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Patient Safety Learning

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  1. Patient Safety Learning
    Two care workers have been charged with the ill-treatment of four people at a mental health unit which featured in an undercover BBC investigation.
    The Panorama programme, broadcast in 2022, revealed that patients were humiliated and bullied at the Edenfield Centre in Prestwich, Greater Manchester.
    Support worker Sheryl Price, 45, of Eldergreen Close in Bolton, faces 14 charges, while 42-year-old nurse Sara Coleman, of Mitford Street in Stretford, is accused of five.
    Both have been bailed and are due to appear at Manchester Magistrates' Court on 25 March.
    A undercover Panorama reporter filmed staff at the Edenfield Centre - one of the UK's biggest mental health hospitals - using restraint inappropriately and patients enduring long periods of seclusion in small, bare rooms.
    Staff swore at patients and on occasion were seen slapping or pinching them.
    Some workers were sacked after the BBC's findings were broadcast.
    The programme sparked an independent report, which found Greater Manchester Mental Health NHS Foundation Trust repeatedly missed opportunities to act on concerns and had a culture of "suppressing bad news".
    The trust was again rated "inadequate" by the Care Quality Commission earlier this year despite some improvements having been made.
    Criticisms included issues with patient safety and pressures on staff, with some still feeling unable to speak up about their concerns.
    Read full story
    Source: BBC News, 9 November 2025
  2. Patient Safety Learning
    A wide-ranging review into paracetamol use by pregnant women has found no convincing link between the common painkiller and the chances of children being diagnosed with autism and ADHD.
    Publication of the work was fast-tracked to provide prospective mothers and their doctors with reliable information after the Trump administration urged pregnant women to avoid paracetamol – also known as acetaminophen or Tylenol – claiming it was contributing to rising rates of autism.
    Speaking at the White House in September, the US president said women should talk to their doctor about limiting the use of the painkiller while pregnant and followed up with far stronger language, telling women to “fight like hell” not to take it.
    While rates of autism have risen in recent decades, many scientists believe the trend is driven by greater awareness, improvements in diagnosis and a substantial broadening of the criteria doctors use to describe the condition.
    In an umbrella review published in the British Medical Journal on Monday, researchers analysed previously published scientific reviews on whether paracetamol raised the likelihood of pregnant women having children who are diagnosed with autism or ADHD.
    They concluded the quality of the reviews ranged from “low to critically low”, while any apparent link between the painkiller and autism was probably explained by family genetics and other factors.
    Prof Shakila Thangaratinam, a consultant obstetrician and senior author on the review at the University of Liverpool, said: “Women should know that the existing evidence does not really support a link between paracetamol and autism and ADHD.
    “If pregnant women need to take paracetamol for fever or pain then we would say please do, particularly because high fever in pregnancy could be dangerous to the unborn baby.” Alternative painkillers such as ibuprofen are not recommended during pregnancy.
    Read full story
    Source: The Guardian, 10 November 2025
  3. Patient Safety Learning
    Just four months after a young woman died in a London mental health unit,, another patient tried to harm herself in startlingly similar circumstances, leaked documents seen by the BBC show.
    Alice Figueiredo, a patient at Goodmayes Hospital, which is run by North East London Mental Health Trust (NELFT), attempted to harm herself using plastic or bin bags on 18 occasions, mostly taking them from the same shared toilet. On the 19th occasion, in July 2015, she managed to take her own life.
    Just four months later, in November 2015, another young woman also on Hepworth ward attempted to harm herself using a bin bag. She survived.
    Mental health campaigners say it suggests a worrying failure to learn from tragedies.
    "It's shocking and distressing that this was still going on four months after Alice died," says Jane Figueiredo, Alice's mother. "The bin bags could and should definitely have been removed, but instead patients continued to be put at unnecessary risk."
    NELFT says all bin bags have been removed and "it is committed to learning from every incident and continuously improving" the care it provides.
    Read full story
    Source: BBC News, 10 November 2025
  4. Patient Safety Learning
    The new chief of the UK’s crisis-hit nursing watchdog has admitted it got things “completely wrong” following a series of revelations by The Independent exposing a “toxic” culture in which rogue nurses were free to work in the NHS.
    In his first national interview as head of the Nursing and Midwifery Council (NMC), Paul Rees apologised for a string of scandals which have dogged the watchdog and prompted a major overhaul of the beleaguered organisation.
    He admitted the regulator – which is responsible for overseeing nearly 800,000 nurses, midwives and nursing associates in the UK – had got its handling of sexual misconduct cases “completely wrong” when it refused to investigate nurses who had been accused of committing sexual assault outside of work.
    He also conceded the body should have suspended Lucy Letby when she was first arrested. The NMC failed to suspend the nurse until she was charged with a series of shocking crimes a year later, blaming a loophole in its guidance. Mr Rees has now admitted that was wrong, after this publication uncovered a secret report into failings over the convicted killer’s treatment.
    He told The Independent: “We have to be honest about things that have gone wrong. And things have gone wrong in the past.”
    Ten months into his role, Mr Rees insists the watchdog, the largest professional regulator in Europe, has undergone a major change of its leadership team. But he warned it could take years to turn around the organisation, which was found in an independent review to have a “dysfunctional” and “toxic” culture due to evidence of racism and sexism within its ranks.
    Read full story
    Source: The Independent, 9 November 2025
  5. Patient Safety Learning
    NHS staff on the frontline are being forced to plug gaps in services that should be filled by skilled managers and admin staff, according to a new report.
    Despite a widespread perception that the health service is beleaguered by a top-heavy structure, new research by the King’s Fund suggests that there are now a “near record low” number of NHS managers for each member of staff.
    According to its analysis of NHS hospital and community data, there are now 33 staff members for each manager, compared to 27 staff in 2010.
    “The narrative that there are too many managers does not survive contact with reality,” said Suzie Bailey, director of leadership and organisational development at the King’s Fund.
    Skilled clinical professionals are being forced to spend hours each week “chasing paperwork, managing rotas or navigating broke administrative systems”, she said.
    Read full story
    Source: The Independent, 10 November 2025
  6. Patient Safety Learning
    Social media misinformation is driving men to NHS clinics in search of testosterone therapy they don’t need, adding pressure to already stretched waiting lists, doctors have said.
    Testosterone replacement therapy (TRT) is a prescription-only treatment recommended under national guidelines for men with a clinically proven deficiency, confirmed by symptoms and repeated blood tests.
    But a wave of viral videos on TikTok and Instagram have begun marketing blood tests as a means of accessing testosterone as lifestyle supplement, advertising the hormone as a solution to problems such as low energy levels, poor concentration and reduced sex drive.
    Doctors warn taking testosterone unnecessarily can suppress the body’s natural hormone production, cause infertility, and increase the risk of blood clots, heart problems and mood disorders.
    The online demand for treatment is so great that medical professionals have now begun to see it mirrored in their clinics.
    Prof Channa Jayasena, of Imperial College London, who is chair of the Society for Endocrinology Andrology Network, said hospital specialists were seeing growing numbers of men who had had private blood tests, often promoted on social media, and been told incorrectly that they needed testosterone.
    “At the national meeting, we asked 300 endocrinologists across the UK; everyone is seeing patients from these clinics every week,” he said. “They are filling our clinics. We used to see people with adrenal problems and diabetes, and it’s really affecting NHS care. We are all asking how to deal with this.”
    Read full story
    Source: The Guardian, 8 November 2025
    Further reading on the hub:
    14 top picks: Men's health
  7. Patient Safety Learning
    A joint Channel 4 News and New Statesman investigation has revealed shocking allegations against Oxford University Hospitals NHS Foundation Trust, including that a baby declared stillborn was later found to be alive.
    The two news organisations have been investigating John Radcliffe Hospital – one of the UK’s most prestigious research hospitals – and its maternity and neonatal unit for several months.
    The investigation has heard from more than 20 families who say they have lost babies, had children born with severe disabilities, or suffered serious harm themselves, as a result of poor care at the Trust, with many women still searching for answers.
    Amongst the numerous harrowing cases disclosed to the news organisations includes the testimony from Emma Cox, who gave birth to twins aged 17.
    “At 24 weeks I went into spontaneous labour. They were born. I was told that one of them was stillborn and the other one was taken and resuscitated and taken to the neonatal unit. A short time later Lilly was brought back to me and they said the mortuary was unable to take her because she was actually alive”, said Ms Cox.
    Read full story
    Source: Channel 4 News, 5 November 2025
  8. Patient Safety Learning
    A palliative care nurse in Germany has been sentenced to life in prison after he was convicted of the murder of 10 patients and the attempted murder of 27 others.
    Prosecutors alleged that the man, who has not been publicly named, injected his mostly elderly patients with painkillers or sedatives in an effort to ease his workload during shifts overnight.
    The offences were committed between December 2023 and May 2024 in a hospital in Wuerselen, in western Germany.
    Investigators are reported to be looking into several other suspicious cases during his career.
    According to media outlet Agence France-Presse (AFP), the unnamed man had been employed at the hospital in Wuerselen since 2020, after completing training as a nursing professional in 2007.
    Prosecutors told a court in Aachen that he showed "irritation" and a lack of empathy to patients who required a higher level of care, and accused him of playing "master of life and death".
    The court was told that he injected patients with large doses of morphine and midazolam, a type of sedative, in an effort to reduce his workload during night shifts.
    When issuing the life sentence, the court said that the man's crimes carried a "particular severity of guilt" which should bar him from early release after 15 years.
    Read full story
    Source: BBC News, 6 November 2025
  9. Patient Safety Learning
    Valerie Kneale was chatting away, sitting upright in her hospital bed, when her family left her behind on the ward.
    Hours before, the 75-year-old grandmother had been admitted to Blackpool Victoria Hospital in Lancashire in November 2018 after suffering a stroke while eating her dinner.
    But she appeared to have made a remarkable recovery. Her husband and two children were assured by hospital staff that they could go home and she would be looked after overnight.
    The next morning, Mrs Kneale’s family returned to discover that she had slipped into a coma. She died three days later.
    The post-mortem examination revealed that she had been sexually assaulted while on the ward, where entry was controlled by key card, with such force that it had caused severe, fatal blood loss.
    Lancashire Constabulary immediately started a murder investigation but seven years on, the force has stopped searching for who was responsible for attacking Mrs Kneale.
    Her death – and the failure to find a culprit – is but one tragedy in a hospital that appears to be out of control.
    A weeks-long Telegraph investigation has uncovered a litany of failures at Blackpool Victoria:
    Eight other deaths on the stroke ward in 2018 are being investigated, “Corrupt” nurses were jailed for drugging patients to keep them compliant, Powerful medicines went missing, A heart surgeon was imprisoned for groping the breasts and bottoms of female colleagues, Doctors shared sexist jokes in WhatsApp groups called “cardiac sluts” and “work slags”. With no one held accountable for the deaths and a police investigation into corporate failings at the stroke unit still ongoing after two years, the families of several victims told The Telegraph that only a public inquiry could answer their questions.
    Read full story (paywalled)
    Source: The Telegraph, 6 November 2025
  10. Patient Safety Learning
    Patients across England are set to gain direct access to specialist care via the NHS App, as dozens of new pilot schemes aim to streamline healthcare and ease pressure on hospitals.
    This initiative, encompassing 45 pilots across 37 trusts, is projected by the government to free up 500,000 hospital appointments annually once fully implemented.
    Officials believe allowing patients to self-report vital health data, such as blood pressure and oxygen levels, through technology could significantly reduce strain on the health service, particularly ahead of winter.
    The schemes will primarily focus on five key specialisms: ear, nose, and throat (ENT), gastroenterology, respiratory medicine, urology, and cardiology.
    Patients will utilise the NHS App to complete necessary forms and questionnaires, negating the need for in-person hospital visits.
    This expansion of remote care coincides with a world-first NHS trial exploring remote support for motor neurone disease patients.
    Health Secretary Wes Streeting said: “Patients expect care fit for the 21st century and that’s what I’m determined to deliver.
    “This is a government that puts the NHS and patients first as our record investment in the service shows.
    “Using tech to bring care closer to home frees up hospital appointments for those who truly need them and makes life simpler for everyone.
    “That’s our mission: care that’s easier, faster, and always within reach."
    Read full story
    Source: The Independent, 7 November 2025
  11. Patient Safety Learning
    Cancer patients should have the legal right to be treated within two months, even if that means the NHS has to pay for them to be treated privately or abroad, according to international experts.
    Writing in the Lancet Oncology, they say cancer patients should have the legally enforceable entitlement to be treated within 62 days of an urgent referral by a GP.
    This would bring the UK in line with Denmark, where cancer patients already have a statutory right to timely treatment.
    International research shows that every four weeks of delay in cancer treatment increases the risk of death by up to 10%. But the NHS has not met its target for 85% of cancer patients to start treatment within 62 days since December 2015.
    he authors argue that without legal rights in the UK, the government’s forthcoming national cancer plan risks being a paper exercise that will fail to get the UK off the bottom of cancer survival league tables.
    “The concern is that the [cancer plan] will be a consensus plan to appease multiple stakeholders, rather than to provide radical, accountable, independent leadership,” the Lancet paper concludes.
    Statutory rights to timely treatment would cut waiting lists and improve survival rates, the experts argue. Eduardo Pisani, a co-author of the paper and chief executive of All.Can, a global nonprofit that aims to improve cancer care efficiency, said: “International evidence shows that strong cancer plans, supported by legal rights, ensure patients have guaranteed access to timely, high-quality care. This protection promotes early treatment, reduces inequalities and ultimately improves health outcomes.”
    Read full story
    Source: The Guardian, 6 November 2025
  12. Patient Safety Learning
    A national investigation into maternity services in Scotland is to be carried out, the BBC understands.
    Ministers have indicated that the review will happen when an expert health group assesses how best to conduct it.
    It comes after a BBC Disclosure investigation heard calls from families, NHS staff and experts for urgent action to improve maternity safety across the country.
    Parents featured in the documentary who lost their babies in Scottish hospitals had demanded an inquiry into maternity services.
    Following a damning report into maternity care at the Royal Infirmary of Edinburgh, one of the busiest maternity units in the UK, the Scottish government announced last week that it would set up an expert maternity and neonatal taskforce.
    Health Secretary Neil Gray, who revealed that he "nearly lost" his wife during pregnancy after "inaccurate assessments", said the taskforce would listen to "women's experiences of maternity services" and also "the voice of frontline midwives".
    Following pressure from bereaved parents, MSPs and health experts, ministers have since confirmed that the taskforce will consider the scope of a national review and examine whether to look into problems with culture alongside the design and delivery of services.
    The government confirmed that commitment after a Labour debate at Holyrood calling for a national investigation, with families featured in the Disclosure documentary attending parliament.
    Scottish Labour deputy leader Jackie Baillie said: "The heartbreaking truth is too many women and babies are being let down by dangerously overstretched maternity and neonatal services."
    Read full story
    Source: BBC News, 6 November 2025
  13. Patient Safety Learning
    The father of a baby girl who died five days after she was born in a Leeds hospital has said he wants an independent inquiry into maternity services to focus on culture as well as potential negligence.
    Freyja Green died in March 2019 after a traumatic birth at St James's University Hospital.
    Her father, Damon Green, who is part of a campaign group calling for action over failings in maternity services run by Leeds Teaching Hospitals NHS Trust, said his family had received poor bereavement care following Freyja's death.
    While an inquest found no medical negligence, the trust has apologised for the bereavement care Freyja's parents experienced, adding it was "deeply sorry for the tragic loss".
    In October, Health Secretary Wes Streeting confirmed there would be an independent inquiry into the trust's maternity units.
    Mr Green said he felt the trust was more concerned with protecting its reputation than with bereaved families, and suggested there was a "culture of arrogance".
    Read full story
    Source: BBC News, 6 November 2025
  14. Patient Safety Learning
    Specialist ADHD services for adults in England are stopping taking on new patients as they struggle to cope with demand, a BBC investigation has shown.
    The BBC has identified 15 local areas that have closed waiting lists and another 31 that have introduced tighter criteria, making it more difficult to access support.
    Reacting to our investigation, Prof Anita Thapar, chair of NHS England's ADHD taskforce, said the findings were "disturbing", adding there were "enormous risks" for patients.
    It comes as she publishes her report into the state of ADHD services on Thursday, which recommends an overhaul of the way people are supported.
    ADHD - attention deficit hyperactivity disorder - affects the way the brain works and can cause people to act impulsively and become easily distracted.
    The taskforce report said it was being under-diagnosed and under-treated and calls for more joint-working across health, education and the criminal justice system to identify people with ADHD.
    It said this would require staff to get training and for community NHS staff, such as GPs and pharmacists, to get more involved in supporting people with ADHD. Currently, specialist services take responsibility for this.
    Read full story
    Source: BBC News, 6 November 2025
  15. Patient Safety Learning
    A hospital trust has declared a critical incident following the launch of its new electronic patient record system.
    Nottingham University Hospitals Trust (NUH) went live with the Nervecentre EPR over the weekend but “technical issues” with the rollout have resulted in “prolonged periods of downtime”.
    In an email sent to staff and seen by HSJ, the trust said it declared a critical incident on Tuesday as it was experiencing a “prolonged period of sustained pressure” due to high demand and acuity, as well as challenges around staffing, flow and discharge.
    This was compounded by the issues with the new EPR, which had led to business continuity plans being enacted.
    The trust said: “We know how difficult the issues with [the] EPR are making an already challenging situation, and we are sorry for the impact it is having. Our teams are working tirelessly alongside our EPR provider, Nervecentre, to resolve performance issues as quickly as possible.”
    However, the trust added that it “will only return to Nervecentre when we have confidence in the ability of the EPR to handle demand”.
    Read full story (paywalled)
    Source: HSJ, 5 November 2025
    Related reading on the hub:
    NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn? Electronic patient record systems: Putting patient safety at the heart of implementation
  16. Patient Safety Learning
    Nottingham University Hospitals NHS Trust (NUH) has confirmed a critical incident is ongoing due to "sustained pressures" across the organisation.
    NUH, which runs both the Queen's Medical Centre and City Hospital, said its emergency department was especially under strain.
    The critical incident was declared just after 16:00 GMT on Tuesday after the trust said there were 24 ambulances waiting outside A&E and "large numbers" of people in the department.
    The trust, which is one of the busiest in the country, said there had been issues with the technical roll-out of a new electronic patient record system which had added to the ability to manage the current levels of pressure.
    Andrew Hall, chief operating officer at NUH, said: "Our staff are working tirelessly to care for patients, but the pressure on our services is causing very long waits and this is causing overcrowding in our emergency department.
    "We know how frustrating this will be to people waiting in the department. Our staff are working as hard as they possibly can to get to them as soon as possible."
    "Our aim is to prioritise patients with the highest level of need and ensure that we continue to manage emergency care."
    Read full story
    Source: BBC News, 4 November 2025
  17. Patient Safety Learning
    The “rapid national investigation” into maternity and neonatal services will no longer publish its interim findings this year, claiming its work has been delayed by this month’s resident doctors strike.
    The review – headed by former government minister Baroness Valerie Amos – was announced in June and originally intended to finish by the end of this year. This was subsequently revised to producing an interim report in December, followed by a final one in the spring.
    It was announced by health and social care secretary Wes Streeting in June after months of pressure from campaigners in various parts of England, many of whom wanted to see a public inquiry.
    A letter to families from Baroness Amos, sent yesterday and seen by HSJ, says: “I will now provide an update on the investigation in December. I plan to give my initial reflections on what I have heard so far; outline plans for the next phase of the investigation, which will include the expected timeframe for publishing my initial findings; and publish the methodology for the investigation, which you have provided helpful feedback on.”
    She concluded: “I understand that changes to the timings for the Call for Evidence and content of the December report will be frustrating for some of you. My priority remains ensuring that families’ voices are heard throughout the investigation.”
    One bereaved parent said: “It is worrying, both that the timescales are moving out and that the review aims to be finalised so soon after the call for evidence is released.”
    Read full story (paywalled)
    Source: HSJ, 5 November 2025
  18. Patient Safety Learning
    A council has won a High Court battle to vaccinate a baby against her mother's wishes.
    Islington Council faced a legal challenge by one of its residents after it arranged for her eight-month-old daughter to receive routine vaccinations while the child was in its care.
    The mother, known only as Ms S, had refused the vaccinations out of her belief there was a link between the jabs and autism – a claim science does not support.
    At the High Court, Mr Justice McDonald decided that not vaccinating the girl would leave her at risk of childhood disease "at a very young age when she remains vulnerable," and ruled in favour of the local authority.
    The baby, known only as P, has been under the north London council's guardianship since February due to concerns that her mother could not meet her or her older siblings' basic care needs.
    In July, the council proposed the infant stay with her mother at the family home while under its supervision, until it was decided whether or not she would permanently be taken out of her mother's care.
    During this time the mother refused to have her daughter vaccinated.
    After the council moved ahead with the appointment out of concern for the child's welfare, Ms S took the local authority to the High Court to try to stop it.
    Read full story
    Source: BBC News, 5 November 2025
  19. Patient Safety Learning
    Babies born to black mothers in England and Wales and those from the most deprived areas are significantly more likely to die while in neonatal units, according to analysis revealing the “deeply concerning” figures.
    The study, led by academics at the University of Liverpool, examined data on more than 700,000 babies admitted to an NHS neonatal unit across England and Wales between 2012 and 2022.
    Babies born to black mothers had the highest mortality rates for the majority of years in the study, with an 81% higher risk of dying before discharge compared with babies born to white mothers.
    The highest mortality rate for black babies stood at 29.7 deaths per 1,000 babies, with the highest rate for white babies at 16.9 deaths per 1,000 babies.
    For babies born to mothers living in the most deprived areas of England and Wales, the elevated risk stood at 63% compared with the least deprived babies.
    The highest mortality rate for babies born to the most deprived mothers was 25.9 deaths per 1,000 babies in 2022, compared with 12.8 deaths per 1,000 for their least deprived counterparts.
    Samira Saberian, a PhD student at the University of Liverpool and the lead author of the study, said the analysis showed that “socioeconomic and ethnic inequalities independently shape survival in neonatal units, and maternal and birth factors explain only over half of the socioeconomic and ethnic inequalities”.
    She added: “To reduce these inequalities, we need integrated approaches that strengthen clinical care while also tackling the wider conditions affecting families.
    “By improving services and addressing the root drivers of inequality, we can give the most vulnerable babies a better chance of survival.”
    Read full story
    Source: The Guardian, 4 November 2025
  20. Patient Safety Learning
    A coroner has warned a trust over communication failures, leadership and a “lack of professional curiosity” in relation to a patient’s death, which appear to echo previous cases at the provider.
    Hampshire and Isle of Wight Healthcare Foundation Trust was criticised by area coroner Nicholas Walker after the death of 34-year-old Abigail Jelley, who took her own life last year while suffering from post-natal depression.
    Mr Walker said he was concerned “structural issues with the leadership of [the trust]” could result in harm done to future patients.
    He referred to an internal investigation report that he said described a “lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation”.
    The coroner described how Ms Jelley, who began to struggle with her mental health after the birth of her second child in 2024, was seen by different mental health professionals “whose job it was to react to that crisis and attempt to assist her through it”.
    Ms Jelley had been living with her parents before she died, who could have provided valuable information, but they were not spoken to by medical professionals, the coroner said. 
    He noted: “It was accepted [by the trust] that there was a lack of professional curiosity shown by professionals both in Abigail’s case and generally.”
    It was also found that community mental health teams do not receive mandatory training on perinatal “red flags”, and despite requesting it longer than a year ago, the team had yet to receive it. 
    Read full story
    Source: HSJ, 5 November 2025
  21. Patient Safety Learning
    America may be on track to losing its longstanding measles “elimination status,” held by the United States since 2000.
    The status indicates that there has not been continuous spread of the infectious disease for more than a year – but vaccine hesitancy and other factors have sent infections rocketing to their highest levels in 25 years.
    There have been 1,648 cases and three deaths tied to the virus this year so far, according to Centers for Disease Control and Prevention data.
    And if recent cases, reported in South Carolina or Utah, are tied back to a deadly West Texas outbreak that started in January and health authorities can’t bring the areas under control before the new year, the country’s elimination status is at risk.
    In South Carolina, the outbreak fuelled by exposures at Spartanburg County elementary schools has grown to 37 cases, including many unvaccinated students. Utah has seen 64 cases largely around the Southwest, 61 of whom were unvaccinated.
    The measles-mumps-rubella vaccine is 97% effective against infection. That’s how the U.S. reached its elimination status initially.
    However, child vaccination rates have fallen across the U.S. since before the pandemic, with fewer than 92.5 percent of kindergarteners getting a measles shot for this 2024-2025 school year. Doctors say falling rates are tied to increasing vaccine hesitancy and the spread of misinformation about vaccine safety.
    Read full story
    Source: The Independent, 4 November 2025
  22. Patient Safety Learning
    A major trust has been accused of presiding over “serious and systemic failures in leadership” and rated inadequate in the well led domain by the Care Quality Commission. 
    Mid and South Essex Foundation Trust, which was previously rated “requires improvement” in 2022 for the leadership domain, said it accepted the regulator’s findings.   
    The CQC said: “Many described a culture where poor behaviours went unchallenged, and where financial pressures were perceived to take priority over quality and safety.
    “Staff across all three hospital sites told us they felt disconnected from senior leaders, undervalued, and unable to raise concerns without fear.”   
    However, the report, which followed an inspection in May, also said leaders had demonstrated “integrity and compassion” and “the scale of the challenge facing the trust required continued energy, enthusiasm, and tenacity”. 
    It added: “The assessment team noted signs of fatigue and pressure, which may impact leaders’ ability to lead effectively during a period of significant organisational change.” 
    Read full story (paywalled)
    Source: HSJ, 5 November 2025
  23. Patient Safety Learning
    At aged 50, Susie Martin has already undergone her fair share of health procedures. She has endured dozens of surgeries - once going through five procedures in a single year - and will need to have screening for the rest of her life.
    She believes it’s all because of a drug her mother was given by medics during pregnancy.
    Ms Martin is one of the hundreds of victims of a “silent scandal” involving the pregnancy drug diethylstilbestrol - a synthetic form of the female hormone oestrogen, commonly known as DES, which has been linked to cancer. Like many others, she says the drug, also known as DES, caused her to develop a lifelong gynaecological condition. She now lives in fear for her health, facing tests each year to ensure she hasn’t developed cancer.
    A campaign group of more than 300 people, including Ms Martin and her mother Jennifer Bradley, is calling on the government to launch a public inquiry to address what it describes as a national scandal.
    Clare Fletcher, partner at the Broudie Jackson Canter solicitors, which represents the group, said: “This is the silent scandal, with victims suffering in pain for decades with limited medical support and no government recognition for what they have been through.
    “It is one of the most devastating pharmaceutical failures in UK history and the people whose lives have been marred by it deserve answers.”
    Read full story
    Source: The Independent, 4 November 2025
  24. Patient Safety Learning
    Independent readers expressed frustration and disbelief over the government’s decision to restrict free Covid booster jabs to a smaller group of people, describing the move as “a national scandal”.
    Many shared stories of being denied the vaccine despite chronic or respiratory illnesses, saying the policy risks leaving vulnerable people like Ella Halpern-Matthews – who has caught Covid three times since losing eligibility – without adequate protection.
    Several said they had been forced to pay privately for the jab, effectively creating what they saw as a two-tier health system.
    One reader remarked that it felt “as if the NHS would rather pay the hospital bill than for a cheap jab”, while others highlighted the inconsistency of vaccinating care home residents but not staff, and the false economy of cutting the rollout.
    Some questioned why countries such as France and Germany continue to offer free or low-cost boosters to wider groups, while the UK “quietly withdrew” access.
    Overall, readers urged the government to review eligibility urgently – calling for clearer communication, fairer access, and stronger protection for those still at risk.
    Read full story
    Source: The Independent, 3 November 2025
  25. Patient Safety Learning
    Women must be given clearer warnings on the potentially fatal dangers of giving birth at home and should only be aided by experienced midwives, experts have said.
    Maternity services worldwide are dealing with an increase in the number of women with more complex pregnancies. Many are choosing to have their baby in a familiar environment, in the comfort and privacy of their own home. Some choose a home birth because having their first baby in hospital was “deeply traumatic” and they are reluctant to repeat the experience.
    But access to safe, reliable and unrestricted home birth services is patchy, and varies enormously depending on where you live, experts say. Healthcare services in lots of countries struggle to offer home birth services because of staffing shortages, inconsistent training or local policy limitations. Some have dedicated home birth teams, while others rely on overstretched community staff.
    The Guardian has spoken to leading doctors, academics and pregnancy experts about home births after a coroner’s court in Rochdale, England, ruled that a mother and daughter died following a home birth owing to “a gross failure to provide basic medical care”.
    Jennifer Cahill, 34, died at North Manchester general hospital hours after suffering a haemorrhage while giving birth at home in Prestwich on 3 June 2024. Her baby, Agnes Lily, was delivered not breathing, with the umbilical cord wrapped around her neck. She died at the same hospital as her mother a few days later.
    In England and Wales, about one in 50 births take place at home. However, they are recommended only for low-risk pregnancies. Cahill’s pregnancy was considered high-risk because she had suffered a postpartum haemorrhage after giving birth to her first child in 2021.
    Because of this, she was advised to have her second baby in hospital. But her husband, Rob, told the court the dangers of a home birth had not been fully explained. Phrases such as “out of guidance” were favoured, rather than “against medical advice”, and the risk of death was not explicitly raised, the inquest was told.
    “This is an unbearably sad case of two avoidable deaths,” said Kim Thomas, chief executive of the Birth Trauma Association, one of the first charities in the world to support women and families who have experienced traumatic births. “We often hear from women who, having had a deeply traumatic first birth in hospital, are reluctant to give birth in hospital again. Some choose not to have another baby, while others opt for home birth.
    “Unfortunately, for women like Jennifer Cahill, who had experienced numerous complications in her previous birth, a home birth can be particularly risky. Several things seem to have gone wrong in this case. It seems staff were reluctant to spell out the risks to Mrs Cahill, so she was not able to make a fully informed decision.”
    Read full story
    Source: The Guardian, 4 November 2025

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