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Patient Safety Learning

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  1. Patient Safety Learning
    Expensive, over-the-counter hormone tests for menopause are clinically useless and risk undermining women’s healthcare, senior doctors have warned.
    The testing kits, offered by private clinics and available to buy for self-testing, claim to offer tailored insights through measuring hormone levels. But they have been described by experts as misleading and medically unnecessary.
    “There are lots of private healthcare and telehealth clinics offering tests and increasing numbers of medically untrained, self-proclaimed ‘experts’ giving advice on social media and podcasts to get these tests done,” said Dr Stephanie Sterry, who recently co-wrote an editorial for the BMJ titled Menopause Misinformation is Harming Care.
    “Unfortunately, these tests are not evidence-based,” she added. “They’re not giving us any new information or making treatment more effective. All they are doing is encouraging women to spend hundreds of pounds on tests that don’t make any difference to the treatment they should be given.”
    Read full story
    Source: The Guardian, 7 September 2025
  2. Patient Safety Learning
    The government has ordered a spending freeze and told the NHS to absorb the £300m cost of the most recent resident doctors’ strikes from existing budgets, HSJ  has learned.
    The Department of Health and Social Care has told all arm’s-length bodies to pause any uncommitted spending outside a small number of essential priorities, according to an internal NHS England document.
    The paper reveals for the first time the estimated £300m bill for July’s industrial action, which it says “cannot be easily covered”.
    It says NHSE is also preparing to impose fixed prices for commissioner-funded drugs, and offer “incentives” for local systems to spend less than planned this year, to help “support the overall NHS position”.
    The NHSE paper, written by NHSE deputy chief financial officer Nicci Briggs, states: “The resident doctors’ industrial action has introduced extra challenge that cannot be easily covered within the Spending Review settlement. Initial analysis indicates that industrial action has already cost the NHS approximately £300m.
    “It is in this context that the DHSC has introduced an admin or programme [resource department expenditure limit] (revenue) spending moratorium with immediate effect… [it] sets out that new, uncommitted spend cannot now go ahead unless it is considered an exception.”
    Read full story
    Source: HSJ, 5 September 2025
  3. Patient Safety Learning
    More than 13,000 heroin and opioid deaths have been missed off official statistics in England and Wales, raising concerns about the impact on the government's approach to tackling addiction.
    Research from King's College London, shared exclusively with BBC News, found that there were 39,232 opioid-related deaths between 2011 and 2022, more than 50% higher than previously known.
    The error has been blamed on the government's official statistics body not having access to correct data and it is understood ministers are now working with coroners to improve the reporting of deaths.
    A former senior civil servant said fewer people might have died if drug policies had been based on accurate statistics.
    The number of opioid deaths per million people in England and Wales has almost doubled since 2012, but this new study means the scale of the problem is likely to be even greater.
    Researchers from the National Programme on Substance Use Mortality at King's used data from coroners' reports to calculate a more accurate estimate of opioid-related deaths.
    Read full story
    Source: BBC News, 16 September 2025
  4. Patient Safety Learning
    Calls are being made for an immediate suspension of rectopexy bowel mesh surgery after the surgeon who pioneered the procedure was struck off.
    Bristol surgeon Tony Dixon was removed from the medical register for serious misconduct, including performing unnecessary surgeries and fabricating patient records.
    Patient safety campaigners and MPs say there is now growing concern over the credibility of his research, which underpins the procedure used to treat bowel conditions.
    Kath Sansom, founder of the patient-led campaign group Sling the Mesh, said: "The government must suspend rectopexy mesh procedures immediately and launch a full review."
    The National Institute for Health and Care Excellence there are "well‑recognised, serious but infrequent complications" with this type of surgery.
    But Ms Sansom said: "Women have suffered horrific complications - pain, mesh erosion where it slices into nearby organs and tissues, nerve damage - and many were never warned.
    "Our rectopexy members suffer some of the most horrific life-changing complications, including a high number now living with stoma bags as a result."
    Mr Dixon pioneered the LVMR (laparoscopic ventral mesh rectopexy) procedure and promoted it through a series of studies.
    But two separate tribunals found him to have performed operations on five patients without obtaining informed consent and that one of these procedures was not clinically indicated.
    They also found that he failed to provide post operative care and to have dishonestly created patient records long after he was involved in their care.
    Read full story
    Source: BBC News, 4 September 2025
     
  5. Patient Safety Learning
    Errors by machines used to diagnose diabetes mean at least 55,000 people in England will need further blood tests, a BBC investigation has discovered.
    Some patients have been wrongly diagnosed with type 2 diabetes and even prescribed medication they don't need - and there could be more people affected, say NHS England.
    NHSE has confirmed 16 hospital trusts use the machines, made by Trinity Biotech, which have produced inaccurate test results.
    In a statement, Trinity Biotech says it is working closely with the UK health regulator and has contacted all hospitals which use the machines.
    The BBC first reported in September 2024 that 11,000 patients faced re-testing after a machine at Luton and Dunstable Hospital issued incorrect diabetes results.
    NHS England now say type 2 diabetes diagnoses rose by 10,000 in 2024, 4% more than expected.
    The procedure, known as the haemoglobin A1C test, measures average blood sugar levels which are used to diagnose type 2 diabetes and monitor the condition.
    According to the medicines and healthcare regulator (MHRA), issues with the tests on these machines was first reported in April 2024.
    Read full story
    Source: BBC News, 5 September 2025
  6. Patient Safety Learning
    The US health secretary, Robert F Kennedy Jr, faced the Senate finance committee in a tense and combative hearing on Thursday, during which lawmakers questioned his remarks expressing vaccine skepticism, claims that the scientific community is deeply politicized and the ongoing turmoil plaguing the Centers for Disease Control and Prevention (CDC).
    In a hearing lasting more than three hours and ostensibly about the Trump administration’s healthcare agenda, Kennedy defended his leadership at the Department of Health and Human Services (HHS), claiming that his time at the agency will be focused on “unbiased, politics-free, transparent, evidence-based science in the public interest”.
    Senate Democrats on the committee began the hearing calling for Kennedy’s resignation. “Robert Kennedy’s primary interest is taking vaccines away from Americans,” ranking member Ron Wyden, a Democratic senator from Oregon, said in his opening remarks. “People are hurt by his reckless disregard for science and the truth in this effort. I hope the very least, Robert Kennedy has the decency to tell the truth this morning.”
    Raphael Warnock, also a Democrat, called Kennedy a “hazard to the health of the American people”, repeating calls for him to step down or for Donald Trump to fire him.
    Last week, Kennedy fired the CDC director, Susan Monarez, less than a month after she was confirmed to her position. She is now mounting a legal case challenging her removal.
    Shortly after Monarez’s termination, several leading public health officials at the CDC resigned from their positions, citing frustration with Kennedy’s approach to vaccines and his management style.
    Read full story
    Source: The Guardian, 4 September 2025
  7. Patient Safety Learning
    Thousands of pregnant women with type 1 diabetes are to be given a special artificial pancreas to reduce the risk of stillbirth and miscarriage.
    Mothers-to-be with the condition have higher risks as pregnancy hormones can make it harder for them to regulate their blood glucose levels.
    Now, expectant mothers in England will be offered a “game-changing” specialised tool to help them manage their blood glucose levels effectively.
    The new tool, also known as a hybrid closed loop system, will be offered to the 2,000 women with type 1 diabetes who fall pregnant each year.
    It will be also offered to women who have type 1 diabetes and are planning a pregnancy, NHS England said.
    The technology, which is linked to a mobile phone app, delivers the precise insulin dosages a woman requires before and during pregnancy.
    Unlike other artificial pancreases, this allows pregnant women to set a glucose target to the lower level required to achieve better outcomes in pregnancy, NHS England said.
    It also allows remote monitoring by health workers which means fewer check-ups for mothers-to-be.
    Read full story
    Source: The Independent, 5 September 2025
    Related reading on the hub:
    Diabetes tech: Do national aspirations and local practice align? Diabetes technology is life-changing, but we need to be prepared when it fails - A blog by Andrew Stroud How safe are closed loop artificial pancreas systems?
  8. Patient Safety Learning
    Less than half of England has access to tirzepatide (Mounjaro) through general practices, despite the NHS roll-out of the weight-loss jab having officially started over two months ago, The BMJ can disclose.
    Just 18 of 42 commissioning bodies across the country confirmed that they had started prescribing tirzepatide in line with NHS England’s primary care roll-out plan.
    The data, obtained through a freedom of information request, also show that, despite NHS England stating it expects 70% of eligible patients to come forward for treatment, only a fraction of integrated care boards (ICBs) have enough funding for that.
    Experts warned that the lack of funding and poor communication to the public about the roll-out were resulting in “distress and uncertainty both in patients and primary care” and had left ICBs in a difficult financial situation.
    Four ICBs reported that the NHS funding they had received covered just 25% or less of their eligible patients, with Coventry and Warwickshire faring the worst. That ICB told The BMJ it had received funding to cover just 376 patients, despite identifying 1795 eligible patients in the first year, meaning it can cover only 21% of its patients.
    Because of the large number of people who could benefit from tirzepatide—an estimated 3.4 million—and the drug’s price, NHS England and its spending watchdog, the National Institute for Health and Care Excellence (NICE), agreed that the injections would be rolled out in phases over 12 years.
    Jonathan Hazlehurst, consultant endocrinologist and academic clinical lecturer at the University of Birmingham, said that although the central funding from NHS England was “extremely welcome” the roll-out had so far been “significantly underfunded.”
    He said, “That clearly drives up distress and uncertainty both in patients and primary care and runs the risk of inequity in access to treatment, and that’s my biggest concern.”
    Read full story
    Source: The BMJ, 4 September 2025
  9. Patient Safety Learning
    One of the country’s biggest trusts has ordered a review following staff accusations of racism and bullying, including an official complaint against a board member, HSJ can reveal.
    Mike Baker, Leeds Teaching Hospitals Trust’s senior independent director, has commissioned The Employers Network for Equality and Inclusion to review its diversity and inclusion policies in response to a number of incidents.
    This review, started in June, is taking place while the trust separately investigates an official complaint of bullying and racism made against one of its directors, HSJ understands. The specific nature of the complaint against the director, who HSJ has decided not to name, is unclear.
    The complaint is among a number of issues that the trust has dealt with during the past 18 months, including staff receiving an “anonymous” email describing “distressing experiences” of employees from a minority ethnic background.
    In June 2024, an emergency department worker at one of LTHT’s hospitals was accused of unprofessional conduct for the way they responded to being racially abused on shift, and later faced disciplinary action.
    A group of more than 40 medical consultants working in the trust’s emergency departments signed a letter voicing their support for the worker, who they described as a “dedicated and incredibly well-liked team player”.
    In the letter, seen by HSJ, the consultants said the disciplinary actions faced by the worker appeared “unjust and disproportionate” given the circumstances of the incident, which raised “serious questions” about the “handling of workplace harassment and the rights of staff members to maintain their dignity and safety”.
    Read full story (paywalled)
    Source: HSJ, 4 September 2025
  10. Patient Safety Learning
    A mother who feared her two-year-old son's untreated constipation could have killed him is calling for access to children's continence services to be made a national priority.
    Elissa Novak said Ivan was constantly vomiting, losing weight and in severe pain when it was at its worst, and a doctor said 2kg of his 10kg (22lb) body weight was estimated to be stool.
    The number of children aged up to 16 admitted to English hospitals suffering with constipation, among other symptoms, is at a 10-year high, with more than 44,000 admissions in 2023-24, according to NHS figures.
    Children are being failed by the absence of dedicated bladder and bowel services in some parts of the country, an expert said.
    About 1.5 million children in the UK suffer with constipation, according to the charity Bladder and Bowel UK.
    As many children returned to school this week, charities have told the BBC they are seeing a spike in calls to their helplines.
    "It's a huge problem and many healthcare professionals don't consider it a serious issue in children," said Davina Richardson, a children's specialist nurse with the charity.
    "Discussing wee and poo is very un-British. It's not something that we as a culture do."
    Read full story
    Source: BBC News, 4 September 2025
    Related reading on the hub:
    National primary care clinical pathway for constipation in children  
  11. Patient Safety Learning
    Staff working for a scandal-hit NHS trust allegedly made "heartless" criticisms about families involved in the largest-ever maternity review and claimed relatives are taking part so they can seek compensation.
    Families also said they have been accused of grooming other affected families to join senior midwife Donna Ockenden's independent review of maternity services at Nottingham University Hospitals NHS Trust (NUH).
    The review began three years ago after allegations of harm to babies and mothers, and now involves nearly 2,500 families.
    Trust chief executive Anthony May described the alleged comments made by staff as "shocking".
    Speaking at the trust's annual meeting on Wednesday, Mr May said: "Some families very recently have fed back to me shocking examples of being stigmatised or gaslit - criticised for either being part of the independent review or for campaigning for better services.
    "Families have heard that they are criticised for being in the review, and that they are in the review on the basis that they are seeking compensation.
    "The families tell me that there are instances where they feel they have reason to believe they can trace that back to colleagues that work in NUH."
    Dr Jack and Sarah Hawkins, who both used to work for the trust until their daughter Harriet was stillborn in 2016, have been campaigning to highlight failures at NUH ever since.
    They described the comments as "horrific" and "unfathomably heartless".
    Dr Hawkins said: "We have been called 'compo seekers'.
    "There has been a comment made that people are in this group because they have been groomed by Sarah and I and other people who have been around for a long time, and that has come out of NUH.
    "We want change. We don't have any other reason to be in this fight.
    "The first thing to allow you to change is to recognise that you need to change. And if your attitude is that you don't and that we are, in fact, scamming the system in some way, then it's so disheartening.
    "We're not doing this for any reason other than babies are dying and being harmed and mums are dying and being harmed and families are being ripped apart."
    Read full story
    Source: BBC News, 3 September 2025
  12. Patient Safety Learning
    Government must deliver on its manifesto commitment to “regular, independent workforce planning” for health and social care, royal colleges and others warned Wes Streeting today.
    Some 74 health and care organisations today wrote to the health and social care secretary urging him to engage with them on his 10-year NHS workforce plan.
    It is due to be published this year but government and NHS England are yet to begin detailed discussions with the sector. 
    The government’s 10-Year Health Plan says there will be fewer staff than proposed in the 2023 long-term workforce plan. It says there will need to be more flexible working and changes to staff roles, to increase productivity – moves likely to be unpopular with some professionals.
    The wide-ranging groups that have written the letter – which include most royal colleges – warned a “robust stakeholder engagement process” was crucial if the plan is to be “thorough [and] credible”, and to get support from the sector. There should be an accompanying implementation plan, they say.
    “We remain supportive of a regularly refreshed, credible national workforce plan for the NHS with independently verified modelling,” the letter adds. “We are clear that funding will need to be attached to any priorities that the plan sets.”
    Read full story (paywalled)
    HSJ, 3 September 2025
  13. Patient Safety Learning
    High street optometrists are set to gain expanded powers to treat common and emergency eye conditions under new government proposals.
    The changes aim to shift more healthcare into community settings and alleviate pressure on general practitioners.
    Under the proposed rules, optometrists and contact lens opticians would assume a significantly broader role in diagnosing patients and prescribing essential medications.
    This includes drugs for issues such as dry eye, severe allergies, and bacterial conjunctivitis. They would be authorised to sign off on prescription-only medicines in emergencies or for prescriptions to be filled at local pharmacies.
    Among the specific medications that could be prescribed is acetylcysteine, used to manage tear film abnormalities in dry eye cases where standard treatments are ineffective.
    Dr Paramdeep Bilkhu, clinical adviser at the College of Optometrists, said: “Enabling optometrists to supply a wider range of prescription-only medicines will ensure more patients receive effective treatment for many common minor eye conditions at their local optical practice, without having to be referred to a prescriber or wait for a GP appointment.
    “If these proposals are agreed and implemented, optometrists can continue to play a key role in reducing the burden on A&E departments and GPs, who often lack the specialist ophthalmic training and equipment needed to handle most eye conditions.
    “By expanding the number of medicines that all optometrists can supply to patients, optometrists’ core skills will be better utilised to improve patient outcomes and experiences, particularly where commissioned acute eye care services are available.
    “We urge our members, all healthcare professionals and the public to support these proposals to improve eye care in the community.”
    Read full story
    Source: The Independent, 4 September 2025
  14. Patient Safety Learning
    The family of a nurse whose body was found in a river after a three-week search have said she was failed by “systemic neglect and under-resourcing in mental health services”.
    Victoria Taylor, 34, went missing from her home in Malton, North Yorkshire, on 30 September last year. Her body was recovered from the River Derwent on 22 October after an extensive search.
    The inquest into her death in Northallerton heard that Taylor struggled with alcohol and mental health problems related to a childhood trauma.
    Coroner Catherine Cundy said the trauma left “an indelible mark” on Taylor’s life “in the form of depression, anxiety and chronic feelings of worthlessness”. Recording a narrative verdict, Cundy said she could not be sure of Taylor’s intentions when she went into the river.
    In a statement issued afterwards, Taylor’s sister, Emma Worden, said she hoped the inquest would be a turning point. She said: “Vixx was a devoted mother, a loving fiancee and a fiercely loyal sister. She showed up for those she loved with warmth, humour and a deep sense of care.
    “She reached out for help. She made herself visible to services. And yet, time and again, she was failed and left without the support she needed. The failures in her care were not isolated incidents. They were part of a wider pattern of systemic neglect and under-resourcing in mental health services.
    “Vixx deserved better. She deserved to be seen, heard and supported. Instead, she was left to carry burdens alone. Her death is a tragedy, but it must also be a turning point. Let this inquest be a step toward accountability, learning and change.”
    During the daylong inquest Worden turned to representatives of Tees, Esk and Wear Valleys NHS foundation trust (TEWV) saying they were going “round in circles”. She said: “Nobody looked her in the eye and said: ‘We will help you,’ and she’s not here now because you failed her.”
    The coroner said she would be writing to TEWV and a number of other agencies with her concerns over the support Taylor was given.
    She said she found it “difficult to understand” why community mental health services repeatedly declined to offer Taylor support as her situation deteriorated during 2024.
    Read full story
    Source: The Guardian, 3 September 2025
  15. Patient Safety Learning
    Martha’s rule, which lets NHS patients request a review of their care, is now in operation in every acute hospital in England, health service bosses disclosed on Thursday.
    The system has helped hundreds of people receive potentially life-saving improvements to their treatment since its rollout began last year. It has led directly to patients being moved to intensive care or receiving drugs they needed, such as antibiotics, or benefiting from other vital interventions.
    It is named after Martha Mills, who died in 2021 at the age of 13 from sepsis after a bicycle accident. A coroner found she would probably have survived if she had been moved to the intensive care unit at King’s College hospital in London when she began deteriorating. Martha would have been 18 on Thursday if she had lived.
    Martha’s rule became available in 143 acute hospitals in England last year. But it has also been implemented in the other 67 such sites, which means all 210 acute facilities are covered.
    It gives patients, their loved ones and NHS staff the right to ask for a different medical team to examine the care being provided and recommend changes.
    NHS England’s national medical director, Prof Meghana Pandit, said it is having “a transformative impact” on how hospitals work with patients and their families when their condition is worsening.
    Read full story
    Source: The Guardian, 4 September 2025
  16. Patient Safety Learning
    Some of the NHS’s best performing trusts have a big gap between waiting times for their most and least deprived patients. 
    NHS England published data for the first time this summer which breaks down waiting times for each trust and integrated care system by the index of multiple deprivation (IMD).
    HSJ  has analysed the new data. At a national level, it confirms the widely accepted view that a greater share of patients who live in postcodes with the worst IMD ratings are waiting longer for elective care. The same applies to people with a Bangladeshi or Pakistani background, and some mixed ethnic backgrounds.
    However, HSJ’s  analysis also reveals some trusts and systems have a much bigger gap than others when it comes to the percentage of more and less deprived people waiting more than 18 weeks.
    Several of those trusts and systems with the biggest gaps serve a wealthier than average population overall, and are among the better performers nationally when it comes to treating their patients from the wealthiest areas.
    Nationally, 59.2% of patients on the elective waiting list who are living in postcodes in the most deprived IMD decile (1) have been waiting within the national target time of 18 weeks. This compares to 60.9% of those living in areas earmarked as belonging to the wealthiest decile (10) – a gap of 1.7 percentage points.
    Read full story (paywalled)
    Source: HSJ, 4 September 2025
  17. Patient Safety Learning
    An AI assistant has allowed NHS staff to spend nearly 25 % more of their time interacting with patients, a trial has found.
    The technology, known as Tortus, transcribes consultations automatically and produces summaries for medics to review.
    Tortus uses so-called ambient voice technology, a mix of speech recognition and artificial intelligence, to pick up relevant medical information from a conversation, while filtering out background noise and irrelevant chat.
    The study found the platform helped increase direct interaction between patients and clinicians by 23.5% during appointments.
    It also reduced the overall length of appointments by 8.2%.
    Health minister Stephen Kinnock, said: “This is exactly the kind of innovation we need as we work to build an NHS fit for the future and end hospital backlogs.
    “By freeing up clinicians from administrative burden to spend more time with patients, we’re not just improving efficiency, we’re enhancing the human connection that sits at the heart of great healthcare.”
    Read full story
    Source: The Independent, 4 September 2025
    Related reading on the hub:
    Balancing promise and risk: AI hallucinations, confabulations and omissions in healthcare Patient safety and the role of AI in a cautiously optimistic future: A blog by Ian Fearnley New AI system to identify patient safety issues announced: Patient Safety Learning’s initial reflections
  18. Patient Safety Learning
    Kathryn Wheeler can't remember where she was when her TikTok feed showed her a video of a woman holding her stillborn baby, but she remembers how she felt. "At first, it appeared like any other video of a woman holding a newborn. It was tightly wrapped in blankets while she cradled it in her arms. She was crying, but so are most of the women in these post-birth videos. It wasn’t until I read the caption that I realised what I was looking at. Her baby had been delivered at 23 weeks. I was 22 weeks pregnant. I felt doomed," she says.
    Her social media algorithms knew she was pregnant before family, friends or her GP. Within 24-hours, they were transforming her feeds.
    "On Instagram and TikTok, I would scroll through videos of women recording themselves as they took pregnancy tests, just as I had done. I “liked”, “saved”, and “shared” the content, feeding the machine, showing it that this is how it could hold my attention, compelling it to send me more. So it did. But it wasn’t long before the joy of those early videos started to transform into something dark."
    The algorithm began to deliver content about the things you fear the most while pregnant: “storytimes” about miscarriages; people sharing what happened to them and, harrowingly, filming themselves as they received the news that their baby had no heartbeat. Next came videos about birth disfigurements, those found by medical professionals early on, and those that were missed until the baby’s birth.
    On TikTok, there are more than 300,000 videos tagged under “miscarriage”, and a further 260,000 under “miscarriageawareness”. One video with the caption “live footage of me finding out I had miscarried” has almost half a million views. Another showing a woman giving birth to a stillborn baby has just under five million.
    For Dr Christina Inge, a researcher at Harvard University specialising in the ethics of technology, these experiences are not surprising. “Social media platforms are optimised for engagement, and fear is one of the most powerful drivers of attention,” she says. “Once the algorithm detects that a person is pregnant, or might be, it begins testing content – the same as it does with any other information about a user. If a user lingers on an alarming video on pregnancy, even if just for a second, that is interpreted as interest. The system then feeds you more of the same.
    “Distressing content isn’t a glitch; it’s engagement, and engagement is revenue,” Inge continues. “Fear-based content keeps people hooked because it creates a sense of urgency; people feel they need to keep watching, even when it’s upsetting. The platforms benefit financially, even as the psychological toll grows.”
    The negative effect of social media on pregnant women has been widely researched. In August, a systematic review into social media use during pregnancy considered studies from the US, the UK, Europe and Asia. It concluded that while social media can offer peer-to-peer advice, support and health education, “challenges such as misinformation, increased anxiety and excessive use persist”. The review’s author, Dr Nida Aftab, an obstetrician and gynaecologist, highlights the role healthcare professionals should play in helping women make informed decisions about their digital habits.
    Read full story
    Source: The Guardian, 3 September 2025
  19. Patient Safety Learning
    Scotland remains the drugs death capital of Europe for the seventh year in a row despite a 13% fall in fatalities, official figures suggest.
    There were 1,017 drug misuse deaths in 2024, external, down 155 from the previous year.
    National Records of Scotland said the latest figure was the lowest annual number since 2017. It brings the total in a decade to 10,884.
    After adjusting for age, there were 191 drug misuse deaths per million people in Scotland in 2024.
    According to the most recent European data, the next highest rate was Estonia with 135 deaths per million in 2023.
    Scottish Drugs Minister Maree Todd said the fall in deaths was welcome but that there was "still work to be done".
    Experts say they are concerned about the potential for deaths to increase again this year.
    Kirsten Horsburgh, chief executive of the Scottish Drugs Forum said the recent arrival of deadly synthetic opioids known as nitazenes was "a crisis on top of a crisis."
    Suspected deaths early in 2025 "are already higher than they were last year, external" she said.
    Read full story
    Source: BBC News, 1 September 2025
  20. Patient Safety Learning
    People with learning disabilities and autism in England are dying almost 20 years younger than the rest of the population, a long-awaited report has said.
    The annual mortality review commissioned by NHS England, external was originally meant to be published last year but faced repeated delays.
    It found 39% of deaths of people with learning disabilities and autism were classed as avoidable in 2023, almost twice as high as the general population.
    NHS England said it was rolling out more training for staff and identifying patients with learning disabilities earlier so they can be given more appropriate care.
    The charity Mencap says about 1.5 million people in the UK have a learning disability which it defines as a lifelong reduced intellectual ability, usually identified soon after birth or in the early years.
    The Learning Disabilities Mortality Review (LeDeR) was created in 2015 to try to understand why so many in that group were dying younger than the wider population and from avoidable causes.
    The latest research, led by a team at King's College London, looked at data from the deaths of 3,556 adults in 2023 and compared it to previous years.
    It found that while there had been some improvements, with life expectancy increasing slightly to 62.5 years old, those with learning disabilities and autism were still experiencing significant inequalities.
    "These stark new figures show people with a learning disability are dying a shocking 19.5 years younger than the general population," said Mencap's chief executive Jon Sparkes.
    "People with a learning disability and their families deserve better. In this day and age, no one should die early because they don't get the right treatment."
    Read full story
    Source: BBC News, 2 September 2025
  21. Patient Safety Learning
    When Pippa Dungey went to her GP suffering from numbness in both her legs last year, she was told she faced a waiting list of 10 months for specialist neurology services.
    Two months later, the 25-year-old trainee solicitor, from southeast London, ended up in A&E unable to walk.
    Ms Dungey first went to see her doctor in September last year and was referred to a neurologist, but warned to expect a long wait for an appointment.
    As she waited, her symptoms worsened, and eventually they became so bad she was unable to lift her right leg and forced to drag it around.
    She sought help from A&E and her GP, but was turned away and told she would have to wait for her neurology appointment.
    But eventually she was forced to go back to A&E, where she was admitted for a week and unable to walk and was later diagnosed with multiple sclerosis (MS).
    Ms Dungey said: “By November I was really concerned. I couldn’t lift my right leg and was just dragging it around, which was really scary. I felt like I’d been hung out to dry and didn’t know who to turn to. Everyone was telling me that they couldn’t do anything. I even tried to go privately, I was exhausting every avenue and didn’t know what to do."
    Ms Dungey was one of the hundreds of thousands of people waiting for NHS neurology services - 6,175 of whom have been waiting for more than a year.
    Charity the MS Society has warned people living with MS were waiting an average of five months for their first neurology appointment in 2023-24, a 65 per cent increase on the average wait time in 2019-20.
    The charity have warned MS patients left waiting are at risk of “irreversible disability” and have said the government has so far overlooked neurological conditions in its 10 year plan.
    Read full story
    Source: The Guardian, 3 September 2025
  22. Patient Safety Learning
    NHS England has warned integrated care boards it is “not acceptable” to set “minimum waiting times” of more than 18 weeks for elective care.
    The warning follows proposals by several ICBs to set minimum waiting times above the 18-week statutory target. One system proposed a 28.5-week minimum wait for some procedures.
    In an official briefing for NHS leaders, NHSE elective chief Mark Cubbon said: “I’m aware that some ICBs have set minimum waiting times above 18 weeks. This is not acceptable, given our commitment to the constitutional standard.
    “These ICBs have been asked to urgently review their approach and work with providers to ensure patients can be treated sooner.”
    The introduction of minimum waiting times prompted concerns from patient and clinical groups, who warned patients were facing “unnecessary pain”. The Nuffield Trust said the proposals gave “no clear process” to ICBs on how to ration funding and that this “will lead to inequity and undermine public trust in the NHS”.
    Royal College of Surgeons vice president Frank Smith said: “It is deeply concerning that some ICBs have set minimum waits above 18 weeks. It is right NHS England intervenes, but this is another symptom of the NHS under severe strain.”

    The Independent Healthcare Providers Network CEO David Hare said: “It is hard to see how minimum waits set even below [18 weeks] will support the government’s elective recovery targets and clear commitments to supporting and promoting patient choice.
    “We know that many patients value the option of choosing a provider with a short waiting time and that a degree of contestability in the system drives up efficiency and productivity.”
    Read full story (paywalled)
    Source: HSJ, 3 September 2025
  23. Patient Safety Learning
    A California couple are suing OpenAI over the death of their teenage son, alleging its chatbot, ChatGPT, encouraged him to take his own life.
    The lawsuit was filed by Matt and Maria Raine, parents of 16-year-old Adam Raine, in the Superior Court of California on Tuesday. It is the first legal action accusing OpenAI of wrongful death.
    The family included chat logs between Adam, who died in April, and ChatGPT that show him explaining he has suicidal thoughts. They argue the programme validated his "most harmful and self-destructive thoughts".
    In a statement, OpenAI told the BBC it was reviewing the filing.
    "We extend our deepest sympathies to the Raine family during this difficult time," the company said.
    It also published a note on its website on Tuesday that said "recent heartbreaking cases of people using ChatGPT in the midst of acute crises weigh heavily on us". It added that "ChatGPT is trained to direct people to seek professional help," such as the 988 suicide and crisis hotline in the US or the Samaritans in the UK.
    The company acknowledged, however, that "there have been moments where our systems did not behave as intended in sensitive situations".
    The lawsuit, obtained by the BBC, accuses OpenAI of negligence and wrongful death. It seeks damages as well as "injunctive relief to prevent anything like this from happening again".
    According to the lawsuit, Adam began using ChatGPT in September 2024 as a resource to help him with school work. He was also using it to explore his interests, including music and Japanese comics, and for guidance on what to study at university.
    In a few months, "ChatGPT became the teenager's closest confidant," the lawsuit says, and he began opening up to it about his anxiety and mental distress.
    By January 2025, the family says he began discussing methods of suicide with ChatGPT.
    Adam also uploaded photographs of himself to ChatGPT showing signs of self harm, the lawsuit says. The programme "recognised a medical emergency but continued to engage anyway," it adds.
    Read full story
    Source: BBC News, 27 August 2025
  24. Patient Safety Learning
    Doctors have raised the alarm about high levels of vaping among children worldwide, saying they are convinced e-cigarettes are causing irreversible harm to their health.
    Cardiologists, researchers and health experts said they were “extremely concerned” about the harmful effects of e-cigarettes on millions of teenagers and young people, including exposure to toxins and carcinogens – some of which are still unknown.
    Nicotine levels in e-cigarettes can be very high, raising the risk of addiction and injury to the developing brains of adolescents. Children are also risking long-term cardiovascular effects as a result of vaping at school and college, experts say.
    Speaking at the European Society of Cardiology (ESC) annual congress in Madrid, the world’s largest heart conference, Prof Maja-Lisa Løchen, a senior cardiologist at the University hospital of North Norway, said she was concerned that millions of children could face ill health in future.
    She said: “I worry that vaping may be causing irreversible harm to children’s brains and hearts. Of course we have to wait for long-term data, but I am concerned. It increases your blood pressure, your heart rate, and we know that the arteries become more stiff.”
    Also speaking in Madrid, Prof Susanna Price, a consultant cardiologist at Royal Brompton hospital in London and the chair of the ESC advocacy committee, said: “We are seeing an increase in children vaping but what we don’t yet know is what that translates to in long-term cardiovascular risk because they haven’t been around long enough.
    “I think there is a push to suggest that vaping is safe but we don’t know that. It’s my concern that we’re going to replace one highly addictive substance with another one that may have a similar profile with respect to cardiovascular risk.”
    Read full story
    Source: The Guardian, 1 September 2025
  25. Patient Safety Learning
    Concerns have been raised that plans to cease funding for the body which develops clinical information standards for health and social care could stall digital ambitions in the 10 year health plan.
    Digital Health News has learned that the contract for the Professional Record Standards Body (PRSB), which was founded in 2013, will not be renewed when it ends in December 2025 because NHSE intends to develop and maintain clinical standards in-house.
    In a statement on behalf of its members, PRSB said: “We believe that removing independent clinical and technical expertise and dis-establishing a trusted, cross-sector community network will reduce the momentum behind digital transformation, and the consequences will be felt across the health and care system, by doctors and nurses, allied health professionals, social care professionals and, most importantly, by patients and service users.”
    It adds: “If it ceases to exist, we risk losing both critical capability and the hard-won trust that underpins successful, joined-up digital care for the 10 year plan.”
    PRSB is writing to the Department of Health and Social Care (DHSC) to see if it would be willing to fund the organisation going forward.
    Oliver Lake, chief executive of PRSB, told Digital Health News: “Our widely implemented standards, backed by clinical expertise and strong partnerships across the sector, are helping to improve patient records and patient safety.”
    He added that despite uncertainties around funding, PRSB hopes to “work collaboratively with NHSE and the DHSC to improve data quality”.
    Read full story
    Source: Digital Health News, 1 September 2025

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