescriptive interventions, but a reframing of patient safety —expanding its repertoire beyond compliance and error management towards managing safely as a dynamic, collective achievement.
  11. News Article
    Nearly half of patients who arrive at hospital in ambulances are being discharged without needing major care, according to data obtained by HSJ. Experts said the research also revealed a “postcode lottery”, with patients more likely to be taken to A&E in some areas due to a lack of alternative settings. The internal NHS England data has tracked how many ambulance patients were later discharged without any inpatient or “same day” emergency care, or transfer to another service, at different sites. These patients may have required hospital-based diagnostics, for example, or review from emergency clinicians before they could be sent away. At 24 hospitals, more than 50% of ambulance patients are being discharged without going to an inpatient or ambulatory unit. The highest proportion was 85% at St Peter’s Hospital in Surrey. It was at less than a third at other sites. This put the national average at 46%, according to data obtained by a Freedom of Information request. There was a wide range of acuity levels among ambulance patients discharged without further serious care. Read full story (paywalled) Source: HSJ, 8 April 2026
  12. News Article
    A trust which took an employee to court for thousands of pounds has been accused of “legal bullying”. Court documents seen by HSJ  reveal Lancashire Teaching Hospitals Trust attempted to sue its staff member Jonny Slade for “fundamental dishonesty” after he brought, and then dropped, a workplace injury claim against the trust. The trust later withdrew its claim against the worker – in which it had sought around £14,000 in costs from Mr Slade – after a hearing had begun at Preston County Court. The court proceedings finished in 2023, but Mr Slade told HSJ he had now decided to speak publicly about the case because he had exhausted official channels with health and safety concerns he has been raising. He said: “I felt the only way to ensure the issues were taken seriously was to speak publicly. “I simply hope [this] encourages greater accountability and ensures that staff who raise genuine safety concerns are treated fairly, rather than facing what I went through.” Workplace culture expert Roger Kline said: “I hope this case acts as a lesson to NHS trusts to stop pursuing staff for extortionate costs when they have in good faith lodged a claim… It is a form of legal bullying.” He said this kind of action was a “surprisingly common feature” of his recent report into workplace investigations. Read full story (paywalled) Source: HSJ, 8 April 2026 Related reading on the hub: Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Power and the sound of silence—A blog by Roger Kline Patient Safety Learning’s response to the NHS Staff Survey Results 2025
  13. Content Article
    The government has published its much-awaited Neighbourhood Health Framework. It sets out in new detail what neighbourhood health aims to do and how this will be achieved, building on the 10 Year Health Plan, the Neighbourhood health guidelines 2025/26 and the Medium Term Planning Framework.  The framework describes neighbourhood health as putting the person at the centre of how local services are organised and delivered – including GP and community services, urgent care and outpatients, as well as services commissioned by local authorities such as social care and public health.   The new guidance brings some long-awaited clarity to commissioners and providers about what neighbourhood health should deliver. There is much to welcome. But questions remain around whether targets can ease pressures on the acute sector as well as improve patient care and experience; whether focus can be maintained on long term population health priorities among a plethora of specific shorter term delivery goals; whether permissiveness in designing local services and rigid structures can coexist; and, fundamentally, whether integrated care boards (ICBs) and other organisations have the capacity to action it all.  In this King's Fund article, experts set out their more detailed analysis of the framework. They consider the parts to celebrate, the aspects that raise some concerns, what’s missing, and the questions that remain outstanding.  
  14. News Article
    Women’s deaths during pregnancy, labour or soon after giving birth are at the highest level for two decades despite the NHS receiving dozens of recommendations to act on life-threatening symptoms. An investigation by The Times shows the NHS was issued with 67 separate warnings between 2013 and 2023 to take signs of potentially fatal complications in mothers — known as red flags — seriously. Over the same decade, there was a 50% rise in the UK’s maternal death rate — defined as deaths in pregnancy, childbirth, or the six weeks after giving birth — from 8.54 deaths per 100,000 pregnancies in 2013 to 12.80 in 2023. The last time the rate was this high was in 2005. The most recent available data shows 257 women died in the two years to 2023. The biggest killer was blood clots, followed by heart issues, suicide, stroke, sepsis and severe bleeding. Over the past decade, a string of reviews have issued 748 recommendations for improving NHS maternity services across 59 official reports, yet death rates have soared. Wes Streeting, the health secretary, has commissioned a national maternity inquiry led by Baroness Amos, a Labour peer, which is due to deliver its recommendations in the summer. Campaigners are sceptical about whether another report will result in real change. Theo Clarke, a former Conservative MP who led a parliamentary inquiry into birth trauma in 2024, said it was a “national scandal” that maternal deaths were rising while “recommendations are ignored”. She said: “NHS maternity services are swamped with recommendations from scores of reports, and still women and their babies are being harmed by a lack of focus and leadership necessary to implement them.” Read full story (paywalled) Source: The Times, 5 April 2026
  15. Content Article
    This Health Service Safety Investigations Body (HSSIB) investigation focuses on how the health needs of people in prison are assessed and the provision of safe living conditions for people in prison who use a wheelchair or have mobility issues. This investigation explored how healthcare provision for a whole prison’s population is assessed and commissioned using health needs assessments. How outdated assessments may present a patient safety risk through mismatched staffing skill mix and services that don’t match the patient’s needs. These risks may result in physical injuries, psychological distress and dignity violations, each of which can impact on patient wellbeing. It looked at challenges related to this approach, cost implications of the current system and ongoing developments. Disability access within prisons is complicated by the original design and purpose of prison buildings. Some of the prison estate dates back as far as 1800, making adaptations and provision for wheelchair users, for example, difficult. The investigation explored the prevalence of this issue, the impact on people in prison and potential areas for improvement. Findings The investigation explored two main themes: health needs assessments and access for physically disabled people within prisons. These themes were identified during the evidence gathering phase for the three previous HSSIB reports in this series. The findings have been separated into these two themes and are listed below: Health needs assessments (HNAs) The current process of developing an HNA for a prison population, which are generally conducted at most every 3 years, means that HNAs are frequently out of date by the time they inform commissioning decisions. There is often a delay in prison healthcare providers being made aware of likely changes to the prison population by HM Prison and Probation Service (HMPPS). This can impact on providers’ ability to ensure the required healthcare provision is in place to serve the new population. Outdated HNAs lead to mismatched healthcare provision, forcing providers to submit business cases for additional services or absorb the financial impact of changes to their services. The business case processes were slow and did not support the needs of a rapidly changing prison population, resulting in services that may pose patient safety risks due to mismatched healthcare services, incorrect staff skill mix requiring retraining, recruitment, and removal/addition of new services. HNAs were commissioned by NHS England regional commissioning teams and did not include social care requirements as this is commissioned by local authorities, which made planning and provision of social care difficult and often resulted in delays in care. In response to limitations in the current HNA process, some regions had introduced alternative approaches, including digital data dashboards and artificial‑intelligence‑enabled tools. Different approaches to assessing healthcare requirements for prison populations contributed to variation in how healthcare services were commissioned and delivered across the prison estate. Stakeholder engagement in assessing prison population health requirements was limited; local authorities and other relevant bodies were rarely consulted, contrary to guidance. Physical disability access Wheelchair users experienced harm and dignity concerns, including injuries from unsafe chair-to-chair transfers and deteriorating mental health caused by being housed in inappropriate accommodation. The number of wheelchair users in prisons is increasing, and many prisons cannot easily accommodate wheelchair users or people with mobility issues. None of the prisons visited had enough wheelchair-accessible cells. In some regions there were none. Accessible cells are sometimes located only on vulnerable prisoner wings, potentially wrongly associating wheelchair users with that cohort of prisoners. The current system for gathering information on the physical accommodation needs of people in prison is ineffective; this can impact on the ability to place people in appropriate accommodation. HSSIB makes the following safety recommendations HSSIB recommends that HM Prison and Probation Service, in collaboration with the Department of Health and Social Care, formalises arrangements for alerting healthcare commissioners and providers to changes in prison populations likely to impact on healthcare provision requirements. This is to ensure that healthcare commissioners and providers can plan for changes to healthcare services that are necessary to meet the changing needs of the prison population. HSSIB recommends that the Department of Health and Social Care works with local authorities to redesign how the health and social care needs of prisons’ populations are assessed. This is to ensure that appropriate services are commissioned to meet the needs of people in prison and prevent possible delays in care. HSSIB recommends that HM Prison and Probation Service reviews and amends its information gathering processes for accommodation requirements for wheelchair users and people with mobility issues, to identify and mitigate risks for people whose accommodation does not meet their needs. This is to enable and support the effective identification of appropriate prison accommodation for these groups.
  16. Content Article
    This paper from the Healthcare People Management Association looks at the impact of the disciplinary policies we follow on the employee under investigation. It also examines the impact on the people leading and supporting the process, including line managers, HR staff, witnesses and trade union representatives. It summarises recent research on the issue and identifies new ways of managing investigations which support and protect the wellbeing of everyone involved. Research shows that the way we manage investigations can have a negative impact on the culture of our organisations. This paper suggests ways of managing investigations which help to foster the positive working culture we all want to work in.
  17. Event
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    The change in approach to investigations under PSIRF has resulted in some practical challenges to the way in which information and organisational learning evidence is presented to the coroner for inquests. Join Browne Jacobson for a discussion on how the PSIRF and coronial processes can work more effectively together to ensure that coroners receive the information they need for inquests while preserving PSIRF’s core principle of fostering a learning culture within healthcare. Bringing together perspectives from across the system, we will explore some of the key challenges and, importantly, share positive and practical examples of how a collaborative approach across both learning and coronial processes can ensure that relevant information is shared effectively. Chaired by Amelia Newbold, Risk Management Lead and Katie Viggers, Professional Development Lawyer in the Inquest and Advisory Team, we are delighted to be joined by an experienced panel who will share their experiences and insights: Mr Graeme Irvine, HM Senior Coroner for East London. Lauren Mosley, Head of Patient Safety Incident Response Policy, NHS England. Stef Cormack, Head of Patient Safety at Sandwell and West Birmingham NHS Trust. Conor Lees, Head of Legal Services at Sandwell and West Birmingham NHS Trust. Delegates will have opportunities to put questions to the panel, gain their perspectives on specific issues, and share ideas and solutions with organisations across the health sector. Register
  18. News Article
    Millions of people across the UK living with incontinence are facing shortages of sanitary products due to supplies being rationed by NHS trusts, according to a coalition of charities. The shortages are leading to a “pad gap” where people are having to pay for incontinence products themselves, according to an open letter from organisations including the Royal College of Nursing, Prostate Cancer UK, and Bowel and Bladder UK. Around 14 million people across the UK experience incontinence. Healthcare workers in the NHS expect to fit up to five pads a day for patients who experience incontinence, according to research, but freedom of information data from 110 NHS trusts show that more than half (53%) have a cap on the availability of products. Of these trusts, 34% have a cap of three products a day, while the remaining 66% have a cap of four products a day, which is lower than the expected need. As a consequence of the shortages, many people with incontinence and their families are forced to use their pension or personal independence payment (PIP) to purchase these products while struggling to cover other basic costs. According to the letter, these measures represent a “once in a generation opportunity to improve health outcomes for all” that will benefit people who experience incontinence and ease the burden on NHS staff and carers. Prof Alison Leary, the deputy president of the Royal College of Nursing, said she often heard from nurses who were concerned about the shortages of incontinence products. “The effective rationing of incontinence products means that staff and patients both suffer – patients do not get the dignified care they need and nursing colleagues feel they are not meeting patients’ fundamental needs,” Leary added. Read full story Source: The Guardian, 6 April 2026
  19. Event
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    Health Innovation East Midlands and the Midlands Clinical Senate are hosting a new Innovation Insights webinar exploring the key challenges to implementing artificial intelligence (AI) in healthcare, and the practical steps that can help organisations overcome them. The webinar will share insights from the Midlands Clinical Senates’ work examining the barriers to the widespread adoption of AI in health and care, including findings published in the peer-reviewed journal article ‘A Systematic Review of the Barriers to the Implementation of Artificial Intelligence in Healthcare’. This session will include: Insights from the Clinical Leadership Fellows who led the research. Case studies from health and care teams who have experienced – and successfully navigated – the challenges of introducing AI into practice. Actionable insights to apply in your practice to mitigate AI implementation barriers. Speakers: Dawn Plummer, Digital Health Innovation Lead, Health Innovation East Midlands Emma Orrock, Head of Clinical Senates, Health Innovation East Midlands Midlands Clinical Senate Fellows: Brendan Spooner, John Isherwood, Imad Ahmed, Mark Lane Health care case studies from: Ben Madden, Lead Reporting Radiographer, Kettering General Hospital NHS Foundation Trust Neil Frazer, Medical Director, Primary Integrated Community Service (PICS). This session is free to attend and open to everyone, regardless of your role or organisation. Register
  20. News Article
    More than 2,000 Black men will die from prostate cancer in the next 10 years if the UK doesn’t change its screening programme, new figures reveal. Around 1 in 4 Black men in the UK will be diagnosed with the disease – twice the rate of white men. The reasons for the disparities vary, but contributing factors include genetics, a lack of awareness, delays in seeking help and barriers to accessing diagnostic tests. Last month, the government’s National Screening Committee (NSC) rejected proposals for a targeted prostate cancer screening programme for high-risk men, which includes Black men and those with a family history of cancer, because it said the harms of widespread testing outweigh the benefits and also cited a lack of available data on Black patients. Now, new estimates from the charity Prostate Cancer UK, shared with The Independent, suggest that if nothing changes, more than 2,300 Black men will die over the next decade, and at least 16,000 men will be diagnosed, if current rates of the disease continue. Amy Rylance, director of health services, equity and improvement at Prostate Cancer UK, said: "We were bitterly disappointed by the UK NSC's announcement that the evidence isn't yet strong enough to recommend targeted screening for Black men. “While we accept the committee's decision that the data they reviewed had too many gaps, a significant opportunity has been missed. The NHS holds electronic health data that could fill these gaps – but nobody has made full use of these records, and they weren't reviewed by the committee." She said that the charity would work alongside the NSC to find the missing data and build the evidence base needed to secure screening for Black men. Read full story Source: The Independent, 6 April 2026
  21. News Article
    The medicines regulator is investigating whether UK clinics are breaking the law by making claims about the benefits of unregulated, experimental peptide therapies, the Guardian can reveal. Interest in experimental peptides has boomed in recent years. The substances are delivered by injection and are touted by sellers, influencers and even some medics as aiding everything from anti-ageing to recovery from injury. There is little scientific evidence to support such health and wellness claims in humans. Where studies have been carried out, most are in animals or cells. The Medicines and Healthcare products Regulatory Agency (MHRA) has said clinics are not permitted to make medicinal claims for the peptide treatments offered by their service. An MHRA spokesperson said: “If clinics offering peptide injections make medicinal claims for those treatments, the products will be considered medicines and subject to regulation under the Human Medicines Regulations 2012. “The MHRA will take action against clinics which are identified as breaching the legal requirements.” However, a Guardian investigation has found a number of clinics operating in the UK offering a variety of unregulated, experimental peptides and making a host of claims about their benefits on their websites. These include approved prescription weight-loss medications based on synthetic peptides that mimic natural hormones, such as semaglutide and tirzepatide, found in weight loss drugs such as Wegovy and Mounjaro respectively. But many other peptides on the market have not undergone the strict regulatory processing that those used in medications have undergone, and remain experimental. Read full story Source: The Guardian, 4 April 2026
  22. News Article
    The NHS has not made a “life-changing” treatment for stroke available around the clock across England despite ministers repeatedly promising that it would. The health service was expected to improve stroke care by making a clot removal technique called mechanical thrombectomy available everywhere in the country 24/7 from 1 April. Doctors describe it as a gamechanging intervention that, if done quickly, can help someone who has had a severe stroke avoid ending up with a serious disability as a result. However, seven of England’s 24 regional stroke centres are still not providing thrombectomy on an all-hours basis, mainly because they do not have enough doctors and other staff to do so. Experts fear the NHS’s failure to deliver universal 24/7 access to the treatment could mean patients who have a stroke overnight, in the evening or at weekends in underserved areas may become avoidably severely disabled, or may even die, because they could not have the procedure. More than 100,000 people a year in the UK have a stroke, of whom 38,000 die and many others are left with life-changing disabilities that rob them of their independence. Dr Sanjeev Nayak, a stroke specialist at the Royal Stoke hospital in Stoke, said: “A patient presenting during normal working hours in a well-served area may receive rapid, life-changing treatment, whereas the same patient presenting at night or in a different region may not receive thrombectomy at all. This creates a real postcode lottery in access to one of the most effective treatments in modern medicine.” Read full story Source: The Guardian, 6 April 2026
  23. News Article
    A trust group that has seen a rise in “never events” has been heavily criticised for “inadequate” oversight and management of patient safety. An assessment commissioned by the Humber Health Partnership also found incidents were “not always being escalated appropriately” and reported “persistent delays” in addressing issues previously raised by the Care Quality Commission. Hull University Teaching Hospitals and Northern Lincolnshire and Goole trusts, which formed the group in 2024, were subject to NHS England intervention over major performance, safety and governance concerns last year. Late last year, the trusts commissioned a firm called Thevaluecircle to carry out an independent review of governance. The assessment, which was finalised in January, has now been released to HSJ following a freedom of information request. It found there was “inadequate rigour in the management of never events and other patient safety incidents” and claimed risks had been “normalised over time, reducing the sense of urgency and active management”. HUTH recorded six never events in the six months to January, the ninth highest figure for a provider, while NLAG recorded one. Never events are the most serious preventable clinical mistakes and include wrong site surgery, leaving surgical instruments inside a patient after surgery, and blood transfusion errors. Read full story (paywalled) Source: HSJ, 7 April 2026
  24. News Article
    An NHS trust has abandoned plans to trial a major US supplier’s ambient voice technology after concerns were raised about its compliance with NHS England accreditation requirements, HSJ has revealed. Epic Systems had this week planned to launch a trial of its native AI Charting functionality at Frimley Health Foundation Trust, despite not holding Medicines and Healthcare products Regulatory Agency (MHRA) Class I medical device status, which is required of all AI scribing tools capable of summarisation. Frimley Health has since confirmed the trial did not go ahead as it had not gone through the trust’s internal governance processes and has been paused pending further work. Epic’s AI Charting tool does not appear on the MHRA Class I medical device registry and the company is also not on NHSE’s AVT registry. HSJ understands that two other trusts – understood to be one in the north of England and one in the east – are currently live with Epic’s AVT. Several other trusts are understood to be in conversations with Epic about trialling its AVT, including University College London Hospitals FT, Birmingham Women’s and Children’s FT, the Royal National Orthopaedic Hospital Trust, and East Suffolk and North Essex Foundation Trust. Read full story (paywalled) Source: HSJ, 1 April 2026
  25. Content Article
    More information about "Designing AI with patient safety at its core: Reflections from the Patient Safety Forum 2026"
    Last month, Public Policy Projects hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients.  In this article, Patient Safety Learning reflects on one of the panel discussions—AI for patient safety: Innovation, assurance and strengthening communication. From AI-enabled ambient scribing tools that reduce the burden of administration, to predictive systems capable of detecting early warning signs before harm occurs, AI has significant potential to improve patient care and outcomes. Yet, alongside these benefits come risks—algorithmic errors, data bias, and challenges in maintaining trust, governance and oversight. At the Patient Safety Forum 2026 an expert panel was convened to discuss this topic, with the following members: Clive Flashman, Chief Digital Officer, Patient Safety Learning Dr Alison Cave, Chief Safety Officer, Medicines and Healthcare products Regulatory Agency (MHRA) Anil Mistry, AI Safety Lead, Guy’s and St Thomas’ NHS Foundation Trust Dr Basil Bekdash, Clinical Safety Officer, Sheffield Children’s NHS Foundation Trust Aleksander Alski, Head of Region – USA, Canada and UK, Vasco Electronics Panellists had a lively discussion with each other and the audience about how to balance innovation with assurance, to ensure that the use of AI in healthcare enhances safety rather than undermines it. They spoke about how AI should be understood as a support tool for healthcare professionals—it provides information and removes burden but, ultimately, staff treat patients. In this blog we highlight several key topics that emerged from this debate. Importance of patient safety A key theme running throughout the panel’s discussion was the importance of patient safety being built into AI development at the outset. Clive Flashman from Patient Safety Learning reflected on this point, suggesting that too often this is seen as a compliance ‘tick box’ or treated as an afterthought. Speaking to digital innovators, his message was that “you need to think about this from the very start when you are conceptualising the product”. Panellists also recognised that putting safety at the centre of discussions around AI and healthcare means involving all stakeholders, not just the healthcare professionals using these technologies but suppliers too. Alexander Alski from Vasco Electronics emphasised the importance of this being an area of shared responsibility between suppliers and healthcare providers. Getting regulation right Alison Cave from the MHRA spoke about the ongoing work of the National Commission into the Regulation of AI. This Commission was established by the MHRA to review current regulations and provide recommendations for a new regulatory framework for AI in healthcare. It held a public call for evidence which Patient Safety Learning responded to earlier this year. Discussing how to approach future regulation, she highlighted the importance of ensuring that “the risk is associated with the decision, not the technology itself”. It was noted that in some cases there may be very complex pieces of software in use, but these may be making very low-risk decisions. Panellists underlined the importance of having a risk-proportionate regulatory framework to support safe innovation. Predicting future harm The potential to use AI to identify patient safety issues is understandably an area of significant interest. Last year the Department of Health and Social Care announced that it planned to develop a world-first artificial intelligence (AI) early warning system to automatically identify safety concerns across the NHS. Panellists were asked to consider what examples they had seen of AI moving from reacting to incidents, to predicting and preventing future harm. They spoke about the value of AI as a support tool for clinicians and more broadly how it might be used to identify emerging patient safety issues. Basil Bekdash from Sheffield Children’s NHS Foundation Trust spoke about work that had been trialled in this area, but noted that currently there have not been many examples where these have been proven on a significant scale, stating: “None of them have really quite got to the point where they're proven in widespread deployment and so I'm not going to predict that's going to happen in the next five years.” Tackling bias While an AI tool may be safe when properly implemented and used by a well-trained healthcare professional, it could be potentially dangerous if such training and support is absent. Panellists concurred that having appropriate training and tackling bias were issues of critical importance in ensuring the safety of AI in healthcare. In particularly they discussed risks presented by: Confirmation bias—healthcare professionals favouring AI outputs that align with their pre-existing view and overlooking signals that may challenge this. Automation bias—over-reliance on AI systems and accepting their recommendations without sufficient critical evaluation. Alison Cave from the MHRA said that part of the training should be ensuring that healthcare professionals understand the devices they are using and where there are trade-offs between sensitivity and a specificity. Basil Bekdash from Sheffield Children’s NHS Foundation Trust noted the importance of having in mind the different levels of digital competence of staff, stating that when designing AI systems: “It is best to test by using your least capable people who are the least digitally enabled and that's not a criticism that's just the reality of the normal spread of what people do, and their primary function is to look after patients.” Transparency and patient communication As use of AI grows in healthcare, it is vital that patients understand how this is being applied if they are to have confidence in its safety. Panellists discussed issues around how to inform patients when AI influences their care, particularly when it affects clinical judgments. Anil Mistry from Guy’s and St Thomas’ NHS Foundation Trust suggested that: “If the AI result is going to affect their patient’s care, and it's going to limit their access to finite resources like a waiting list or appointments or ICU beds, then absolutely have that sort of communication.” However, he also spoke about some of the challenges this raises; for example, if a patient asked about whether AI has been used in their care. In practice this could cover a very broad range of areas, from the use of ambient scribes to take notes to tools that analyse images from scans. Panellists indicated that transparency needed to be balanced and proportionate to both the risk and impact on individual care. Governance requirements AI healthcare technologies have significant scope to evolve and change over time. When they iterate rapidly (with new versions being released at regular intervals) it can be difficult for existing governance frameworks, designed for other types of medical devices, to keep up. Panellists discussed the importance of having flexibility to governance arrangements. There was the suggestion that lower risks tools (such as those in Class 1 for Medical Devices under the MHRA framework in the UK) should have greater flexibility, with higher levels of scrutiny reserved for decision-influencing tools. It was also made clear that any new regulation will need to carefully consider the level of ongoing evaluation that will be required to account for these systems evolving and changing over time. This may be much longer than for other medical devices and change at significant pace. One audience member commented that with these tools becoming increasingly complex, in the future “realistically there is going to be a need for an AI tool that assesses AI tools”. Panellists also considered how procurement processes could act as potential leverage mechanisms for AI technologies in healthcare. It was noted they offer the potential opportunity to embed the open standards we want to see being used by AI technologies in the earliest stages of their design, putting safety concerns at the centre of the product before it ever reaches patients. Improving the quality of data Data accuracy, completeness and representativeness is key to ensuring AI technologies work safely in health and care environments. Panellists noted that poor foundational data standards undermine AI model training and lead to unreliable outputs. Their discussion reflected that a significant proportion of time is often spent on data cleaning before even applying AI. Improving this would have wider benefits for research, operational efficiency and public healthcare. As we increase the use of AI health technologies, it is vital that we do not embed existing health inequalities. Following on from comments in an earlier session from Professor Bola Owolabi from the Care Quality Commission, Alison Cave from the MHRA noted a “perennial challenge in all of our areas is to ensure that the training data is representative”. Training data for AI systems must be representative of diverse populations and care settings. Sharing insights from the frontline If healthcare organisations, professionals and suppliers are to share responsibility for the safe implementation of AI technologies in healthcare, this must go hand in hand with shared learning. Panellists discussed the need for sustained and transparent feedback loops between suppliers, regulators and healthcare organisations. On this point an audience member asked: “How do we ensure our learning keeps pace so that existing insight from frontline teams that really know the business can optimally inform the evolution of products, but without stifling the pace?” Panellists highlighted the absence of standardised mechanisms for frontline staff to provide real-time, structured feedback to AI suppliers on safety issues. One proposed suggestion to this was the potential to mandate native feedback functionality within AI health technologies. This would mean that feedback mechanisms are built directly into the AI tool’s user interface and workflow, allowing those using them to provide input about the AI’s output without leaving the system. Find out more about the Patient Safety Forum 2026 You can read more about different discussions and panel sessions at this year’s event in the below: Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026 Safe systems, safe cultures: reflections from the Patient Safety Forum 2026

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