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Patient Safety Learning

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  1. Patient Safety Learning
    Thousands of cancer patients from minority ethnic backgrounds will have access to “groundbreaking” genetic testing on the NHS that previously discriminated against them.
    This routine form of genetic testing, used before chemotherapy treatment, could save the lives of Black and minority ethnic cancer patients who already face poorer health outcomes after diagnosis compared with their white counterparts.
    Before undergoing chemotherapy, cancer patients across England undergo genetic testing that can lead to changes in treatments to reduce the adverse side-effects chemotherapy can have, including mouth sores, hair loss, nausea and fatigue, and which can also be fatal. Up to 40% of the 38,000 patients treated with fluoropyrimidine-based chemotherapy in England will develop an adverse drug reaction to the treatment.
    Until last year, these genetic tests only looked for four types of DPYD gene variants, which are mainly found within the DNA of people from white European backgrounds. Consequently, this genetic testing was less effective on Black cancer patients, leading them to be more likely to experience severe side-effects including death after chemotherapy.
    These genetic tests are now being offered by the NHS across England to include testing for a fifth DPYD genomic variant, which is more prevalent among people from Black and minority ethnic backgrounds.
    Dr Veline L’Esperance, the senior clinical adviser at the NHS Race and Health Observatory, said that the introduction of these new genetic tests represents “tangible results for patients who have historically been left behind”.
    “Patients of African ancestry deserve the same standard of safety as everyone else, and now clinicians have the means to deliver it,” L’Esperance said. “What makes this significant is that it moves the conversation about ethnic health inequality in cancer care from words to action. This is the first concrete, clinical response to the evidence that Black and ethnic minority patients were being failed by tests designed around white European genetics.”
    Read full story
    Source: The Guardian, 13 April 2026
  2. Patient Safety Learning
    Two in five international health workers are considering leaving the UK, with many citing feelings of not being welcome amid anti-immigrant rhetoric.
    The union Unison warns that government proposals to tighten settlement rules for migrant workers, coupled with escalating visa fees and restrictions, threaten to deepen the ongoing NHS staffing crisis.
    A Unison survey of nearly 1,900 international health professionals working in Britain found that 43% are now considering departure, with a quarter feeling unwelcome and a fifth reporting they feel unsafe.
    The union’s head of health Helga Pile said: “The UK’s health and care services would collapse without the skilled workers who’ve come here from overseas. How we treat them matters – they should be respected, not taken advantage of and abused.
    “It’s shocking so many NHS staff say they don’t feel safe or welcome in this country. No wonder so many are thinking of leaving.
    “These findings make it clear ministers must think again about trebling the settlement period for crucial migrant health and care staff. Otherwise, the workforce crisis will get worse.
    “Politicians of all stripes need to stop demonising people who are doing crucial work, often for very low pay. They’re the ones shoring up the UK’s crumbling health and care sectors. We simply cannot do without them.”
    Read full story
    Source: The Independent, 14 April 2026
  3. Patient Safety Learning
    An inquiry into the preventable deaths of babies in Sussex will fail to learn the lessons as it “systematically” excluded dozens of families, Wes Streeting has been warned before a meeting with bereaved parents.
    The health secretary has ordered a review of nine infant deaths at the University Hospitals Sussex NHS foundation trust amid maternity scandals across England. However, families are calling on Streeting to expand the investigation to all those who died and might have survived with better care.
    To date, the families of more than 60 babies who died between 2019 and 2023 have expressed concerns about their care, although the true figure is expected to be higher.
    Dr Marija Pantelic, a public health expert whose baby Sasha died in the care of UH Sussex in January 2022, said the narrow scope and opt-in nature of the review was dangerous and potentially harmful as it would be based on the experiences of an “overwhelmingly white and British” group of parents.
    Parents want an expanded investigation to be led by Donna Ockenden, the senior midwife who is leading maternity inquiries into preventable deaths at NHS trusts in Nottingham and Leeds. They also want the Sussex investigation to actively seek out families who are affected so it is not based only on the nine cases whose parents have raised the alarm.
    Pantelic, an associate professor in public health who specialises in health inequalities, said it should alarm Streeting that the review would be based on the experiences of the “overwhelmingly white and British” families who had come forward.
    “If you only hear from certain groups, you will only see certain problems,” she said. “For instance, you can be sure not to identify racism if you only hear from white families. If you fail to identify the real drivers of harm, the solutions you propose will be partial at best, and harmful at worst.”
    Read full story
    Source: The Guardian, 13 April 2026
  4. Patient Safety Learning
    Private firms providing services to the NHS including healthcare and consultancy have made £1.6bn in profits over the last two years, research reveals.
    The findings – on the basis of contracts worth £12bn – have prompted claims of “scandalous” profiteering, concern that the health service is being “taken for a ride” and calls for ministers to impose a cap on maximum profit levels.
    The £1.6bn in profits made in 2023-24 and 2024-25 would have been enough to pay for 9,178 doctors or 19,428 nurses during that time, according to the Centre for Health and the Public Interest.
    Its findings are based on analysis of NHS contracts in England, with 760 private firms providing services including diagnostic tests such as CT scans to patients, and treatments including hip and knee replacements, and for skin problems and mental health conditions.
    Helen Morgan, the Liberal Democrats’ health spokesperson, said: “Private companies making super-profits from our NHS is an unacceptable waste. This money should be going on frontline services, not fattened profits for big corporations.
    “The NHS should be able to benefit from economies of scale and use its power as a major buyer to drive down prices. I’m afraid it looks like our health service is being taken for a ride.”
    Read full story
    Source: The Guardian, 13 April 2026
  5. Patient Safety Learning
    A trust chair “exceeded her authority” and “badly handled” the suspension of its chief executive, according to investigation findings seen by HSJ.
    Annette Doherty, chair of East Kent Hospitals University Foundation Trust, gave chief executive Tracey Fletcher less than 24 hours to either accept a settlement package or face suspension during a mid-year performance review on 18 November last year.
    Ms Fletcher was formally suspended three days later. In December, she raised a grievance concerning the handling of her suspension and the matters leading up to it.
    HSJ has seen a draft report into that grievance prepared by a specialist HR consultant firm, dated 15 March. The document says that it “details high-level interim findings based on the evidence gathered so far”, although the author believed further information was “unlikely to change the findings”.
    It concluded that on the basis of the evidence, the chair’s actions were “not in line with the NHS values and expectations of a senior leader”.
    Read full story (paywalled)
    Source: HSJ, 13 April 2026
  6. Patient Safety Learning
    The government has revealed the locations of 40 new and expanded urgent care centres and same-day emergency care units.
    The programme, backed by £215.5m, includes 10 new urgent treatment centres, four expanded UTCs, five new same-day emergency care services and 21 expanded SDECs. They are across 33 hospital trusts.
    A government announcement said the facilities would tackle corridor care by “reducing waiting times and improving patient flow through hospitals” – but the Royal College of Emergency Medicine has disputed this claim.
    While many of the hospitals set to host the new UTCs and SDECs are above the national average for 12-hour waits in A&E, others appear to have less of a problem with long A&E waits. This measure is a close barometer of corridor care.
    “Expert teams” from NHS England’s Getting It Right First Time programme are also being sent to the hospitals with the highest levels of corridor care to provide “bespoke clinical support to leadership staff”, the government has said.
    RCEM president Ian Higginson welcomed the government’s commitment to eradicate corridor care, but said urgent treatment centres “are not the answer to reducing corridor care and will not make a dent in the number of people who are enduring long waits on trolleys in inappropriate places such as corridors”.
    “These services focus on the least unwell patients, and it’s the most unwell or those with mental health problems who are filling our corridors,” he added.
    Read full story (paywalled)
    Source: HSJ, 11 April 2026
  7. Patient Safety Learning
    Malina Lee, a 31-year-old wedding baker based in San Antonio, Texas, joined TikTok during the Covid pandemic lockdowns in 2020. Like many people at the time, she was bored and began using the platform to pass the time and advertise her business. She didn’t expect a cancer diagnosis.
    Four years after Lee joined the app, a commenter with the username “PickleFart” told her that her neck looked asymmetrical in a way that could suggest she had a goiter – an enlarged thyroid gland – and that she should get it checked out. The anonymous amateur clinician turned out to be right – Lee had thyroid cancer, received treatment quickly, and, less than a year later, was cancer free.
    TikTok users are increasingly reporting that the app’s hyper-specific algorithm has steered them towards detecting medical problems before they were aware of them themselves. In many instances, users reported that symptoms described by other TikTokers matched their own inscrutable set of ailments, which led to diagnoses. In instances like Lee’s, human commenters were responsible for diagnoses that doctors had missed or not yet identified.
    Lee is not the only user that PickleFart, whose real name is Billie Jean Tuomi, has accurately diagnosed in a comment section. By her estimate, Tuomi has commented on dozens of videos alerting content creators of potential thyroid problems – and correctly spotted serious problems in at least four cases that she knows of, including Lee’s.
    Tuomi’s career as the “thyroid avenger”, as some have started to call her, is personal in its origins: she herself was diagnosed with thyroid cancer in 2012, and after two years of treatment was declared cancer-free. But obtaining a diagnosis and undergoing the subsequent treatment were difficult processes. She now finds herself trying to spare strangers on the internet what she went through.
    “It’s something that you don’t ever stop struggling with – it’s constantly on my mind,” she said. “The earlier you get diagnosed, the easier it is to treat, so I feel like it’s important to say something if you see something.”
    Craig Mittleman, director of the department of emergency services at Lawrence + Memorial hospital in Connecticut, said in the last five years of his 36-year career practicing medicine, he has seen a sharp increase in patients coming in with internet-influenced diagnoses – for better and for worse.
    “In some ways, it’s allowed patients to feel empowered to ask certain questions and be more informed,” he said. “But I also find that we are often, as emergency physicians, spending a lot of time debunking information that patients present, which they’ve procured through social media.”
    Read full story
    Source: The Guardian, 12 April 2026
  8. Patient Safety Learning
    At the height of Covid, hundreds of cancer patients had mastectomies without the reconstruction that would normally accompany them. They would eventually get the surgery, they were told – but for many that promise feels more meaningless by the day
    Every time she lifts her arms to get dressed or hang out her washing, Julie Ford gets a painful reminder of one of the most terrifying experiences of her life. At 7am one day in April 2021, she had gone into hospital, alone and wearing a mask, to have her right breast and lymph nodes removed in a bid to stop breast cancer from spreading. Later that day, still groggy from the anaesthetic, in pain and with surgical drains hanging from both sides of her chest, she had staggered to the door with the help of two nurses. She was eased into a friend’s car and driven home to fend for herself.
    While Julie’s breast had been removed, it was not reconstructed. Usually, both procedures are carried out in the same operation. But as reconstruction using tissue from the patient’s abdomen is a complex, eight-hour procedure requiring a large surgical team, it was considered “non-essential” and paused by most NHS trusts during the Covid-19 pandemic.
    Like hundreds of women with breast cancer who underwent urgent mastectomies without reconstruction in 2020 and 2021, Julie was assured she could have the procedure once Covid restrictions lifted.
    But five years later, Julie, now 62, is still waiting.
    A national shortage of specialist surgeons and theatre space, as well as the need to prioritise new cancer cases, means many women like her, who had breasts removed during lockdown, feel they have been abandoned. They live in daily physical discomfort and mental distress as they continue to await the reconstructions they were promised years ago.
    A 2024 study found at least 2,200 patients who have survived breast cancer, or who were at high risk of developing it, were waiting for surgery across 40 NHS centres in England, with an average wait of 2.5 years.
    And Wood fears there is little to encourage struggling hospitals to clear the backlog. Instead of investing resources into “expensive and lengthy” surgeries such as breast reconstructions, NHS trusts that want to reduce the size of their overall waiting list have an incentive to prioritise quick, simple operations where several patients can be ticked off the list in a short time, he says. “There are capacity issues, with growing demand and a shortage of theatre time and surgeons’ time, but to tackle it you need to have [NHS trust] management that is bothered to find a solution, not just sit on their hands.”
    Read full story
    Source: The Guardian, 13 April 2026
  9. Patient Safety Learning
    ChatGPT has helped to uncover a woman's rare condition after years of being misdiagnosed by doctors.
    Phoebe Tesoriere, 23, claims she was told she was anxious, depressed, had epilepsy and warned she'd be treated as a mental health patient if she kept returning to A&E.
    Following three days in a coma after a seizure, Phoebe, from Cardiff, put her symptoms into the AI chatbot.
    She said it suggested a number of conditions, including hereditary spastic paraplegia, external, which Phoebe presented to her GP. Genetic testing confirmed the diagnosis.
    Dr Rebeccah Tomlinson is a GP serving Cardiff and Vale of Glamorgan, and said: "It's difficult for GPs to know everything.
    "With the pressure on the NHS, we have to know even more.
    "Patients coming with information helps me understand what they are thinking and guide the discussion more clearly.
    "It's good as a starting talking point [AI tools] which should be followed by going to a medical professional to discuss concerns further.
    "It's helpful for patients to come armed with information but the GP has to be open and receptive to the patient.
    "General practice has to be a two-way conversation."
    A recent University of Oxford study found that people using AI for healthcare advice were given a mix of good and bad responses, making it hard to identify what advice they should trust.
    Phoebe understands the challenges the hospital faced diagnosing her, but said she turned to AI after finding the experience "really lonely".
    "I had to fight to be listened to," she added.
    Read full story
    Source: BBC News, 9 April 2026
  10. Patient Safety Learning
    Training for NHS midwives will be overhauled to tackle a “national emergency” of racism, which means black women are three times more likely to die in childbirth.
    The Nursing and Midwifery Council (NMC), which regulates the profession, is introducing mandatory anti-racism training in degrees to combat “systemic” discrimination.
    Maternity scandals and reviews have highlighted how racism is contributing to the avoidable deaths of mothers and babies in Britain.
    Black mothers have been denied pain relief or emergency care by NHS staff after being stereotyped as “tough” or “demanding” and better able to endure pain.
    The Times revealed that the NHS has been issued with 22 separate safety warnings by official bodies to address racial disparities in maternity care over the past decade, yet the situation has not improved.
    Under the initiative, all universities offering midwifery degrees will have to update their curriculum to include awareness of racial biases and discrimination. From the next academic year, students will be taught about how racial stereotypes can affect care and how skin colour can affect the presentation of symptoms.
    Read full story (paywalled)
    Source: The Times, 8 April 2026
  11. Patient Safety Learning
    The NHS could save tens of thousands of pounds per patient each year by prescribing tablets instead of liquid medicine to children with a particular medical condition, experts have revealed.
    Researchers at Great Ormond Street Hospital (Gosh) found that patients as young as seven were not only able to successfully transition to pills but often expressed a clear preference for them over the taste of their liquid medicine.
    The study focused on children suffering from congenital hyperinsulinism (CHI), a condition characterised by elevated insulin levels that necessitate regular, often multiple daily, doses of diazoxide to maintain stable blood sugar.
    Until now, this vital treatment has predominantly been administered in liquid form, with liquid diazoxide costing a significant £15.50 per 50mg.
    Experts have estimated that switching from liquid to tablets could save the NHS £40,000 per patient per year.
    Jess Manktelow, who has CHI and has been a Gosh patient since she was 15 months old, was one of the children who took part in the project.
    The 11-year-old, from Kent, was switched to diazoxide tablets in April 2025.
    “It has made a big difference taking medicine that doesn’t taste horrible,” she added.
    “There were times where I didn’t want to take it because of the taste.
    “It makes things very easy for me now, I’m able to do it myself and it doesn’t take up as much time at school or when I’m doing things I like, like climbing, it doesn’t have as much impact and that makes me happy.”
    Kate Morgan, Gosh clinical nurse specialist who co-led the project, said: “We knew the potential this trial had for savings, but the scale of the quality-of-life improvements for children and their families we are seeing is something we didn’t anticipate.
    “Children are so much more than their diagnoses – they have full lives and families and their illnesses affects everyone, so it is very important we do all we can to make simple, positive changes that impact everyone for the better.”
    Read full story
    Source: The Independent, 10 April 2026
  12. Patient Safety Learning
    A former finance director has claimed he was ousted and subjected to a campaign to “silence” him by his trust after he asked “inconvenient” questions about race inequalities.
    Don Richards, who was chief finance officer at West Hertfordshire Teaching Hospitals Trust until 2024, told an employment tribunal preliminary hearing in Watford on Wednesday that he had been “pushed” into signing a settlement agreement.
    He left the trust shortly after two other executive directors wrote to chief executive Matthew Coats saying they had “no confidence” in him. Days earlier, the integrated care board CEO had sent a separate letter to Mr Coats saying she had concerns over the trust’s financial leadership. 
    Mr Richards said in the hearing that there had been a “continuing campaign first to remove me, then to silence me”.
    He said this stemmed from a board meeting – which took place in the same month the letters were sent – where he had raised queries about mortality rates among Black women in maternity services, as well as staff with a minority ethnic background being passed over for promotion.
    He told the hearing: “I asked inconvenient questions, and the chief executive at the trust didn’t like that. His expedient solution was to remove me.”
    Read full story (paywalled)
    Source: HSJ, 10 April 2026
  13. Patient Safety Learning
    A child spent more than two months in A&E following a breakdown of a care placement, in what the trust described as “one of the longest waits we’ve seen”.
    Barking, Havering and Redbridge University Hospitals Trust said the young person was at its Queen’s Hospital A&E for more than 70 days, while another was there for more than 30.
    They were both under the care of councils “outside our area”, and their care placements had broken down, the trust said. It has declined to say which councils.
    Both children had “complex behavioural needs” which meant they could not be moved on to children’s wards, the east London trust said. Speaking last week, it said the children had recently moved on to other placements.
    The trust has previously highlighted long waits for children under care at Queen’s A&E – including a wait of 44 days in 2024 – and said care placement breakdowns were the most common reason.
    Trust CEO Matthew Trainer said: “We’re seen as a place of safety for children and young people with mental health issues and/or challenging behavioural needs. This means several young people have experienced long waits for the right support in A&E.
    “It’s unacceptable and distressing for both patients and our staff, and something we’ve been discussing at our board meetings for several years, as well as working with mental health trusts and councils to see how we can reduce delays.”
    Read full story (paywalled)
    Source: HSJ, 9 April 2026
  14. Patient Safety Learning
    Mental health patients in crisis are facing "inhumane" conditions due to legal ambiguities, an investigation has found.
    The Health Services Safety Investigations Body (HSSIB) revealed that A&E staff lack powers to prevent patients awaiting assessment or admission from leaving.
    This forces doctors into a difficult choice, described by the HSSIB as selecting the "least harmful way to break the law".
    One consultant psychiatrist highlighted the "dilemma is stark" of unlawfully holding someone, breaching human rights, or allowing them to go.
    Inspectors from the health safety watchdog saw a patient who had been locked in a single room, with only a toilet, for more than four days.
    “It was not safe for staff to be in the room with them and it was not safe for the door to be unlocked as the patient kept attempting to leave and was desperate to end their life,” a new interim HSSIB report said.
    “Staff described that the patient was not receiving any therapeutic intervention and it felt ‘cruel’ and ‘inhumane’ for them to be waiting so long for a bed when they were so mentally unwell.”
    Nichola Crust, senior safety investigator at HSSIB, said: “Unclear legal powers don’t just create operational complications for care.
    “They can have a devastating impact on patients, leaving them exposed to uncertainty, emotional distress and an increased risk of harm at a time when being as safe as possible is paramount.
    “Without clear legal frameworks, staff repeatedly told us that they are placed in an impossible position when trying to keep people safe.”
    Read full story
    Source: The Independent, 9 April 2026
  15. Patient Safety Learning
    NHS England’s chair is leading a national review of mental health services and productivity, HSJ  has learned.
    The work, being referred to as a “supply-side review”, is running alongside the more high-profile independent analysis of demand for MH and learning disability services commissioned by Wes Streeting last year.
    HSJ understands Dr Dash’s deep-dive is expected to be complete in the autumn, around the same time as the government review.
    Analysis has begun in recent months, including on spending, variation, productivity and the potential for “reinvesting” current funding, according to sources briefed on the project.
    The review has been referred to as “internal” and NHSE does not appear to be planning to publish it.
    It was initiated by the “quad” of senior officials across NHSE and the Department of Health and Social Care (Dr Dash herself, NHSE CEO Sir Jim Mackey, DHSC permanent secretary Samantha Jones, and DHSC lead non-exec director Alan Milburn).
    The review is also being overseen by an advisory group, with representation from mental health trusts, and others.
    Read full story (paywalled)
    Source: HSJ, 8 April 2026
  16. Patient Safety Learning
    Health service staff have expressed alarm that engineers working for controversial tech company Palantir have been given NHS email accounts.
    Employees using NHS.net email accounts have access to a directory with the contact details of up 1.5 million staff. Sources believe Palantir staff were granted the same access.
    Palantir staff working on the introduction of its Federated Data Platform (FDP) for NHS England have also been given access to NHS SharePoint filesharing systems and internal Microsoft Teams groups.
    Hospital trusts and integrated care boards across the country are being encouraged to adopt FDP, which Palantir won a £300m contract to provide in 2023. NHS England says FDP allows NHS organisations to connect patient records historically held across different systems, allowing staff to manage waiting lists, allocate appointments, speed up diagnoses and personalise treatment more effectively. It is part of the government’s plan to “reinvent the NHS” through “radical shifts”, including moving systems from “analogue to digital”.
    The use of NHS email accounts and internal systems by private contractors is not unusual. However, Palantir’s association with AI-powered surveillance and war technology has made some staff, patients and human rights campaigners question the ethics and implications of allowing the spy-tech company to become embedded in the UK public sector.
    Rory Gibson, a resident doctor, said: “I – as a doctor – absolutely don’t want my personal email and number to be accessible to someone who works for Palantir on the NHS, and might next month be working on systems for drone strikes. NHS staff have not consented to sharing their email addresses with Palantir staff.”
    Read full story
    Source: The Guardian, 8 April 2026
  17. Patient Safety Learning
    Nearly half of patients who arrive at hospital in ambulances are being discharged without needing major care, according to data obtained by HSJ.
    Experts said the research also revealed a “postcode lottery”, with patients more likely to be taken to A&E in some areas due to a lack of alternative settings.
    The internal NHS England data has tracked how many ambulance patients were later discharged without any inpatient or “same day” emergency care, or transfer to another service, at different sites. These patients may have required hospital-based diagnostics, for example, or review from emergency clinicians before they could be sent away.
    At 24 hospitals, more than 50% of ambulance patients are being discharged without going to an inpatient or ambulatory unit. The highest proportion was 85% at St Peter’s Hospital in Surrey.
    It was at less than a third at other sites. This put the national average at 46%, according to data obtained by a Freedom of Information request.
    There was a wide range of acuity levels among ambulance patients discharged without further serious care.
    Read full story (paywalled)
    Source: HSJ, 8 April 2026
  18. Patient Safety Learning
    A trust which took an employee to court for thousands of pounds has been accused of “legal bullying”.
    Court documents seen by HSJ  reveal Lancashire Teaching Hospitals Trust attempted to sue its staff member Jonny Slade for “fundamental dishonesty” after he brought, and then dropped, a workplace injury claim against the trust.
    The trust later withdrew its claim against the worker – in which it had sought around £14,000 in costs from Mr Slade – after a hearing had begun at Preston County Court. 
    The court proceedings finished in 2023, but Mr Slade told HSJ he had now decided to speak publicly about the case because he had exhausted official channels with health and safety concerns he has been raising. 
    He said: “I felt the only way to ensure the issues were taken seriously was to speak publicly.
    “I simply hope [this] encourages greater accountability and ensures that staff who raise genuine safety concerns are treated fairly, rather than facing what I went through.”
    Workplace culture expert Roger Kline said: “I hope this case acts as a lesson to NHS trusts to stop pursuing staff for extortionate costs when they have in good faith lodged a claim… It is a form of legal bullying.” He said this kind of action was a “surprisingly common feature” of his recent report into workplace investigations.
    Read full story (paywalled)
    Source: HSJ, 8 April 2026
    Related reading on the hub:
    Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Power and the sound of silence—A blog by Roger Kline Patient Safety Learning’s response to the NHS Staff Survey Results 2025
  19. Patient Safety Learning
    Women’s deaths during pregnancy, labour or soon after giving birth are at the highest level for two decades despite the NHS receiving dozens of recommendations to act on life-threatening symptoms.
    An investigation by The Times shows the NHS was issued with 67 separate warnings between 2013 and 2023 to take signs of potentially fatal complications in mothers — known as red flags — seriously.
    Over the same decade, there was a 50% rise in the UK’s maternal death rate — defined as deaths in pregnancy, childbirth, or the six weeks after giving birth — from 8.54 deaths per 100,000 pregnancies in 2013 to 12.80 in 2023. The last time the rate was this high was in 2005.
    The most recent available data shows 257 women died in the two years to 2023. The biggest killer was blood clots, followed by heart issues, suicide, stroke, sepsis and severe bleeding.
    Over the past decade, a string of reviews have issued 748 recommendations for improving NHS maternity services across 59 official reports, yet death rates have soared.
    Wes Streeting, the health secretary, has commissioned a national maternity inquiry led by Baroness Amos, a Labour peer, which is due to deliver its recommendations in the summer. Campaigners are sceptical about whether another report will result in real change.
    Theo Clarke, a former Conservative MP who led a parliamentary inquiry into birth trauma in 2024, said it was a “national scandal” that maternal deaths were rising while “recommendations are ignored”.
    She said: “NHS maternity services are swamped with recommendations from scores of reports, and still women and their babies are being harmed by a lack of focus and leadership necessary to implement them.”
    Read full story (paywalled)
    Source: The Times, 5 April 2026
  20. Patient Safety Learning
    Millions of people across the UK living with incontinence are facing shortages of sanitary products due to supplies being rationed by NHS trusts, according to a coalition of charities.
    The shortages are leading to a “pad gap” where people are having to pay for incontinence products themselves, according to an open letter from organisations including the Royal College of Nursing, Prostate Cancer UK, and Bowel and Bladder UK.
    Around 14 million people across the UK experience incontinence. Healthcare workers in the NHS expect to fit up to five pads a day for patients who experience incontinence, according to research, but freedom of information data from 110 NHS trusts show that more than half (53%) have a cap on the availability of products.
    Of these trusts, 34% have a cap of three products a day, while the remaining 66% have a cap of four products a day, which is lower than the expected need.
    As a consequence of the shortages, many people with incontinence and their families are forced to use their pension or personal independence payment (PIP) to purchase these products while struggling to cover other basic costs.
    According to the letter, these measures represent a “once in a generation opportunity to improve health outcomes for all” that will benefit people who experience incontinence and ease the burden on NHS staff and carers.
    Prof Alison Leary, the deputy president of the Royal College of Nursing, said she often heard from nurses who were concerned about the shortages of incontinence products. “The effective rationing of incontinence products means that staff and patients both suffer – patients do not get the dignified care they need and nursing colleagues feel they are not meeting patients’ fundamental needs,” Leary added.
    Read full story
    Source: The Guardian, 6 April 2026
  21. Patient Safety Learning
    More than 2,000 Black men will die from prostate cancer in the next 10 years if the UK doesn’t change its screening programme, new figures reveal.
    Around 1 in 4 Black men in the UK will be diagnosed with the disease – twice the rate of white men. The reasons for the disparities vary, but contributing factors include genetics, a lack of awareness, delays in seeking help and barriers to accessing diagnostic tests.
    Last month, the government’s National Screening Committee (NSC) rejected proposals for a targeted prostate cancer screening programme for high-risk men, which includes Black men and those with a family history of cancer, because it said the harms of widespread testing outweigh the benefits and also cited a lack of available data on Black patients.
    Now, new estimates from the charity Prostate Cancer UK, shared with The Independent, suggest that if nothing changes, more than 2,300 Black men will die over the next decade, and at least 16,000 men will be diagnosed, if current rates of the disease continue.
    Amy Rylance, director of health services, equity and improvement at Prostate Cancer UK, said: "We were bitterly disappointed by the UK NSC's announcement that the evidence isn't yet strong enough to recommend targeted screening for Black men.
    “While we accept the committee's decision that the data they reviewed had too many gaps, a significant opportunity has been missed. The NHS holds electronic health data that could fill these gaps – but nobody has made full use of these records, and they weren't reviewed by the committee."
    She said that the charity would work alongside the NSC to find the missing data and build the evidence base needed to secure screening for Black men.
    Read full story
    Source: The Independent, 6 April 2026
  22. Patient Safety Learning
    The medicines regulator is investigating whether UK clinics are breaking the law by making claims about the benefits of unregulated, experimental peptide therapies, the Guardian can reveal.
    Interest in experimental peptides has boomed in recent years. The substances are delivered by injection and are touted by sellers, influencers and even some medics as aiding everything from anti-ageing to recovery from injury.
    There is little scientific evidence to support such health and wellness claims in humans. Where studies have been carried out, most are in animals or cells.
    The Medicines and Healthcare products Regulatory Agency (MHRA) has said clinics are not permitted to make medicinal claims for the peptide treatments offered by their service.
    An MHRA spokesperson said: “If clinics offering peptide injections make medicinal claims for those treatments, the products will be considered medicines and subject to regulation under the Human Medicines Regulations 2012.
    “The MHRA will take action against clinics which are identified as breaching the legal requirements.”
    However, a Guardian investigation has found a number of clinics operating in the UK offering a variety of unregulated, experimental peptides and making a host of claims about their benefits on their websites.
    These include approved prescription weight-loss medications based on synthetic peptides that mimic natural hormones, such as semaglutide and tirzepatide, found in weight loss drugs such as Wegovy and Mounjaro respectively. But many other peptides on the market have not undergone the strict regulatory processing that those used in medications have undergone, and remain experimental.
    Read full story
    Source: The Guardian, 4 April 2026
  23. Patient Safety Learning
    The NHS has not made a “life-changing” treatment for stroke available around the clock across England despite ministers repeatedly promising that it would.
    The health service was expected to improve stroke care by making a clot removal technique called mechanical thrombectomy available everywhere in the country 24/7 from 1 April.
    Doctors describe it as a gamechanging intervention that, if done quickly, can help someone who has had a severe stroke avoid ending up with a serious disability as a result.
    However, seven of England’s 24 regional stroke centres are still not providing thrombectomy on an all-hours basis, mainly because they do not have enough doctors and other staff to do so.
    Experts fear the NHS’s failure to deliver universal 24/7 access to the treatment could mean patients who have a stroke overnight, in the evening or at weekends in underserved areas may become avoidably severely disabled, or may even die, because they could not have the procedure.
    More than 100,000 people a year in the UK have a stroke, of whom 38,000 die and many others are left with life-changing disabilities that rob them of their independence.
    Dr Sanjeev Nayak, a stroke specialist at the Royal Stoke hospital in Stoke, said: “A patient presenting during normal working hours in a well-served area may receive rapid, life-changing treatment, whereas the same patient presenting at night or in a different region may not receive thrombectomy at all. This creates a real postcode lottery in access to one of the most effective treatments in modern medicine.”
    Read full story
    Source: The Guardian, 6 April 2026
  24. Patient Safety Learning
    A trust group that has seen a rise in “never events” has been heavily criticised for “inadequate” oversight and management of patient safety. 
    An assessment commissioned by the Humber Health Partnership also found incidents were “not always being escalated appropriately” and reported “persistent delays” in addressing issues previously raised by the Care Quality Commission.
    Hull University Teaching Hospitals and Northern Lincolnshire and Goole trusts, which formed the group in 2024, were subject to NHS England intervention over major performance, safety and governance concerns last year.
    Late last year, the trusts commissioned a firm called Thevaluecircle to carry out an independent review of governance. The assessment, which was finalised in January, has now been released to HSJ following a freedom of information request.
    It found there was “inadequate rigour in the management of never events and other patient safety incidents” and claimed risks had been “normalised over time, reducing the sense of urgency and active management”.
    HUTH recorded six never events in the six months to January, the ninth highest figure for a provider, while NLAG recorded one. Never events are the most serious preventable clinical mistakes and include wrong site surgery, leaving surgical instruments inside a patient after surgery, and blood transfusion errors.
    Read full story (paywalled)
    Source: HSJ, 7 April 2026 
  25. Patient Safety Learning
    An NHS trust has abandoned plans to trial a major US supplier’s ambient voice technology after concerns were raised about its compliance with NHS England accreditation requirements, HSJ has revealed.
    Epic Systems had this week planned to launch a trial of its native AI Charting functionality at Frimley Health Foundation Trust, despite not holding Medicines and Healthcare products Regulatory Agency (MHRA) Class I medical device status, which is required of all AI scribing tools capable of summarisation.
    Frimley Health has since confirmed the trial did not go ahead as it had not gone through the trust’s internal governance processes and has been paused pending further work.
    Epic’s AI Charting tool does not appear on the MHRA Class I medical device registry and the company is also not on NHSE’s AVT registry.
    HSJ understands that two other trusts – understood to be one in the north of England and one in the east – are currently live with Epic’s AVT.
    Several other trusts are understood to be in conversations with Epic about trialling its AVT, including University College London Hospitals FT, Birmingham Women’s and Children’s FT, the Royal National Orthopaedic Hospital Trust, and East Suffolk and North Essex Foundation Trust.

    Read full story (paywalled)
    Source: HSJ, 1 April 2026

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