Patient Safety Learning
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Content Article
In this Guardian article, George Monbiot argues that people with ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome) have been systematically neglected, disbelieved and harmed by healthcare systems despite the severe, life-limiting nature of the condition. In the UK, an estimated 400,000 people live with the condition. It affects women far more than men, by a ratio of about 4:1, according to a study in England. The number of people with long Covid, some of whom meet the diagnostic criteria for ME/CFS, was estimated in 2024 at 2 million in England and Scotland. Drawing on hundreds of patient testimonies, he describes experiences of being dismissed and denied support: “I’ve just been completely abandoned”; “a 10-year waiting list for treatment”; “we’ve given up seeking medical support”; “stuck in limbo”; “I just felt utterly unheard, invalidated”. Further reading on the hub: Exploring the barriers that impact access to NHS care for people with ME and Long Covid Improving healthcare services for people with ME and Long Covid: Patients share their challenges, and the actions needed -
Content Article
Each year, World Patient Safety Day focuses on a critical area of healthcare safety. This year's theme is ‘Safe care for non-communicable diseases'. In this context, pathology plays a central role in timely, accurate diagnoses and appropriate interventions across the 17 specialties. Pathologists and laboratory staff play a critical, often behind-the-scenes role in managing non-communicable diseases (NCDs), such as cancer, diabetes and cardiovascular diseases, which are responsible for the majority of deaths in the UK. This September, the Royal College of Pathologists hosted a series of webinars. -
News article
The chief people officer of a leading hospital trust has been subjected to “racist” abuse by colleagues, HSJ has learned. Frimley Health Foundation Trust chief executive Lance McCarthy sent an all-staff email claiming the provider’s CPO Shajeda Ahmed “was subjected to anonymous comments that became personal and aggressive” during an online briefing. She was also “repeatedly muted while trying to speak”, said Mr McCarthy. The CEO’s email, which was sent on the eve of the trust’s annual inclusion conference and has been seen by HSJ, continued: “Given that Shajeda was the only person from a minority ethnic background speaking on that call, the circumstances raise serious concerns that this was not simply unacceptable behaviour but had a racialised dimension. “It is not the first time Shajeda, or other colleagues from a minority ethnic background, have faced hostility while trying to lead difficult conversations on behalf of this organisation and, ultimately, for the benefit of our patients.” The CEO declared: “This makes me angry. Not concerned. Angry.” Read full story (paywalled) Source: HSJ, 24 September 2026 -
News article
The Professional Standards Authority for Health and Social Care (PSA) and 38 health and social care regulators and registers have committed to developing shared principles for the use of AI across the UK. The organisations have signed a joint Statement of Intent supporting the safe, effective and ethical use of AI by health and social care professionals. The work aims to bring greater consistency to regulatory expectations, while protecting patients, service users and public confidence as the use of AI across health and social care grows. The statement highlights the need for clarity on when patients and service users should be told that AI is being used in their care. It also says professionals must remain accountable for decisions made with AI-assisted tools. The signatories comprise the PSA, 10 professional regulators and the Accredited Registers Collaborative (ARC), which represents 28 Accredited Registers. They include the General Medical Council, Nursing and Midwifery Council, General Dental Council, General Pharmaceutical Council and Health and Care Professions Council. Caroline Corby, chair of the PSA, said that “as AI becomes increasingly embedded in health and care, regulation must keep pace”. “Confidence by the public and professionals in the benefits of AI rests on appropriate safeguards, accountability and consistency in expectations about how it is used. “By working together, we can take a preventative approach to regulation that supports innovation while maintaining professional standards,” she added. Read full story Source: Digital Health, 17 September 2026 -
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There is concern that decisions around care and products for patients with bladder and bowel intimate care needs are being made on the basis of cost to the NHS, at the expense of patients receiving the right care and treatment for their needs. Working in partnership with patients, the Patients Association and Coloplast have developed a number of resources that are designed to support patients understand their rights and get access to the products and services they need. At this free Patients Association webinar, you'll hear about patients' experiences of accessing bladder and bowel products and services, including some of the challenges people face in getting care that meets their individual needs. It will explore the importance of shared decision-making between patients and healthcare professionals, and how working together can help ensure people have a say in decisions about their care and are able to access the products, treatment and support that are right for them. You'll also hear from the team that developed the resources about how they can help patients understand their rights, have more informed conversations with healthcare professionals, and advocate for their individual needs. Register -
News article
Hospital chiefs in County Durham have agreed to review up to a further 4,500 breast cancer cases after failings including delayed diagnoses and unnecessary surgeries were found. Hundreds of patients suffered harm under County Durham and Darlington NHS Foundation Trust, according to a review of cases dating back to 2023. The BBC previously investigated the failings and has spoken to multiple women affected, including one who said she felt "mutilated" and the trust's mistakes were "absolutely unforgivable". Ahead of agreeing to expand the review to cases dating back to 2015, members of the trust's board offered "sincere" apologies for the failings and harm caused. At an extraordinary meeting of the board held in Durham, board chair Alison Marshall said: "I would like to offer a sincere apology to all the women and their families who have been affected by the failings in our breast services. "I can't imagine the impact that has had." She said they could "not turn back the clock" but would be "open, honest and transparent" about the failings. Read full story Source: BBC News, 24 September 2026 -
News article
The trust where Lucy Letby worked has been heavily criticised for how it looks after the bodies of fetuses. The Countess of Chester Hospital did not have procedures in place to check the condition of bodies of babies and fetuses and a “small number” were incorrectly kept in refrigerators instead of freezer storage, according to the Human Tissue Authority. The trust told HSJ this involved two fetuses and no babies. Moving a body to a freezer after 30 days is normally recommended because of the risk of deterioration. Failure to do so is regarded as a “critical shortfall”, its more serious censure, by the HTA. The authority also discovered a number of “major shortfalls” at the trust. These included a risk of families viewing the wrong body or the wrong body being released to funeral directors. The use of three identifiers before a body is viewed or released is standard practice but the inspection team found that operating procedures at the Countess of Chester did not always comply with this approach. Some forms used by the trust to authorise the release of bodies say families only need to confirm two identifying details and can “rely on the name of the deceased if attendees do not know the date of birth”. SOPs – such as weekly checks of bodies – were not always carried out, while one 2025 review included no “physical audit of bodies”. Read full story (paywalled) Source: HSJ, 23 September 2026 -
News article
The mother of a teenage boy who died in hospital has said she is "deeply concerned and hurt" after learning his medical records may have been accessed inappropriately for years after his death. Paula McGowan, whose 18-year-old autistic son Oliver died in 2016, was told that at least five members of staff at Bristol Foundation NHS Trust may have accessed his records without permission as recently as this year. The trust said it was "deeply sorry" for any stress and anxiety caused. It said it had voluntarily referred itself to the Information Commissioner's Office. It is the latest case involving concerns that NHS staff may have accessed patient records without a legitimate professional reason. In July the head of NHS England, Sir Jim Mackey, issued a "stark warning" that staff could face the sack or even prison for doing so. Oliver, who had a mild learning disability and epilepsy, died in 2016 at Southmead Hospital in Bristol after being given anti-psychotic medication that his family had repeatedly warned he should not receive. After requesting information about his medical records, his mother was told that 38 people had accessed the data since his death, with 637 items viewed and 67 printed off. Most access was appropriate and linked to complaints, legal proceedings, and the coroner's inquest into his death. But three nursing staff not involved in his care are currently under formal investigation after initial inquiries could find no evidence they had a legitimate reason to view her son's records. Read full story Source: BBC News, 24 September 2026 -
News article
Only half of people being treated by a GP for high blood pressure in England have it under control, and millions more are completely unaware they have the “silent killer” condition, research reveals. Most people with hypertension (59%) are in the dark and undiagnosed, raising their risk of stroke, heart attack and early death, according to the largest ever study of its kind. Even among those who are diagnosed and receiving medication via their family doctor, in 50% of cases their blood pressure is out of control, the Oxford University study of 1.4 million adults suggests. Researchers said the findings, published in journal BMJ Public Health, suggested the current approach to detecting and treating high blood pressure in England was “not fit for purpose”. Wenyu Liu, a medical statistician at Oxford Population Health and lead author of the study, said: “While hypertension is largely a ‘silent killer’, the current approach to detecting and treating high blood pressure is not fit for purpose. “Our study highlights the prevalence of hypertension across demographics. This underscores the need for population-wide prevention strategies alongside targeted treatment for people at high cardiovascular risk.” Read full story Source: The Guardian, 23 September 2026 -
Content Article
Falls contribute significantly to injury and mortality among community-dwelling older adults, with societal costs expected to rise. In the Netherlands, a nationwide falls prevention pathway, aligned with World Falls Guidelines was introduced. This includes case finding, multifactorial falls risk assessments, evidence-based interventions and sustained exercise programs. This study explores its implementation, focusing on barriers and facilitators. -
Content Article
The National Patient Safety Improvement Programmes 2025-2026 impact report highlights the NHS's commitment to continuous improvement in patient safety. The report details the progress made in implementing various safety initiatives, such as Martha's Rule, which allows patients and families to request rapid reviews of deteriorating conditions. It also discusses the implementation of a new early warning system for staff treating children and the rollout of tools for early identification of deterioration in maternity and neonatal care. -
Content Article
In this blog, Kath Sansom, founder of Sling the Mesh, argues that Sunshine legislation, which requires pharmaceutical and medical device companies to publicly disclose payments to healthcare professionals and organisations, is essential for improving transparency and patient safety. She highlights concerns that undisclosed financial relationships can influence research, prescribing and treatment recommendations, potentially leading to patient harm. -
Content Article
Global health days endorsed by the World Health Assembly (WHA) play a distinctive role in elevating priority issues, mobilizing political commitment, and catalysing collective action. Among them, World Blood Donor Day (WBDD) and World Patient Safety Day (WPSD) stand out as landmark initiatives that emerged not only from technical necessity but also through sustained collaboration among Member States, WHO, and key partners including international organisations, professional bodies, civil society, and advocates. WBDD and WPSD have become influential global platforms for advancing safety, solidarity, and health system action. Yet the processes behind their establishment, including the consultations, negotiations, consensus building, and collaborative efforts that culminated in their adoption through WHA resolutions, remain largely undocumented. In this article, Neelam Dhingra offers a first-hand account of how these two global health days were conceived, negotiated, and established, drawing on more than two decades of leadership and programme coordination in blood safety (2000–2014) and patient safety (2014–2024) at WHO headquarters in Geneva, Switzerland. The article examines collaboration as the critical enabler of success and distils lessons for global health governance. While both initiatives involved extensive contributions from Member States, WHO, international organizations, professional bodies, civil society, and advocates, this article covers their development trajecto -
News article
"Everyone made it out to be so easy, but my face felt like it was on fire and there was a horrible smell of burning skin," says Nikita Morgan, as she describes her eyelid surgery. She decided to get a blepharoplasty, or a "bleph", removing skin from just above the eyes - after seeing videos about it on social media. Even though she was given a local anaesthetic, Nikita felt extreme pain. Oculoplastic surgeons - doctors specialising in surgery around the eyes - say a concerning number of patients are reporting problems from cheap bleph surgery, typically carried out abroad. They have told the BBC the demand for this procedure, which normally costs thousands of pounds in the UK, has increased as part of a wider aesthetic trend to tighten, smooth and lift the face. Surgeons say complications have been linked to clinics across mainland Europe, Africa and Asia, and, when they occur, the lack of aftercare puts a burden on the NHS. UK surgeons have also told us they have seen patients unable to close their eyes properly after treatment abroad. Read full story Source: BBC News, 23 September 2026 -
News article
Trusts have been told to fit CCTV in neonatal units by the end of November and to “urgently” tell staff and boards that child death protocols cover babies who never leave hospital. National chief nursing officer Duncan Burton and chief operating officer Sarah-Jane Marsh said in a letter to all local organisations on Tuesday that last week’s inquiry report was a “sobering moment”. Lady Justice Thirlwall reported on the events surrounding the murder and attempted murder of babies at the Countess of Chester Hospital Foundation Trust between 2015 and 2016, for which neonatal nurse Lucy Letby was convicted in 2023 and 2024. The letter said trusts should: Install CCTV cameras in neonatal units focused on storage fridges, cupboards or units by 30 November. Inform all relevant staff and the board about the Sudden and Unexpected Death in Children protocol by Monday 28 September (if the trust has a neonatal unit). Ensure all neonatal units meet requirements for access control and storage of insulin by 31 March 2027. Consider the Thirlwall report findings at their next public board meeting. Read full story (paywalled) Source: HSJ, 23 September 2026 -
News article
An NHS policy to remove “ghost patients” from GP lists is inadvertently leaving some of the poorest people in England without vital healthcare, analysis has found. Under previous NHS rules, inactive patients at risk of being removed from their GP practice were given six months to respond to outreach. But under NHS England’s accelerated list validation timeline, introduced last October, patients now have only three months to reply. According to analysis by Healthtech-1, registered GP lists in English practices declined by 483,019 patients between October 2025 and July 2026, with the most deprived fifth of practices accounting for about 138,400 of the net decline – just under 30% of the national decline. While GP lists need reviewing as people move away or die, GPs have said the accelerated timeline has inadvertently led to patients from deprived areas being incorrectly removed, creating barriers to receiving treatment. Consequently, GPs and practice managers have reported having to re-register vulnerable and elderly patients, creating an additional administrative burden. De-registering patients can also cause gaps in care and disruption to treatment. Read full story Source: The Guardian, 23 September 2026 -
Content Article
Patient safety is often discussed in terms of policies, protocols and clinical competence. While these are fundamental, they are only part of the equation. Safe nursing practice also depends on something less tangible but equally important: the confidence of the nursing workforce. Confidence enables nurses to question decisions, escalate concerns, seek support and advocate for patients. When confidence is undermined, safe practice is inevitably compromised. -
News article
Hospitals and general practices across the country are asking patients to “describe their experience in their own words” amid a rise in overly complex AI written complaints. In new guidance, GPs have said that, although they understand AI tools such as ChatGPT can help patients organise their thoughts, they can also “make it harder for practices to understand what actually happened.” This is because AI tools can provide “incorrect information, add details that are not true, include laws, rules, or rights that do not apply, use language that is too formal or difficult to understand, or make your complaint longer than it needs to be.” Created by Gloucestershire Local Medical Committee (LMC) and shared across the country, the guidance reads: “You do not need to use legal words or quote laws or NHS rules for us to take your complaint seriously.” Similar advice has also been provided to hospital patients. Stockport NHS Trust told patients that “while there can be benefits to using AI, we encourage complainants to describe their experience in their own words wherever possible.” Although the trust “will not reject a complaint simply because it is complex or because AI has been used,” it has urged patients to keep their complaint “focused on the issues that matter most” to them. Read full story Source: BMH, 21 September 2026 -
Content Article
A new report shows how England’s NHS could be short of at least twice as many registered nurses as first thought, as testimony from nursing staff shows how workforce shortages have led to fractures, delays to life-saving medication and brain bleeds. It includes new analysis of hospital trust board papers which reveals that hundreds of patient safety incidents are taking place each month linked to having too few registered nurses on shift. The report from the Royal College of Nursing found that despite the clear evidence of harm caused by too few registered nurses, the number of doctors has grown nearly twice as fast. Had nurse numbers grown at the same rate as doctors since 2009, England's NHS would have more than 77,000 additional nurses today. Overall, the analysis found that based on the increase in NHS activity since 2009, including admissions, attendances and appointments, the health service is actually short by an estimated 55,000 registered nurses to deliver care safely, more than double the official number of NHS vacancies, which stands at 23,046 as of August. Included in the report is an audit of recent trust board papers which shows that some hospitals are reporting hundreds of “red flag” patient safety incidents a month. These are safety reports arising from staff shortages including delays to pain relief, essential medication and missed care. -
News article
The NHS in England could prevent 20,000 deaths and save £33bn a year by cutting red tape and boosting productivity, a report says. Research by the Health Foundation found the health service has been held back for decades by excessive regulation, short-term planning and insufficient capability to deliver major change. But rewiring the NHS, the world’s largest single healthcare system, by harnessing new technology, empowering staff and increasing capital investment could save both lives and money, it found. There is “substantial scope to improve outcomes within the funding already available to the NHS”, which could result in up to four extra years of good health for people on average, the report said. In terms of where deaths could be prevented, focusing on diagnosing cancer earlier and finding people with high blood pressure or conditions such as diabetes quicker would be key, it added. The report called for a series of changes, such as releasing the NHS from unnecessary regulation, reporting and compliance tasks, as well as launching a “test-and-learn” approach to scaling up things that could improve productivity, such as use of artificial intelligence. “Our analysis suggests that if the NHS in England achieved outcomes closer to the best-performing comparable health systems, without spending more each year, it could potentially result in 18,500–20,600 fewer deaths each year from treatable causes and 2.5 to 4.5 additional years that people spend in good health on average,” the report said. Read full story Source: The Guardian, 22 September 2026 -
News article
Martha’s rule, which lets NHS patients, staff and relatives request a review of their care, is being expanded to every A&E in England, health officials have announced. The system gives patients, their loved ones and health workers the right to ask for a different medical team to examine the care being provided on inpatient wards and to recommend changes. It has already potentially saved hundreds of lives, official figures show. Now it will be rolled out to every emergency department in England, including waiting rooms, offering “a critical new lifeline” to improve care and save more lives, NHS England said. The system is named after Martha Mills, 13, who died in 2021 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. In the first 16 months of the scheme after its introduction in England in 2024, helplines received more than 10,000 calls, potentially saving 446 lives, figures show. Thousands of patients were either moved to intensive care, received drugs they needed or benefited from other changes as a direct result of the calls. In June this year, the initiative was expanded to every maternity and neonatal unit in England, giving women and parents the right to a second opinion about the care of a mother or baby. From this month, it will be expanded to A&E units. It means patients, loved ones and staff in busy emergency departments will be able to call a dedicated phone number to trigger an urgent review if a patient’s condition is deteriorating and they think their concerns are not being listened to. Read full story Source: The Guardian, 22 September 2026 -
News article
A major acute trust has launched two reviews over care failures potentially affecting 130 children, HSJ has learned. Nottingham University Hospitals Trust wrote to everyone on the list for its scoliosis service to inform them that it had launched an internal investigation and commissioned a separate external review. It said, “some patients may not have received the level of medical monitoring that we would expect whilst they were waiting for surgery.” In the letter sent on Friday, seen by HSJ, NUH chief operating officer Andrew Hall said the trust was “truly sorry”. It said it was not aware of specific concerns about their care, but was “seeking additional external reassurance”. In 43 of the cases, however, the trust said “immediate concern has been identified” – such as longer waits for monitoring – and in these “we have [already] reached out to those patients and their parents/carers to consider next steps.” HSJ understands NUH discovered that missed appointments may have been discovered at the end of last year, and the internal review took place earlier this year. However, it did not contact most of the families until nine months later. It has not explained the delay. It said it does not yet know the level of any harm caused. However, children whose scoliosis goes unmonitored risk deteriorating to the point where intervention becomes more complex. Read full story (paywalled) Source: HSJ, 22 September 2026 -
News article
A hospital trust is providing a “pretty awful” standard of care, its interim chief executive has declared. The blunt statement was made by David Loughton – who joined University Hospitals of Liverpool Group in the summer – at a board meeting on Thursday. He said there had been “enormous progress” with partners to fix some of its clinical problems, which had to be addressed before financial gaps could be tackled. But he added: “I think you’ve got to take a cold, hard look at the quality we are providing at the present time, which is pretty awful.” Pressed for examples, he said six patients had spent a day in the discharge lounge before returning to a hospital bed on Tuesday night “because we cannot get non-emergency ambulances” to transport them elsewhere. He added: “I met in detail with the renal teams and some of the quality of what we’re providing to patients who are coming here three times a week for the foreseeable future [for dialysis] is really poor.” But he said: “The problem here is it is not down to this organisation. I’ve come into this, and I can freely say… the system leaves an awful lot to be desired at how it works together, or it doesn’t work together, and we’ve got to fix some of the problems in the community to impact in the hospitals.” Read full story (paywalled) Source: HSJ, 21 September 2026 -
Content Article
The Patient Safety Commissioner Scotland annual report provides: A review of issues identified by the Commissioner as relevant to the Commissioner's functions during the reporting period. A review of the Commissioner's activities, including steps taken in connection with each of the Commissioner's statutory functions. Recommendations arising from those activities. -
Content Article
A woman in her third trimester of pregnancy was cared for in a surgical area of the hospital following a non-pregnancy related surgical procedure. During her recovery, she went into labour; there were delays in recognising her condition and in assessing the wellbeing of the baby, who died before birth. Nursing staff did not have clear guidance, support, or easy access to midwifery/obstetric teams or care plans to help them care for the woman safely.
