Patient Safety Learning

Staff could face the sack or even time in prison if they access patient records without a legitimate reason, Sir Jim Mackey has warned. In a letter to hospital and regional leaders today, the NHS England chief executive called on boards to put a “renewed focus” on educating staff and implementing a “tough approach” in response to staff who “breach patient trust in this way”. HSJ revealed in June that multiple hospital staff had viewed medical records of Southport attack survivors without clinical reason in 2024 – resulting in allegations of a “cover up” and with no clear firm disciplinary action having been taken. Also in June, Nottingham University Hospitals announced it was sacking 11 staff for snooping on records after three people were killed in a stabbing in 2023. HSJ has revealed thousands of other similar concerns have been reported nationally, and that Cambridge University Hospitals has recently sacked staff. Sir Jim’s letter said: “There can be no place in the NHS for those who misuse patient information. Patient trust in our handling of their most sensitive data cannot be taken for granted and it is therefore critical that we both educate staff and take a hard line when their access to records falls below the standards we expect. “Anyone considering accessing records for personal reasons or out of curiosity should be in no doubt they could be putting their career at risk, and may face disciplinary action, dismissal, referral to the regulator or even time in prison.” NHSE has also published staff guidance and launched a campaign to remind them “of the law and the potential impact” of snooping. The headline messaging warns: “Don’t let curiosity kill your career.” Read full story (paywalled) Source: HSJ, 8 July 2026

Accessing patient records out of curiosity or for personal reasons is illegal. It causes real harm to patients and could end your career. Everyone working in health and care has a professional and legal responsibility to protect people’s confidential information. This includes accessing patient records only where there is a clear and legitimate reason and doing so in a way that respects patients’ dignity and trust.  Accessing records for any reason other than work purposes is both unethical and illegal. If you intentionally access people’s health and care records without an appropriate and approved work reason, you may be committing a criminal offence under the Data Protection Act 2018 and Computer Misuse Act 1990. It is also a serious breach of your employment contract and could result in disciplinary action, including dismissal. It could also result in a referral to your professional regulator and could end your career.  NHS England has published Stopping unlawful access to records guidance for patients and service users.

The NHS staff standards set national minimum employment requirements to improve staff experience, outlining employer actions and what staff can expect.

Almost half of patients who travelled abroad for cut-price cosmetic surgery returned home with serious complications such as splitting wounds, tissue death and sepsis, a new study has revealed. The medical tourism industry is estimated to be worth more than £20 billion, with surgery packages abroad often marketed at prices up to 80% lower than procedures in the UK. But if there are complications following the surgery patients can face difficulty accessing follow up support and plastic surgeons in the UK have warned “a cheaper operation can end up becoming a very expensive complication.” A study from the British Association of Aesthetic Plastic Surgeons (BAAPS) analysed almost 200 cases of patients treated in the UK after undergoing cosmetic procedures overseas. Nearly three in four patients required medical procedures or surgery after returning home, while almost half needed an operation under general anaesthetic to correct complications. The most common problems included severe infections, wounds splitting open, tissue death, nipple loss and fluid collections requiring repeated treatment. Tragically, one patient died from a pulmonary embolism. However, the NHS is footing the bill, which between September 2022 and 2024 is estimated to have cost about £1.8 million - approximately £5883 to £9328 per patient. Read full story Source: The Independent, 7 July 2026

Thousands of women could be spared having a painful intrusive exam for suspected cancer thanks to a new AI-powered blood test being trialled by the NHS. Around 90,000 postmenopausal women a year in England are referred by their GP to be investigated for possible womb cancer because they are bleeding a lot. Around 10,000 women a year in England are diagnosed with the disease – which is also known as uterine or endometrial cancer – and 2,700 die from it. However, the PinPoint blood test could save one in five of those women – 18,000 a year – from needing to undergo a diagnostic procedure called a transvaginal ultrasound scan, which measures the thickness of the lining of their womb, and many find uncomfortable or painful. Avoiding having that test unnecessarily has become a realistic prospect because, although 20% of women referred turn out not to have the disease, under the current NHS system of diagnosing cancers of the reproductive system, all have a pelvic examination involving an ultrasound scan. If doctors still suspect cancer, women potentially then have a tissue sample taken during a biopsy and a further examination called a hysteroscopy, which can often be painful. Prof Sean Duffy, the firm’s chief medical officer – an ex-NHS England national clinical director for cancer – said the test’s 99% accuracy for womb cancer “is remarkable by any clinical standards”. “But equally, its value lies in safely ruling out very low-risk women. This has the potential to spare thousands of patients from painful invasive procedures they do not need.” Read full story Source: The Guardian, 8 July 2026

Board members will be held accountable for tackling workplace racism via personal objectives that must be made public under new national standards. The government’s NHS staff standards guidance, published this week, says organisations must “ensure every board member (including non-executive directors) has a published… objective on tackling racism”. They must appoint either their chief executive or chief operating officer as the senior responsible officer for tackling racism, and they will be “held to account against relevant workforce data [with] strong and clear consequences for poor performance”. “Tackling racism” is one of six staff standards set by the Department of Health and Social Care, as proposed in last year’s 10-Year Health Plan. The guidance said: “The 2025 NHS Staff Survey showed that instances of staff experiencing discrimination at work from patients, their families and the general public, managers or other colleagues, had increased again and are higher among ethnic minority staff compared to white staff. “Given these inequalities, this standard sets out the minimum national expectations for how all NHS organisations must prioritise, prevent, respond to and learn from incidents of racism in the workplace.” Read full story (paywalled) Source: HSJ, 8 July 2026

Mental health is at risk of being “left behind” by the first online NHS hospital, a top mental health chief executive has said. Ify Okocha, CEO of Oxleas Foundation Trust told his board last week that he had personally challenged NHS Online’s new chair over the exclusion of mental health from the service’s initial plans. He said: “I feel strongly about it. This is often what happens – mental health is left behind, and then we’re told ‘we don’t quite know how to help you’. I’m keen for us to be a part of that.” The NHS “online hospital” will offer remote specialist treatment to patients referred by their GP. It is scheduled to see its first patients in 2027. Last month, one of NHS Online’s non-executive directors pledged that safeguards would be put in place to prevent the organisation from “draining the resources” of the wider NHS workforce. The trust is currently recruiting for its chief digital and information officer. In January, NHS England announced nine areas which would be the focus of the new hospital, including women’s health issues, prostate problems, and ophthalmology conditions. Dr Okocha said he was “struck by” the emphasis being placed on services like ophthalmology “but no mention of mental health”. He said he had raised this issue with those overseeing the hospital launch and was told, in essence, that “the service needed to start somewhere”. Read full story (paywalled) Source: HSJ, 7 July 2026

The National Audit of Dementia (NAD) has published a report on the Service Mapping Exercise carried out across Memory Assessment Services in England and Wales, plus Jersey, in 2025. The report highlighted continuing demand for services, increase in waiting times, and wide variation in service staffing, specific diagnoses, and post diagnostic provision. Analysis of figures provided by services found approximately 2 referrals for every 1000 people in the catchment population. The median waiting time from referral to diagnosis has increased by 5 days to 137 days since the 2023 spotlight audit, despite low staff vacancies reported. There was great variation in staffing numbers and roles, and in services provision, with 23% of services not providing Cognitive Stimulation Therapy post-diagnosis. There continues to be wide variation in diagnoses at a service level, compounded by many services being unable to return data on diagnoses. Services reported low clinical vacancy rates overall. Over half reported joint working with neurology and geriatric medicine to enhance the diagnostic process.

Earlier this year, Clare Collins from Northumbria Healthcare NHS Foundation Trust gave a presentation at the Patient Safety Management Network (PSMN) meeting on how their Trust has aimed to improve patient safety though a project to remove caffeinated drinks. In this blog, Clare shares their journey and what they have learned about implementation, engagement, organisational readiness and sustainability. 

If the NHS focused on removing ‘failure activity’, it could transform its productivity One common theme in discussions about NHS productivity is a pervasive pessimism about the impossibility of big improvements. Some, such as NHS Alliance chief executive officer Sir Ciaran Devane, believe the NHS would be lucky to eke out marginal improvements in the rate of productivity growth, and even that might depend on significant additional investment. That pessimism is misplaced. There are huge opportunities to drive big leaps in productivity. To understand why this is the case, we need to consider the misleadingly named concept of Failure Demand, writes Steve Black in this HSJ article.

This study looked at the role of human factors on surgical outcomes, with a series of 243 arterial switch operations performed by 21 surgeons taken as a model.

This white paper from the Beryl Institute examines one of healthcare’s most persistent challenges: waiting. Grounded in insights from their Community Council and healthcare leaders from around the world, this report reveals the innovative ways organisations are addressing the experience of waiting. The findings suggest that organisations making the greatest progress are those reframing wait times through two interconnected lenses: An operational lens: Improving operational flow and reducing unnecessary delays. A human lens: Improving the human experience of waiting itself. Packed with 48 strategies shared by over 30 global leaders, learn how organizations are working to reduce unnecessary delays while also improving how the wait is experienced by patients and families through communication, transparency, empathy, and coordinated care delivery.

Health officials are urgently calling on approximately one million families to ensure their children receive vital vaccinations against potentially deadly childhood diseases. The NHS has initiated a catch-up campaign targeting parents of children aged two to 11 who have missed their measles jabs. This push comes after two children in England tragically died from measles this year, amidst a significant rise in cases. The UK Health Security Agency (UKHSA) reports 801 measles cases already this year, compared with 959 cases in 2025. The MMR/V vaccine provides crucial protection against measles, mumps, rubella, and chickenpox. General practitioners will be contacting parents of children under six to arrange these essential immunisations. Those with children aged six to 11 will be contacted via the NHS App, text, email or letter. Read full story Source: The Independent, 7 July 2026

A trust has been slow to provide records to an inquiry examining more than 2,000 deaths, because it underestimated the resources needed, its former CEO has admitted. Paul Scott, who left Essex Partnership University Foundation Trust last month, said the trust “underestimated at the outset the scale and complexity of what would be required of it” as the main NHS trust respondent to the Lampard Inquiry. Baroness Kate Lampard is investigating more than 2,000 mental health deaths in Essex between 2000 and 2023, with her inquiry due to report in 2028. In a statement read to the inquiry on Monday afternoon, Mr Scott said: “That underestimation was not in bad faith, but rather an error of planning and resourcing in not appreciating the wide focus which would be put on the delivery of services by it and predecessor trusts. “This had real consequences: it generated delay, eroded the inquiry’s confidence, and [in some cases] directly affected bereaved families.” The problems included a failure to quickly forward 30 “next of kin” letters provided by the inquiry in February. EPUT said it was trying to validate families’ addresses, but has apologised for the unacceptable delay. Read full story (paywalled) Source: HSJ, 6 July 2026

NHS England took action at a maternity scandal trust over “immediate risks” to women and babies, HSJ can reveal. Leeds Teaching Hospitals was placed in “enhanced support” because of “quality and safety” concerns in its antenatal and newborn screening services last year, according to a letter released following a freedom of information request. The programme includes tests for infectious diseases and some genetic disorders during pregnancy, as well as checks for hearing and some conditions after birth. Senior midwife Donna Ockenden, who earlier this month found hundreds of mothers and babies had suffered avoidable harm in Nottingham, is set to begin a similar exercise in Leeds in the coming months. An independent review into maternity services at the trust was announced in October, amid concerns that its mortality rates were an outlier. Now HSJ has learned NHSE’s screening quality assurance service wrote to the provider in September last year to warn of “immediate risks” to women and babies. This included late or missed interventions and wrongful birth claims, in which disabilities or health conditions that should be detected in pregnancy are not picked up. NHSE said it was not clear the trust had enough staff to safely deliver the service, or that all eligible women and babies were tested, or that there were “timely processes to put things right… when things go wrong in the screening pathway”. Read full story (paywalled) Source: HSJ, 7 July 2026

Dying patients and their loved ones are being "let down" by inadequate communication, a failing that is "adding to their grief," an ombudsman has warned. The Parliamentary and Health Service Ombudsman (PHSO) issued a stark warning, emphasising that such breakdowns can not only impact a patient's immediate care but also lead to "severe consequences" for their families, exacerbating an already difficult time. A new PHSO report highlighted a particularly distressing case where one man, referred to as Mr O, discovered he was dying "by accident". An NHS trust had failed to inform him that his bowel cancer, which had spread to his liver, was terminal. The hospital, according to the PHSO, "failed to clearly and promptly inform" Mr O about the disease's spread and its fatal nature. Instead, he only learned of his terminal diagnosis when his GP "unintentionally disclosed it". The PHSO said this delay “denied Mr O additional time to prepare for the end of his life”. The man’s wife told the PHSO: “What stays with me most is how alone and powerless we felt. “We weren’t kept informed, we didn’t understand what was happening, and we lost precious time that we can never get back." The report also highlights cases of families not being informed and “left unprepared”. The authors add: “It meant families missed the opportunity to spend meaningful time with their loved one in their final days.” Meanwhile, families also described feeling dismissed or not properly listened to. One family member of a dying person told the PHSO: “There were comments around the fact that I was a nuisance… It was obvious anyway, that I was not welcome.” Read full story Source: The Independent, 7 July 2026

Good end of life care depends on good communication. When patients and families receive clear, honest and timely information, they are better able to face what lies ahead. When communication breaks down, the consequences can last a lifetime. Since 2020, the Parliamentary and Health Service Ombudsman (PHSO) have investigated complaints about palliative and end of life care services across England. They found that communication is the most common failing - patients not told their diagnosis, families kept in the dark, and vital information lost when people move between services. This PHSO report draw on the experiences of families and clinicians to set out where communication most often falls short and what needs to change. 

Two tests that can dramatically speed up diagnosis of endometriosis are to be made available on the NHS in England and Wales, in a move hailed as a “gamechanger” for millions of women. One in 10 women of reproductive age are affected by the condition, where tissue similar to that found in the womb lining grows elsewhere, such as the ovaries and fallopian tubes. Symptoms include painful periods, painful bowel movements, pain when urinating and pain during or after sex. Current tests include ultrasound scans, MRI or a laparoscopy – where a camera is inserted through a tiny cut in the stomach. But despite the devastating effect it can have on a woman’s physical and mental health, and the large numbers affected, getting a diagnosis can take years. Now the National Institute for Health and Care Excellence has given the green light to two tests, EndoSure and Endotest. It says they will help rapidly reduce the time it takes for women to be told whether they have the condition. One provides results in just 45 minutes. Dr Anastasia Chalkidou, Nice’s healthtech programme director, said: “A diagnosis of endometriosis can for some women take the best part of a decade, with the UK average standing at nine years and four months, and rising to 11 years for those from ethnically diverse communities.” Delays meant chronic pain, affecting daily life, relationships and work, she said. “These technologies have the potential to change that by giving primary care professionals better non-invasive tools to identify endometriosis earlier, allowing earlier and better treatment. “Our draft guidance reflects our commitment to getting promising innovations to patients quickly, while making sure the evidence to support their wider use is built in a rigorous way.” Read full story Source: The Guardian, 7 July 2026

The first complaints about the alleged inappropriate use of AI by clinicians have been received by professional regulators, HSJ can reveal. The General Medical Council received eight complaints against the same number of individual doctors in 2025. It received a further six complaints concerning five individual doctors in the first half of 2026. Two of the 2025 complaints progressed to investigation, with one still ongoing and one closed. The other six complaints were closed at triage. The Nursing and Midwifery Council saw its first four referrals in 2025 and has received one to date in 2026. All the complaints involve different registrants. One of the referrals has progressed to a full investigation. In response to this new class of complaint, The GMC has published guidance which states: “Doctors, physician associates, and anaesthesia associates are responsible for the decisions they take when using new technologies like AI, and the principles in our professional standards continue to apply. “For example, it’s important to discuss the use of innovative technologies with patients, what other options may be available and any uncertainties and limitations, so they can make informed decisions. This is in line with the principles set out in good medical practice and our guidance on decision making and consent.” Organisations, in contrast, would be responsible if, for example, AI was used to share data inappropriately via electronic patients records. However, there remain considerable grey areas in what is a fast-developing field and Alastair Denniston’s review on AI regulation commissioned by government is considering this and is due to report this summer. Read full story (paywalled) Source: HSJ, 6 July 2026

Francine Gilmore, a patient with vestibular migraine, has written a report in a personal capacity* examining a patient safety gap where migraine prescribing overlaps with mental health risk. Drawing on Freedom of Information responses from 26 organisations and related evidence, the report identifies fragmented safeguards, unclear ownership and potential barriers to suitable treatment for clinically complex patients. In this blog, Francine shares her experience, the findings from her report and the actions she would like to see taken. The findings point to a clear need for change: migraine pathways must make mental health risk visible, owned in governance, recorded in clinical systems and reviewed for patient-safety learning. *The full report can be downloaded from the attachment at the end of the page.

During the last 25 years public policy in the UK has aimed to replace ‘club' cultures and their supposedly suspect reliance on trust between professionals and public with a new public culture based on accountability and ‘transparency'. These transformations have changed both clinical practice and public health policy in deep ways. Are the new conceptions of accountability adequate? Are obligations to be ‘transparent' any more than requirements to disclose information which overlook the need for genuine communication? Can demands for ever fuller informed consent improve accountability to individual patients and research subjects? Could we devise more intelligent conceptions of accountability that support more intelligent placing and refusal of trust? What might intelligent conceptions of accountability suggest about proper clinical practice, public health medicine and professional responsibilities?

Pharmacies are “bracing themselves” for an influx of patients seeking weight loss drugs as the Wegovy pill becomes available. The Wegovy tablet, manufactured by Novo Nordisk, became the first GLP-1 pill for weight loss to be approved by the UK’s medicines regulator last month. The starting dose is 1.5mg, gradually increasing to 4mg, 9mg and 25mg, with patients required to remain on each dose level for at least a month before progressing. From Monday, the initial 1.5mg and 4mg doses will be accessible to eligible patients through weight management programmes in select pharmacies. A recent survey conducted by the National Pharmacy Association (NPA) among 310 pharmacies revealed that 76 per cent expect to start a significant number of new eligible patients on the pill in the coming months. Olivier Picard, chairman of the NPA, said: “This is a significant day and pharmacies are bracing themselves for a surge in demand for this new form of weight loss treatment. This is particularly significant for patients who cannot or do not want to take an injectable medicine. “The NHS rollout remains extremely slow and community pharmacy is ready to support a wider rollout, which will help eligible patients access treatment safely and help mitigate the impact of obesity on the NHS.” Read full story Source: The Independent, 6 July 2026