Patient Safety Learning
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EventAny staff with responsibility for implementing the duty of candour and/or PSIRF and those responsible for quality; safety; clinical governance; safety investigations; complaints; CQC compliance; or patient experience/ involvement would benefit from attending this one-day training. The course will provide participants with an in-depth knowledge and understanding of how to not only comply with the duty of candour and the Patient Safety Incident Response Framework (PSIRF), but to do so in an emotionally intelligent way, with empathy and compassion for all involved. Practical guidance on complying with the regulations and guidance The “grey areas” and what people most often get wrong Using emotional intelligence to understand the difficult emotions experienced by patients/those closest to them and staff following patient safety incidents What empathy and compassion mean in practice Handling difficult and emotive conversations well Making a meaningful apology How Duty of Candour and PSIRF work alongside other policies and procedures including complaints; litigation; Martha’s Rule and the soon to be introduced “Hillsborough Law” How the new “Harmed Patient Pathway” can help you get it right 7 How to ensure communication moves beyond compliance and frameworks but remains emotionally intelligent and personal Register hub members receive 20% discount. Email [email protected] for discount code.
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EventA clear, factual walkthrough of what happened, where, and when — and how a patient safety concern became blurred, delayed, and distorted by a disciplinary process. Delegates will explore the key lessons from the NHS internal investigation and the emerging recommendations from the Thirlwall Inquiry, with a focus on whether similar vulnerabilities exist within their own Trust. What to expect: The Key Facts: What Happened, Where, and When How a Patient Safety Issue Was Blurred by a Disciplinary Investigation Key Lessons from the NHS Internal Investigation Key Lessons & Recommendations from the Thirlwall Inquiry Could This Happen in Your Trust? Who should attend? This course is open to Board members, Senior leaders, Patient Safety Specialists, Triumvirates, Safety and Governance Teams. Register hub members receive a 20% discount. Email [email protected] for code.
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EventThis practical masterclass introduces statistical process control in a clear, accessible and confidence-building way. Participants will learn how to understand variation, choose the right chart, interpret signals, avoid common mistakes and use SPC to support better improvement, assurance and decision-making. Healthcare teams are surrounded by data, but data alone does not lead to better decisions. Many services still rely on red, amber and green ratings, two-point comparisons, averages, rankings and narrative explanations that can obscure whether performance is genuinely changing. Statistical process control (SPC) offers a more useful way to understand variation over time, distinguish signal from noise, and decide when action is needed. This masterclass will demystify SPC for all attendees. It will explain the core concepts in plain language, using practical healthcare examples rather than mathematical theory. Participants will learn why plotting data over time matters, how common cause and special cause variation affect decision-making, when to use run charts, along with other chart types, and how to interpret process limits and rules for special cause variation. The session will link SPC to national expectations around improvement, productivity, quality, safety, operational performance and better use of data. It will support participants to move beyond simply producing charts towards using SPC as a practical tool for learning, improvement, assurance and leadership conversations. By the end of the masterclass, participants will be able to use SPC more confidently in improvement projects, service reviews, board reports and day-to-day management. This masterclass is aimed anyone who wants to use data for improvement and performance more effectively, including clinicians, operational managers, service managers, analysts, transformation leads, quality and safety teams, and executives and board members. It is particularly relevant for people who: Regularly review performance, quality, safety, access, flow, workforce or patient experience data; Support improvement projects or transformation programmes; Need to understand whether changes are leading to real improvement; Want to avoid overreacting to normal variation or missing important signals; Are involved in reporting data to teams, committees, executives or boards; Are new to SPC or have used charts but want greater confidence in interpretation. No advanced statistical knowledge is required. The session is designed for people who want SPC explained clearly, practically and without unnecessary jargon. Register hub members receive a 20% discount. Email [email protected] for code.
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News article
The United States government’s decision to block a major global declaration on pandemic preparedness “severely weakens” the effort, and signals intent to disrupt international cooperation, says Prof Lawrence Gostin, a leading expert on global health law from Georgetown University. The United Nations general assembly had been due to adopt a political declaration on pandemic prevention, preparedness and response on 25 September after a high-level meeting on the subject. The document would have seen countries agree to work together in solidarity to tackle global health threats and express concerns that the world remains unready to deal with future pandemics. However, the US delegate said it was “not in a position” to support the text, blocking its adoption by consensus – the UN process whereby negotiated documents are assumed to be agreed unless there is an objection. Dr Erica Schwartz, the director of the Centers for Disease Control and Prevention, said critical issues remained unresolved, referring to “the inclusion of divisive ideologies that lack definitional consensus” and references within the document to ongoing, WHO-led negotiations over the fair sharing of vaccines and drugs between countries in any future pandemic. It is understood that the Trump administration was unhappy with mentions of equity and universal access to sexual and reproductive healthcare services. Earlier this year, President Trump signed executive orders expanding a “global gag” rule that bans US aid recipients from work related to abortion to also include bans on diversity, equity and inclusion initiatives and what it called “gender ideology”. Read full story Source: The Guardian, 28 September 2026 -
EventJoin THIS Space 2026 to explore what works in healthcare improvement and innovation, what doesn’t, and why. Discover the latest evidence, share learning and connect with others committed to improving the quality and safety of healthcare. Evaluating AI for the NHS is there a better way? Patient and public involvement in digital transformation. Transgressive behaviour as a patient safety challenge. Improving governance of evaluation. Improving healthcare inclusively. ...and much more! Register
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News article
The winners of the HSJ Patient Safety Awards 2026 were announced last night, recognising outstanding efforts to make care safer. This year’s event attracted 427 entries, with 217 shortlisted across 25 categories. Categories included the Improving Medicines Safety Award, the Urgent and Emergency Care Safety Initiative of the Year, the Maternity, Midwifery and Neonatal Safety Initiative of the Year, and Patient Safety Team of the Year. The 25 awards span three broad areas: clinical and specialist excellence, organisation-wide change, and service and system innovation. They also include awards for digital clinical safety, surgical care, the use of data and analytics, and patient involvement. Opening the event, HSJ editor Alastair McLellan said patient safety had returned to the top of the health agenda over the past year, but warned the debate had focused overwhelmingly on maternity services. He said safety in emergency departments and acute wards was receiving less attention, with debate instead dominated by access and waiting times. He noted that long accident and emergency department waits, particularly those of more than eight hours, were strongly associated with increased mortality. Mr McLellan also praised those shortlisted for achieving improvements despite the pressures facing the NHS. He said work to prevent patient harm was not always welcomed amid unprecedented demand and the drive to recover performance, adding that the finalists’ achievements showed “what is possible in even the most unpromising situations”. Read full story (paywalled) Source: HSJ, 29 September 2026 -
News article
Hospitals are being hit by shortages of key drugs used to provide pain relief, prevent blood clots and tackle high blood pressure. Dozens of NHS trusts in England have encountered scarcities of aspirin, the painkiller co-codamol – a combination of paracetamol and codeine – and ramipril, a blood pressure tablet. Nine trusts have had problems getting enough supplies of two of those three common medications, while one ran short of all three. The shortages underline how precarious the health service’s supply chains for basic medicines have become in recent years as a result of trade disputes, global conflict and manufacturing problems. Pharmacists have said supply problems have become a “national crisis” and in some cases have left patients unable to access their usual medications for weeks at a time. Hospitals’ drug supply problems have emerged in freedom of information requests by Dr Rodolfo Catena, an expert in global health supplies at University College London, about stock levels of the three drugs. Sixty of the 184 trusts from which he sought figures responded. The most widespread shortage involved aspirin, which is used to reduce pain and the risk of blood clots. Twenty-six (62%) of the 42 trusts that responded about it had experienced disruption to their supplies between last December and March this year. Thirteen (31%) of the 42 trusts that replied on co-codamol had run short of that drug, which helps relieve muscle pain, period pain and toothache. York and Scarborough NHS trust’s supplies had been disrupted since May 2025, and Royal Wolverhampton NHS trust had trouble getting enough co-codamol for the 10 months between October 2025 and August this year. Read full story Source: The Guardian, 29 September 2026 Related reading on the hub: Creon shortages: “It’s just another thing patients with cystic fibrosis could do without” Medication supply issues: A pharmacist’s perspective Medicines shortages: minimising the impact on patients (a blog by Catherine Picton) -
Content Article
Healthcare professionals frequently collect patient safety data, but many lack the knowledge and structured processes needed to interpret these data and translate findings into meaningful improvement actions. This gap results in underutilised opportunities to identify risks, apply evidence-based interventions, engage interdisciplinary teams, and measure impact. Addressing this gap helps the healthcare team more effectively use data to guide patient safety and quality improvement efforts. In this recorded webinar from the Patient Safety Authority, Andrea Atkinson, BSHCA, RRT, director of quality management; Christy Kitta, BSN, RN, quality and patient safety officer; and Ziad Dimachkie, MD, chief medical officer, all from Uniontown Hospital: Describe how patient safety data could be transformed into actionable insights to improve patient safety outcomes. Identify key sources of patient safety data and explained how each contributed to understanding safety gaps. Recognize strategies for engaging interdisciplinary teams and leadership in data‑informed patient safety improvement efforts. -
Content Article
The Sick List is a range of practical guides, made by patients, to help hospital stays, treatment days and recovery at home more comfortable and less stressful. The guides covers things from what eye masks help to actually block out hospital lights, to toiletries that will protect your dignity, to the random things no one tells you to pack in your bag but make a huge difference. If you're a patient about to go into hospital, or you know someone who is and would like to support them practically, this resource can really help. -
Content Article
Dominic Shadbolt, founder of PatientSignal and an multiple sclerosis (MS) patient of 35 years, has published a number of blogs on his Substack on AI in healthcare. -
News article
NHS England’s patient safety chief has said the service is having to “battle against a narrative” that it has not improved safety. Aidan Fowler, NHSE’s national director for patient safety, told HSJ’s Patient Safety Congress in Telford today that the narrative, which he described as “really challenging”, “sometimes says we haven’t made progress on patient safety when we know we have”. He said ministers had “understandably” wanted to suggest “everything that happened [during] the last government was terrible, and that includes some of the work that people here have done”. Dr Fowler said there “has been progress”, but this meant they “have to keep restating that, making the argument again”, which could “feel like quite hard work”. The NHS Patient Safety Strategy was launched in 2019, and the new NHS quality strategy published this summer suggested it would need another refresh in the near future. Dr Fowler admitted that some of this work, which has included changing the way the NHS responds to incidents through the Patient Safety Incident Response Framework, “is not very sexy”, so people have not heard about it. He added: “I get that if you try and explain to all our patients what PSIRF is, they’re going to struggle with [it], I understand that. “But I think that stuff has been foundational and important. We’ve created some bits of work that I think are really important, and we have made a difference.” The national director also stressed there was “of course much more to do”, and that improvement was a “continuous process”. Read full story (paywalled) Source: HSJ, 28 September 2026 -
EventHealthcare is delivered through complex and constantly changing systems. Staff make difficult decisions while managing high workloads, interruptions, time pressures, new technology and competing demands. Human factors enables organisations to examine how these conditions interact with people, tasks, equipment, environments and organisational processes — and to redesign care so that safe practice is supported rather than dependent on individuals overcoming weaknesses within the system. The conference will also consider the growing human factors implications of electronic patient records, automation, ambient documentation and artificial intelligence. While digital technology can improve safety, productivity and access to information, poor usability, alert fatigue, automation bias and disrupted workflows can introduce new risks. Safe implementation requires technology to be designed around patients and staff, with frontline users involved in its design, testing and evaluation. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/a-practical-guide-to-human-factors-in-healthcare or email [email protected]. Follow the conference on X @HCUK_Clare #HumanFactors hub members receive a 20% discount. Email [email protected] for discount code.
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EventThis National Summit focuses on improving NHS complaints handling and supporting services to implement, embed and evidence adherence to the PHSO NHS Complaint Standards. The conference takes place at a critical time for complaints reform. The 10 Year Health Plan for England is clear that the NHS complaints procedure is far from where it needs to be, and commits to updating complaints regulations, setting clearer standards for the timeliness and quality of responses, improving response times, and increasing the use of AI tools to support faster collection and response to complaints data. For more information https://www.healthcareconferencesuk.co.uk/virtual-online-courses/nhs-complaints-summit or email [email protected]. hub member receive a 20% discount. Email [email protected] for discount code. Follow the conference on X @HCUK_Clare #NHSComplaints
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News article
A coroner has issued an urgent warning that the failure to implement an emergency cardiac pathway could result in more deaths. Malcolm Budd, aged 65, was admitted to Royal Derby Hospital, part of University Hospitals of Derby and Burton Trust, in February with a suspected aortic dissection. This is a medical emergency in which a tear happens in the inner layer of the aorta, the body’s main artery. For a severe ‘Type A’ dissection – which requires emergency surgery – mortality increases by up to 2 per cent each hour without treatment. However, Mr Budd was not transferred to the specialist cardiac centre at Glenfield Hospital, part of University Hospitals of Leicester Trust, until almost 8.30pm, eight hours after he was first admitted to Royal Derby. NHS England published a Standard Operating Procedure and a toolkit which aimed to standardise and improve aortic dissection pathways in 2022. This has been implemented in other parts of the country but not the East Midlands. Dianne Hocking, assistant coroner for Leicester City and South Leicestershire, has now issued a Prevention of Future Deaths (PFD) notice in relation to this issue. The PFD was issued before the inquest into Mr Budd’s death begins next month due to the urgency of the coroner’s concerns. Read full story (paywalled) Source: HSJ, 28 September 2026 -
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A Pre-Inquest Review Hearing took place on the 21 July 2026 which heard that Mr Budd died on the 24 February 2026 aged 65 years. He was admitted to the Royal Derby Hospital on the 24 February 2026 at 12:26. He presented with sudden onset left sided jaw pain which radiated to the occipital region and thoracic spine. Suspecting aortic dissection or subarachnoid haemorrhage a CT scan was requested along with a D Dimer at 15:55. He was diagnosed with an aortic dissection following CT scan at 17:45 (reported at 18:03). There was discussion between the Year Two Foundation doctor and the on call cardiac surgeon in Derby. University of Hospital Nottingham cardiac team were contacted who confirmed that they were unable to deal with this type of surgery and Derby was advised to contact Glenfield who agreed to have Mr B admitted for surgery. Adult Critical Care Co-Ordination and Transfer Service (ACCOTS) was contacted and transferred Mr B to Glenfield Hospital, Leicester, arriving at 20:26 in ventricular fibrillation from which he could not be recovered and died at 20:45 despite resuscitation attempts. -
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This report explores the experiences of Black women who experienced mental health difficulties during pregnancy and after birth, and what happened when they needed support. These findings come from the mental health questions included in the 2025 Five X More Black Maternity Experiences Survey. It looked specifically at the experiences of 527 Black women who reported experiencing mental health difficulties, to better understand their experiences of accessing support and receiving care. Free registration required to access this report. -
News article
A friendly chat with your GP about your life, health and happiness was once a key part of the UK’s family doctor service. But most GPs no longer have time to have pastoral conversations, because they are too busy dealing with the country’s rising tide of illness, research reveals. Three out of four family doctors are now too time-pressed to talk to patients in depth about how they might stop smoking, lose weight or get more sleep, the Royal College of GPs has found. Intense demands and 10-minute appointment slots mean they also miss opportunities to discuss taking more exercise or review their medications to see if they still need to be on them. An RCGP survey of 2,316 GPs across the UK found that 75% had too little time to offer preventative healthcare, such as offering lifestyle advice and giving advice on vaccinations. The results have raised concern about the government’s drive for the NHS – especially GPs – to do more to prevent people getting ill in the first place. One health expert called them alarming. The college’s president, Prof Victoria Tzortziou Brown, who is a GP in east London, said: “General practice is dealing with enormous demand, so in a busy consultation we inevitably have to prioritise the problems that most need our attention that day. “We will always act on symptoms or findings that need investigation or treatment. What can be squeezed out is the time to step back and look more holistically at how we can help that patient stay well in the long term. “That might mean having a proper conversation with someone who smokes. We will of course advise patients about stopping smoking. But in a busy consultation there may not be enough time to explore in depth whether they want to stop, what has made it difficult in the past, what concerns they have and what support or treatment might work best for them. “It is often the depth of those conversations, rather than simply identifying a risk and giving brief advice, that requires time.” Read full story Source: The Guardian, 27 September 2026 -
News article
Ten NHS staff have been removed from duty or suspended after a data breach involving the digital medical records of three-year-old Noah Woods. Launching an "urgent" investigation, Dr Martin Mansfield, deputy chief medical officer at East Suffolk and North Essex NHS Foundation Trust, said that any unauthorised access of patient data was "completely unacceptable". The trust has apologised "unreservedly" to Noah's family and said disciplinary action would be taken if needed. A major search for Noah was carried out in the village of Brantham, Suffolk, after the child went missing on 15 September. His body was found the next day in a nearby pond by police divers. A spokesperson for the trust said 10 employees had been "removed from active duty or suspended whilst investigations are concluded". It comes after Sir Jim Mackey, the chief executive of NHS England, wrote to every trust on Friday, ordering stronger measures to tackle data breaches. "We have seen too many cases of people abusing that trust, and enough is enough," said Sir Jim. "Anyone who thinks they can satisfy their curiosity by looking at a patient's record should know this: they will be found out, they may lose their career and could end up with a criminal record." Read full story Source: BBC News, 27 September 2026 -
Content Article
The General Optical Council (GOC) commissioned Shift Insight to carry out research to explore how commercial practices in primary eye care may affect patient safety, patient experience and the working lives of individual registrants. This work forms part of the GOC’s wider thematic review of commercial practices and patient safety. The research focused on four areas identified by earlier GOC work: booking practices (including overbooking, rolling clinics and ‘ghost clinics’) short sight test times sales targets and incentives price transparency. Fieldwork involved in-depth interviews with four stakeholder groups: Individual registrants – optometrists and dispensing opticians Business registrants – owners, directors and practice managers of GOC-registered optical businesses Non-registered eye care staff – for example, optical assistants Patient representative organisations – Healthwatch, Royal National Institute of Blind People (RNIB), Thomas Pocklington Trust, SeeAbility and Glaucoma UK. -
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This HSJ article argues that the key lesson from the Thirlwall Inquiry is not simply about accountability for individuals, but about the NHS's repeated failure to properly investigate patient harm when warning signs emerge. The Thirlwall Inquiry exposes a fatal failure to investigate harm. Rebuilding patient safety requires truth, not scapegoating. -
Community PostThis Human Rights Day (10 December), INQUEST wants to deliver 100 handwritten letters to the Prime Minister calling for an urgent action plan to establish a National Oversight Mechanism. The families we work with all have different journeys in the search for truth and accountability. But they agree: the most important thing is to stop what happened to them happening to anyone else. Too often lessons identified after deaths and disasters do not result in necessary, life-saving change. INQUEST need your help to write, post or hand-deliver 100 letters that make that show why this campaign cannot be ignored. Find out more about how to get involved: https://lnkd.in/e4Xx92DY
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News article
The BMA has published a series of “disturbing” reports warning that patient safety is being repeatedly put at risk when those patients are looked after by less-qualified advanced practitioners (APs,) rather than doctors. Earlier this year the BMA revealed that nearly three quarters of doctors reported that advanced practitioners, staff who originally trained as nurses, paramedics, pharmacists, midwives or other professional roles, are routinely replacing doctors in their workplaces. In FOI responses to the BMA, half of hospitals in the UK admitted to using advanced practitioners to cover doctor rota gaps and including these staff on doctors’ rotas. The BMA believes this places staff without the necessary medical training in difficult and inappropriate positions with clear risks to patient safety. With concerns rising over the deployment of advanced practitioner roles, the BMA launched a new tool in January for doctors to share their experiences directly. Doctors have since reported hundreds of patient safety incidents. These include a case where an advanced practitioner failed to arrange vital testing and referral for a child with meningitis and another in which advanced practitioners missed a cancer diagnosis, resulting in a patient “losing out on 6 weeks of time to get her affairs in order before dying.” Responding to the accounts now made public, Dr Tom Dolphin, chair of BMA council, said: “These are shocking accounts of patients being let down by the system. Patients are being put at risk of harm or even death because hospital managers are putting advanced practitioners and others into roles that should be filled by doctors, as this report and multiple inquests suggest. "We have made clear, over and over, that there are times when patients must be seen by a doctor and this testimony lays out why in extensive, excruciating detail. Patients with missed diagnoses, patients with severe conditions given nothing but mild pain relief and sent on their way, and patients facing end of life conditions being offered totally substandard care: they all deserved so much better Read full story Source: BMA, 22 September 2026 -
Content Article
Advanced Practitioners (APs) are healthcare professionals deployed in a variety of heterogeneous roles around the NHS; they bring skills and knowledge from their various background professions to their work, and patients can benefit from that experience in the right role. The healthcare team benefits from different perspectives and skill sets being present. However, around the NHS there is wide variation in how AP roles are designed and deployed, what the staff in those roles are expected to do, and who regulates them. The medical profession is increasingly concerned that some APs are being asked to do things that only doctors should be doing. This blurring of roles is often driven by understaffing of medical rotas or misunderstanding of what different professions are for. It leads to risks to patients where critical decisions and interventions that should be made by a doctor are made by others. In response to growing concerns within the medical profession about how NHS employers are utilising and deploying advanced practitioners, the BMA launched a new reporting system in January 2026 to understand its depth and breadth. In April a series of Freedom of Information requests by the BMA revealed that half of hospitals in the UK deployed advanced practitioners to cover doctor rota gaps and included these staff on medical rotas. Those who admitted to directly replacing doctors with differently qualified staff told the BMA, in a series of admissions, that this practice should no -
Content Article
A report commissioned by the Royal College of Nursing warns that England is at risk of repeating a damaging cycle of nursing workforce shortages because of poor long-term planning, stagnant domestic training numbers and a sharp fall in international recruitment. While NHS nurse numbers grew strongly between 2015 and 2025, much of that increase was driven by overseas recruitment, which has now dropped significantly, raising concerns about future staffing levels. Nick Kituno argues that achieving the government's ambition to reduce reliance on international recruits will require sustained investment in nurse education, improved retention, better career progression and a realistic approach to workforce supply. -
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Ten years after Scan4Safety was launched, a new independent report brings together evidence of how barcode scanning and GS1 standards are supporting patient safety across healthcare. The findings show how scanning can provide an additional check before medicines or medical devices are used. They also demonstrate how better information and inventory management can reduce manual work and return valuable time to clinical care. In this blog, Georgina Lawton, head of healthcare at GS1 UK, reflects on what she has learned from working with healthcare organisations on Scan4Safety. She explains why successful implementation starts with a patient safety problem, rather than the technology, and why clinical involvement, senior leadership, reliable data and dedicated capacity all matter.
