Patient Safety Learning

A new report, jointly produced by charities Cysters and Endometriosis UK, sheds light on the biases and inequalities faced by endometriosis patients from ethnically diverse communities. The report reveals that patients from these communities are waiting more than 16% (1 year and 8 months) longer than the UK average waiting time for an endometriosis diagnosis time. The report draws on findings from more than 500 people from ethnically diverse communities living with endometriosis, as well as ten supplementary interviews. Findings: People from ethnically diverse communities wait, on average, 11 years for an endometriosis diagnosis in the UK. This is compared to the UK-wide average diagnosis time of 9 years and 4 months. Patients from ethnically diverse backgrounds wait more than twice as long (4 years) between seeing a gynaecologist and being diagnosed with endometriosis as the UK-wide average (1 year and 10 months). This is despite going to their GP sooner after first noticing symptoms, and waiting less time to see a gynaecologist. More than two thirds (68%) believed their ethnicity either played a role in their diagnosis, proved a barrier to diagnosis, or was the subject of assumptions made by healthcare practitioners. Just 11% believed healthcare providers are culturally sensitive.

Aarav died from the consequences of a cardiac arrest caused by severe bleeding following damage to an intercostal artery during a liver biopsy which went undiagnosed and untreated at the time of the procedure. His death was contributed to by poor planning before the procedure when there was no consideration of stopping antiplatelet medication, poor written and oral communication about the complication that occurred during the procedure all of which hampered treatment after his collapse. His death was contributed to by neglect.  MATTERS OF CONCERN Prophylactic antibiotics for severely immunocompromised patients: The inquest heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. The concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. The concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training. Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. The concern is that there is currently no way to obtain consent when a trainee will be doing the procedure. Individual patient risk factors: Aarav had a complex medical background and several risk factors for any procedure. The concern is that there is currently no mechanism to identify individual patient’s risk factors so that all clinicians involved in their care are aware. Learning from deaths: The initial M&M meeting after Aarav’s death was described as inadequate. The concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity. Electronic patient records: Evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details. The concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment.

Since 2013, Healthwatch has operated nationally and locally to gather the views of people using the health and care system in England. Its primary role has been to support improvements to services by reporting people’s experiences, which it has done by working with communities across England, collecting feedback on health and care services, and sharing this information with government bodies and local systems to inform policy and service development.  On 27 June 2025, the government announced plans to close Healthwatch England and the network of 153 local Healthwatch organisations. In line with recommendations from the Dash review of patient safety, the government plans to transfer the strategic functions of Healthwatch England to the Department of Health and Social Care (DHSC), and the statutory functions of local Healthwatch organisations to NHS integrated care boards (ICBs) on healthcare and local authorities for views on adult social care.  In light of these planned changes, this research from the King's Fund explores what can be learned from the Healthwatch model, including what has worked well, what the challenges have been and how this can inform the government’s planned changes to how patient and service user experiences are collected and used. The King’s Fund reviewed existing evidence, conducted interviews and carried out two workshops with local and national stakeholders. 

Are you looking to better understand healthcare improvement approaches but not sure where to begin? Do you struggle to find time to fit learning into your busy day? Explain THIS is a series of short, accessible microlearning resources to help people working in healthcare improvement understand key concepts and approaches. Whether you’re new to improvement work or looking to refresh your knowledge, the resources offer: clear definitions to help grasp key terms essential models and frameworks with examples of how they have been used practical questions to guide planning and decision-making links to further reading to support your learning. Topics available now include: Governance and leadership. Implementation science. Collaboration approaches. Spread, scale-up and scalability.

This leaflet produced by the Nursing and Midwifery Council (NMC) can help you decide what you could do if you think a midwife, nurse or nursing associate may have done something wrong. This leaflet explains how we can help if someone has concerns about the care provided by a midwife, nurse or nursing associate during pregnancy, birth or the postnatal period. It covers: what the NMC does and when concerns should be raised with us what happens when someone contacts the NMC where people can go for other types of support, including employers and other organisations that may be better placed to help.

Teams-Based Quality Review for Clinical Practice (TBQR) is an innovative training programme designed to equip healthcare professionals with the knowledge and practical skills to lead meaningful safety reviews and organisational learning. Developed in partnership with NHS Education Scotland and the c, the course introduces a structured, evidence-based approach to team learning in clinical practice, building on existing processes such as morbidity and mortality meetings and significant event reviews. Participants will learn how to apply contemporary safety science, including principles of Human Factors and Systems Thinking to analyse clinical work, identify system strengths and vulnerabilities, and translate insights into sustainable improvement. The TBQR course at the Royal College of Surgeons of Edinburgh is open to anyone with an interest in patient safety, governance and medical education, including clinicians, managers, educators and those involved in governance or safety review processes. It provides a unique opportunity to develop the capability to design, lead and implement modern team-based safety reviews, while connecting with a growing international network of professionals committed to advancing patient safety. Through interactive workshops, case discussions and practical frameworks, delegates will gain the confidence and tools needed to embed updated safety science and foster cultures of learning, psychological safety and continuous improvement within their organisations. Please do not hesitate to get in touch if you wish to learn more about this course or have any questions about registration. Contact: [email protected]

The Covid-19 Inquiry published its third report and recommendations following its investigation into ‘the impact of the Covid-19 pandemic on the healthcare systems of the United Kingdom’ on Thursday 19 March 2026. It examines the governmental and societal response to Covid-19 as well as dissecting the impact that the pandemic had on healthcare systems, patients and healthcare workers. Recommendations There are many lessons to be learned from the experiences of the UK’s healthcare systems during the Covid-19 pandemic and many areas for improvement. The Inquiry has made 10 recommendations and considers them all to be necessary to prevent healthcare systems being overwhelmed in the next pandemic: Recommendation 1: Ensure that decision-making on infection prevention and control is underpinned by clear structures and a cautious approach to transmission risk The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready to be convened at the outset of any future pandemic, to consider and draft infection prevention and control guidance for healthcare settings. This body must: have clear lines of responsibility and a clear, pre-defined role and remit during a pandemic have multidisciplinary membership, including experts in the science of viral transmission as well as those with clinical expertise ensure that its guidance accounts for the risk of all plausible routes of transmission until sufficient evidence emerges to rule out specific routes ensure that guidance clearly explains the underlying rationale for the precautions recommended. Separately, the Department of Health and Social Care, NHS National Services Scotland, Public Health Wales and the Public Health Agency (Northern Ireland) should review the national infection prevention and control manuals and any future guidance to ensure that the approach to identifying risk of transmission is not confined solely to specific procedures. Emphasis should be placed on a combination of risk factors, such as rates of transmissibility, environment, setting and procedure. Recommendation 2: Guidance for visiting restrictions The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should publish guidance for the implementation of visiting restrictions in hospitals in the event of a future pandemic. The guidance should identify the circumstances in which visiting restrictions should be introduced, escalated, decreased and removed alongside the measures and exemptions at each level. The guidance should be led by the following core principles: Measures applied should be the least restrictive possible, both in terms of severity and the length of time for which they apply. Restrictions should be decided upon and applied at the most local level possible. Unless restrictions are applied at a specified level, trusts and health boards should take decisions on the severity of restrictions based on local risk assessments. Communications with the public must clearly explain the measures in place and the reasons why restrictions apply. The guidance should be reviewed every three years in line with the Inquiry’s Module 1 Report (Recommendation 4) Recommendation 3: Better preparation for fit-testing The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review the availability of qualified fit testers and take steps to increase the number of fit testers accordingly. Availability should be reviewed every three years in line with the Inquiry’s Module 1 Report (Recommendation 4). The Health and Safety Executive and the Health and Safety Executive for Northern Ireland should update their guidance to employers to emphasise the need to ensure that sufficient fit-testing capacity is available. Recommendation 4: Improve data systems to identify individuals at high risk during a pandemic The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in a future pandemic. This should include action to improve health data systems and patient record-keeping by: improving patient data by enabling more granular diagnostic coding ensuring that care records are compatible across primary and secondary care enabling secure data-sharing and linkage across multiple health datasets and systems for identifying individuals at high risk. Recommendation 5: Prepare to scale up urgent and emergency care capacity The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for surge capacity in urgent and emergency care during a pandemic. Plans must ensure that there is sufficient workforce capacity and the ability to surge, including the number and type of staff required, recruitment and training provision. This should be completed as part of the whole-system civil emergency strategy recommended in the Inquiry’s Module 1 Report (Recommendation 4). Plans should be published and subject to review every three years. Recommendation 6: Prepare for and test the ability to scale up hospital capacity The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with trusts and health boards to ensure that pandemic plans include practical steps to rapidly scale up hospital capacity to treat acutely unwell patients. This should include critical care services that can deliver multiple levels and types of organ support. It should also cover necessary equipment, supplies, space and staff, including redeployment and training. All trusts and health boards must keep an easily accessible, up-to-date record of the information needed to implement these plans in the hospital sites they operate. This should include technical aspects of critical care expansion such as power, ventilation, oxygen and waste management systems. Plans for expanding capacity should be published, subject to review every three years and tested as part of the pandemic response exercises recommended in the Inquiry’s Module 1 Report (Recommendation 6). Recommendation 7: A framework to guide the allocation of intensive care resources in the extreme event of saturation The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of adult intensive care resources in the extreme event that they are saturated during a pandemic. That framework must: be informed by comprehensive engagement with the public and developed in conjunction with professionals across healthcare, law and ethics, as well as with regulators of healthcare professionals set out clearly established triggers for its use, based at least in part on a UK-wide system that measures critical care capacity strain and facilitates mutual aid (such as the CRITCON tool used in England) establish clinicians’ legal and professional duties in applying the framework, which should be clearly explained to clinicians through guidance be regularly reviewed with reference to contemporary patient data during a pandemic, and any future use of it must be evaluated and reported on publicly. A plan and timeline for completing this work should be published within six months of this Report. Application of the framework should be tested as part of the pandemic response exercises recommended in the Inquiry’s Module 1 Report (Recommendation 6). Recommendation 8: Systematically recording and publishing healthcare worker deaths The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers to develop nation-specific mechanisms to collect, analyse and publish data systematically on the deaths of healthcare workers in the event of a pandemic outbreak. The UK Statistics Authority should work with data providers to ensure that the data are comparable across the four nations of the UK. Recommendation 9: A standardised process for advance care planning across the UK The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for clinicians to ascertain and record their patients’ wishes and preferences for future care and treatment in order to inform individualised decision-making, including Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) notices. Recommendation 10: Psychological and emotional support for healthcare workers The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place plans to deliver effective support for healthcare workers at scale from the outset of a pandemic. Plans should cover the nature and level of support that will be provided during and after a pandemic. All four governments should develop a programme of peer support visits that can, from the outset of a pandemic, be targeted towards areas of acute hospitals under considerable strain. The purpose of the visits should be to support front-line staff, collect insights on the pressures that healthcare workers are facing and understand what further support they might need. See also: UK Covid-19 Inquiry Module 1: The resilience and preparedness of the United Kingdom Covid-19 Inquiry: Module 2, 2A, 2B, 2C Report – Core decision-making and political governance

A year into the Care Quality Commission’s (CQC) major turnaround programme, a difficult job just became even harder The unexpected departure of its highly regarded chair, Professor Sir Mike Richards, so soon after the loss of its CEO, will leave many concerned that the inspection body’s urgent need for a reset and recovery will be delayed even further. The next 12 months offer the CQC a precious window of opportunity to fundamentally change how it regulates services. But this causes us to confront a bigger question: what is health and care regulation actually for, and is the CQC up to the job? Regulation should play a vital role in the health and care system, and when done well, it adds real value for patients, providers and the wider public. Patients should know that the services they use are high quality, safe, and represent good value for money.