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Patient Safety Learning

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  1. News Article
    A trust has pleaded guilty to fire safety offences relating to a patient’s death in a rare case where a fire service has brought a prosecution against an NHS provider, HSJ can reveal. Christian Raeburn died aged 36 following a fire at Pendleview Mental Health Unit, which is part of Blackburn Hospital, on 25 December 2023. Lancashire and South Cumbria Foundation Trust submitted its guilty plea to six offences under fire safety legislation for commercial buildings last month. The charges included breaches of the Fire Safety Order relating to general fire safety precautions, maintenance, and staff training. Police told local media they were called following a report of arson and found a man unresponsive at the scene, who died the following day. It is extremely rare for an NHS trust to be prosecuted by a fire service. There have only been two cases in England between 2016-17 and 2024-25, according to government statistics. Mr Raeburn reportedly set fire to a mattress in his room and died the following day from injuries sustained in the fire. Read full story (paywalled) Source: HSJ, 19 May 2026
  2. Content Article
    This webinar, hosted by the International Association of Medical Regulatory Authorities (IAMRA), explored how medical and health profession regulators and broader patient safety systems can work more closely together to strengthen care and reduce harm to patients. It aims to help improve understanding of the opportunities to better connect people and system focused safety systems, including through potential partnership models, to best support and ensure a safe and competent health workforce. Facilitator: Professor Martin Fletcher, IAMRA Board Member Speakers: Helen Hughes, Chief Executive, Patient Safety Learning, UK, and Dr Gerry Hickson, Vanderbilt University Medical Center, USA. Related reading on the hub: Professional regulation and patient safety systems: parallel planets or partners in improvement? Professional regulation and patient safety: parallel systems or purposeful partners?
  3. Event
    The workshop explores the importance of integrating human factors into healthcare AI design, development, testing, and implementation. Participants will learn how to apply complex systems thinking models to consider, ‘How might integrating AI into this healthcare setting impact on system performance and human well-being?’ Designed for healthcare professionals from all care settings, the workshop content is interactive and engaging. Email [email protected] to book your place
  4. News Article
    More than 100 maternity staff are taking legal action against a hospital trust after being exposed to what they say were "hazardous" levels of nitrous oxide. The staff, who include midwives and healthcare assistants, all worked at Basildon Hospital in Essex between 2018 and 2023. Symptoms including fatigue, anxiety, headaches and "brain fog" were reported. The trust that runs the hospital has said it "should have acted faster to address the issues". The Mid and South Essex NHS Foundation Trust has already paid out £89,000 in settlements over claims staff were exposed to "excessive and foreseeably dangerous" levels of Entonox, which is often called gas and air. A total of 141 claims have been received, according to the NHS. Entonox is a mixture of nitrous oxide and oxygen that is used as pain relief for women giving birth. According to the claimants, levels of nitrous oxide can build up quickly in maternity units with poor ventilation. The gas enters the atmosphere when birthing mothers exhale, when gas lines are leaky, and when cannisters of nitrous oxide are opened and connected to equipment. Maternity staff were exposed to gas levels up to 30 times higher than the legal workplace exposure limit, an internal hospital report found. For people giving birth, the NHS says gas and air is "generally very safe", and side effects are not expected until after patients have used it for longer than six hours. Read full story Source: BBC News, 18 May 2026
  5. News Article
    Cancer patients are among dozens of people found to have been “harmed” after their diagnosis and treatment were delayed due to administrative failures at an NHS trust, The Independent can reveal. A review of hundreds of gynaecology patients under the care of consultant Dr Jim Wolfe at Salford Royal Hospital, in Greater Manchester, in 2024, was prompted by concerns that the necessary follow-ups were not carried out. The months-long audit revealed that some women had not been sent letters about their treatment, or their results had not been acted on for conditions including cancer, and concluded many had been “harmed” as a result. Northern Care Alliance Trust (NCA) NHS Trust, which manages the hospital, has apologised for the “distress we’ve caused” and said those affected had been offered support and ongoing treatment plans. Sources confirmed that Dr Wolfe is still working at the trust, but NCA said it would not comment on the status of its employees. But the revelation comes amid wider staff unrest over the trust’s gynaecology services with concerns about patient safety, workforce pressures and unsafe workloads. Read full story Source: The Independent, 17 May 2026
  6. News Article
    Almost two-thirds of nurses believe there are too few of them working in the NHS to keep patients safe and give them proper care, a survey has revealed. Understaffing and the increasingly complex medical needs posed by an ageing population are creating a “deadly mix” for patients, the Royal College of Nursing warned on Monday. More than one in five (22%) of nurses working in hospitals or community settings across the UK told the RCN that the number of nurses on duty in their last shift was “well below what was needed”, which left care “significantly compromised” and a “high level of risk of harm to patents and staff”. Of the more than 13,000 nurses who took part in the survey 64% said they thought that the number of registered nurses on that shift was “below” or “well below” what was needed to ensure safe care. One nurse working in an A&E in England told the union: “The shift was completely unsafe and it felt like a miracle that avoidable harm was not caused.” Prof Nicola Ranger, the RCN’s chief executive and general secretary, will urge ministers to bring in mandatory minimum safe nurse staffing levels when she opens its annual congress on Monday. “Widespread vacancies of registered nurses are always unsafe,” she said. “But the risk is being compounded by the demands of delivering ever more complex care to an ageing, sicker population, with multiple conditions. It’s a deadly mix.” Speaking in Liverpool, she will accuse ministers of failing to ensure that the health service has enough nurses and the nursing profession is being “set up to fail”. Read full story Source: The Guardian, 18 May 2026
  7. News Article
    Proposed amendments to UK medical device regulations are “a disgrace” and risk creating the lowest barrier to entry for high-risk AI devices in the developed world, sector experts have told HSJ. Under the draft rules, which have been submitted to the World Trade Organisation ahead of being laid before Parliament, software designed to diagnose a condition can face greater regulatory scrutiny than software designed to treat one. This means a company could deploy an AI chatbot designed to treat patients with severe mental health problems without independent regulatory scrutiny by self-certifying its own safety in the same category as a walking stick. The Medicines and Healthcare products Regulatory Agency (MHRA) has published draft pre-market regulatory requirements for medical devices and in vitro diagnostic devices entering the market. This was the most significant update to the UK Medical Device Regulations (MDR) 2002 since Brexit, when the UK left the EU MDR. However, regulatory leaders have aired concerns about the draft amendments, particularly around the risk classification of software. Read full story (paywalled) Source: HSJ, 18 May 2026
  8. Content Article
    The Maternity and Newborn Safety Investigation (MNSI) has reviewed 20 investigations into the cooling of term babies across England. The findings show that national guidance on continuous temperature monitoring during cooling was not followed in half of cases. Ensuring continuous temperature monitoring during newborn cooling is an important area of learning identified through our neonatal investigations. A review of 20 investigations found opportunities to strengthen practice in line with national guidance in half of cases. The new MNSI safety briefing draws on what we have learned through our investigations and aims to support the safe care of babies undergoing cooling in maternity and neonatal settings. The briefing shares our evidence and insight on this topic and provides prompts for maternity and neonatal providers to consider: Whether local guidance on cooling aligns with national guidance, including when to commence passive cooling and the use of rectal temperature probes. Whether staff have the training and equipment they need to initiate cooling safely and consistently.
  9. Content Article
    This Maternity and Newborn Safety Investigation (MNSI) safety spotlight shares what they found regarding nitrous oxide decommissioning and offers prompts to help providers keep staff informed and equipment checks consistent.
  10. Content Article
    One in three women and girls in the UK experience physical or sexual violence during their lifetime. The NHS has more contact with victims and perpetrators than any other public service. Yet the uncomfortable truth is that many women and girls who seek help from the health service do not receive the right support.  The government and expert organisations supporting victims and survivors say there should be no wrong front door for those seeking help. In reality, it can feel like there is no right door.
  11. Content Article
    A new guidance supplement has been published by the Intensive Care Society that aims to improve the safety and quality of care when critically unwell pregnant or recently pregnant women are moved between areas within one hospital or moved to a different hospital (transfers). It builds on existing guidance and acknowledges some important additional factors that need to be considered around the time of the transfer. This is the first time that transfer guidance has been published by the Intensive Care Society relating specifically to pregnant or recently pregnant women.
  12. News Article
    The US supreme court upheld nationwide access to mail-order mifepristone, an abortion medication, in a shadow-docket decision on Thursday. Louisiana sued the US Food and Drug Administration (FDA) in October in a bid to curtail the regulatory agency’s rules on prescribing mifepristone remotely, arguing that it interfered with the state’s ban on abortion. The fifth circuit ruled in Louisiana’s favor on 1 May, effectively banning mail-order mifepristone for the entire country. Two mifepristone manufacturers, Danco Laboratories and GenBioPro, filed an emergency request with the supreme court, which granted a temporary stay until at least Thursday. In a 7-2 decision with dissents from justices Clarence Thomas and Samuel Alito, the court sided against the fifth circuit, ending the ban – for now. In his dissent, Thomas called the mailing of mifepristone to patients “criminal enterprise”. He also noted that the 1873 Comstock Act, which broadly banned people from using the mail to send anything “obscene, lewd or lascivious”, including “any article or thing designed or intended for the prevention of conception or procuring an abortion”, should apply to mifepristone. Medication accounts for approximately two-thirds of abortions in the US. In large part because of mailed medication, abortion rates have stayed steady in the US despite bans in several states. Years of research have shown that abortion medications are safe and effective. The recent legal challenges, after the Dobbs decision that upended nationwide access to abortion, have been based on politics rather than evidence, experts say. Read full story Source: The Guardian, 14 May 2026
  13. News Article
    Hard-won successes in efforts to stop women and babies dying in childbirth have faced a serious setback with recent cuts to foreign aid – and the trend is now reversing in some countries, new figures show. Significant progress in tackling preventable maternal mortality across the globe had seen the rate decline by 40% in the last two decades. However, the latest data from the World Health Organisation (WHO) suggests this progress has slowed in recent years, and recent aid cuts by the US, as well as other countries including Britain, will start to reverse those crucial gains. With Donald Trump in particular slashing America’s foreign assistance programmes by 57%t last year, global aid fell by 23% cent in 2025 compared to 2024, and is projected to drop by a further 5.8% in 2026. Maternal mortality is particularly acute in parts of Africa, and is already playing out in the Central African Republic, which has the second-highest rate of neonatal deaths globally, according to the UN. Monica Ferro, head of the United Nations Population Fund’s London office, said that the work over the last 20 years had given the world “hope that finally the world would be on track to reach zero preventable maternal deaths”. “We know that when funding is cut, services are shut down and women die. It is that simple. It may sound cruel, but it is that simple, and we have the evidence to prove it.” “It is very disappointing. The women and girls who are losing access to services will not forgive us for promising them a world with more dignity and then failing them because funding is being withdrawn.” Read full story Source: The Independent, 10 May 2026
  14. News Article
    Taking antidepressants during pregnancy does not increase the risk of children going on to develop autism or attention deficit hyperactivity disorder (ADHD), according to an analysis of more than half a million pregnancies. The study, conducted by researchers at the University of Hong Kong and published in the Lancet Psychiatry, analysed data from 37 existing studies that included 600,000 pregnant women who had taken antidepressants, and 25 million women who had no antidepressant use during their pregnancies. Before controlling for key factors such as pre-existing mental health conditions, the analysis found that antidepressant use by the mother during pregnancy was associated with a 35% increased risk of ADHD and a 69% increased risk of autism. However, when controlling for confounding factors such as pre-existing mental health conditions, this risk became non-significant. This means the meta-analysis found no significant link between antidepressant use during pregnancy and a greater risk of autism and ADHD in children, after controlling for the mother’s mental health or other influencing factors such as genetics. Dr Wing-Chung Chang, a professor at the University of Hong Kong and lead author of the study, said: “We know many parents-to-be worry about the potential impact of taking medication during pregnancy; our study provides reassuring evidence that commonly used antidepressants do not increase the risk of neurodevelopmental disorders such as autism and ADHD in children. “While all medications carry risks, so too does stopping antidepressants during pregnancy due to an increased risk of relapse. Therefore, for women with moderate-severe depression, doctors and patients must carefully weigh the potential risks and benefits of continuing antidepressant treatment during pregnancy against the potential harms of untreated depression. “Although our study found a small increase in the risk of autism and ADHD in the children of women who had used antidepressants during pregnancy, it also found that this risk disappeared when we accounted for other factors. The increased risk was also seen in the children of fathers who took antidepressants and of mothers with antidepressant use before, but not during, pregnancy. “Together, this suggests that it is not the antidepressants themselves causing an increased risk in autism and ADHD but it is more likely to be due to other factors, including genetic predisposition to conditions such as ADHD, autism, and mental health conditions.” Read full story Source: The Guardian, 14 May 2026
  15. News Article
    The government has hit an interim target for speeding up hospital treatment in England. The goal was for 65% of patients to be treated within 18 weeks by March 2026 – and it hit that, but only just, with the figure reaching 65.3%. It was seen as the first stepping stone to hitting the 92% target by the end of the Parliament in 2029 – a key manifesto pledge of Labour's. The news came just hours before Wes Streeting resigned as health secretary, saying there needed to be a leadership challenge as he had lost confidence in the Prime Minister. Speaking before he resigned, he hailed the achievement – performance was below 59% when Labour came to power. He said: "It means we are right on track to deliver the fastest reduction in waiting times in the history of the NHS. "That is thanks to the government's investment, modernisation, and the remarkable efforts of staff right across the country. "Lots done, lots more to do." Read full story Source: BBC News, 14 May 2026
  16. News Article
    Hospital staff inappropriately accessed the medical records of victims of the 2024 mass stabbing at a dance class in Southport, HSJ can reveal. Three young girls – Elsie Dot Stancombe, Alice da Silva Aguiar, and Bebe King – were killed in the attack on 29 July 2024, while 10 others were injured. The perpetrator was jailed for life last year. Some of the injured were treated at University Hospitals of Liverpool Group. HSJ has learned that a “standard” information access audit carried out by the trust in the days after the incident revealed that 48 staff accessed their records without a good reason. However, this information was not given to the patients involved until this week, following HSJ’s inquiries. Leanne Lucas survived the Southport attack and was one of UHLG patients whose records were inappropriately accessed. She told HSJ: “I am absolutely devastated and horrified that my privacy has been invaded when I was at my most vulnerable. Nothing will take away my gratitude to the staff who saved my life, but 48 people not involved in my care abused their position of trust to access the files of victims who have suffered unspeakable trauma. The decision to keep this from me for almost two years is a new low. I am speaking out as I want this scandal and the attempted cover-up by senior management exposed for what it is.” The trust denies any attempt at a cover-up. Its board had originally planned to tell those involved about the breach. However, HSJ understands its leadership changed their mind sometime in 2025, after trust directors decided that informing the patients would not be in their best interests, as it risked retraumatising them. Read full story (paywalled) Source: HSJ, 14 May 2026
  17. News Article
    Governors at one of the largest trusts in the country have warned that moving patients from beds to chairs to free up space is a risk to staff and public morale. University Hospitals Birmingham Foundation Trust has been moving patients from beds on wards to trolleys and chairs in corridors for at least the past two months, to make way for patients who need beds after arriving in an ambulance or attending A&E. However, staff raised concerns during a governors’ meeting last month that it had also begun moving patients from beds in the middle of the night, and in a way that undermined their privacy. Staff governor Lee Williams said this was “sitting very uneasily with the staff” and “badly affecting morale”. Mr Williams said: “My big fear is the advances the trust has made in terms of its morale in the clinical areas is going to haemorrhage away.” He added: “Sometimes the [location] of these temporary escalation spaces is preventing other healthcare professionals providing the care that they would like to in cramped spaces in bays… and relatives are very unhappy with the situation too.” Another governor, Gerry Moynihan, described the situation as “shocking”. He questioned if patients are being displaced “so that we can have statistics that say we’ve offloaded ambulances quickly”. He said that at Heartlands Hospital, patients were being offloaded “very quickly”. Read full story (paywalled) Source: HSJ, 14 May 2026 Further reading on the hub: How corridor care in the NHS is affecting safety culture Corridor care guidance needs to move beyond what “should” happen and grapple honestly with why it isn’t Corridor care: are the health and safety risks being addressed?
  18. Content Article
    Following the publication of their 2025 to 2027 strategy in December 2025, Maternity and Newborn Safety Investigations (MNSI) shared more about their work and future ambitions with stakeholders across maternity and neonatal services. The event featured four presentations covering: Structured Perinatal Analysis Report Coding (SPARC) explored how we use coded, thematic data from MNSI investigations to identify patterns and support learning at both local and national level. Culture of Organisations and its iMpact on PatientS' Safety (COMPASS) focused on how we measure and support improvement in safety culture across maternity and neonatal services. Health Equity Warning Score and Health Equity Assessment and Resource Toolkit (HEART) looked at how we identify and address health inequalities through our investigations, ensuring that the findings we generate reflect the experiences of all families. Our investigations and the wider stakeholder environment set our work in context, exploring how MNSI investigations connect with the broader landscape of maternity and neonatal safety improvement. If you missed the event, recordings are available on the MNSI website.
  19. Content Article
    Patients, service users, their loved ones and carers have the right to raise concerns about the care they receive under the NHS in Wales. This can be done through the Listening to People NHS Wales Complaints, Incidents, and Redress process. Raising a concern can be difficult and distressing. People often come forward because something has had a real impact on them or their loved ones. This guidance explains what support you can expect and what will happen when you raise a concern. A concern can include a complaint, patient-safety incident or any other issue relating to an organisation’s health services. Responsible bodies, which are organisations that are legally responsible for your care, have a duty to listen to, act on, investigate and respond to concerns, and to learn from them to improve care and reduce the risk of harm re-occurring in the future. Responsible bodies can be an NHS organisation, a GP practice, dental practice or an Independent Provider delivering NHS funded care. Raising a concern often follows upsetting or traumatic experiences and NHS organisations in Wales aim to respond in ways that are compassionate, respectful and sensitive to the impact on you and your loved ones.  Further reading on the hub: How to make a complaint
  20. News Article
    Demand for blood needed to treat rare disorders such as sickle cell has soared by more than 130% in 10 years, forcing the NHS to ask for more donors to come forward. Requests for haemoglobin S (HbS)-negative blood, the type most used in blood transfusions for sickle cell anaemia patients, stood at 82,181 units in 2015. But last year, more than 191,000 units were needed, a 132% increase. HbS is a type of haemoglobin commonly found in people with sickle cell trait and sickle cell disorder. It gives red blood cells a crescent or ‘sickle’ shape, reducing the flexibility of the cells in blood vessels. The NHS Blood and Transplant service (NHSBT) has highlighted the soaring demand from sickle cell disease patients and has made urgent appeals for Black people to donate. It has about 775,000 blood donors overall, about 21,500 of them of Black or mixed Black ethnicity. John James, chief executive of the Sickle Cell Society, said: “These figures show an urgent need for more blood donors, especially from Black and brown heritage communities. The blood types most commonly needed for sickle cell patients are more prevalent in people of Black heritage, who remain under-represented in the donor pool. “That’s why, working in partnership with NHS Blood and Transplant, we’ve developed our Give Blood, Spread Love programme to increase the number of Black-heritage donors. Giving blood is a simple act that can save or improve up to three lives, and for people with sickle cell it can be life-saving.” The increase in demand has been attributed to a range of factors, including an ageing population, more use of transfusions where all of a patient’s blood is replaced and an increase in numbers from areas where sickle cell is more common. Many sickle cell patients develop antibodies that mean they require very closely matched blood. Read full story Source: The Guardian, 14 May 2026
  21. Content Article
    In this blog, Ted Baker discusses a new paper by Health Services Safety Investigation Body (HSSIB) colleagues and highlights the call for a fundamental rethink of how the NHS views and prioritises patient safety. Ted argues that healthcare has long confused quality with safety, often treating safety as just one dimension alongside outcomes and patient experience. This framing has encouraged a false idea that trade‑offs are acceptable, particularly under pressure, even though safety and outcomes are interdependent and should never be weighed against one another. A new HSSIB research paper reviewing 118 national investigation reports, found that where trade‑offs occurred, safety almost always lost out to efficiency, timeliness or experience initiatives, and there were no examples where prioritising safety harmed other aspects of quality. This directly challenges claims that the NHS has focused too much on safety.
  22. News Article
    Hundreds of children with a rare muscle-wasting disease will be able to receive two drugs that can improve their survival in a move parents hailed as a “lifeline”. The National Institute for Health and Care Excellence (Nice) has published final draft guidance recommending that any patient who would benefit can have either drug. The move means that anyone in England, Wales or Northern Ireland with spinal muscular atrophy will from Thursday be able to get either nusinersen, also known as Spinraza, or risdiplam, also known as Evrysdi, from the NHS. SMA is a progressive genetic disorder that causes severe muscle weakness and can affect the ability to move, breathe and swallow. Without treatment, patients face devastating consequences including profound disability and reduced life expectancy. Children with the most severe form of SMA – type 1 – usually die before they reach two. Prof James Palmer, NHS England’s national medical director for specialised services, said: “These lifeline treatments have offered a phenomenal step forward in care for children and families affected by such a debilitating condition and it is fantastic that they will now be available on the NHS in the long term. “For parents who faced the unimaginable pain of thinking their child would not reach their second birthday, they now have hope of seeing them walk to school and play with their friends, thanks to these lifechanging new therapies.” Read full story Source: The Guardian, 14 May 2026
  23. News Article
    One in seven people are using AI chatbots for health advice instead of seeing their GP, a UK study has found. The poll of more than 2,000 people found that – of the 15% turning to chatbots – one in four had done so because of long NHS waiting lists. The study analysed by researchers at King’s College London revealed the potential risks of using AI for health advice. A fifth of respondents who did so said the technology did not encourage them to seek a professional opinion and a similar proportion said they decided against seeking a consultation because of something an AI chatbot had told them. The research is the first to quantify the use of AI chatbots for health advice, according to the researchers, and signals how the technology is changing the way people are dealing with health problems. Prof Graham Lord, the lead author of the study, said growing individual use of chatbots was creating “an unregulated AI healthcare system alongside the NHS”. He added: “This research underlines the scale and pace at which AI is already shaping how people access healthcare. While the opportunities are significant, it also highlights concerns about safety and accountability. “When something goes wrong with AI, responsibility is often placed on clinicians, even where they have limited control over how AI tools are introduced. To realise AI’s potential, we need greater transparency about what works, what is safe, how decisions are made and how issues are handled – so staff and patients can feel confident in its use. It is vital we respond to what the public are telling us and ensure we build and maintain trust with them and the AI tools we look to deploy.” Read full story Source: 13 May 2026
  24. News Article
    Four of England’s 10 ambulance trusts are expecting to miss the headline response time target for 2026-27, according to their plans for the year. Details of trusts’ plans as agreed with their commissioners, collected by HSJ, suggest Category 2 performance could be around 26 minutes 30 seconds nationally, rather than the 25m recovery target. Recovering response times for Category 2 incidents – which include suspected heart attacks and strokes – has been a key ask from government and NHS England for several years, and has clear targets in the medium-term planning framework. However, ambulance trusts typically agree their target times each year with integrated care board commissioners and NHSE, based on funding on offer and the expected impact of hospital handover delays, which take crews out of action. They then plan for on-road hours and the staffing needed. An NHSE spokesperson said: “We have started the year well on track to hit ambitious national targets for category two calls, and we are supporting every ambulance trust to improve their response times and, in some cases, exceed the national target.” Read full story (paywalled) Source: HSJ, 13 May 2026
  25. Content Article
    Implementing safe and effective handover in maternity and gynaecology is now live. The consultation is open for comment for 4 weeks (closing date: Thursday 4 June). Full details on how to provide feedback on this paper are available on the Royal College of Obstetricians & Gynaecology (ROCG) website. Peer review is a vital stage in guidance development and aims to ensure that the draft content accurately reflects and explains the latest high-quality evidence and best practice. In order to achieve this, RCOG invite a wide cross-section of stakeholders to provide comments on an individual basis.

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