Patient Safety Learning

Hospitals are persisting with using variable methods and tools to measure the growth of unborn babies, which experts say is leading to avoidable deaths, HSJ can reveal. Fetal growth restriction is a leading cause of stillbirth, and failure to detect it means maternity services are missing opportunities to intervene. However, HSJ research reveals significant fragmentation in the tools used and concerns about whether some are flawed. HSJ found that across 113 trusts with maternity services that provided information, eight different types of growth charts were used, including several with their own localised system. Some 14 trusts continue to use in some capacity a system called Intergrowth, despite NHS England warning in December that it is flawed for estimating fetal weight. A small number of providers persisted in using it for this purpose, and NHSE said it was “now seeking assurance” they had stopped. Recent maternity reviews by Baroness Valerie Amos and Donna Ockenden acknowledged concerns about growth charts, but did not shed light on the huge fragmentation in the tools used. Read full story (paywalled) Source: HSJ, 14 July 2026

Longstanding issues with leadership and clinical oversight across two trusts contributed to failures surrounding the death of a teenager, two independent reviews have found. Lucy Curtis, 17, died in hospital on 1 January 2024, five days after an incident of self-harm where she was found unresponsive at the Riverside Adolescent Unit at Blackberry Hill Hospital in Bristol. The hospital is run by Avon and Wiltshire Mental Health Partnership Trust. Lucy had previously been admitted “informally” to Wessex House General Adolescent Unit, which is run by Somerset Foundation Trust, after her mental health deteriorated in summer 2023, and had been discharged on 27 November. An inquest into her death finished on Friday. It found there were “multiple missed opportunities and failures” in Lucy’s care across both trusts, which “possibly” contributed to her death. Its judgment was critical of poor communication around Lucy’s discharge from Wessex House, and a delay in accepting her onto the caseload of the AWP child and adolescent service. It also criticised Riverside’s failure to adequately observe her, and problems with delivering emergency treatment when she was discovered by staff. In addition, an independent review published earlier this year, commissioned by the South West mental health provider collaborative and shared with HSJ, found “systemic failures across the care pathway”, which left Lucy “without timely, coordinated, and effective support at critical points”. Read full story (paywalled) Source: HSJ, 13 July 2026

From 1 July 2026, following a recommendation by the Dash review of patient safety across health and care, NHS England will deliver some activities previously undertaken by the National Guardian’s Office (NGO). Trusts, primary care organisations, integrated care boards (ICBs) and independent providers will be taking on greater responsibility and accountability for embedding effective Freedom to Speak Up (FTSU) arrangements. More information is available in The future of Freedom to Speak Up publication.

We often hear from the Patient Safety Management Network that members are in interested in how others from different industries do things. In this hub top picks, we have pulled together useful websites on safety and investigations in other industries, including aviation, rail, nuclear and defence.

Sebastian Gonzalez, hub topic lead and learning disability lead nurse at Barts Health NHS Trust, reflects on the lack of progress made in reducing health inequalities for people with a learning disability despite a number of reports and recommendations over the last few years. He highlights the new reasonable adjustment digital flag that is being implemented across the NHS, which allows the sharing of detailed information across the healthcare system about the reasonable adjustments individuals require. Sebastian asks you to explore what your organisation is doing to implement the reasonable adjustment digital flag to help identify and support patients with a learning disability.

Healthcare Quality Improvement Partnership (HQIP) Clinical Audit Awareness Week ran from 22-26 June 2026. Designed to celebrate the critical role of clinical audit and data-driven healthcare improvement, the campaign explored how insight becomes action across five themed days. Through a packed programme of events and awards, it showcased practical examples, innovation and collaborative projects. Find out more about what took place, with event recordings and slides on HQIP's website.

In a LinkedIn article, Roger Kline highlights the significance of the EHRC’s 2024 Sexual harassment and harassment at work: technical guidance. It rightly emphasises the proactive, preventative duty on employers to prevent sexual harassment. But it goes further and sets out how legislation now applies (with one exception) to any form of harassment linked to most protected characteristics. Its emphasis is in sharp contrast to the emphasis on supporting individuals to make that characterise much work on equality. The NHS England policy rightly states at para 1.2. “The new Worker Protection (Amendment of Equality Act 2010) Act 2023 creates a duty on employers to take reasonable steps to prevent sexual harassment in the workplace”. However, in Roger's view, it does not sufficiently emphasise the central importance of the anticipatory requirement on employers.

In this King's Fund article, Danielle Jefferies explores the link between delayed discharges and corridor care, the growing financial cost of both and why action beyond hospital walls will be essential if we are serious about reducing pressure on hospitals. Further reading on the hub: The crisis of corridor care in the NHS: patient safety concerns and incident reporting Corridor care guidance needs to move beyond what “should” happen and grapple honestly with why it isn’t Corridor care: are the health and safety risks being addressed?

More than 2,700 people may have died from heat-related causes in England and Wales during the exceptionally hot weather in May and June, experts' estimates suggest. The figure, from a team at Imperial College London, the Met Office and the London School of Hygiene and Tropical Medicine, is based on what's known about the dangers of extreme heat. Most deaths will have occurred in the June heatwave, they say - the warmest June on record in England, when temperatures hit 37.7C (99.9F) at Lingwood, Norfolk, smashing the previous high of 35.6C set in 1957. A rare red heat alert, external was issued for parts of England and Wales at the time, warning even healthy people of the significant risk to life. Many UK homes are not built to cope, leaving people vulnerable to prolonged, high temperatures. Heat puts immense physical strain on the body, made worse if you are dehydrated, with the heart pumping harder and faster to cool you off. Babies and older people are among those most at risk of harm, as well as those with existing health conditions. It can lead to more heart attacks, strokes and other potentially fatal emergencies. Intense heat can affect anyone, including fit and healthy people, and is dubbed a 'silent killer' because early symptoms are easily overlooked. And when the hot air is very wet or humid, like it was in June, it's more difficult for the body to cool down through sweating. Prof Fredi Otto, an expert in climate science at Imperial who was involved in the research, told the BBC's Today Programme: "Don't underestimate the risks. Just because you're fit and healthy, you're not safe." Read full story Source: BBC News, 13 July 2026

As he speaks, there’s fear in Grant McPherson’s eyes. “You won’t make me go back, Dad. Horrible. Nasty. They hurt me dad. Stay here.” Grant, 48, is in the living room of the specially adapted house he shares with his father Leonard McPherson in Wolverhampton. He has cerebral palsy, sight impairment, epilepsy, a learning disability and uses a wheelchair due to paralysis following a spinal operation as a child. Grant and his father are happy. But they have endured years of heartache in their bid to be reunited at their family home. Leonard is one of hundreds of people across the country who have faced ongoing battles to advocate for their vulnerable loved ones in care after raising concerns about their treatment. During five years trapped in council-sponsored accommodation, Leonard says Grant suffered physically and mentally. Among the roll call of injuries, Grant suffered a severely broken leg, contracted two life threatening infections and was burnt twice – the second time so severely that he spent three months in hospital. But, as Grant was moved between different council care, it was his father Leonard who was put under scrutiny when he asked to remove Grant from care and take him home instead. Incredibly, Leonard was also gagged with legal orders, meaning he could not talk publicly about his struggle to bring his son home. Leonard was on the cusp of being restricted to seeing Grant for just one hour a week – an issue the government has now vowed to crack down on – when a judge finally agreed that Grant could return home to live with his father. This is not an isolated case, with concerns raised nationally about draconian conditions placed on parents and guardians, preventing them from advocating for their children, with restrictions often put on visiting rights. Earlier this year, the government vowed to crack down on care companies and councils that ban families from visiting vulnerable relatives and promised to improve visitation rights. The chief inspector of the Care Quality Commission, the independent regulator of health and social care in England, also admitted that care companies who look after people with learning disabilities need to be inspected “more consistently and more regularly”. Read full story Source: The Independent, 11 July 2026

Private providers have accused 10 integrated care boards of blocking access to eye care, which they argue is redirecting tens of thousands of patients to A&E and GPs. Providers Newmedica and Specsavers identified 10 ICBs as decommissioning services, setting minimum waits, and capping referrals. The restrictions will lead to additional pressure on accident and emergency departments, GPs and other services, they argued in evidence submitted to the Parliamentary committee considering the Health Bill. The ICBs told HSJ they aimed to balance “patient need, clinical safety, waiting times, value for money and the fair use of public resources” – and argued NHS-provided alternatives were available. Newmedica said Leicester, Leicestershire and Rutland ICB had used an “indicative activity plan” to cut activity in its elective ophthalmology service by more than half year-on-year. Meanwhile, Specsavers’ submission also identified Coventry, Sussex and Leeds as having either withdrawn or restricted community urgent eye care. The high-street chain said in each of these areas, tens of thousands of patients were “now diverted to A&E or GPs”. In addition, it said Hampshire and Isle of Wight ICB had moved community glaucoma schemes back into hospitals and planned to cancel community eye care when its contract expires this year, with GPs and pharmacies to carry out the work. Specsavers said the ICBs had restricted access to services to “save money”, but these would not be realised because they will “simply reappear as a trust overspend against its block contract for urgent and emergency care”. Read full story (paywalled) Source: HSJ, 13 July 2026

I have spent almost three years as an NHS stop smoking advisor in Luton. A client called me five days after removing her nicotine patch due to a skin reaction. She had started smoking again. She was distressed and convinced she had failed. The answer to her question took me thirty seconds. She could have had it five days earlier if there had been anywhere to turn at the moment she needed it. That moment made me ask whether technology could do what the NHS structurally cannot. Provide trusted, clinically grounded support at any hour, in any language, in the moments when relapse is most likely to happen. So, I developed an AI-powered stop smoking support tool. This blog is about what building this innovative product taught me about patient safety.

Pregnant women were put at “unacceptable risk” by a service which was “deviat[ing] from guidelines”, had poor “surgical competency”, and was over-reliant on a single consultant at “significant risk of burnout”. Independent experts identified an “overuse” of a surgical procedure, a lack of guidance around scans, and risks posed by a single consultant running high-risk perinatal care at Blackpool Teaching Hospitals Foundation Trust. NHS England requested a review of the trust’s fetal medicine service early last year following a spate of rapid reviews raising concerns about ultrasounds and preterm clinical pathways. HSJ has now obtained a copy of the 2025 report, which was led by Birmingham Women’s Hospital consultant Leo Gurney, via a Freedom of Information request. It said: “There was evidence of unacceptable patient risk within the preterm birth prevention service, particularly concerning cervical cerclage insertion, with deviations from guidelines and a lack of senior oversight and adherence to multi-disciplinary team processes.” The review said there appeared to be an “overuse” of cervical stitches – which are meant to be used to prevent premature labour where it is a risk – that could “contribute to high surgical complexity”. Other risks from the procedure include infection or the potential to induce labour. Read full story (paywalled) Source: HSJ, 10 July 2026

The share of patients reporting a good experience when contacting their GP practice has increased for the second year running, while the number going online has increased, new figures show. However, the annual GP patient survey – contrary to other research – suggested many more are still relying on the phone rather than websites or the NHS App. Results published on Thursday of the large national survey found 72.6% of respondents said their experience of contacting their practice was “very good” or “fairly good” – up from 69.6% in 2025. The survey question was revised in 2024 from asking about “making an appointment” to “contacting your GP practice”. The survey, carried out by Ipsos for NHS England, ran between January and April, with more than 650,000 respondents from a random sample of those who use GP services. 54% per cent said they had used the phone to contact their practice on their most recent attempt – down steeply from 62% in 2025 and 68 per cent in 2024. Meanwhile, 31% had used the GP practice’s website or the NHS App, up from 22% in 2025 and 17% in 2024. Read full story (paywalled) Source: HSJ, 9 July 2026

A new paper from NIHR RSET, in collaboration with Sands, describes the experiences of different families of advocacy support in maternity and neonatal services. Based on conversations with 34 families, the findings suggest that independent advocacy could help ensure that families are listened to, heard and supported following an adverse outcome.

A royal college has added to concerns that a shift in NHS funding to expand “neighbourhood” care risks undermining “safe, sustainable hospital services”. The Royal College of Physicians issued its statement in response to a HSJ interview with Shane DeGaris, chief executive of Barts Health Trust, who warned against “top slicing” acute budgets for neighbourhood schemes when “the work still comes to hospitals”. The RCP said that while it supports the potential to move services closer to home, “it must be underpinned by adequate investment, workforce capacity and clear plans to maintain safe hospital services during the transition”. Shifting care out of hospitals without the right infrastructure, specialist input and capacity in community services “risks increasing pressure elsewhere in the NHS, rather than delivering the integrated, patient-centred care that patients need”, it argued. The Department of Health and Social Care has previously said it is up to integrated care boards to shape service transformation in their area. RCP’s clinical vice president Hilary Williams said: “The key challenge is not whether we shift care closer to home, but how we do it. Any transfer of funding or workforce must be accompanied by realistic transition arrangements, investment in community capacity, interoperable digital systems and a clear plan for maintaining safe acute care.”

A manager at the mental health trust at the centre of a public inquiry has said concerns she raised before the death of a patient were not acted on. Chloe Cawston was giving evidence to the Lampard Inquiry, which is examining the deaths of more than 2,000 patients who received care from mental health services in Essex between 2000 and the end of 2023. Cawston was a ward manager at Basildon Mental Health Unit when 28-year-old Bethany Lilley died in January 2019. The inquiry heard she had raised concerns about patient transfer procedures before and after Bethany's death. Asked whether any action had been taken before she died, Cawston replied: "Not that I can recall." Bethany was found unresponsive after being transferred to Basildon. The inquiry heard the ward did not receive all the relevant paperwork or case notes and there was not an appropriate handover between hospitals. Cawston told the inquiry she had been a registered mental health nurse since 2011 and became a ward manager at Basildon in 2018. During her evidence, she also accepted there had not always been enough beds for people in mental health crisis. "Nationally there's been a shortage of mental health beds," she said. She told the inquiry that if no bed was available, a plan would be put in place for a patient to attend A&E if they needed immediate help. Cawston said if someone left A&E before a bed became available, staff would try to contact them and alert police if necessary. Asked about ward culture, she said staff falling asleep at work had been "a feature throughout her whole career", although it was less common now. She also accepted that risk assessments before patients went on leave had not always been carried out properly. Read full story Source: BBC News, 10 July 2026

An NHS consultant doctor has been struck off after it emerged he failed to disclose 14 convictions from Australia, including stalking and threatening to kill his victim. Dr Salah-ud-Din Taj had claimed that the offences were not "serious" enough to mention when he applied to work in the UK. Dr Taj, who qualified from the University of the Punjab in Pakistan in 1996, worked as a Medical Registrar in Australia between 2007 and 2017. During this period, he was convicted of 14 offences over four months, including stalking and threatening to kill, at the Magistrates Court of Victoria in Melbourne. He received a one-year community correction order, which included 150 hours of unpaid work and supervision. When applying for registration to work as a doctor in the UK, Dr Taj "dishonestly" ticked the 'no' box regarding previous convictions on his forms. In 2019, he lied again to North Cumbria University Hospitals NHS Trust to secure himself a job. He later claimed that he thought the stalking conviction “was not serious” and was therefore “filterable” and did not need to be declared. Dr Taj said that he did not declare the conviction because it “had not involved any physical element, did not touch upon his clinical practice and did not result in a custodial sentence”. His prior convictions were discovered by the General Medical Council (GMC) and an investigation was launched into the doctor. In the course of the investigation, it was also discovered that Dr Taj had been dishonest about practicing in Australia exclusively between 2007 and 2017, as he took breaks and also went to Pakistan. A panel from the Medical Practitioners Tribunal Service found that Dr Taj could not remain on the register after lying about his convictions. Read full story Source: The Independent, 9 July 2026

Patients with lung disease suffered harm or died after treatment was repeatedly delayed or replaced with alternatives which had no evidence base, an independent review has found. The Royal College of Physicians was commissioned by Epsom and St Helier University Hospitals Trust to review the care of 30 patients with interstitial lung disease (ILD) treated by Veronica Varney, a former consultant respiratory physician. It found the majority of patients came to moderate harm or worse, with failures including delayed referrals, keeping patients on clinical trials after they were halted and prescribing treatments with no evidence base for the condition. The 30 affected patients are a sample of 216 patients with ILD, which the trust previously found received poor care. Many of these patients have since died. The review graded 12 cases as causing “severe clinical harm” and three as resulting in death. The review found that Dr Varney “initiated non-evidence-based and off-label treatments for ILD”, including advising patients to avoid covid and flu vaccines and rapeseed oil, and prescribing medications not intended for ILD. It said treatment decisions “were not consistently supported by clinical guidelines and were not always clearly documented as having been discussed with the patient or colleagues”. Dr Varney was “reportedly instructed to cease non-evidence-based ILD treatments”, but the practice continued. “The lack of monitoring at this point was a missed opportunity to ensure compliance and patient safety,” the report said. Read full story (paywalled) Source: HSJ, 9 July 2026

Sonographers have been on the UK’s national Shortage Occupation List for more than 10 years. The government has repeatedly acknowledged that the NHS does not have enough of them, that recruitment is difficult, and that the workforce is essential to diagnostic pathways. Yet despite this longstanding national shortage, sonography remains one of the few clinical workforces in the NHS that is not recognised as a profession in its own right. This contradiction is more than a workforce anomaly. It is a governance gap with implications for patient safety, legal accountability, and the credibility of the UK’s diagnostic strategy, writes Kalpana Lakhani in this HSJ article.

The NHS 10-Year Health Plan promised transformative change, but one year on, implementation remains slow, uneven, and lacking transparency. So, what should we make of all this? Siva Anandaciva suggests two things in this HSJ article. First, delivering a national plan is hard enough, but harder still while you are merging or abolishing NHS England, Integrated Care Boards, Integrated Care Partnerships, and Healthwatches. As the government’s own impact assessment for the plan wisely notes: “Making simultaneous changes to multiple layers of the NHS hierarchy creates a risk that there is insufficient capacity to accelerate change.” Second, nearly one year after the plan was published, we have only the haziest of notions of what should have been delivered, when it should have been delivered, and who was meant to deliver it. Developing the health plan cost £3m and took eight months. A comprehensive progress report is the least we could ask for. Because although taxpayers know exactly what we spent on the 10YHP, we are still working out exactly what we bought.

A German palliative care doctor has been sentenced to life imprisonment for killing 15 of his patients. A court in Berlin found the 41-year-old man, named only as Johannes M. in line with German privacy rules, guilty of murdering 12 women and 3 men between September 2021 and July 2024. The authorities believe these killings could be just the tip of the iceberg. Prosecutors are currently investigating dozens of other incidents involving the doctor. His victims were between the ages of 25 and 94. The court heard how they were all critically ill, but that their deaths were not imminent. Prosecutors said that during home visits, the doctor administered a lethal combination of various medicines without his patients' consent. On several occasions, they said he set fires to cover his tracks. In July 2024, shortly before his arrest, prosecutors said the doctor killed two patients in a single day - a 75-year-old man at his home in central Berlin and, a few hours later, a 76-year-old woman in a neighbouring district. They said the doctor tried to set fire to the woman's house, but failed. For much of the trial, which has gone on for about a year, the doctor said nothing. But last month, he confessed to having "killed people," twelve of his severely ill patients. He told the court he had convinced himself that he was doing the right thing, sparing them "suffering and infirmity". Read full story Source: BBC News, 8 July 2026

An average of 80,000 people visited A&E every day last month for the first time ever in June, as record temperatures hit the UK. The NHS has said it is under just as much pressure as in winter and staff are facing an “onslaught of demand” amid heatwaves and the World Cup. Average daily A&E attendances reached 81,264 for the first time ever in June - setting a new daily attendance record. NHS national medical director Professor Frankie Swords said: “These figures show that summer is now putting the NHS under just as much pressure as winter, with staff facing an onslaught of demand – and we have to prepare for it in the same way. “What we’re seeing on the ground is really busy Mondays following weekends of football and sunshine, so please don’t delay coming forward for care when you need it, even if it’s in early hours on a weekend. “In the continuing warm weather, please take precautions like staying hydrated, and check in on loved ones or those who are vulnerable, and as always, please dial 999 in an emergency, and otherwise use 111.” Read full story Source: The Independent, 9 July 2026

Large acute trusts are shouldering unreasonable risk because their funding has been “top sliced” to pay for “well meaning” but unproven “neighbourhood health” schemes, a leading London CEO has told HSJ. Shane DeGaris, of Barts Health Trust, said the financial transition to realise the hospital-to-community “shift” was currently “not clear”, and much of the risk was with with hospital providers. Mr DeGaris said his £2.7bn organisation was “supportive” of neighbourhood health, and in “live discussions” on how responsibility for it can be divided up in North East London. But in an interview with HSJ, he warned his and other acutes were facing potential deficits, with the funding regime becoming “increasingly bad” for them. Mr DeGaris said his trust “fully supports” the shift of services from hospital to community, but added: “There’s going to be a huge chunk of work still going to be required to do in hospitals… “[We need to make sure] all the stranded costs aren’t there for the hospitals in a world where accountability now is all about individual trusts. Read full story (paywalled) Source: HSJ, 9 July 2026

This article argues that while colour-coded scrubs can help identify healthcare staff, relying on scrub colour alone is an unreliable way to distinguish roles during emergencies. Drawing on a patient safety incident, the author describes how clinical students wearing the same colour scrubs as licensed professionals created confusion during a cardiac arrest response, making it difficult to identify who was qualified and who still needed to attend. The article highlights that colour cues are vulnerable to errors caused by stress, poor lighting, visual overload and differences in colour perception. Instead, it recommends stronger, layered approaches to role identification, including clearly labelled staff badges, predefined emergency response roles, designated team leaders and structured communication techniques such as callouts and check-backs. Related reading on the hub: Patient safety starts with knowing who is in the room