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Patient Safety Learning

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  1. Patient Safety Learning
    Cardiff University’s Division of Population Medicine has been officially designated as the WHO Collaborating Centre for Patient Safety, Learning and Improvement, under the leadership of Professor Andrew Carson-Stevens, Professor of Patient Safety. 
    The new Centre’s technical remit is to support WHO in drawing lessons from Member States’ implementation of the “WHO Global patient safety action plan 2021–2030” and supporting WHO’s work on patient safety incident reporting and learning systems. Professor Carson-Stevens and his team have previously supported WHO in producing the most recent “Global patient safety report 2024”. 
    Speaking about the designation, Professor Carson-Stevens said, “This is a significant moment for Cardiff University and for global health. Patient safety challenges are universal, but solutions emerge when Member States learn with, from and about each other’s experiences. By working together, guided by the Global patient safety action plan, we can strengthen systems, reduce avoidable harm and ultimately save lives. Our Centre is committed to supporting WHO and its Member States in this shared mission.” 
    The Collaborating Centre will be formally launched on World Patient Safety Day (17 September 2025), which this year has a global theme of “Safe care for every newborn and every child”. 
    “This collaboration will serve as a force multiplier in our global efforts to improve patient safety. Cardiff University’s WHO Collaborating Centre will play a vital role in strengthening the capacity to learn from patient safety data and incident reports, turning information into meaningful insights and concrete actions. This is essential for countries and health-care facilities working to implement the WHO Global patient safety action plan 2021–2030 and eliminate avoidable harm in health care,” said Dr. Nikhil Prakash Gupta, Responsible Technical Officer for Patient Safety and Quality of Care at WHO.
    To reflect the theme of World Patient Safety Day, the launch of the new Centre will highlight recent findings by Cardiff University researchers on the role of parents in protecting children from harm in health-care settings.
    A recent study published in the British Journal of General Practice analysed national patient safety incident reports involving children. It revealed that, in nearly 77% of cases, parents took proactive steps, such as identifying medication issues, chasing delayed referrals or raising concerns to protect their children from harm. Parent actions helped avert or reduce harm in more than half of the incidents reviewed.  
    The research underscores the vital role parents play as partners in safer care, particularly as children are more vulnerable to health-care-related harm and depend on parents and caregivers to advocate on their behalf. The study calls for greater collaboration between health-care providers and parents to co-design safer systems and improve patient safety outcomes for children. 
    Read full story
    Source: WHO, 15 September 2025
  2. Patient Safety Learning
    Health experts have issued a warning over the use of illicit weight-loss jabs after The Independent uncovered drugs that have not yet been approved for use being offered for sale on social media.
    Retatrutide, or “Reta”, is manufactured by Eli Lilly, the pharmaceutical giant behind Mounjaro, which tripled in price in the UK last week, prompting many users to seek out cheaper alternatives.
    Retatrutide has been dubbed the “Triple G” of weight-loss drugs because of its unique ability to mimic the actions of three different hormones – GLP-1, glucagon and GIP – which are released after eating and work to reduce appetite, help regulate blood sugar levels and support fat loss. Similar drugs on the market, such as Mounjaro, typically target only two receptors.
    The injection is not yet approved for human use and is still undergoing clinical trials, but The Independent has uncovered dozens of accounts on TikTok, Instagram, and X purporting to sell it – despite TikTok and Meta saying such activity is banned on their platforms.
    The Medicines and Healthcare products Regulatory Agency (MHRA), which approves and regulates drugs in the UK, and Eli Lilly have warned that such compounds are illegal and could expose users to “dangerous ingredients that can have serious health consequences”.
    Read full story
    Source: The Independent, 14 September 2025
  3. Patient Safety Learning
    The financial burden of breast cancer on the UK economy is projected to surge by nearly a third, reaching £4.2 billion within the next 25 years, according to new analysis.
    The charity Breast Cancer Now has issued a stark warning, stating the UK faces "dire consequences" unless decisive action is taken to ensure "everyone an equal chance of the best diagnosis, treatment and care".
    A collaborative study by Breast Cancer Now and the think tank Demos estimates that breast cancer is already costing the UK economy between £3.2 billion and £3.5 billion in 2025.
    These figures encompass the direct costs to the NHS for diagnosing and treating the disease, alongside the economic impact of lost productivity when patients or their informal carers are unable to return to work.
    The report indicates that without intervention, this total could escalate by 31% to £4.2 billion by 2050.
    Claire Rowney, chief executive of Breast Cancer Now, commented on the findings, asserting that the report "sets out loud and clear the huge challenges in tackling breast cancer and the dire consequences we’ll face unless urgent action is taken now to save more lives from the disease and give everyone an equal chance of the best diagnosis, treatment and care".
    Read full story
    Source: The Independent, 15 September 2025
  4. Patient Safety Learning
    Patients needing NHS gender care face a 42,000-long waiting list, with some waits as long as eight years, health secretary Wes Streeting has revealed.
    Mr Streeting has vowed to address the “unacceptable” waits for tens of thousands of people needing access to NHS adult gender dysphoria services, The Independent can reveal.
    At a speech for the NHS England LGBT+ Health Annual Conference in London on Monday, the health secretary will say: “Evidence shows trans people have higher rates of mental health conditions, including depression, when compared to the general population. Longer wait times only steepen this pain.
    “Over 42,000 people are still waiting, often for years, for their first appointment at adult gender dysphoria clinics. That’s 42,000 people who are hurting, anxious, and exhausted.
    “This breaks my heart...42,000 or more individuals should not be feeling invisible, misunderstood or unsupported.”
    A national review of adult gender dysphoria clinics, led by Dr David Levy, is being carried out following concerns raised by Dr Hilary Cass, who led the Cass Review into gender services, about adult services.
    The review is looking into how the services operate, areas of concern, and action being taken to improve services.
    In a statement ahead of the pilot announcement, Mr Streeting said: “It is fundamentally wrong that so many LGBT+ people still face challenges when accessing healthcare – including barriers such as discrimination, misunderstanding, and miseducation…
    “This pilot marks a major step – acknowledging the unacceptable waits endured by thousands of transgender patients and starting to tackle it head on.”
    Read full story
    Source: The Independent, 15 September 2025
  5. Patient Safety Learning
    Many maternity and newborn units are at “serious risk of imminent breakdown”, regularly hit by leaks and floods, and too cramped to provide the necessary care, an official NHS England report admits.
    The national survey of all maternity and neonatal services found 42 per cent nationally were “operational” but in need of “major repair or replacement… soon”. Seven per cent were judged to be even worse, at “serious risk of imminent breakdown”.
    Around 155 maternity units were surveyed nationally, and a similar number of neonatal services.
    The report said doctors and midwives were losing significant time due to the state of buildings, with 14,500 incidents over the past three years, including power outages and faulty nurse call systems. 
    The most common issues disrupting services were water, sewerage and drainage issues – such as leaks and flooding – with more than 5,300 such incidents. This was followed by ventilation and heating – where a typical problem is overheating – at 2,913.
    The NHSE review said: “The survey findings demonstrate that much of the current maternity and neonatal estate lacks sufficient physical space to operate in accordance with best practice under current activity levels.
    “These existing infrastructure issues will be further exacerbated with the trend towards more complex births, requiring larger teams and more specialist equipment, and many women and families staying longer in hospital.”
    Read full story (paywalled)
    Source: HSJ, 12 September 2025
  6. Patient Safety Learning
    Three in four NHS hospital trusts are failing cancer patients, according to the first league tables of their kind, prompting experts to declare a “national emergency”.
    Labour published the first league tables to rank hospitals in England since the early 2000s this week. The overall rankings score trusts based on a range of measures including finances and patient safety, as well as how they are bringing down waiting times for operations and in A&E, and improving ambulance response times.
    Guardian analysis of the underlying data has found that about three-quarters of trusts are failing to hit either of the two cancer targets in the tables.
    Ninety of the 118 trusts (76%) are missing the first target of ruling cancer in or out within 28 days of urgent referrals in at least 80% of cases.
    The analysis also reveals that 86 of the 118 trusts (73%) are failing to hit the second cancer target measured in the tables, of starting treatment within 62 days in 75% of patients.
    Delaying cancer diagnosis or treatment can lead to worse outcomes for patients, fewer options for tackling the disease, and earlier death. 
    Cancer experts said they were alarmed by the Guardian’s findings. Paula Chadwick, the chief executive of the Roy Castle Lung Cancer Foundation, said: “Three-quarters of NHS hospitals failing to meet cancer targets is nothing short of a national emergency.
    “Behind every missed target is a person left waiting, a family left in limbo, and lives put at greater risk because the system simply isn’t moving fast enough. Cancer does not wait. Delays in diagnosis and treatment cost lives – it’s as stark as that.”
    Read full story
    Source: The Guardian, 15 September 2025
  7. Patient Safety Learning
    Mothers and babies being harmed in the NHS risks becoming normalised because of its toxic cover-up culture, a health leader will say, as it emerged that 14 trusts are the focus of a national maternity investigation in England.
    Charles Massey, the chief executive of the General Medical Council, will tell a conference on Monday that “something must have gone badly wrong” when trainee obstetrics and gynaecology doctors are fearful of speaking up.
    The “tribal” nature of medicine with doctors and other staff pitted against each other could be preventing people from raising their concerns or admitting when things go wrong, Massey will say.
    His stark warning came as the government named 14 NHS trusts that are being examined as part of its rapid inquiry into maternity and neonatal services in England.
    They are:
    Barking, Havering and Redbridge university hospitals NHS trust. Blackpool teaching hospitals NHS foundation trust. Bradford teaching hospitals NHS foundation trust. East Kent hospitals NHS trust. Gloucestershire hospitals NHS foundation trust. Leeds teaching hospitals NHS trust. Oxford university hospitals NHS foundation trust. Sandwell and West Birmingham hospitals NHS trust. Shrewsbury and Telford hospital NHS trust. The Queen Elizabeth hospital, King’s Lynn NHS foundation trust. University hospitals of Leicester NHS trust. University hospitals of Morecambe Bay NHS foundation trust. University hospitals Sussex NHS foundation trust. Yeovil district hospital NHS foundation trust/Somerset NHS foundation trust. The investigation, first announced in June and being led by Valerie Amos, will use lessons learned from previous inquiries to create one “clear set of actions”, in an effort to improve NHS care.
    Alongside the investigation, which is due to report preliminary findings in December, a maternity and neonatal taskforce has been set up, chaired by Wes Streeting and made up of experts and bereaved families.
    Read full story
    Source: The Guardian, 15 September 2025
  8. Patient Safety Learning
    Campaigners affected by the medical scandals of pelvic mesh implants, Primodos, and sodium valproate gathered outside Parliament to mark Patient Safety month with a powerful protest demanding justice and reform.
    Joined by cross-party MPs from the First Do No Harm All-Party Parliamentary Group (APPG), the demonstrators called on the Government to fully implement all recommendations of the landmark Cumberlege Review.
    The protest (Wednesday 10 September) was led by representatives impacted by the three medical interventions investigated in the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Julia Cumberlege.
    The review, published in 2020, exposed systemic failures in patient safety and called for sweeping reform – including of the regulator the MHRA, an independent redress agency, specialist centres for treatment, financial redress and Sunshine legislation to improve transparency of payments from industry to the health sector.
    Sharon Hodgson MP, Chair of the First Do No Harm APPG, who has been a vocal advocate for justice for women – including her mam who has been harmed by pelvic mesh, said after the event: “We are now five years on from the Cumberlege Review and over 18 months since the Hughes Report on redress – yet thousands of women and children are still waiting to be heard, acknowledged, and properly cared for. This is not just a delay; it is a systemic failure. Their pain, their stories, and their voices must not be ignored. Women and children deserve to be seen, believed, and supported. Campaigners are right to stand firm because until the Cumberlege recommendations are implemented and justice is truly delivered, the fight must go on.”
    Read full story
    Source: Sling the Mesh, 10 September 2025
  9. Patient Safety Learning
    NHS England’s outpatients’ recovery efforts have been stymied by a lack of funding and because “we’ve struggled to get the clinical community uniformly behind it”, Sir Jim Mackey has told MPs.
    The NHSE chief executive told a Public Accounts Committee evidence session that national leaders all accepted “we have to do more on outpatients” and revealed that a new outpatient recovery plan was being finalised for next year.
    Asked if outpatients should have been more of a focus of NHS resources, Sir Jim said: “Yeah. I think the programme probably was under-resourced at the time.”
    He added: “But I think the material issue throughout has been clinical engagement, and we’ve struggled throughout to get the clinical community uniformly behind it. So, once we’ve achieved that, the thing will get resolved.”
    He continued: “The big concern that’s prevented us from going really hard at it is the concern about missing clinical risk. So, if we do really sweeping changes without really strong clinical engagement, that [could mean] a patient should have been seen in a follow-up setting and wasn’t and comes to harm. None of us wants that.
    “We all agree outpatients is the big untapped thing for us to go at that can be dealt with without a lot of resource, but it’s very complicated.”
    Read full story (paywalled)
    Source: HSJ, 11 September 2025
  10. Patient Safety Learning
    Children as young as nine detained under the Mental Health Act are spending hours in NHS accident and emergency departments under police control rather than in specialist mental health assessment suites.
    The detention under the act of children in England and Wales in police cells was banned in 2017 but a lack of suitable options has led to the use of A&E departments.
    Research to be presented at a British Sociological Association conference at Northumbria University on Friday found that 187 nine-to-18-year-olds were detained under the act in a single constituency in the north of England between 2017 and 2021. Three-quarters were taken to A&E, where legally they could wait for up to 24 hours, accompanied by police officers, until they were assessed.
    It was mainly children aged 16 and over who were able to access adult facilities who were taken to specialist suites under the care of trained mental health staff.
    The author of the research, Dr Jayne Erlam, of Liverpool John Moores University, will tell the conference: “What is clear is that the youngest detained do not gain access to specialist suites and instead are taken to A&E.
    “Taking into consideration that the person has been detained because of mental distress, such a public environment under the gaze of others can do nothing to alleviate any distress. The public nature of A&E departments is concerning, and police officers are fiercely against the use of them as a place of safety.
    “Shortfalls in health and social care provision increase police contact with persons experiencing mental distress to the point where there is a reliance on policing to bridge gaps and to safeguard people who are at risk of future episodes of acute mental distress.”
    Read full story
    Source: The Guardian, 12 September 2025
  11. Patient Safety Learning
    Doctors say the NHS is struggling to meet demand in England as new data shows the waiting list for routine treatment increasing for the second month in a row.
    An estimated 7.4m planned procedures were waiting to be carried out in July, up 34,000 on the previous month and the highest level since March.
    NHS England said many more patients were coming forward for treatment and a doctors' strike in July left 50,000 appointments cancelled.
    The Royal College of Surgeons said the system was coming under severe strain and called for more money for new operating theatres in the autumn budget.
    "Crumbling hospital buildings are leading surgeons to have to compete for space, directly contributing to delays and leaving patients waiting for the care they need," said the organisation's vice president Prof Frank Smith.
    The latest monthly data also showed the number facing very long waits to start routine treatment had increased.
    There were 1,429 patients waiting more than 18 months in July, up from 1,103 in June, though down sharply compared to last year.
    Routine treatment includes anything booked in advance, from a consultation with a specialist to minor operations or major surgery.
    Read full story
    Source: BBC News, 11 September 2025
  12. Patient Safety Learning
    The government’s flagship NHS policy is at odds with what the general public view as a top priority, a new poll suggests.
    Prime Minister Sir Keir Starmer’s “plan for change” pledged that by July 2029, 92% of patients will be seen within 18 weeks for routine hospital treatment such as hip and knee replacements.
    But cutting waiting times for routine hospital services ranks only fifth for the public in terms of NHS priorities, the poll suggests.
    The public’s top priority for the NHS is making it easier to access GP appointments followed by improving A&E waiting times and reducing the number of staff leaving the NHS, the Health Foundation think tank found.
    Researchers found that public confidence in the government’s NHS policies “remains low” after just over half (53 per cent) said they disagree that the government has the right policies for the health service, compared to 16% who agree.
    They said that public perceptions of the NHS “remain negative overall” but there are some signs that views are “slowly improving”.
    Read full story
    Source: The Independent, 12 September 2025
  13. Patient Safety Learning
    Parents are spending thousands of pounds to bank stem cells from their children’s milk teeth—but the recipient companies’ claims about their future medical value are unproved and potentially misleading, an investigation by The BMJ has found.
    The three UK companies advertising tooth banking services tell parents that milk teeth are a “valuable” source of stem cells, with the ability to repair tissue cells throughout the body. Their claims include that these stem cells are already being used in treatments for autism and diabetes. They also point to current research using stem cells in multiple sclerosis, myocardial infarction, and Parkinson’s disease.
    But several experts have told The BMJ that they are concerned about the claims being made, which risk exploiting parents—with the promise of a treatment for autism deemed particularly outrageous.
    The BMJ found that the three companies in the UK offering tooth stem cell banking—BioEden, Future Health Biobank, and Stem Project—all operate through one laboratory. The Advertising Standards Agency (ASA) says it will review concerns we have raised about how the service is promoted on their websites.
    Read full story
    Source: The BMJ, 20 August 2025
  14. Patient Safety Learning
    Both NHS and private fertility clinics must stop offering unproven treatments that don't help people have children, new official guidelines say.
    The draft guidance advises against several popular fertility "add-ons", including so-called endometrial scratches.
    These add-ons can "give false hope and put people through unnecessary procedures at an already difficult time", experts at the National Institute for Health and Care Excellence (NICE) say.
    They also recommend fertility preservation services such as egg freezing should be more widely available, including to women with severe, recurrent endometriosis.
    The guideline committee considered a recent survey by the fertility regulator, the Human Fertilisation and Embryology Authority (HFEA), which showed almost three-quarters of people who had had fertility treatment between September and October 2024 had said they were using additional tests or emerging technologies, despite most not being proven to work.
    And only 37% of those questioned said the risks of any add-ons had been explained.
    The updated draft guidance specifically advises against:
    intracytoplasmic sperm injection, external (ICSI) for men with healthy semen – where a sperm is directly injected into an egg in a laboratory endometrial scratch – where the lining of the womb is "scratched" with a small sterile plastic tube before IVF hysteroscopy - a fine telescope like instrument is used to visualise the womb, as a pre-treatment to improve IVF outcomes tests on the lining of the womb called endometrial receptivity testing, external, as a suggested add-on before embryo transfer The guidance says patients must be given all the information necessary about treatments, including how likely they are to be successful and the risks and benefits involved.
    Read full story
    Source: BBC News, 10 September 2025
  15. Patient Safety Learning
    Senior cancer doctors are warning that excessive red tape means some patients in England are struggling to access the latest cancer treatments.
    The Royal College of Radiologists (RCR) says bureaucracy is "stifling innovation" and that applying for funding to pay for new treatments can be "cumbersome" for some cancer centres.
    It says the situation is leading to an unacceptable postcode lottery with some cutting-edge treatments only available in the larger, better-funded units.
    The government says a new cancer strategy, due later this year, will "put the NHS back at the forefront of global cancer care".
    Survival rates for many common cancers have been rising, partly driven by new technologies such as immunotherapy drugs and more advanced radiotherapy.
    But the body representing both radiologists, who analyse scans and treat patients, and cancer doctors says that NHS bureaucracy means some are missing out on the latest life-saving treatments.
    The RCR says that even some well-established advances, such as Stereotactic Ablative Body Radiotherapy - or SABR - can still be difficult to access.
    SABR is a way of more accurately targeting the disease with a precise dose of high-strength radiation, and is typically used to treat very small tumours in the lungs, liver, lymph nodes and brain.
    The RCR says individual cancer units still have to apply to NHS England to fund its use, leading to a postcode lottery where some patients lose out.
    "That is inequitable and unjust and not compatible with the National Health Service," says Dr Nicky Thorp, a practising cancer doctor and vice president for clinical oncology at the RCR.
    "We would like red tape to be cut and the commissioners to listen to clinicians who really understand the impact on patient care," she added.
    Read full story
    Source: BBC News, 11 September 2025
  16. Patient Safety Learning
    Claire Murdoch, NHS England’s national mental health director for the last nine years, has today resigned “with immediate effect”.
    In her resignation letter to Sir Jim Mackey, seen by HSJ, Ms Murdoch said it had become “common knowledge that change at the top is wanted” and that she “could no long lead the sector when the political leadership don’t want to engage with me”.
    Ms Murdoch wrote in her letter, which is attached to this article, that since it was ”apparently widely already known” that ministers wanted change that ”I cannot continue to do the job in the way it deserves to be done and it’s best you quickly find someone that you and the political leadership can have confidence in.”
    Ms Murdoch’s letter also raises concerns about mental health spending and described maintaining its share of NHS funding as “critical”. She said it “…fell last year and will again this year. It likely will continue to do so over the next 3 years. I hope I am wrong.” HSJ reported earlier this year the proportion the NHS spends on mental health was this year cut for the first time in several years. 
    Ms Murdoch said tackling inequalities and reducing the premature mortality of people with serious mental illness remains an area that we have sadly made “insufficient progress on”. More needs to be done she said, “much of which does not require additional investment …. but much of which, absolutely does”.
    Read full story (paywalled)
    Source: HSJ, 11 September 2025
  17. Patient Safety Learning
    More than 1,000 people across the UK with suspected dementia are to be offered a blood test for Alzheimer's disease which it is hoped could revolutionise diagnosis of the disease.
    The blood test can detect biomarkers for rogue proteins which accumulate in the brains of patients with the condition and will be used in addition to pen and paper cognitive tests, which often misdiagnose it in its early stages.
    Scientists leading the trial at University College London believe the blood test will improve the accuracy of diagnosis from 70% to more than 90% and want to see how that helps patients and clinicians.
    Patients will be recruited at 20 memory clinics as part of the study, which aims to see how well the test works within the NHS.
    The new blood test, which costs around £100, measures a biomarker called p-tau217, which reflects the presence of both proteins.
    Previously, the only way to confirm Alzheimer's was by specialist PET brain scans and lumbar punctures to extract cerebrospinal fluid.
    However, these "gold standard" tests are not part of routine Alzheimer's diagnosis and only 2% of patients ever receive them.
    Professor Fiona Carragher, chief policy and research officer at the Alzheimer's Society, said: "Our recent Lived Experience Survey revealed that only a third of people with dementia felt their experience of the diagnosis process was positive, while many reported being afraid of receiving a diagnosis.
    "As a result, too often, dementia is diagnosed late, limiting access to support, treatment and opportunities to plan ahead."
    Read full story
    Source: BBC News, 9 September 2025
  18. Patient Safety Learning
    Corridor care has become the new normal in England, experts have said, as a national survey found that one in five patients admitted to hospital had to wait in such settings.
    The report by the Care Quality Commission (CQC) also found that nearly 10% of patients waited more than 24 hours to be admitted to hospital and 17.5% waited 12 to 24 hours. More than half of all patients waited more than six hours.
    Nearly half waited in a treatment bay, but 18% had to wait in a corridor, 31% in a waiting room and 1%, or 361 patients, said they had to wait in a storage room or cupboard in November last year.
    The CQC’s chief inspector of hospitals, Dr Toli Onon, said trolley waits were regrettable and must not become the norm. She said it was great to see improvements since but that reports of lengthy waits and patients whose health had deteriorated was a real concern.
    “Patients should receive safe and effective care in an environment that allows for their privacy and dignity to be protected,” she said. “Corridor care must not become normalised – however, these survey results demonstrate that in some cases the short-term use of temporary escalation spaces to relieve pressure on the ambulance sector is a regrettable reality.”
    Read full story
    Source: The Guardian, 9 September 2025
    Further reading on the hub:
    Corridor care and patient safety A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift My experience of the 'Wait 45' policy How corridor care in the NHS is affecting safety culture: A blog by Claire Cox
  19. Patient Safety Learning
    The first wave of 43 areas chosen to take part in the national neighbourhood health implementation programme can be revealed.
    The places, which were selected from 141 applications, represent the first cohort of the programme, which invited bids in July.
    Successful sites were told in a letter from the national programme leads: “We had an overwhelming response to the programme and received 141 applications (approximately 83 per cent of the number of places in England).
    “It has been encouraging to see so many good examples of neighbourhood working across the country and commitment to go further, backed by senior leaders across health, care, the voluntary and community sector and their wider partners.”
    The focus of the programme will initially be on improving services for management of people with multiple conditions and complex needs. 
    Read full story (paywalled)
    Source: HSJ, 9 September 2025
  20. Patient Safety Learning
    The CEOs of seven reformed NHS regions are to be made directly responsible for “the success of the health system they manage”, according to the new “blueprint” for their future.
    The Model Regional Blueprint, obtained by HSJ,  confirms the regions will cover the same seven areas as the current NHS England regions. As NHSE is abolished, they will become part of the Department of Health and Social Care, rather than independent health authorities. 
    The blueprint, drawn up by current regional leaders alongside the DHSC and NHSE, states: “There is a need to strengthen the regional governance and leadership model. Regional CEOs will have responsibility for the success of the health system they manage, with a clear line to the CEOs of provider and commissioner organisations.”
    To strengthen regional leadership, the government plans to “create the new role of regional chair with responsibility for supporting the non-executive directors in ICBs and NHS providers in their region to put in place effective governance and operate to the highest standards”. At present, the seven teams are led by a “regional director” and have no chair.
    The new chairs will also “provide assurance to the national centre and the public by formulating an independent view on non-executive capability”, according to the blueprint. It adds: “They will be a driver of improvement, not a further structural or bureaucratic layer, and so will not be part of a board, undertake line management or hold operational responsibilities.
    “CEO and chair bilateral discussions with providers and commissioners will be particularly crucial in situations where intervention or regulatory levers are required.”
    Read full story (paywalled)
    Source: HSJ, 10 September 2025
  21. Patient Safety Learning
    The UK is falling behind other high-income countries when it comes to the diagnosis of diabetes, a new study has found.
    Just under three-quarters (74.2 per cent) of people with diabetes are estimated to have been diagnosed in the UK, compared with an average of 79.5 per cent for all high-income nations.
    In Canada, some 86 per cent of cases have been diagnosed, while diagnosis rates in the US stand at around 82.8 per cent, according to a study comparing the detection and treatment rates of diabetes in countries around the world.
    Researchers, led by academics at the University of Washington in Seattle, in the US, estimated that in 2023, some 77.5 per cent of patients aged 15 and over in western European countries had received a diagnosis.
    Among western European countries, only Switzerland and France had lower diagnosis rates than the UK.
    Researchers pointed out how complications linked to diabetes “can be averted with timely and appropriate diagnosis”.
    “We find major gaps in diagnosing, treating, and managing diabetes globally, with substantial variation between countries,” the authors of the report wrote in the journal Lancet Diabetes and Endocrinology.
    “Despite improvements over the past two decades, underdiagnosis and suboptimal glycaemic management of diabetes remain major challenges globally, particularly in low-income and middle-income countries.
    “These findings highlight the urgent need for enhanced strategies and capacity building to improve the detection, treatment, and management of diabetes worldwide.”
    Read full story
    Source: The Independent, 8 September 2025
  22. Patient Safety Learning
    New league tables rating the performance of NHS trusts in England have been published for the first time, external, with specialist hospitals taking the top slots.
    Number one is Moorfields Eye Hospital NHS Foundation Trust, followed by the Royal National Orthopaedic Hospital NHS Trust and cancer centre the Christie NHS Foundation Trust.
    At the bottom is Queen Elizabeth Hospital in King's Lynn, which has had major problems with its buildings because of structural weaknesses and the need for props to hold up ceilings.
    Health Secretary Wes Streeting said the tables would help inform the public and allow them to exercise choice - but trusts have questioned whether they were using the right metrics.
    The rankings score NHS trusts on seven different areas including waiting times for operations, cancer treatment, time spent in A&E and ambulance response times.
    Their finances are also assessed, and it is possible that a hospital rated highly for clinical care will be marked down if they are running up a larger than expected deficit.
    They are then sorted into four categories, the first of which reflecting the best performers and the last listing the worst.
    The public will be able to use the league tables check the performance of their local hospital, ambulance service or mental health trust.
    Read full story
    Source: BBC News, 9 September 2025
  23. Patient Safety Learning
    A trust has apologised after an external review into maternity failures concluded that nine neonatal deaths may have been avoidable.
    Gloucestershire Hospitals Foundation Trust announced in 2024 that its board had commissioned external reviews into deaths at its maternity services.
    This followed an “inadequate” rating from the Care Quality Commission and a subsequent BBC Panorama investigation which raised concerns over cultural and staffing issues.
    The reviews, which examined seven maternal deaths between 2017 and 2023 and 44 neonatal deaths between 2020 and 2023, found that nine of the neonatal deaths warranted further investigation due to “missed opportunities” in care that “could have potentially changed the outcome”.
    Concerns included “incomplete risk assessments” during pregnancy, particularly around reduced foetal movements, and “misinterpreting” foetal heartbeat monitoring during labour and “delaying calling for senior review”.
    Read full story (paywalled)
    Source: HSJ, 8 September 2025
  24. Patient Safety Learning
    Only 10 integrated care boards have set up a mental health crisis text service, leaving a “gap” in service provision that could risk future deaths, a coroner has warned.
    Joanne Kearsley, senior coroner for Manchester North, raised this concern in a Prevention of Future Deaths report relating to 27-year-old Jessica Smithson, who died by suicide last August. 
    During the inquest, the coroner discovered that before her death Ms Smithson, who was under the care of Pennine Care Foundation Trust, contacted Shout, a mental health crisis text message service, after making an allegation of sexual assault to Greater Manchester Police.
    Ms Kearsley noted that Shout receives 1,500 to 2,000 crisis texts per day and is contacting police forces with, on average, 28 cases per day where there is an immediate risk to life.
    The coroner found that the text crisis service did not know Ms Smithson’s name or location but had an arrangement with the Metropolitan Police, who have the power to try to locate anyone who is at “real immediate risk”.
    It was found the service did not contact the police but should have done, although Ms Smithson’s death would not have been averted even if contact was made, Ms Kearsley said.
    However, Greater Manchester ICB is one of about 30 ICBs which have not commissioned a local crisis text service, and the coroner warned that this created a “gap” across much of the country, which is being filled by more informal services run by charities. These are not connected to local healthcare providers, and have different policies if someone’s life is at risk, resulting in a “lack of consistency”. 
    The coroner warned: “As they are not linked into local NHS trusts, [these [providers] have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.”
    Read full story
    Source: HSJ, 5 September 2025
  25. Patient Safety Learning
    Women living with polycystic ovarian syndrome (PCOS) face prolonged delays in diagnosis and limited access to treatment, according to a report by a parliamentary group.
    More than a third of women with the condition had to wait longer than four years for a PCOS diagnosis, according to the report, and after diagnosis almost two-fifths (38%) of respondents were not provided with any resources.
    Published by the all-party parliamentary group on PCOS, the report consists of oral evidence sessions, a survey of more than 2,000 patients on their experiences, as well as freedom of information requests to all 42 Integrated Care Boards (ICBs) in England.
    Only 3% of patients with the condition felt supported by healthcare providers, with almost a third (28%) feeling dismissed or not taken seriously.
    “PCOS affects one in eight women and those assigned female at birth, yet for too long it has been sidelined in policy, overlooked in funding, and misunderstood in practice,” said Michelle Welsh, Labour MP for Sherwood Forest and chair of the APPG on PCOS. “This report sets out a clear and urgent case for reform. If we are serious about improving women’s health, we must act now to break the cycle,” she said.
    Stark inequalities were also highlighted by the report, with women from Black and Asian backgrounds being up to 2.5 times more likely to be diagnosed with the condition, and those from ethnic minority backgrounds more likely to present with more severe symptoms such as insulin resistance.
    Dr Itunu Johnson-Sogbetun, GP and founder of the Royal College of GPs’ Women’s Health Special Interest Group, said the report reflected “what many of us with PCOS already know from lived experience: care is fragmented, diagnosis is delayed, and long-term risks are too often ignored.”
    She said: “PCOS is a multisystem condition, yet the NHS frequently treats it narrowly as a fertility or gynaecological issue. The report rightly highlights the postcode lottery of care, the lack of national pathways, and the absence of coordinated support for the metabolic, cardiovascular, and psychological complications that come with PCOS.”
    Read full story
    Source: The Guardian, 7 September 2025

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