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Patient Safety Learning

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  1. Patient Safety Learning
    “Racism and marginalisation” at Nottingham University Hospitals Trust meant families “felt pushed out” and resulted in “tragic outcomes”, according to the chair of the inquiry into its maternity services. 
    Senior midwife Donna Ockenden told HSJ’s Patient Safety Congress that talking to the hospitals’ “wider community” found “significant evidence of racism, marginalisation… ignoring, turning the backs on” people.
    “A whole community felt pushed out in the cold,” she said, and families had been confronting a “brick wall” when dealing with the maternity unit.
    They met an attitude from staff that “you are not coming in here, we are not listening to you, you can’t be in labour, we know what we are doing, and you don’t,” Ms Ockenden said. “There were a number of really tragic outcomes, with babies being born in the wrong place without the correct equipment.”
    Some 2,460 families’ cases are now formally included in the review, and there were a further 520 which could be learned from, she said. There are 850 current and former staff engaged, and Ms Ockenden said she was working closely with current trust leadership. She said several senior doctors had told her team they had raised safety issues at earlier stages.
    Read full story (paywalled)
    Source: HSJ, 22 September 2025
  2. Patient Safety Learning
    Ministers should overhaul the NHS spending watchdog to enable millions more people to be put on weight-loss jabs, Tony Blair’s think tank has said.
    Experts are calling for the National Institute for Health and Care Excellence (Nice), which decides which drugs the NHS should buy, to start factoring in the wider economic benefits of medication rather than just their health effect.
    The Tony Blair Institute for Global Change (TBI) has calculated that giving weight-loss jabs such as Mounjaro and Wegovy to 15 million eligible overweight adults would save the economy £52 billion in the long term. By cutting rates of illnesses such as heart disease, people would stay in work for longer, saving billions of pounds in benefit payments and increasing tax revenues.
    There are 15 million obese adults in the UK who could benefit from weight-loss jabs but the NHS is embarking on a rollout of Mounjaro, offering it to just 220,000 people over three years. The NHS has said it cannot afford a mass introduction.
    Dr Charlotte Refsum, the director of health policy at TBI, said Nice should consider “the wider economic benefit of medications because a healthy working-age population drives economic growth”. She added: “Prevention should be part of the Treasury’s growth agenda and Nice’s remit should be expanded to consider the macroeconomic benefits of medicines, including anti-obesity drugs.”
    Read full story (paywalled)
    Source: The Times, 19 September 2025
  3. Patient Safety Learning
    Two ambulance workers in the South West have been arrested as part of a major investigation into six deaths, a trust and police have confirmed.
    Wiltshire police today said a man in his 30s was arrested in June 2024 on suspicion of six counts of gross negligence manslaughter and four counts of ill-treatment or wilful neglect by a care worker, while a 59-year-old woman was arrested in March this year on suspicion of gross negligence manslaughter.
    Both individuals, who have since been released on conditional bail, were employees of South West Ambulance Service Foundation Trust in 2023 when Wiltshire police began its investigation following an initial report.
    SWASFT confirmed that both individuals were suspended “as soon as the trust became aware of any concerns” and that one of the two individuals “is no longer employed by the trust”.
    Police said the arrests relate to an investigation into “several adult deaths in and around Wiltshire”.
    SWASFT said it wanted to “reassure people that this is an isolated situation and there is no on-going risk to patients”.
    Read full story (paywalled)
    Source: HSJ, 19 September 2025
  4. Patient Safety Learning
    A chief executive has blamed his trust’s electronic patient record for the collapse of its diagnostic performance.
    Professor Clive Kay told his board at King’s College Hospital Foundation Trust that the implementation of Epic in October 2023 had contributed to the organisation dropping to the bottom tenth of national rankings for diagnostic waiting times.
    At last week’s public meeting, Professor Kay said the trust had fallen from being ranked 11th-best nationally for diagnostic waits to 11th from the bottom.
    “As good as Epic is, the radiology elements of Epic were really very challenging for colleagues,” he told his board.
    Electronic patient record systems from USA-based Epic have a reputation for having a lot of functionality, but being particularly expensive.    
    While the rollout did not affect the range of diagnostic tests the trust was able to carry out, it caused significant disruption, including data migration discrepancies that affected the accuracy and availability of migrated records, as well as a number of manual workarounds required.
    While no patient harm has been identified, a review is underway which includes a structured harm assessment.
    Read full story (paywalled)
    Source: HSJ, 19 September 2025
    Related reading on the hub:
    Electronic patient record systems: Putting patient safety at the heart of implementation
     
  5. Patient Safety Learning
    England’s social care system is at “breaking point”, with the number of unpaid carers increasing by 70% over the past two decades, according to a report.
    Research for the Institute of Public Policy Research (IPPR) found rising demand, shrinking supply, and a growing reliance on unpaid carers.
    Analysis for the report, conducted by the Joseph Rowntree Foundation (JRF), revealed the number of people providing 35 hours or more a week of care increased from 1.1 million in 2003/04 to 1.9 million in 2023/24.
    The report says unpaid care – whether by parents, spouses or adult children, and most frequently women – is relied on too heavily to fill in the gaps of the “inadequate and expensive” adult social care system.
    Abby Jitendra, author of the IPPR discussion paper and principal policy adviser at JRF, said: “Millions of us are carers or need care, and this number will surge in the future, but families are being left to navigate a neglected system – paying sky-high costs, sacrificing work to care, and too often going without the support they need.
    “We need to build a care system that works like a public service: universal, affordable, reliable and fair. That means bold reform now – not another decade of drift.”
    Read full story
    Source: The Independent, 19 September 2025
  6. Patient Safety Learning
    A powerful vaccines committee for the US Centers for Disease Control and Prevention (CDC) voted on Thursday to change US vaccine policy and start recommending that children receive multiple vaccines to protect against measles, mumps, rubella and chickenpox, instead of a single vaccine that can protect against all four diseases.
    The new recommendations from the panel, the advisory committee on immunization practices (ACIP), arrived just a day after top former CDC officials said Robert F Kennedy Jr was a threat to US children’s ability to receive vaccines on schedule. The committee’s work typically determines which vaccines are provided free of charge through the US government, shapes state and local laws around vaccine requirements, and influences which vaccines health insurers tend to cover.
    Previously, the panel had recommended that children receive the MMRV vaccine, which offers combined protections against measles, mumps, rubella and chickenpox, which is also known as varicella. Parents could still choose to immunize their children through multiple vaccines. Under the committee’s new recommendations, children should receive multiple vaccines: one vaccine that guards against measles, mumps and rubella, which is known as the MMR vaccine, and a separate vaccine that immunizes them against chickenpox.
    However, the committee also voted not to change the vaccines that are provided free to low-income children through a US government program called Vaccines for Children. That discrepancy sparked outcry and confusion among several members of the committee, who at times seemed unsure about the meaning of their votes.
    The panel has already drawn extensive criticism, as Kennedy, who leads the Department of Health and Human Services and has repeatedly questioned the safety of vaccines, fired its previous members and replaced them with his own handpicked advisers. Several of his advisers have little to no documented expertise with vaccines or have criticised them.
    Read full story
    Source: The Guardian, 18 September 2025
  7. Patient Safety Learning
    A woman has said she is living in constant pain and is unable to breathe through her nose after having dental work in Turkey.
    Leanne Abeyance, 41, from Telford, said she had been left with a painful, infected face and the implants could not be removed due to the infections.
    Her dental work also caused a collapsed septum which she said the NHS would not fix as it was deemed a cosmetic procedure.
    She spent £3,000 on the initial treatment, she said, and has since spent another £2,000 on private work at home to relieve the pain. The government has warned people about the risks of travelling abroad for cosmetic procedures.
    "Every day I wake up and I can't breathe through my nose," Ms Abeyance, a DJ and producer, said.
    She decided to travel to Antalya in April 2024 to get four dental implants after previously having veneers fitted in the country.
    She said she had been quoted about £50,000 to get the work done in the UK but found a dental practice in Antalya which took £3,000 in cash up front.
    The NHS guidance is that while being treated abroad might be cheaper than the UK, the risks need to be weighed against the savings.
    It adds that patients should consult their NHS dentist first as standards vary in different countries.
    Read full story
    Source: BBC News, 17 September 2025
  8. Patient Safety Learning
    The cost of seeing private psychologists is soaring and many are so busy they are turning away new clients, research has found.
    The prices psychologists charge have risen by 34% since 2022 and 12 sessions now cost an average of £1,550, compared with £1,152 just three years ago, according to a survey by myTribe Insurance, which tracks the cost of private medical care.
    Almost three in 10 (29%) psychologists are already treating so many patients that they are not taking on new ones, according to a survey of practitioners across the UK.
    The sometimes months-long delays people face in their efforts to access NHS mental healthcare and the record number of people seeking help, usually for anxiety or depression, appear to underlie the double-whammy facing patients of fee uplifts and closed waiting lists.
    Chris Steele, the founder of myTribe Insurance, said: “What we’ve seen over the last three years is a market that has become significantly more expensive for patients. A 34% rise in consultation fees is not just a statistic. It shows how private talking therapies are moving further out of reach for many people who need them.”
    While many people are seeking help from a psychologist in private practice, the survey of 349 practitioners found that doing so can involve high prices, long waits and online-only care.
    Read full story
    Source: The Guardian, 18 September 2025
  9. Patient Safety Learning
    UK doctors who are guilty of sexual misconduct are not being appropriately sanctioned due to weak disciplinary processes, research reveals.
    Nearly a quarter (24%) of doctors found guilty of sexual misconduct were handed suspensions but allowed to continue working in medicine, according to analysis of fitness to practice tribunals by the Royal College of Surgeons (RCS). This is despite the regulator, the General Medical Council (GMC), recommending they be struck off the medical register.
    The GMC investigates complaints against doctors and refers the most serious cases to the Medical Practitioners Tribunal Service (MPTS) to adjudicate on whether they remain fit to practice.
    The study analysed 222 new MPTS tribunal cases between August 2023 and August 2024 and found that out of the 46 proven cases of sexual misconduct identified, the MPTS imposed the same disciplinary sanction as the GMC recommended in 35. In 11 cases, the MPTS decided to only suspend the doctor rather than erase them from the medical register, and in no case did the MPTS impose a tougher sanction.
    Mei Nortley, a consultant vascular surgeon and lead author of the research, said: “We hope this study aids the MPTS to reflect on whether it delivers its aims of protecting the public, ensuring doctors meet professional standards and promoting public confidence in the medical profession. Allowing rapists, sexual predators and those who use manipulation and coercion to return as practising doctors brings this into question.”
    The research, published in the Bulletin of the Royal College of Surgeons of England, found that all perpetrators were male doctors, with more than 80% holding positions of authority. Several cases involved multiple targets, showing repeated and systemic abuse.
    Read full story
    Source: The Guardian, 18 September 2025
  10. Patient Safety Learning
    A single joint executive team will be established at the Department of Health and Social Care (DHSC) and NHS England as part of the transition to one organisation.
    It will provide unified leadership across both organisations, bringing policy and delivery together. The team will manage directors from related work areas from 3 November 2025 and will begin to combine resources.
    In March, the Prime Minister announced NHS England would be brought back into DHSC to end the duplication resulting from two organisations doing the same job in a system currently holding staff back from delivering for patients. By stripping back layers of red tape and bureaucracy, more resources will be put back into the frontline rather than being spent on unnecessary admin.  
    The single Joint Executive Team will comprise of:
    Professor Chris Whitty – Chief Medical Officer Tom Riordan – Chief Operating Officer/Second Permanent Secretary Matthew Style – Director General, System Development (working with Glen Burley who continues as NHSE’s Financial Reset and Accountability Director) Duncan Burton – Chief Nursing Officer for England Catherine Frances – Director General, Global, Public Health and Emergencies Professor Lucy Chappell – Chief Scientific Adviser and Director General, Science and Research Sally Warren – Interim Director General, Adult Social Care (recruitment to the permanent role began in July) TBC – Interim Director General, Technology and Data (recruitment to the permanent role will take place during autumn) Elizabeth O’Mahony – Interim Director General, Finance (recruitment to the permanent role began in August) David Probert – Interim Director General, Performance and Delivery (and continuing as NHS England’s Interim Deputy CEO) Jo Lenaghan – Interim Director General, People (recruitment to the permanent role began in August) Dr Claire Fuller and Professor Meghana Pandit – Interim Medical Directors (recruitment to the permanent role will take place during autumn) TBC – Interim Director General, Strategy and Healthcare Policy (recruitment to the permanent role began in July) TBC – Interim Director General, Commercial and Growth (recruitment to the permanent role began earlier in September) Joint regional teams are also being established to serve as the delivery arm of the centre, driving improvement and performance locally.
    Regional leadership:
    Louise Shepherd – Regional Director, North West Fiona Edwards – Regional Director, North East & Yorkshire Dale Bywater – Regional Director, Midlands Clare Panniker – Regional Director, East of England Caroline Clarke – Regional Director, London Sue Doheny – Regional Director, South West (while Elizabeth O’Mahony is NHS England’s Chief Financial Officer) Anne Eden – Regional Director, South East (until she leaves at the end of March) Existing DHSC Regional Public Health Directors will begin to report into Regional Directors in the same area from 3 November, subject to appropriate consultation, while continuing to work with the Director General of Public Health and Emergencies.
    National Priority Programmes are also being set up to drive delivery of the government’s key health priorities, drawing together teams and expertise from across the organisations and the country.
    National Priority Programmes:
    Mark Cubbon – National Priority Programme Director for Planned Care Sarah-Jane Marsh – National Priority Programme Director for Urgent and Emergency Care Duncan Burton – Interim National Priority Programme Director for Maternity, Women’s Health, Children & Young People Dr Claire Fuller – Interim National Priority Programme Director for Neighbourhood Health  Recruitment to the role of National Priority Programme Director for Mental Health, Learning Disability & Autism will start shortly. Dr Amanda Doyle will continue as NHSE’s National Director of Primary Care and Community Services, and Glen Burley will continue as NHSE’s Financial Reset and Accountability Director, both reporting to the NHSE CEO. Read full story
    Source: Department of Health and Social Care, 18 September 2025
  11. Patient Safety Learning
    A watchdog has urged greater awareness for the NHS Health Check after revealing over a third of adults are unfamiliar with the service.
    The screening is commonly referred to as the "mid-life MOT." But Healthwatch England found 36% of adults unaware of the vital screening.
    A new poll further indicates that many eligible individuals are not receiving invitations. The Savanta survey of 7,407 adults in England found 55% of eligible men and 53% of eligible women have never been invited for the "vital" check-up.
    However, around three in five respondents (62% of men and 60% of women) reported attending every health check they were invited to.
    “The NHS Health Check is a vital prevention tool, but it only works if people are invited, understand its purpose, and feel motivated to attend,” said Louise Ansari, chief executive at Healthwatch England.
    “Our research shows we must ensure that everyone eligible for the Health Check receives an invitation and is given clear information on why it is important.
    “Key to this will be using trusted sources like GPs to reach those most at risk.”
    Read full story
    Source: The Independent, 18 September 2025
  12. Patient Safety Learning
    A hospital boss has apologised after a Kent emergency department resorted to using its cafe as a makeshift ward.
    A&E staff at William Harvey Hospital in Ashford decided to screen off the building's cafe on Tuesday to create space for treating patients.
    East Kent Hospitals University NHS Foundation Trust said the move was due to "significant demand".
    Trust chief executive Tracey Fletcher said: "We know this is unacceptable and we are very sorry to patients who have been cared for in this way."
    A "small number" of patients were looked after in the cafe until emergency patients could be moved to other wards in the hospital, the trust said.
    Ms Fletcher said it was "sometimes necessary" to treat patients in corridors despite staff's efforts, but that use of the cafe, first reported by Kent Online, external, "will not be allowed to happen again".
    Read full story
    Source: BBC News, 18 September 2025
    Related reading on the hub:
    Corridor care and patient safety A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  13. Patient Safety Learning
    Scientists have developed a new artificial intelligence tool that can predict your personal risk of more than 1,000 diseases, and forecast changes in health a decade in advance.
    The generative AI tool was custom-built by experts from the European Molecular Biology Laboratory (EMBL), the German Cancer Research Centre and the University of Copenhagen, using algorithmic concepts similar to those used in large language models (LLMs).
    It is one of the most comprehensive demonstrations to date of how generative AI can model human disease progression at scale, and was trained on data from two entirely separate healthcare systems.
    “Medical events often follow predictable patterns,” said Tomas Fitzgerald, a staff scientist at EMBL’s European Bioinformatics Institute (EMBL-EBI). “Our AI model learns those patterns and can forecast future health outcomes.”
    The tool works by assessing the probability of whether – and when – someone may develop diseases such as cancer, diabetes, heart disease, respiratory disease and many other disorders.
    Named Delphi-2M, it looks for “medical events” in a patient’s history, such as when illnesses were diagnosed, together with lifestyle factors such as whether they are or were obese, smoked or drank alcohol, plus their age and sex.
    The tool also looks at anonymised patient record data to predict what might happen over the next decade and beyond.
    Read full story
    Source: The Guardian, 17 September 2025
  14. Patient Safety Learning
    The Trump administration’s shake-up of the Centers for Disease Control and Prevention (CDC) has forced Mississippi to stop gathering critical data on women’s experiences before, during and after pregnancy – even as the state recently declared a public health emergency over its surging infant mortality rate.
    Mississippi has suspended data collection for Pregnancy Risk Assessment Monitoring System (Prams), a national database that has been integral to policymaking on maternal and infant health for nearly four decades, the Guardian has learned.
    Prams functions as a partnership between state-level health officials and a little-known but influential CDC agency called the Division of Reproductive Health, which has lost most of its staff – nearly 100 people – in the Trump administration’s purges of federal workers, according to records in a lawsuit filed by several Democratic-led states over the purges.
    As a result, many of the division’s projects, including Prams, have sputtered to a halt, the lawsuit alleges.
    The division will likely be unable to obtain accurate nationwide data on maternal and infant health in 2024, 2025 and 2026, an unnamed CDC staffer said in one declaration included in the lawsuit.
    Researchers rely on Prams data to test out potential health interventions to improve maternal and child health, while states use it to make the case for federal funding for programmes that aim to reduce infant deaths, improve care for women and help children with special needs.
    Read full story
    Source: The Guardian, 16 September 2025
  15. Patient Safety Learning
    Caregiving staff say agents in the US are bringing in patients, often denying them visitors and speaking on their behalf to staff.
    Dianne Sposito, a 69-year-old nurse, is laser-focused on providing care to anyone who enters the UCLA emergency room in southern California, where she works.
    That task was made difficult though one week in June, she said, when a federal immigration agent blocked her from treating an immigrant who was screaming just a few feet in front of her in the hospital.
    Sposito, a nurse with more than 40 years of experience, said her hospital is among many that have faced hostile encounters with Immigration and Customs Enforcement (Ice) agents amid the Trump administration’s escalating immigration crackdown.
    The patient was screaming and trying to get off the gurney, and when Sposito tried to assess her, the agent blocked her and told her not to touch the patient.
    “I’ve worked with police officers for years, and I’ve never seen anything like this,” Sposito said. “It was very frightful because the person behind him is screaming, yelling, and I don’t know what’s going on with her.”
    The man confirmed he was an Ice agent, and when Sposito asked for his name, badge, and warrant, he refused to give her his identification and insisted he didn’t need a warrant. The situation escalated until the charge nurse called hospital administration, who stepped in to handle it.
    After the incident, Sposito said that hospital administration held a meeting and clarified that Ice agents are only allowed in public areas, not ER rooms and that staff should call hospital administration immediately if agents are present.
    But for Sposito, the guidelines fall short, as the hostility is unlike anything she has seen in over two decades as a nurse, she said..
    “[The agent] would not show me anything. You don’t know who these people are. I found it extremely harrowing, and the fact that they were blocking me from a patient – that patient could be dying.”
    Since the Trump administration has stepped up its arrest of immigrants at the start of the summer, nurses are seeing an increase in Ice presence at hospitals, with agents bringing in patients to facilities, said Mary Turner, president of National Nurses United, the largest organization of registered nurses in the country.
    “The presence of Ice agents is very disruptive and creates an unsafe and fearful environment for patients, nurses and other staff,” Turner said. “Immigrants are our patients and our colleagues.”
    Read full story
    Source: The Guardian, 16 September 2025
  16. Patient Safety Learning
    Big pharmaceutical companies have ditched or paused nearly £2bn in planned UK investments so far this year, causing “suffering” to patients, as ministers gear up for discussions with Donald Trump amid a row over drug pricing.
    The government’s plan for the life science sector, a key pillar of the economy, has been thrown into disarray, after US drugmaker MSD’s shock announcement last Wednesday that it would scrap its £1bn London research centre. Two days later, AstraZeneca decided to halt a planned £200m expansion of its research facilities in Cambridge.
    Combined with a scrapped project by AstraZeneca in Liverpool and a shelved Eli Lilly lab in London, four projects worth more than £1.8bn have been pulled or paused this year. In total, decisions over 13 major projects or companies have damaged the UK’s pharma industry since 2022, also including site closures and stock market delistings.
    Pharma companies have accused the government of not spending enough on new medicines, arguing that there is little incentive for them to develop drugs and test them in a country that does not value innovation sufficiently.
    Read full story
    Source: The Guardian, 16 September 2025
  17. Patient Safety Learning
    One in three GPs in England do not work in the NHS, with increasing numbers seeking to move abroad or becoming a private contractor, deepening patients’ difficulties in getting appointments.
    The proportion of family doctors who, although qualified, do not provide care through the NHS has risen from 27% in 2015 to 34% last year, according to a study published in the BMJ.
    That means almost 20,000 GPs who could be working in the health service are “lost” to it and are not doing so, despite unprecedented demand for care and many government initiatives to try to increase GP numbers.
    While a total of 58,548 GPs in England were on the General Medical Council (GMC) register at the end of last year, only 38,626 of them were in general practice there – a difference of 19,922.
    The Patients Association said the findings were “deeply distressing” for patients who are often left frustrated by the time it takes to get a consultation with a GP.
    GPs’ heavy workloads, increasing demands from patients they are facing and widespread frustration that they have too little time to care for patients properly are behind burnout among family doctors that is fuelling their increasing dropout from the NHS, the researchers say.
    “While there is a welcome rise in GP numbers on paper, this report that one in three GPs are not working in the NHS is deeply distressing for the patients who already experience frustration and anxiety when trying to access a GP appointment.
    “Long waits, fragmented care and delayed diagnoses are putting people’s health at risk”, said Rachel Power, the Patients Association’s chief executive.
    Read full story
    Source: The Guardian, 17 September 2025
  18. Patient Safety Learning
    A once-a-day pill for obesity could be a cheaper and more accessible weight-loss drug, after a study found the tablet can lead to “significant” reductions in body weight.
    More than 60% of adults living in the UK are obese or overweight – a crisis which is costing the NHS about £107bn a year.
    But almost one in five people taking the drug Orforglipron lost 20% of their body weight after using it for a year and a half, researchers found.
    Although the weight loss seen in people taking the tablet is not as stark as that among patients taking Mounjaro, experts believe the tablet will be more accessible and convenient compared with weight-loss injections.
    “Because this pill is easier to use and may be less expensive, it could allow more people access to effective weight-loss medications and make obesity treatment simpler and more convenient for patients everywhere,” said Dr Stephen Lawrence, GP and associate clinical professor at the University of Warwick.
    Read full story
    Source: The Independent, 17 September 2025
  19. Patient Safety Learning
    A charity will invest £10m in a new scheme that aims to shift care from hospitals into the community.
    Macmillan Cancer Support has partnered with West Hertfordshire Teaching Hospitals Trust and non-profit enterprise Social Finance to create what it described as a first-of-its-kind model for neighbourhood health.
    The programme will focus on supporting older people with multiple health conditions, including cancer, in South and West Hertfordshire. Around 500 patients will be supported in year one in the Hertfordshire district of Dacorum, 500 more in a different area the following year, and then 1,000 in year three – with the aim of reaching 2,000 patients across four neighbourhoods. 
    The initiative, launching in November, has three core elements. The first is a multidisplinary team in the community focusing on preventative care delivered by WHHT’s partner, Central London Community Healthcare Trust; the second a community interest company (CIC) enabling the benefits of reduced hospital spending to be reinvested directly back into neighbourhood teams; and the third a grant-giving enterprise for grassroots organisations to provide additional voluntary support for patients.
    Patients will be supported by MDTs including advanced practitioners, GPs, geriatricians, pharmacists, physiotherapists, nurses and Macmillan community workers and support will include medication reviews, home adaptations and links to voluntary sector groups to help patients and their families live active and fulfilling lives.
    Read full story (paywalled)
    Source: HSJ, 17 September 2025
  20. Patient Safety Learning
    Pharmacy leaders are demanding urgent action to address significant delays in dispensing medication, often caused by widespread shortages.
    Under current regulations, pharmacists cannot modify prescriptions, even when stock issues arise.
    This restrictive framework means pharmacists cannot offer practical alternatives, such as substituting tablets for capsules, or providing two 10mg doses instead of a single 20mg tablet.
    Consequently, patients are frequently forced to visit multiple pharmacies or return to their GP for a new prescription to secure available medication.
    The National Pharmacy Association (NPA) has highlighted that these limitations can leave individuals waiting weeks for essential medicines.
    The organisation attributes the problem to outdated legislation, which it says prevents pharmacists from supplying suitable alternatives.
    The National Pharmacy Association is calling on the Government to change the laws, which have been in place since 1968, to allow pharmacists to make substitutions where a medicine is not in stock, but a safe alternative is.
    Read full story
    Source: The Independent, 16 September 2025
    Related reading on the hub:
    All-Party Parliamentary Group on Pharmacy inquiry into medicines shortages in England Medication supply issues: A pharmacist’s perspective  
  21. Patient Safety Learning
    Black women in England are still facing poorer outcomes in their maternity care due to systemic racism, alongside failures in leadership and data collection, according to a group of MPs.
    Across the UK, black women are more than twice as likely to die in childbirth compared with their white counterparts, while babies born to black mothers are at an increased risk of stillbirth.
    A report by the health and social care committee found that these disproportionately poor outcomes in maternity care for black women were due to a combination of factors including systemic failures in accountability and leadership, with black women’s concerns “not taken seriously” due to bias, stereotyping and racist assumptions.
    “Safe maternal care for Black women depends on a workforce that listens to, understands and respects their needs,” according to Paulette Hamilton, Labour’s MP for Birmingham Erdington and acting chair of the committee. “Leadership must be effective but it must also be accountable. This report proves that this is not, currently, the case.”
    She added that the government’s upcoming investigation into NHS maternity care must be a “turning point” for black women in particular. “In-built structural racism in maternity services repeatedly fails Black women. Acknowledging this and addressing racial disparities in maternal outcomes must be one of the investigation’s core aims,” she added.
    Read full story
    Source: The Guardian, 17 September 2025
  22. Patient Safety Learning
    US health officials are reportedly planning to release data on child deaths and serious side effects they would attribute to Covid-19 vaccines, raising alarm among public health experts who say the publicly available data does not support these claims and the report may lead to increased anti-vaccine sentiment.
    Independent advisers for the US Centers for Disease Control and Prevention (CDC) later this week plan to revisit recommendations for Covid shots as well as vaccines for measles and hepatitis B.
    The move is part of a larger effort to cast doubt on vaccines and reduce access to them, said David Gorski, a professor of surgery and oncology at Wayne State University who has tracked anti-vaccine activism for decades.
    Robert F Kennedy Jr, the secretary of the US Department of Health and Human Services (HHS), is a longtime anti-vaxxer who continues to make sweeping, controversial changes to the US vaccine program, Gorski said.
    “RFK Jr wants to take away your vaccines,” he said.
    Officials are looking at 25 reports of paediatric deaths following Covid vaccination, apparently stemming from the crowdsourced database known as the Vaccine Adverse Event Reporting System (VAERS), according to reporting by the Washington Post.
    Yet years of data and research show that Covid vaccinations are safe and effective.
    Read full story
    Source: The Guardian, 16 September 2025
  23. Patient Safety Learning
    On World Patient Safety Day (17 September), the Medicines and Healthcare products Regulatory Agency (MHRA) is proud to announce a major milestone in its mission to protect public health: for the first time, the importance of medicine safety and how to report side effects of medicines via the Yellow Card scheme is now part of the RSHE statutory guidance for schools in England. 
    Working in close partnership with the Department for Education (DfE), the MHRA has successfully embedded this life-saving knowledge into the statutory Relationships, Sex and Health Education (RSHE) guidance – reaching children and young people in classrooms across the country. 
    This bold step puts patient safety into the hands of the next generation, giving them the tools to recognise and report side effects from medicines. 
    The curriculum changes are reflected in the statutory guidance, which now links directly to the Yellow Card scheme and a dedicated child-friendly guide tested with over 3,500 children and young people.
    The content covers: 
    What a side effect is. Why it’s important to report problems with medicines. How to submit a Yellow Card report. Who the MHRA are and how they help keep the public safe. Lawrence Tallon, MHRA Chief Executive, said: 
    “This World Patient Safety Day, we’re marking a new era in public health. By equipping young people with knowledge about medicine safety, we’re laying the foundations for a lifetime of safer healthcare. The inclusion of information on how to report side effects via the Yellow Card scheme in schools ensures every child knows that their voice matters in making medicines and devices safer for everyone.” 
    Professor Henrietta Hughes, the Patient Safety Commissioner, said: 
    “It’s excellent to see Yellow Card reporting on the school curriculum, so more people know how to report possible side effects.  No one knows themselves better than patients and their families.  When we respect and act on what patients say, improved safety from medicines and medical devices will follow.” 
    Read full story
    Source: MHRA, 17 September 2025
  24. Patient Safety Learning
    New research indicates that individuals living with dementia are being treated with potent antipsychotic medications for periods exceeding recommended guidelines.
    The study further suggests that prescribed doses are often higher than advised, and the practice of stopping and then restarting these drugs is "common".
    While antipsychotics can help manage the behavioural and psychological symptoms of dementia, the National Institute of Health and Care Excellence (Nice) advises their use only for severe agitation or distress, and strictly under specialist supervision.
    Analysis by experts from University College London (UCL) looked at data from 9,819 people living with dementia aged between 60 and 85, who received their first antipsychotic prescription between 2000 and 2023.
    The study found initial treatments lasted seven months, exceeding the Nice guidance of one to three months.
    The analysis also showed almost one in five (18%) patients were given an initial prescription higher than the minimum effective dose.
    Researchers said the findings, published in the Lancet Psychiatry, “highlight a persistent gap between clinical guidelines and real-world prescribing of antipsychotics in people living with dementia, underscoring the need for interventions that prioritise safety and person-centred dementia care”.
    Dr Juan Carlos Bazo-Alvarez, of UCL’s department of primary care and population health, added: “Looking at about two decades of primary care data, we found that many people with dementia remain on antipsychotics longer than guidance recommends, and that stopping and restarting treatment is common.
    “These insights from routine records can help clinicians make safer, more person-centred decisions about prescribing and reviewing medication.”
    Read full story
    Source: The Independent, 16 September 2025
  25. Patient Safety Learning
    Staff have accused leaders of being “quick to find someone to blame” in an inspection that has rated a hospital department “inadequate”.
    The Care Quality Commission said it had found systemic cultural issues in the children and young people’s service at Broomfield Hospital, run by Mid and South Essex Foundation Trust, where employees “did not always feel listened to or feel safe to speak up in fear of being targeted or bullied”.
    The CQC inspection report said: “Staff at all levels were concerned senior leaders within the trust did not fully understand the demand and pressure on staff and told us drastic change was needed.
    “Staff said there was a blame culture when it came to incidents and safety. They told us leaders were quick to find someone to blame without looking at the bigger issues with staffing, capacity and leadership.”
    Read full story (paywalled)
    Source: HSJ, 17 September 2025 

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