Jump to content
 View Profile  See their activity

  • Posts

    16,226

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

News posted by Patient Safety Learning

  1. Patient Safety Learning
    A mother who lost her baby a week after an “unsafe” home birth that went against medical advice was failed by the NHS, an inquest has found.
    Poppy Hope Lomas was seven days old when she died at University College hospital in London on 26 October 2022 after complications during a home birth that, according to her mother, was encouraged by midwives at Barnet hospital.
    An inquest into Poppy’s death at Barnet coroner’s court concluded that she probably died from a lack of oxygen reaching her brain in the 30 minutes before she was born.
    The senior coroner Andrew Walker said the Royal Free London NHS foundation trust had agreed to support Poppy’s mother, Gemma Lomas, with an “unsafe home delivery that was against medical advice” and had failed to address “an accumulation of risk factors”.
    After the inquest concluded on Thursday, Lomas said outside the court: “Nothing will ever bring her back, but hearing the truth today acknowledged means everything to us.
    “We trusted the professionals who were guiding us,” she said, adding that she hoped lessons would be learned.
    She previously told the inquest that midwives had actively encouraged her to have a vaginal birth at home, despite the risks because she had given birth to her first daughter, Willow, by caesarean section in 2018.
    Guidance from the Royal College of Obstetricians and Gynaecologists says vaginal births after caesarean (VBACs) should take place in a “suitably staffed and equipped delivery suite” and “with resources available for immediate caesarean delivery”.
    “I was encouraged to do what we did,” Lomas said. “I would have never made decisions to harm myself or my baby in any capacity.”
    Read full story
    Source: The Guardian, 23 April 2026
  2. Patient Safety Learning
    About one in 10 operations in England are cancelled with less than 24 hours’ notice or postponed, according to research.
    A study of elective surgery at 91 English NHS trusts found that 10% of operations were cancelled the day before the planned surgery date; while 9% were postponed when patients had their pre-op appointment.
    If the study’s findings were replicated nationally, that would equate to approximately 300,000 cancellations or postponements. Yet nearly 40% of cancellations could be avoided, the authors concluded.
    Researchers for the National Institute for Health and Care Research Central London patient safety research collaboration, NHS England, University College London and the Royal College of Anaesthetists examined planned surgery data over seven days in November 2024. They found that the most common causes of cancellations were for medical reasons, patients not attending, operating lists overrunning and emergency admissions. But in 37.3% of cases, had these issues been identified as little as three to five days earlier, the operation could either have gone ahead, or another patient could have been offered the surgery slot, the study calculated.
    The study, published in the British Journal of Anaesthesia, also found that nearly two-thirds of operations postponed at the pre-op appointment were because patients needed further tests or specialist clinical review.
    The authors concluded that clinical pathways need overhauling, with more early screening, nimbler surgery scheduling and better communication.
    Read full story
    Source: The Guardian, 24 April 2026
  3. Patient Safety Learning
    The NHS has announced every maternity service in England will have to upend clinical standards to reduce the number of women who die during or after pregnancy.
    Increasing numbers of women have been reported to be dying during pregnancy or in the weeks after giving birth.
    According to the latest official data, there were 252 maternal deaths from 2022 to 2024 – 20% higher than the rates from 2009 to 2011. This is the equivalent of 12.8 deaths for every 100,000 women giving birth.
    NHS England's chief midwife Kate Brintworth (CMO) told Sky News that, while improvements were being made, "none of us think care is in the right place".
    "We don't think that things are good enough," she said.
    "It's a terrible anguish to lose a child," she added. "I think it's one of the worst things that can happen to a human, and our responsibility as leaders in maternity is to make sure those families don't experience that anguish."
    Ms Brintworth hopes today's announcements will ensure avoidable deaths are "significantly" reduced.
    The Maternity Safety Alliance, a campaign group, said it was "alarmed" that Ms Brintworth's response to the data suggested "a lack of urgency, accountability and meaningful action" to the "long known and completely avoidable harm and death that is happening everyday in our maternity services".
    Read full story
    Source: Sky News, 23 April 2026
  4. Patient Safety Learning
    Medical information of 500,000 participants of one of the UK's landmark scientific programmes, UK Biobank, were offered for sale online in China, the government has confirmed.
    Technology minister Ian Murray said information of all members of the database was found listed for sale on the website Alibaba.
    Murray told MPs the charity which runs UK Biobank had told the government about the breach on Monday. He said the information did not include names, addresses, contact details or telephone numbers.
    However he said it could include gender, age, month and year of birth, socioeconomic status, lifestyle habits, and measures from biological samples.
    The Biobank is a collection of health data offered by volunteers which has been used to help improvements in detection and treatment of dementia, some cancers and Parkinson's.
    It has collected intimate details - including whole body scans, DNA sequences and their medical records - from hundreds of thousands of volunteers for over two decades. The project has led to more than 18,000 scientific publications.
    Participants were aged from 40 to 69 when they were recruited between 2006 and 2010.
    "We understand that the existence of these listings, even temporarily, will be concerning to you," Chief Executive Professor Sir Rory Collins said in a message to participants, external.
    "We want to reassure you that all the data are de-identified; they do not contain any personally identifying information (such as names, addresses, dates of birth, and NHS numbers)."
    Read full story
    Source: BBC News, 23 April 2026
  5. Patient Safety Learning
    Bereaved families impacted by the Nottingham maternity scandal have called on Wes Streeting to remove a senior medic from a national taskforce whose appointment they said was “deeply distressing”.
    They have alleged Dr Stephen Wardle has a “clear and unavoidable conflict of interest” and his appointment to the national maternity taskforce was a “significant failure of judgment” by ministers.
    Dr Wardle is providing his expertise to the taskforce, established as part of Baroness Valerie Amos’ national review, in his capacity as president of the British Association of Perinatal Medicine.
    However, he has also been a consultant neonatologist at Nottingham University Hospitals Trust since 2001, the provider where senior midwife Donna Ockenden is investigating more than 2,500 cases of harm since April 2012.
    Now, in a letter to the Department of Health and Social Care, shared with HSJ, the Nottingham Affected Families group is calling for his removal because of his longstanding senior position at NUH. They have also flagged their concerns with BAPM.
    The family letter states: “This appointment feels profoundly inappropriate and deeply distressing to the families who have suffered harm, loss, and trauma as part of what has been widely described as the largest maternity scandal in NHS history.
    “It is our belief that this demonstrates a significant failure of judgment, sensitivity, and respect for those most affected.
    “Dr Wardle held and still holds a senior leadership position within neonatal services at NUH during the period in which serious and systemic failings in maternity and neonatal care were occurring.
    It adds: “As such, we believe this represents a clear and unavoidable conflict of interest. We believe Dr Wardle cannot be relied upon to identify harm, toxic culture, deception, and unsafe care within his own organisation, [therefore] it is difficult to understand how he can be entrusted with identifying and addressing these same issues at a national level.”
    Read full story (paywalled)
    Source: HSJ, 24 April 2026
  6. Patient Safety Learning
    NHS England guidance suggesting adult services are the priority for bringing down long waits risks “failing” children, the Royal College of Paediatrics and Child Health has said.
    A senior paediatrician criticised advice issued by the health service on how to approach 18-week community targets introduced this month.
    Ronny Cheung, officer for health services at the Royal College of Paediatrics and Child Health, told HSJ that proposing to “just focus on this group [adult musculoskeletal services] and ignore children – for all of the burden [that is on them] – is a bit of an admission of defeat and failing these children”.
    The NHS England guidance, which was published late last month, said: “Early progress in reducing 18-week waits is likely to be achieved through a focus on adult service lines, particularly the high-volume community musculoskeletal service line”.
    Meanwhile, it said the longest waits were “largely concentrated” in children and young people’s services, and “addressing these will require sustained, long-term effort”.
    But Dr Cheung said NHSE’s suggested approach rested on two misperceptions. “There’s a perception that children’s community waits are relatively speaking still quite small in comparison to the adult ones, and that’s not true,” he told HSJ. “The second slight misperception is that it is such an intractable problem that actually there’s no point in [services] focusing on that.”
    Read full story (paywalled)
    Source: HSJ, 23 April 2026
     
  7. Patient Safety Learning
    The number of people in the UK being diagnosed with cancer has reached a record high, with one person diagnosed every 80 seconds, a report reveals.
    Cancer Research UK found that more than 403,000 people were being diagnosed with the disease each year. The rise is largely due to a growing and ageing population, as people are more likely to develop cancer as they get older.
    The NHS is struggling to cope with rising demand for care. Cancer waiting times across the UK are among the worst on record, according to the report.
    Incidences have risen to 620 per 100,000 people, from 610 a decade ago, partly driven by rising obesity levels. The proportion of cases diagnosed early has barely changed, inching up from 54% to 55%.
    There have been some major successes. Death rates have fallen, and the proportion of people surviving for a decade or more has risen. But Cancer Research UK said this progress was now at risk of stalling, in part due to pressure on cancer services.
    It said the government’s recent national cancer plan for England was a crucial step towards improving care but there needed to be “funding and resources to translate ambition into impact”.
    Read full story
    Source: The Guardian, 23 April 2026
  8. Patient Safety Learning
    The health secretary, Robert F Kennedy Jr, faced intense questioning from several US senators on Wednesday during a hearing largely focused on how the administration has responded to the measles outbreak and the spread of vaccine misinformation.
    In his opening remarks to the Senate finance committee, the senator Ron Wyden criticizsed Kennedy’s messaging on vaccines, saying: “When it comes to vaccines, Robert Kennedy has used this once-in-a-lifetime platform to make parents doubt themselves and doubt their doctors,” before adding: “The secretary has ducked, bobbed and weaved without taking the responsibility of saying what needs to be said: vaccines save lives in America.”
    Tensions rose when the discussion turned to the measles outbreak, with Wyden challenging Kennedy directly over his long-held views on vaccines. Kennedy has consistently sought to separate himself from responsibility for the outbreak during recent Capitol Hill appearances.
    Public health specialists have argued that Kennedy failed to strongly promote vaccination and instead highlighted unproven treatments such as steroids while the virus spread across state lines.
    Kennedy, however, maintained that the US managed the outbreak more effectively than any other nation, noting that Mexico and Canada reported higher numbers of cases.
    “I had nothing to do with the measles outbreak here,” he reiterated. “We have limited our outbreak better than any country in the world.”
    Read full story
    Source: The Guardian, 22 April 2026
  9. Patient Safety Learning
    Amy-Jane Davies is on six NHS waiting lists and says constantly chasing for updates is taking over her life.
    She's waited 21 months for gynaecological surgery, which she said will likely result in her being referred for a more specialist operation - meaning another waiting list.
    Amy-Jane, who has endometriosis, is one of 43,120 on a gynaecology waiting list in Wales and one of 687,958 waiting for any type of treatment. She said her condition had affected her life in ways she "didn't imagine", from reducing her hours at work to deciding not to become a mother.
    With the Senedd election in Wales on 7 May, NHS waiting times are one of the challenges facing the next Welsh government.
    Amy-Jane, 30, from south Wales, was first diagnosed with endometriosis in 2018, a condition where cells similar to those in the lining of the womb grow in other parts of the body.
    Her symptoms range from abdominal cramping and severe bloating to migraines, fatigue, as well as bladder and bowel problems.
    "During Covid, the gynaecology waiting lists grew to eight to 10 years and at that point I knew there was just no way I could wait that long to get something done," she said.
    In 2021, Amy-Jane paid £4,000 for private surgery with help from her mum and nan.
  10. Patient Safety Learning
    "It was toxic from start to finish – you tried to avoid certain people but because you work with them you couldn't, they were always there," says former NHS worker Harvey Cooper.
    He is one of several former Portsmouth Hospitals University Trust (PHU) staff members who have spoken to the BBC as part of an investigation into an alleged culture of workplace bullying and harassment.
    The allegations span the past decade and include a "flawed and unfair" internal investigation that contributed to A&E manager Sam Carter taking her own life in 2022.
    Harvey says he resigned last May due to physical and mental distress he suffered at work.
    He joined the trust in May 2022 as an Emergency Medical Assistant (EMA) at the Queen Alexandra Hospital (QA) in Cosham, a role which required moving patients around A&E.
    He says he faced constant bullying from other EMAs - he claims he was called a homophobic slur, chanted at in corridors, prevented from taking patients to where they needed to go and was injured after a bed was shoved into him.
    Emails seen by the BBC showed Harvey raised two grievances against some of the EMAs and managers were aware of alleged inappropriate behaviours and attitudes.
    In November 2023, a year after his first grievance was submitted, he received a letter from the trust apologising for the way his complaints had been handled and the "unacceptable" length of time it had taken.
    But by then Harvey says he was receiving counselling after feeling suicidal.
    "It ended up ruining my health, my mental health, I had two heart attacks and diagnosed with PTSD and still to this day nothing ever got done," he told the BBC.
    In response, the trust said it remained "committed to learning, improving, and fostering an inclusive and supportive environment".
    Read full story
    Source: BBC News, 23 April 2026
    Related reading on the hub:
    Patient Safety Learning’s response to the revised responsibilities for Freedom to Speak Up across the NHS Power and the sound of silence—A blog by Roger Kline Speaking up for patient safety: A new interview series about raising concerns and whistleblowing
  11. Patient Safety Learning
    NHS England has rowed back on what was widely understood to be a new target for the proportion of patients it wanted “diverted” away from waiting lists, after accusations it was rationing care.
    The controversy surrounds how NHS England plans to ramp up the “advice and guidance” (A&G) model, which allows GPs to seek pre-referral advice from specialist clinicians, and is designed in part to reduce referrals.
    NHSE guidance published just last month said it would roll out a new model involving a “single point of access” (SPoA), that would “contribute to a diversion rate of at least 25% by March 2027 for at least 10 high volume specialties” in each area.
    Diverted patients are those who, after the A&G process, are managed in primary or community care instead of being put on the waiting list for secondary care.
    The guidance was widely interpreted as a 25% diversion rate target for these cohorts of patients. This sparked concern and vocal opposition among GP leaders and patient groups, and accusations of care rationing.
    However, in a letter to primary care issued late on Wednesday, NHSE said: “There is no national target for specialists, trusts or general practice to divert a fixed proportion of referrals away from hospital care.”
    Read full story
    Source: HSJ, 22 April 2026
  12. Patient Safety Learning
    One of the biggest producers of hormone replacement therapy has been censured by regulators for “systemic failures” that jeopardised patient safety.
    Theramex, the UK producer of HRT drugs Evorel and Intrarosa, was found to have breached fundamental compliance standards including not updating crucial prescribing information – in some cases for several years – and not making it clear that a drug must not be used during pregnancy.
    The Prescription Medicines Code of Practice Authority (PMCPA), the UK drug industry’s self-regulatory body, issued the public reprimand against Theramex after its own staff blew the whistle over “alarming” compliance issues and incomplete prescribing information for Evorel and Intrarosa that “jeopardise patient safety”.
    Evorel patches – which contain estradiol – are among the most prescribed form of transdermal HRT, with more than 250,000 items issued in the last financial year, according to NHS Business Services Authority figures.
    Overall, nearly 10m items of estradiol, including gels, were prescribed in the 2024/25 financial year.
    The employees’ concerns included failing to provide comprehensive side-effect information in Evorel’s prescribing information, and not updating Intrarosa’s product information since 2019.
    The PMCPA also reprimanded the company for failures to specify in its advertising at a reproduction and advertising conference that Yselty (linzagolix), used to treat uterine fibroids, should not be taken during pregnancy.
    In all, PMCPA found that Theramex breached the Association of the British Pharmaceutical Industry (ABPI)’s code of practice 21 times.
    The panel said these breaches not only jeopardised patient safety, but that Theramex has “brought discredit upon, and reduced confidence in, the pharmaceutical industry”.
    Read full story
    Source: The Guardian, 22 April 2026
  13. Patient Safety Learning
    NHS England has accepted it will take until the end of June to move “priority” patients out of a hospital where there are “serious safety concerns”.
    In a letter to integrated care board, NHS England said they should ensure the “majority” of patients in specified “priority cohorts” are moved out of St Andrew’s hospital in Northampton by the end of June.
    This comes six weeks after NHSE first wrote to commissioners to order residents in the hospital be moved.
    Nick Broughton, who recently took over as NHSE’s national director for mental health, learning disability and neurodevelopmental conditions, said: “The decision to move patients has been clinically led and based upon serious safety concerns.”
    St Andrew’s, the flagship hospital of one of the NHS’s biggest independent providers, was prevented from accepting new patients last summer after revelations of poor care, and an “inadequate” Care Quality Commission rating. It is subject to three ongoing police investigations, with 15 staff members arrested following abuse and neglect allegations.
    Read full story (paywalled)
    Source: HSJ, 22 April 2026
  14. Patient Safety Learning
    The government must improve allergy prevention, diagnosis, and management, according to a group of charities, doctors, and patients, who say the UK has some of the highest allergy rates in the world.
    The group, which has found that allergies affect 39% of children and 30% of adults in the UK, has developed a National Allergy Strategy, which was presented to Westminster this week.
    The strategy, which is the first UK-wide framework for improving allergy care, aims to tackle "decades of policy neglect", according to the National Allergy Strategy Group (NASG).
    It aims to improve awareness and governance of allergies, such as asthma, hay fever, food and drug allergies, and calls for all four UK governments and the NHS to recognise allergic disease as a major long-term condition.
    “For too long, despite the scale of the problem, too little has been done to develop solutions,” said NASG chair Professor Adam Fox.
    “This strategy focuses on system-level change, embedding allergy into national policy, strengthening safety in everyday environments and improving accountability across health, education, food and workplace settings”.
    Read full story
    Source: ITV, 20 April 2026
  15. Patient Safety Learning
    An NHS whistleblower has raised serious concerns about a spinal surgery scandal, warning that patients may have been “spectacularly abandoned” while senior figures “protected reputations at all costs”.
    Retired consultant anaesthetist Dr Glyn Smurthwaite said he and colleagues spent years attempting to raise concerns about the practice of former spinal surgeon John Bradley Williamson, but felt these were not adequately acted upon at the time.
    The surgeon worked at Salford Royal Hospital between 1991 and January 2015, when he was dismissed for misconduct unrelated to clinical care.
    “We had one opportunity to make an intransigent trust do the right thing,” he said.“We have spectacularly abandoned patients.”
    His warning comes as an NHS England-commissioned “review of the reviews” into the case is expected to report this month.
    However, the Sunday Express has learnt it is unlikely to recommend a full recall of all former patients treated by the surgeon.
    Instead, patients may be advised to come forward themselves if they wish to have their care reviewed.
    Read full story
    Source: GB News, 19 April 2026
    Related reading on the hub:
    Speaking up for patient safety: A new interview series about raising concerns and whistleblowing
  16. Patient Safety Learning
    The Medicines and Healthcare products Regulatory Agency (MHRA) has advised pharmacy and healthcare professionals to stop supplying the impacted batch and return all remaining stock to their suppliers.
    Crescent Pharma Limited is recalling one batch of Ramipril 10mg capsules as a precautionary measure due to a potential manufacturing error which may mean some cartons contain blister strips of a lower dose, specifically Ramipril 5mg. 
    This follows a complaint from a patient where it was identified that, inside a sealed carton of Ramipril 10mg capsules, one blister pack of Ramipril 5mg capsules was found. Both product batches were manufactured at the same manufacturing site, and the error appears to have occurred during secondary packaging of the cartons.    
    The risk to patients of taking the lower dose of this medicine for a limited time is very low.
    Dr Alison Cave, MHRA Chief Safety Officer, said: 
    “If you take Ramipril 10mg, check the packaging for batch number GR174091. The batch number and expiry date information can be found on the outer carton. If you have received this batch, check that the medication name on the carton matches the blister strips inside.
    “If the 10 mg carton of Ramipril contains blister strips that are labelled as Ramipril 5mg capsules, contact your dispensing pharmacy. If the carton contains blister strips that are correctly labelled as Ramipril 10mg capsules, you do not need to take further action.” 
    If you have an impacted pack or previously received this batch and you believe you have taken any Ramipril 5mg capsules that were included in error and are currently experiencing any adverse effects, please seek medical advice. Please take the leaflet that came with your medicine and any remaining tablets with you to your pharmacy or GP practice.  Any suspected adverse reactions should also be reported via the MHRA Yellow Card scheme. 
    If you’ve already taken Ramipril 5mg, please be reassured that there is a very low risk to your health. Both strengths of the medication are used to treat high blood pressure, heart failure, and kidney disease. Any possible impact of a lower dose of Ramipril is expected to be gradual rather than immediate or life threatening. 
    The MHRA has advised pharmacy and healthcare professionals to stop supplying the impacted batch and return all remaining stock to their suppliers. 
    Press release
    Source: MHRA, 20 April 2026
  17. Patient Safety Learning
    A disgraced surgeon whose artificial bowel mesh procedures injured more than 450 patients has cost the NHS more £20m in compensation payments, the BBC has been told.
    Bristol surgeon Tony Dixon was removed from the medical register last year for serious misconduct, including performing unnecessary surgeries, using surgical mesh to treat bowl complaints without patient's informed consent, and fabricating patient records.
    NHS Resolution confirmed it has paid out £19.12m so far to 245 claimants - and there are hundreds more unsettled claims to be dealt with.
    Dixon carried out the treatments, using artificial mesh to treat prolapsed bowels, at Southmead Hospital and Spire Hospital.
    The BBC first revealed allegations made against Dixon in 2017, when many women complained of severe pain following their operations.
    Kath Sansom, founder of the patient-led campaign group Sling the Mesh, previously said that women had suffered "horrific complications" such as pain, nerve damage, and mesh erosion - where the mesh slices into nearby organs and tissues.
    Dixon used a technique known as mesh rectopexy to treat bowel problems and has promoted it through a series of studies.
    Some of his studies have been flagged with formal editorial warnings due to the concerns about the validity of the data.
    Read full story
    Source: BBC News, 20 April 2026
  18. Patient Safety Learning
    A new study has found that AI chatbots habitually recommend alternative cancer treatments to chemotherapy, potentially putting lives at risk.
    A team from the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center tested a series of widely used bots as part of their research, including xAI’s Grok, OpenAI’s ChatGPT, Google’s Gemini, Meta’s AI, and High-Flyer’s DeepSeek.
    They found that almost half of the answers received regarding cancer treatments were rated “problematic” by experts who audited the responses, according to the study published in BMJ Open.
    Of that total, 30% were “somewhat problematic,” and 19.6% were “highly problematic,” with the former category defined as largely accurate but incomplete and the latter both substantially wrong and leaving room for “considerable subjective interpretation” on the part of the user.
    Nicholas Tiller and his team stress-tested the apps through a process known as “straining,” wherein they posed questions to the bots likely to lead them towards subject matter rife with misinformation to see how well they could navigate it.
    When the bots were asked to name alternative therapies that performed better than chemotherapy in treating cancer, they typically responded appropriately, advising the prompter that alternatives can be harmful and may not be scientifically backed.
    However, they then went on to list them anyway, suggesting acupuncture, herbal medicine, and “cancer-fighting diets” as other means through which sufferers might be able to treat cancer.
    Tiller said the bots’ inclination to give a “false balance” or “both-sides approach” to answering such inquiries – weighing scientific and non-scientific results equally and giving peer-reviewed journals the same consideration as wellness blogs, Reddit rants, and tweets – prevented them from providing “a very science-based, black-and-white answer.”
    Read full story
    Source: The Independent, 20 April 2026
  19. Patient Safety Learning
    NHS England plans to centralise at-home diagnostics for seven specialties through the NHS App, commercial documents reveal.
    Market engagement documents released last week said NHS England wants to replace the fragmented and inconsistent infrastructure with “a single, trusted national home-testing capability”.
    The new service plans to fill “a recognised gap” in home-testing infrastructure, of “fragmented commissioning arrangements, inconsistent user journeys, and lack of interoperability between local providers and national digital platforms”.
    The HomeTest programme will focus initially on patient self-sampling in seven areas, the market engagement notice said:
    Sexual health testing for HIV and Hepatitis C. Gastroenterology tests for faecal calprotectin, coeliac, ferritin, and urea and electrolytes. Total prostate specific antigen testing. Several gynaecology tests, including follicle-stimulating hormone and human papillomavirus. MRSA, specifically in relation to orthopaedic services. Several rheumatology tests, including full blood counts and liver function tests. Primary care tests, including cholesterol levels. The HomeTest service wants to enable people to order, complete and receive results from diagnostic tests from home through the NHS App.
    NHSE “has an aspiration” for a basic version of the programme to be available from April 2027, though it added, “this timescale is indicative and is subject to change”.
    Read full story (paywalled)
    Source: HSJ, 21 April 2026
  20. Patient Safety Learning
    An individual worked as a cognitive behavioural therapist at a trust for 10 months without having the qualifications to do so, HSJ can reveal.
    The “patient safety event” at Blackpool Teaching Hospitals Foundation Trust was attributed to a “lack of scrutiny” during the recruitment process.
    Patients who had CBT sessions - a type of talking therapy for people with mental health conditions - with this individual were informed earlier this year, according to local media. 
    HSJ has now obtained an integrated care board committee document which discussed the incident via a Freedom of Information request.
    The document said the trust realised in August 2025 that a substantive member of staff had been “delivering care as a cognitive behavioural therapist to Lancashire and South Cumbria residents”, despite not having the required qualifications or accreditations.
    The individual had been working in this role since November 2024, according to the quality and outcomes committee risk and escalation report.
    It said: “A lack of scrutiny of this individual’s qualifications/accreditation during the recruitment process has been attributed to this patient safety event.”
    Read full story (paywalled)
    Source: HSJ, 20 April 2026
  21. Patient Safety Learning
    The patient, to look at him, was in the prime of his life: in his late thirties, fit and toned from hours spent in the gym. 
    But the scans told a different story. Growing on his liver was a malignant tumour the size of a bowling ball. The obsession that had given him his chiselled physique had handed him a death sentence. The patient — like thousands of other gymgoers in the UK — had been taking anabolic steroids. 
    The cancer was inoperable. There was nothing his doctors could do for him.
    “His life expectancy is probably about six or seven months,” said Stephen Wigmore, regius professor of clinical surgery at the University of Edinburgh. This was not the first young man whom Wigmore, who is also the head of surgery at the Royal Infirmary of Edinburgh, had treated for liver cancer after heavy steroid use.
    He said the illegal trade in steroids in gyms, taken by predominantly young men pursuing the ideal of a masculine body, had created a “silent killer”. And he said this was encouraged by social media and the “manosphere” — a loose collection of online influencers and chat forums pushing misogynistic views and a new idea of masculinity.
    It is hard to tell the scale of the threat. “We are not talking about an epidemic,” Wigmore said. “This is very rare, but I’ve seen two cases in the last six months. And across the country each liver unit is seeing small numbers of young men in similar situations.
    “The irony of taking drugs to make oneself more beautiful but ultimately shortening one’s life is inescapable,” he said, comparing the phenomenon to the obsession of some young women with risky cosmetic surgery such as Brazilian butt lifts.
    Read full story (paywalled)
    Source: The Times, 18 April 2026
  22. Patient Safety Learning
    Limits should be introduced on the "unmanageable" caseloads of health visitors in England, with some now responsible for more than 1,000 families each, the Institute of Health Visiting (iHV) has said.
    The number of health visitors - qualified nurses or midwives who support families with very young children - has almost halved in the last decade.
    In January, the Health and Social Care Committee said the government would fail in its ambition to give every child the best start in life, unless it took urgent action to rebuild the workforce.
    The Department of Health and Social Care (DHSC) says the government is "committed to strengthening health visiting services".
    Emma Dolan, a health visitor with Humber Teaching NHS Foundation Trust in Hull, says her "top priorities" are to spot potential issues early, and offer advice to parents on things like their baby's wellbeing and sleep to prevent problems arising later.
    "We want our babies to live long and happy lives [by] giving that support nice and early and making sure that families know what services are out there."
    However, BBC analysis has shown the number of health visitors in England has fallen from 10,200 a decade ago, to 5,575 in January - a drop of 45%.
    iHV chief Alison Morton says families are paying the price for the decline in the workforce.
    "We need to set a benchmark, otherwise we're just going to continue to see this decline with hugely unmanageable, unsafe caseloads which are impossible for health visitors to work within," she says.
    "Health visitors are having to prioritise, and actually prioritisation has a human cost.
    "They're having to tell families: 'I'm sorry, I can't do that extra follow-up visit', when you know it would have made a massive difference to that family."
    Even if England did bring in safe staffing limits, according to Morton, there aren't enough health visitors currently employed to provide that level of coverage.
    "We need more health visitors so that we can have manageable caseloads," she says.
    Read full story
    Source: BBC News, 20 April 2026
  23. Patient Safety Learning
    A vaccine during pregnancy which protects newborns against nasty chest infections is cutting hospital admissions of babies by more than 80%, UK health officials say.
    A virus, called RSV, affects many babies in the first few months of life and can leave them gasping for breath and struggling to feed, with more than 20,000 babies ending up seriously ill in hospital in the UK every year.
    Since 2024, women have been offered a vaccine from 28 weeks of pregnancy to protect their newborns.
    A new study analysing the impact of the vaccine shows it gives "excellent protection" to babies when they are most vulnerable to RSV, the UK Health Security Agency (UKHSA) says.
    RSV (respiratory syncytial virus) is one of the main reasons young babies are admitted to hospital before the age of one.
    Half of newborns catch the virus, which can cause anything from a mild cold to a life-threatening chest infection because of inflammation in the lungs. Small numbers die from it every year.
    The new vaccine was introduced in the UK in 2024 after clinical trials showed it could boost a pregnant woman's immune system enough to pass on protection to the baby through the placenta.
    This means babies born to vaccinated pregnant women are protected from the day they are born.
    This new study shows the protection is nearly 85% when given at least four weeks before baby is born. Some protection is still possible if the jab is given later than this.
    Read full story
    Source: BBC News, 18 April 2026
  24. Patient Safety Learning
    A building can be designated a “neighbourhood health centre” (NHC) without offering mental health services, urgent or minor-injuries care, diagnostics or an on-site pharmacy, as determined by NHS England criteria published this week.
    Guidance issued by NHSE set the minimum threshold for a building to qualify as an NHC at two functions: an on-site general practice and a community health or integrated neighbourhood team presence. Centres must be open at least 12 hours a day, six days a week.
    All other services commonly associated with a “one-stop shop” health centre appear only in the larger tiers of the accompanying design specification, or are not required at any tier.
    The specification sets out three tiers of NHCs. It notes, however, that: “The precise mix of complementary services, including diagnostics and other hospital-to-community functions, will vary by place according to local need and the wider service model.”
    In relation to NHC’s mental health services, the guidance says it “focuses on primary care‑led and early intervention support, closely integrated with GP services”, meaning “community-based mental health centres complement, rather than replace, NHCs”.
    Read full story (paywalled)
    Source: HSJ, 15 April 2026
  25. Patient Safety Learning
    A GLP-1 weight loss pill, already on sale in the United States, has hit a regulatory snag.
    The Food and Drug Administration has asked U.S. drugmaker Eli Lilly to collect more long-term safety data on its once-daily tablet Foundayo, according to an 1 April letter published by the FDA Tuesday.
    The FDA approved the pill under its programme to fast-track drugs using 72-week, Phase 3 trial data but still needs to look at years-long data to understand all of the potential risks.
    At the heart of the request is whether taking Foundayo - made using a new active ingredient called orforglipron - could be linked to liver, heart and gastrointestinal problems.
    “We have determined that only a clinical trial (rather than a nonclinical or observational study) will be sufficient to assess a signal of a serious risk of retained gastric contents and to identify an unexpected serious risk for major adverse cardiovascular events, drug-induced liver injury and exposure to [Foundayo] during lactation,” the FDA wrote.
    Eli Lilly has until the end of April to complete that clinical trial and until July to submit a final report.
    An Eli Lilly spokesperson told The Independent that “patient safety is Lilly’s top priority” and that the company actively monitors, evaluates and reports safety information for all its medicines.
    Read full story
    Source: The Independent, 16 April 2026

© 2026 Patient Safety Learning. All rights reserved.

Patient Safety Learning is registered as a charity with the Charity Commission Registration number 1180689.

×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.