Patient-Safety-Learning

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Diabetes is a condition that causes the amount of glucose in a person's blood to be too high. When you have type 1 diabetes, your body can’t make any insulin at all, whereas with type 2, you either can’t make enough insulin, or it can’t work properly. There are also other types of diabetes including gestational diabetes, which some women develop during pregnancy, maturity onset diabetes of the young (MODY) and latent autoimmune diabetes in adults (LADA). It is important that people with diabetes are supported to maintain good blood glucose control through diet, insulin and other diabetes medications, to prevent both acute and long-term complications. We’ve selected our top picks of useful resources about diabetes. Self-management is perhaps the most important aspect of treating diabetes effectively, so we've included some resources aimed at helping patients manage their diabetes too. 1 HSSIB reports The Health Services Safety Investigation Body (HSSIB) has published a series of reports considering the self-administration of insulin by people with diabetes mellitus. Each report focuses on specific groups of people who, due to their circumstances, may be at increased risk of harm because of the way they self-administer insulin. Insulin: supporting safe self-administration for patients in the community with a mental health problem Insulin: supporting safe self-administration for patients in the community with a disability Insulin: supporting patients to safe administration in inpatient settings 2 Decoding diabetes research – an innovative approach that makes scientific knowledge accessible to everyone In this blog, Jazz Sethi, Founder and Director of the Diabesties Foundation and part of the global team that developed D-Coded, discusses the need for the resource and outlines how it will help people living with diabetes to better understand and manage their condition. 3 Leading for patient safety: a conversation with Partha Kar Partha Kar, National Specialty Advisor for NHS England, has led work that has had an enormous impact for patients and for patient safety. In this video podcast, Steph O'Donohue from Patient Safety Learning talks to Partha about his leadership style and how it has helped him drive forward significant change in an often challenging context. 4 Decision support tool: making a decision about managing type 1 diabetes This leaflet from NHS England aims to help people with type 1 diabetes decide between the different technologies available to manage diabetes. It contains summaries of devices available and infographics outlining eligibility criteria for continuous glucose monitors (CGM), insulin pumps and hybrid-closed loop systems. 5 10 Year Vision: For diabetes prevention, care and treatment This report from Diabetes UK sets out a clear plan for the UK government about how it can improve health outcomes and tackle inequality for people living with diabetes by 2035. 6 D1abasics: Equipping staff to care safely for inpatients with diabetes The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital. 7 Improving diabetes care in inpatient mental health settings Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. 8 Diabetes tech: Do national aspirations and local practice align? In this blog, a person with type 1 diabetes describes their recent experience upgrading their insulin pump, a medical device used to continuously deliver insulin instead of taking multiple daily injections. They describe how communication issues and gaps in staff knowledge led to a significant delay in accessing the pump, which caused them significant stress. They also ask whether recent announcements about increased access to diabetes technology over the next few years will match up to the reality experienced by people with diabetes accessing care at local healthcare organisations. 9 NHS England - Language Matters: language and diabetes The language that healthcare professionals use to talk about diabetes can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it. This guidance by NHS England sets out practical examples of language that will encourage positive interactions with people living with diabetes. When people with diabetes feel encouraged and empowered to manage their condition, it has been shown to make a difference to their health outcomes. The examples in ‘Language Matters’ are based on research and supported by a simple set of principles. 10 Key things to remember if you use injectable medication to treat your diabetes This checklist by TREND Diabetes outlines the steps patients should take to ensure they inject their insulin or other diabetes medication correctly. It explains the importance of taking steps such as moving injection sites and changing needles, and outlines how failing to do this can affect blood glucose control. 11 Improving safety for diabetic inpatients: 4 key steps In this video, Partha Kar, National Specialty Advisor for Diabetes, shares four steps to improve safety for inpatients with diabetes, based on information from the National Diabetes Inpatient Audit. He also highlights key resources to help staff improve their knowledge of diabetes and understand how to offer the safest care to people with diabetes when they are staying in hospital. 12 Diabetes technology is life-changing, but we need to be prepared when it fails In this blog, Andrew Stroud talks about his family's experiences supporting their daughter, Bia, to manage her type 1 diabetes. He describes the huge value of technology in improving diabetes management and reducing the mental burden of the condition on people with diabetes and their parents and carers. However, like all technology, medical devices for diabetes can fail, and Andrew highlights the need to be prepared for this situation to ensure the person with diabetes is safe while they cannot use the devices they rely on every day. 13 How safe are closed loop artificial pancreas systems? Closed-loop artificial pancreas systems are self-regulating systems for administering insulin to patients with type 1 diabetes. They allow for tighter blood glucose control and reduce the decision-making burden for people with diabetes. In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, takes a look at the benefits and potential patient safety risks associated with closed-loop artificial pancreas systems (APS). People with diabetes have developed the algorithm that runs these systems and made it freely available to anyone wanting to build their own DIY artificial pancreas. This has spurred the medical tech industry to develop commercial systems, which will make the technology more widely available. But there are challenges in ensuring accessibility to all people with type 1 diabetes who would benefit from the technology, and there are questions about regulation and liability. 14 A systematic approach to insulin safety (video series by Communications PharmSocNI) This video series looks at systematic approaches to insulin safety, including: Human Factors - A Journey of Discovery; SEIPS – The Swiss Army Knife Approach; and Summary & Applying the Learning. 15 System-wide strategies for better diabetes care chapter 1: Evidence approved medicines and chapter 2: Ensuring equitable access to glucose sensing technology for type 2 insulin users Two reports from Public Policy Projects (PPP). Chapter 1 calls for changes in the use of approved medicines to improve diabetes care in the UK and chapter 2 highlights the opportunities and challenges brought by CGM technology to type 2 insulin users and other patient groups. 16 National Diabetes Foot Care Audit 2018 to 2023 Ulceration of the foot in people living with diabetes presents significant challenges, including emotional, physical and financial costs, and is associated with increased risk of both amputation and death. It affects between 1 and 2% of all people with diabetes each year and its management accounts for approximately 1% of the total NHS budget. The aim of the National Diabetes Foot Care Audit is to measure factors associated with increased risk of ulcer onset and adverse ulcer outcomes, and to share information relating to best clinical practice. 17 Diabulimia: what is it and why have so few people heard of it? Type 1 diabetes with disordered eating (T1DE), or diabulimia as some experts call it, is a serious eating disorder that people with type 1 diabetes can develop where the person reduces or stops taking their insulin as a way of managing their weight. The condition can be life-threatening. Although studies are limited, it’s estimated that eating disorders affect more than a third of patients with type 1 diabetes. This episode of the Healthcare Improvement podcast looks at diabulimia and a new toolkit published by SIGN, part of Healthcare Improvement Scotland, which sets out recommendations to raise awareness and provide guidance on how best to support people living with the diabulimia. 18 NHS England: Children and young people diabetes toolkit This toolkit is designed to support integrated care systems (ICSs) to design, plan, and deliver high-quality treatment and care for children and young adults aged 0-25 years with all types of diabetes. 19 Insulin therapy in primary care The management of insulin therapy requires knowledge of the type of diabetes it is being used for and appropriate dosing, as well as correct injection technique, to prevent complications and medication errors. Diabetes nursing specialist Debbie Hicks shares key points on the management of insulin therapy for nurses in primary care. 20 Handbook: Diabetes footcare in dark skin tones Covering essential topics such as physiology, history-taking, assessment techniques, and investigative methods, this handbook has been designed to provide essential information as well as quick tips to healthcare professionals to improve foot care for people with dark skin living with diabetes. Featuring clinical assessments and visual/audio guides, this handbook is the product of a unique collaboration across healthcare professional specialities, and with input from people living with diabetes. 21 Addressing racial inequalities in paediatric diabetes Dita Aswani and Fulya Mehta are both consultant paediatricians and NHS England national advisors for Children and Young adults’ (CYA) diabetes. In this blog, they outline racial inequalities that persist in paediatric diabetes and present five key areas for change. In summary they talk about what healthcare professionals can do to reduce inequalities through their own practice. Do you have a resource or story about diabetes to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked a range of resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices. 1 Alzheimer's Society: Checklist for possible dementia symptoms This checklist has been developed by the Alzheimer’s Society to allow patients to check symptoms that could be a possible sign of dementia. Endorsed by the Royal College of General Practitioners (RCGP), it is a simple tool to help patients and their families clearly communicate their symptoms and concerns to a GP or other healthcare professional. 2 Seeing the unseen: Rethinking dementia diagnosis Across 2024 and 2025, Alzheimer’s Research UK surveyed more than 500 people affected by dementia and over 160 healthcare professionals to understand the realities of diagnosis. This report shares findings from this process and considers what works, what gets in the way, and what needs to change. 3 Health and social care support for people with dementia The Care Quality Commission (CQC) looked at people's experiences of living with dementia when using health and adult social care services, including the experiences of families and carers. It sets out the main themes that influence whether an experience is good or poor, and what health and care services are doing to improve these experiences. CQC will use the findings in this report to help shape their work to define what good care looks like for people with dementia and inform the next phase of CQC’s Dementia Strategy. 4 Keeping patients with dementia safe: an interview with Alison Keizer and Fran Hamilton When people with dementia enter a new healthcare setting, the environment may be confusing and difficult to navigate. They may be unable to use their usual coping strategies and have difficulty communicating their needs and concerns to staff. This can present a wide range of risks to their safety while accessing care. In this interview, Alison Keizer, trust-wide Dementia Lead, and Fran Hamilton, Occupational Therapist and Deputy Dementia Lead at Sussex Community NHS Foundation Trust, describe the patient safety issues affecting patients with dementia and suggest how they can be supported to reduce these risks. 5 World Alzheimer Report 2025: Reimagining life with dementia – the power of rehabilitation This report from Alzheimer's Disease International explores the important topic of dementia rehabilitation, combining expert essays and real-world case studies from multiple countries globally to examine how the concept is defined and implemented, as well as practical considerations of how to best adapt rehabilitation practices for people living with dementia in different contexts. 6 National Audit of Dementia: Spotlight Audit in Memory Assessment Services 2023/24 This report examines waiting times, access to assessments, treatment, and post-diagnostic support for people with dementia in memory assessment services. The results indicate that there is still a great deal of variation between services in key results such as average waiting time for patients, the proportion of patients diagnosed with dementia, and the provision of post diagnostic support and therapy. 7 The role of integrated care systems in improving dementia diagnosis The Alzheimer’s Society commissioned The King’s Fund to explore the development of Integrated Care Systems (ICSs) through the lens of dementia diagnosis—to consider what opportunities ICSs present to approach dementia differently and to improve diagnosis rates by doing so. The research team explored enablers and barriers to improving dementia diagnosis through interviews with stakeholders and people affected by dementia in three case study ICSs. 8 Alzheimer's Society: 'This is me' leaflet This simple leaflet was developed by the Alzheimer's Society for anyone living with dementia, or experiencing delirium or other communication difficulties. It provides a central place where those closest to the person can fill in key information about them, such as their preferred name, cultural background, routines and likes and dislikes. The leaflet can then be shown to health and social care professionals in new and unknown settings to help them better understand the person and deliver care that is tailored to their individual needs. 9 Dementia UK: Making the home safe and comfortable for a person with dementia Dementia can have a significant impact on a person’s daily life, including how well they function within their home. Memory issues or problems recognising and interpreting the objects around them can cause the person frustration or create safety issues. Dementia UK have produced a leaflet with tips and guidance on how to make the home more safe for someone with dementia. 10 Alzheimer's Society: Tips for carers - questions to ask the doctor about antipsychotics Antipsychotic drugs may be prescribed for people with dementia who develop symptoms such as aggression and psychosis. This webpage from the Alzheimer's Society provides information on the prescription of antipsychotic medications for people living with dementia. It describes their potential side effects and includes a list of helpful questions that carers should ask healthcare professionals before the person they care for is prescribed antipsychotic medication. 11 Assessment, diagnosis, care and support for people with dementia and their carers: A national clinical guideline These national clinical guidelines from Health Improvement Scotland, the first to be published in nearly 20 years, provide recommendations on the assessment, treatment and support of adults living with dementia. It calls for greater awareness of pre-death grief for people with dementia, their carers and their loved ones, as they fear the loss of the person they know. To accompany the guidelines, a podcast has been produced by Health Improvement Scotland speaking to professionals, including Dr Adam Daly, Chair of Healthcare Improvement Scotland’s Guideline Development Group and a Consultant in old age psychiatry, and Jacqueline Thompson, a nurse consultant and the lead on pre-grief death for the guideline. 12 Alzheimer’s Society: Improving access to a timely and accurate diagnosis of dementia in England, Wales and Northern Ireland A formal diagnosis of dementia can help people living with the condition and their families gain a better understanding of what to expect and help to inform important decisions about treatment, support and care. This report from the Alzheimer's Society highlights the barriers to accessing a timely and accurate dementia diagnosis and advocate for practical changes and tangible solutions to overcome them. 13 The current state of dementia diagnosis and care in England The current dementia care system remains fragmented, underfunded, and difficult to navigate, leaving many individuals and families unsupported. In response to these systemic challenges, Care England, in partnership with Dementia Forward and care providers, conducted a national survey in January 2025. This initiative aimed to capture the experiences of people living with dementia, their families, and care staff. The findings highlight significant gaps and inequalities in the dementia care pathway and inform a set of urgent policy recommendations. 14 Raising awareness of normal pressure hydrocephalus: an often misdiagnosed condition Normal pressure hydrocephalus (NPH) is a progressive neurological condition that comes under the dementia umbrella. In NPH, the cerebrospinal fluid-filled ventricles within the brain expand and distort the surrounding tissues. This process causes the neurological symptoms of NPH. Unlike other forms of hydrocephalus, NPH does not result in significantly raised intracranial pressure. NPH is often misdiagnosed as it is similar to neurodegenerative conditions such as Parkinson’s disease and other causes of dementia, such as Alzheimer's disease. However, unlike these other conditions, if diagnosed early there is an effective treatment that can significantly slow disease progression and potentially improve, or even reverse, symptoms in some people. 15 The training gap: a hidden injustice in dementia care and how to fix it This report from Alzheimer's UK reveals huge gaps in dementia training across social care: half of staff receive just one to two hours of dementia learning despite 70% of care home residents living with the condition. It argues that these shortfalls in training are leaving social care staff unprepared, unsupported, and putting people with dementia at risk of inadequate care. It calls on the government to build a bold and ambitious dementia plan, which includes mandatory dementia training for care staff. 16 Alzheimer's Society: Unlocking the door to dementia diagnosis and treatments Systems designed to diagnose and support people with dementia are struggling to keep pace, with delays, inequalities and missed opportunities far too common. Too many people have a poor experience, wait too long for a diagnosis and receive less treatment and support than clinical guidance says they should. Everyone with dementia has the right to an early and accurate diagnosis and the best available treatments. Alzheimer's Society’s two 'Unlocking the door' reports lay out a stark reality – and a clear programme of reform for England, Wales and Northern Ireland. For more resources, take a look at our Dementia area of the hub. Do you have a resource or story to share about dementia or a related condition? Could your insights or experiences help improve patient safety? Leave a comment below (join the hub for free first) or contact us at [email protected].

Good hand hygiene in healthcare is essential to reduce the spread of healthcare associated infections (HAIs), which are the most frequent adverse event in healthcare globally. Although progress has been made in improving hand hygiene, there is still a pressing need to give healthcare professionals around the world the necessary knowledge and facilities to achieve effective infection control. The latest World Health Organization (WHO) data shows that globally, half of healthcare facilities do not have basic hand hygiene services, one in five facilities have no water services and one in ten have no sanitation services. We've pulled together useful resources about hand hygiene that have been shared on the hub. They include advice on effective handwashing, resources for healthcare professionals on how to promote hand hygiene and a global tool for monitoring hand hygiene interventions. 1. Scientia potentia est—Why sharing knowledge about hand hygiene remains important In this blog, hub topic leader Julie Storr looks at the question of why it's still so important to share knowledge about hand hygiene. She highlights the power of sharing knowledge to save lives, the need to address research gaps and that hand hygiene should be integrated into all aspects of frontline care. She also shares tools and resources that can be used to help train and equip frontline healthcare professionals. 2. Health Education for Scotland - Hand hygiene learning resources Resources by Health Education for Scotland to support their e-learning modules on hand hygiene. You will need an account to access the e-learning modules, but the supporting resources are available to download. 3. Improving hand hygiene in the anesthesia workspace: The importance, opportunities, and obstacles Anaesthesia professionals have consistently been leaders in patient safety and have long recognised the importance of hand hygiene in the anaesthesia workspace. Hand contamination is associated with pathogen transmission across multiple anaesthesia workspace reservoirs, and genome analysis of bacteria cultured from provider hands and infection causing pathogens have confirmed that providers transmit pathogens that result in patient infections. These findings should provide the impetus for widespread improvements in hand hygiene compliance for all intraoperative personnel, with anaesthesia professionals taking the lead. 4. WHO: Your 5 moments for hand hygiene This poster summarises WHO’s ‘Five moments for hand hygiene’ model, which WHO released in 2006 in collaboration with the infection prevention and control (IPC) research group at the University of Geneva. The approach aims to facilitate behavioural change and prioritise hand hygiene action at the right time to prevent infection transmission and avoid harm to patients and healthcare workers during care delivery. 5. Hand hygiene acceleration framework tool The Hand Hygiene Acceleration Framework Tool (HHAFT) has been developed by The Global Handwashing Partnership. It tracks the process that governments have taken to develop and implement a plan of action for hand hygiene improvement, and assesses the quality of that plan. It helps identify barriers, opportunities and priority actions for accelerating progress towards hand hygiene and drive investment to these plans. Use of this common framework allows countries to share learning and helps direct and coordinate global action. The webpage includes a dashboard that presents the latest data from different countries. 6. Supporting you to talk about hand hygiene: A primer for those in health care As a champion for hand hygiene, feeling empowered to talk about the topic to a range of colleagues is important. WHO has collated a number of hand hygiene improvement tools to help anyone working in healthcare promote good hand hygiene within their organisation. 7. Video: How to wash your hands Patients can contribute to infection prevention and control by making sure they wash their hands effectively—it’s one of the easiest and most important ways for patients to protect themselves and others from infectious illnesses. This NHS video demonstrates the best way to wash your hands and describes when you should do it. 8. WHO global taskforce on WASH in health care facilities: synthesis 2022-2023 The Global Taskforce on WASH in healthcare facilities aims to provide global strategic direction and coordination to WHO and UNICEF, and to promote information sharing and dialogue. It evolved from a series of think tanks convened by WHO. This webpage links to a summary of their work in 2022-23. 9 WHO Hand Hygiene Self-Assessment Framework 2010 The Hand Hygiene Self-Assessment Framework is a systematic tool with which to obtain a situation analysis of hand hygiene promotion and practices within an individual healthcare facility. 10 Implementation of a quality improvement project using the patient as the observer to improve hand hygiene compliance in ambulatory care practices This study published by the Journal of Hospital Infection, evaluated using patients as hand hygiene observers in an outpatient setting. It demonstrated that the implementation of a hand hygiene compliance improvement programme using the patient as the observer can be adopted successfully in the ambulatory setting. 11 e-Bug: Resources for children and young people about infection control and AMR (UKHSA) e-Bug, operated by the UK Health Security Agency, is a health education programme that aims to promote positive behaviour change among children and young people to support infection prevention and control efforts, and to respond to the global threat of antimicrobial resistance. e-Bug provides free resources for educators, community leaders, parents, and caregivers to educate children and young people and ensure they are able to play their role in preventing infection outbreaks and using antimicrobials appropriately. 12 World Hand Hygiene Day 2026 resources (Australian Commission on Safety and Quality in Health Care) This stakeholder kit supports the promotion of World Hand Hygiene Day, a WHO global initiative, on 5 May. Have your say Do you have any stories, insights or resources related to hand hygiene? We would love to hear from you! Comment below (register for free here first) Get in touch with us directly to share your insights

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  To support. WHO's World Immunisation Week, we have picked 14 resources full of practical advice about vaccination in a range of settings. 1 WHO: Vaccines explained "Vaccines Explained" is a series of illustrated articles from the World Health Organization that describe how vaccines work, how they’re developed and distributed and how their safety is carefully monitored. 2 EDUCATE KS3 lesson pack: HPV vaccination Co-produced by young people and researchers from the University of Bristol and London School of Hygiene and Tropical Medicine, ‘EDUCATE’ helps teach students about the human papillomavirus (HPV) vaccine and provide reassurance about receiving the vaccine, which is usually offered to teenagers at school as part of the national vaccination programme. 3 The Green Book: Immunisation against infectious diseases The Green Book is published by the UK Health Security Agency and contains the latest information on vaccination procedures for vaccine-preventable infectious diseases in the UK. It offers guidance on general safety considerations and clinical procedures relating to immunisation, as well as specific information on a wide range of diseases and vaccinations. 4 Vaccination awareness toolkit for children and young people The School And Public Health Nurses Association (SAPHNA) has coproduced this vaccination toolkit with children and young people. It aims to increase young people's awareness of what vaccines are, why they are important and what to expect from different types of vaccines. 5 Improving communication about the human papillomavirus (HPV) vaccination programme among families In England, young people aged 12 to 13 years are offered immunisation against HPV as part of the NHS vaccination programme. However, research by the National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol has identified sustained inequalities in uptake by area and minority ethnic groups. They have produced a number of information videos to address information needs about HPV among young people. They were coproduced with young people from disadvantaged backgrounds and diverse ethnic groups. 6 A visual guide to vaccines for the UK routine vaccination programme This guide by the UK Health Security Agency is designed to help ensure healthcare workers administer the right vaccines at the right time. It provides photos of all vaccines used in the UK routine immunisation programme, as well as information on when each vaccine should be given and its different trade names and abbreviations. 7 Pain management in infant immunisation: A cross-sectional survey of UK primary care nurses Childhood immunisation is a critically important public health initiative. However, since most vaccines are administered by injection, it is associated with considerable pain and distress. Despite evidence demonstrating the efficacy of various pain management strategies, the frequency with which these are used during routine infant vaccinations in UK practice is unknown. This study aimed to explore primary care practice nurses’ use of evidence-based pain management strategies during infant immunisation, as well as barriers to evidence-based practice. 8 Shingles Vaccination Programme: GP toolkit for improving uptake About 1 in 5 people who have had chickenpox develop shingles, predominantly those who are over 70. However, uptake rates of the shingles vaccine are falling in London and across England. The purpose of this toolkit is to help GPs better protect their patients by suggesting ways to improve uptake of the shingles vaccine. These suggestions are based on best practice and evidence and have been shown to work with little or no cost to practices. 9 Interview with Charlet Crichton, founder of UKCVFamily UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video for the hub, founder of UKCVFamily Charlet Crichton talks about why she established the group and describes the support it offers to patients. 10 Measles and rubella vaccine microneedle patch: new hope to reach the unreached children This Lancet article looks at how microneedle patches (MNPs) could potentially improve coverage of childhood vaccinations by providing a more thermostable, individual-dose, injection-free vaccine delivery device suitable for administration by local, non-medical personnel. MNPs could also reduce wasted vaccine doses, needle-stick injuries and breaks in the cold chain, as well as making waste management easier. 11 Whooping cough resurgence as vaccination rates slump Official data on whooping cough show that reports of suspected cases are at a 15-year high in the first three months of 2024. This article in the Pharmaceutical Journal looks at why cases are increasing, including falling rates of children receiving the childhood 6-in-1 vaccine and maternal vaccination. It outlines the symptoms of whooping cough, describes how it can be treated and includes a map identifying infection 'hot spots' in England and Wales. 12 Enhancing vaccine confidence across ethnic minority communities The Collaboration for Change is a group of two UK universities, nine community organisations and two small and medium size enterprises, who have conducted research on how to improve vaccine uptake among ethnic minority groups. The report highlights the factors influencing vaccine uptake. 13 Vaccination in the UK: Access, uptake and equity Over the last decade, the uptake of vaccines in the UK has stalled and is in many cases falling. Declining rates of routine childhood vaccination in a country with a well-established universal healthcare system are extremely concerning and pose a significant public health risk, with outbreaks of preventable diseases such as measles and whooping cough already being seen. The Royal College of Paediatrics and Child Health (RCPCH)'s Commission on Immunisation policy report assesses how and why vaccine uptake has stalled or declined. It outlines the evidence and our recommendations to increase uptake of routine childhood vaccinations across three broad themes: access to services, improved data systems and strengthening public information, education and communication. 14 UK Covid-19 Inquiry: Module 4 -Vaccines and therapeutics The UK Covid-19 Inquiry has published its fourth report and recommendations following its investigation into ‘Vaccines and therapeutics of the United Kingdom’. It considers and makes recommendations on a range of issues relating to the development of Covid-19 vaccines and the implementation of the vaccine rollout programme in England, Wales, Scotland and Northern Ireland. Issues relating to the treatment of Covid-19 through both existing and new medications were examined in parallel. Do you have a resource or story to share about immunisation safety? We’d love to hear about it - leave a comment below or join the hub to share your own post.

Parkinson’s is the fastest growing neurological condition in the world. It can affect young or old, and in the UK, around 153,000 people are living with the condition. With population growth and ageing, this figure is estimated to increase by 20%, within the next ten years. At the moment, there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. People with Parkinson’s face a number of specific patient safety issues when accessing healthcare including communication difficulties and risks associated with medication delays. In this blog, Patient Safety Learning has pulled together 14 useful resources about Parkinson’s shared on the hub. They include guidance for patients and their families about hospital stays and medication, and awareness-raising resources for healthcare professionals about the patient safety issues people with Parkinson’s face. 1. Keeping patients with Parkinson’s safe in hospital: 4 key actions for staff Dr Rowan Wathes, Associate Director of the Parkinson's Excellence Network at Parkinson's UK, recommends four key actions that healthcare workers can take to improve safety for people with Parkinson’s while they are in hospital. 2. Parkinson's UK: Parkinson's Away-From-Home Kit This kit from the Parkinson's UK Excellence Network comes from 3 years of collaboration with people with Parkinson’s and carers to understand the challenges they face when going into hospital and how we can help. People with Parkinson’s can choose from a range of tools to create a kit that works for them. Every item is designed to support them, and those who care for them, to advocate for their Parkinson's medications to be administered on time, every time. 3. Nurses leading the way: enhancing Parkinson's care in nursing homes In this blog published by the Royal College of Nursing, Jean Almond, Programme Manager at Parkinson's UK, discusses improving the delivery of time critical Parkinson’s medication to care home residents. 4. Preparing to go into hospital – tips for people with Parkinson's and their carers In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK, talks about how people with Parkinson’s can prepare their medication to go into hospital. 5. Time-critical Parkinson’s medication: the human cost of delays and mistakes In this blog, Joanne explains how delays to her mother’s time-critical medication in hospital led to her condition deteriorating. 6. Time critical medication guides for health professionals The Parkinson’s Excellence Network has produced three practical guides to support UK health professionals to deliver time critical Parkinson’s medication on time in hospital: a guide for NHS ward staff, a guide for hospital pharmacists and a swallowing guide for the nurse in charge and ward staff. 7. Electronic prescribing: how it can improve the delivery of time critical medications This resource describes how NHS Ayrshire & Arran hospitals improved their rates for administering patients' Parkinson's medications on time, sharing case studies and tips on how other hospitals might be able to replicate their successful e-prescribing system. 8. Improving the delivery of time critical medications at Bradford Teaching Hospitals NHS Foundation Trust A best practice case study showcasing a quality improvement project at Bradford Teaching Hospitals NHS Foundation Trust. 9. Ask the expert: How to spot fake Parkinson’s medicines online Falsified, fake or counterfeit medicines are medicines disguising themselves as authentic, and they can pose significant health risks. This blog highlights the issue of counterfeit Parkinson's medications being sold illegally online. Mike Isles, Executive Director of the Alliance for Safe Online Pharmacy in the EU describes their high prevalence and gives tips for people with Parkinson's on how to stay safe when buying medicines online. 10. My Parkinson's passport This tool from the Parkinson's Association of Ireland allows people with Parkinson's to record their essential medical information in an easy to access format, should they need assistance or medical treatment. 11. Parkinson's awareness: a 15-minute online presentation for ward staff This 15-minute training video by the Parkinson's Excellence Network pulls together the key symptoms and issues that can affect a person with Parkinson's and their care when admitted to a hospital ward. It aims to help ward staff understand the most important considerations when caring for people with Parkinson's. 12. Medication delays: A huge risk for inpatients with Parkinson’s This blog examines the serious health implications of delayed medication in people with Parkinson’s. It highlights evidence that this is a widespread safety issue and outlines the challenges, barriers and solutions to ensuring patients receive their medication on time. 13. Parkinson’s UK Tech Guide Parkinson’s UK created the Tech Guide so that people with Parkinson’s, and their families, friends and carers, can make the right decisions for themselves about all the devices and apps that claim to be able to help improve their quality of life. To do this, they provide trusted reviews based on the lived experience of people with Parkinson’s, and maintain a catalogue of the various products that are on the market. This is backed up with information about Parkinson’s and evidence-based articles that will help you decide what’s right for you, in your unique circumstances. 14. NHS Northumbria Healthcare: Improving the care in hospital for people with Parkinson’s In this blog, consultant geriatrician, Dr James Fisher, talks about a project at NHS Northumbria Healthcare to improve the experience of Parkinson’s patients by focusing on medication. Have your say Are you a healthcare professional who works with people with Parkinson’s? We would love to hear your insights and share resources you have developed. Do you have, or do you care for someone with Parkinson’s? Please share your experience of health and care services with us. We would love to hear from you! Comment below (register for free here first). Get in touch with us directly to share your insights.

Eating Disorders Awareness Week takes place 23 February - 1 March 2026 Eating disorders are complex mental health conditions that affect an estimated 1.25 million people in the UK. There are many unhelpful myths about who eating disorders affect, what the symptoms are and how to support people in recovery. Alongside a current lack of appropriately trained staff and capacity in mental health services, this can make it challenging for people with eating disorders to access the help and support they need. Patient Safety Learning has pulled together 15 useful resources shared on the hub to help healthcare professionals, friends and family support people with eating disorders. They include awareness-raising blogs, practical tips for patients and their loved ones, and clinical guidance for primary, secondary and mental health providers. 1 Hope Virgo: What needs to happen to stop people with eating disorders being failed by the healthcare system? In this blog, Hope Virgo, author and Secretariat for the All Party Parliamentary Group (APPG) on Eating Disorders, examines the crisis that continues in eating disorder services in the UK and the devastating impact this is having on patients and their families. She highlights how failures in services lead to avoidable deaths. Hope shares the key recommendations from a new report by the APPG and calls for adequate funding and attention to ensure people with eating disorders receive the help they need to recover. 2 Beyond stereotypes: A lived experience guide to navigating support for disordered eating Disordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating. 3 ARFID: A brief evidence review Avoidant/restrictive Food Intake Disorder (ARFID) is a severe feeding and eating disorder marked by food avoidance and/or restricted food intake. Individuals with ARFID can restrict the amount of food eaten, and therefore do not get enough calories, or they can restrict the range of foods eaten and therefore do not get all the nutrients needed for maintaining health. The charity Beat has produced an evidence review on ARFID. 4 Leaflet - Seeking treatment for an eating disorder If someone suspects they may have an eating disorder, their first step in getting treatment is often a visit to their GP. This leaflet contains guidance for people who have, or suspect they may have, an eating disorder, as well as information for GPs and other people who may be supporting them. It’s based on the guideline on eating disorders from the National Institute for Health and Care Excellence (NICE), which GPs should use when making decisions about patients’ healthcare. 5 Feeding or eating disorders hub (NHS England) The NHS England MindEd all-age eating disorders hub is aimed at all professionals, from universal to specialist. It contains key trusted evidence-based learning, curated and approved by an expert panel. You can find information on NHS policy guidance, professional bodies' guidance, professional associations' reports, charities, NHS learning and good practice, legislation and reports, and key and influential texts. 6 People with eating disorders should not face stigma in the health system and barriers to accessing support - a blog by Hope Virgo People with eating disorders often find it difficult to get help and treatment from the health system because of pervasive stigma, misinformation and stereotypes around eating disorders. This blog by eating disorder survivor and mental health campaigner, Hope Virgo, looks at the barriers people face when they try to access support for eating disorders in the UK. She talks about her own experience of being told she was ‘not thin enough for support’ and calls for long-overdue action on funding, training and awareness of eating disorders within the NHS. 7 Medical emergencies in eating disorders (MEED): Guidance on recognition and management To tackle the serious harms, up to and including death, associated with eating disorders it is crucial that more is done to identify them at the earliest stage possible so that the appropriate care and treatment can be provided. This guidance by the Royal College of Psychiatrists provides a comprehensive overview of the latest evidence associated with eating disorders, including highlighting the importance and role of healthcare professionals from right across the spectrum recognising their responsibilities in this area. 8 I survived diabulimia, the world’s most dangerous eating disorder Sarah Rainey talks about her experience of type 1 diabetes with disordered eating (T1DE), which is thought to affect up to 40% of women and 15% of men with type 1 diabetes. People with T1DE, sometimes also called diabulimia, limit their insulin intake to control their weight, which can have life-threatening consequences. Olivia describes how the stress of living with type 1 contributed to her developing T1DE, and how when she finally received treatment and support in her 30s, she was able to deal with her disordered eating and see her health and wellbeing improve. 9 London Assembly Health Committee: Eating Disorders in London In June 2023, the London Assembly Health Committee launched an investigation into eating disorders in London, following reports that referrals for eating disorder services have increased in recent years and performance against waiting time standards dropped during the COVID-19 pandemic. The aim of this investigation was to understand what is driving the increase in referrals, how services are responding to this additional demand and to explore people’s access to, experiences of, and outcomes from treatment services. The report makes 12 recommendations for change. 10 SAPHNA - Eating disorder toolkit This toolkit was co-produced by the School and Public Health Nurses Association (SAPHNA) with school nursing services, mental health campaigners, eating disorder experts, education colleagues and young people with lived-experience of eating disorders. It provides information and guidance for school nurses on how to identify and support students with eating disorders and their families, addressing issues such as consent, confidentiality and referral to specialist services. 11 Tips poster: First signs of symptoms of an eating disorder When someone has an eating disorder, getting early support and treatment can make a huge difference to their recovery. That’s why it's important that everyone can spot the first signs and symptoms of an eating disorder. This poster by the charity Beat Eating Disorders offers tips to help you spot the very first signs of an eating disorder. 12 Eating disorders: a guide for friends and family This booklet from Beat Eating Disorders is for anyone supporting someone with an eating disorder. It covers information about eating disorders and treatment, and offers guidance on how you might approach the subject if you’re worried about someone you know and how to support them after diagnosis, as well as looking after yourself. 13 Medical emergencies in eating disorders: Guidance on recognition and management People with eating disorders can reach a crisis point where their condition becomes a medical emergency resulting in serious harm or even death. This guidance from the Royal College of Psychiatrists makes a series of recommendations for primary care, secondary care and mental health services that aim to make preventable deaths due to eating disorders a thing of the past. There are specific recommendations focused on the needs of children with eating disorders, recognising the physiological differences between adults and children. 14 In conversation with Hope Virgo: “The withdrawal of treatment from people with eating disorders is a national crisis that’s being ignored.” A growing number of patients with eating disorders are reporting having treatment withdrawn by services, often without notice and without their consent. We spoke to eating disorder campaigner Hope Virgo about how pressures on services, enduring stigma around eating disorders and dangerous new narratives are leading to the practice of treatment withdrawal. Hope explains how this is affecting vulnerable patients and highlights that as the number of people developing eating disorders increases, the risks to patient safety will only get worse. 15 National Audit of Eating Disorders Service Mapping Report 2025 The National Audit of Eating Disorders (NAED) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England as part of the National Clinical Audit and Patient Outcomes Programme. In 2025 the NAED team conducted a comprehensive mapping of eating disorder service provision across England. This report provides an in-depth overview of NHS-funded and independent sector services for children, young people, and adults. Have your say Are you a healthcare professional who works with people with eating disorders? We would love to hear your insights and share resources you have developed. Perhaps you have received treatment for an eating disorder—what was your experience of healthcare services? We would love to hear from you! Comment below (register for free first) Get in touch with us directly to share your insights

NHS England has set a target that cervical cancer will be eliminated in England by 2040. Although progress has been made in detecting and treating cervical cancer, there are still many women who are reluctant to go for cervical screening, or who face barriers to accessing screening. These barriers include perceived discrimination, lack of understanding the risk of cervical cancer and unmet access needs. This contributes to persistent health inequalities amongst particular groups. Patient Safety Learning has pulled together 13 useful resources shared on the hub about how to improve access and overcome barriers to cervical screening. 1. Cervical screening, my way: Women's attitudes and solutions to improve uptake of cervical screening This research by Healthwatch explored why some women are hesitant to go for cervical screening. Based on the findings of a survey of more than 2,400 women who were hesitant about screening, it makes recommendations to policymakers on how to improve uptake, including: improvements to the way data about the disability and ethnicity of people attending screening. producing an NHS-branded trauma card for affected women to bring to appointments. ensuring staff are effectively trained on accessibility and adjustments to care. looking at the possibility of home-based self-screening. 2. Facing a smear test after my trauma In this BMJ article, Ruth Ajayi shares her experience of cervical screening after a traumatic childbirth, and how healthcare professionals could offer more compassionate, flexible care. 3. Exploring the inequalities of women with learning disabilities deciding to attend and then accessing cervical and breast cancer screening, using the Social Ecological Model Women with learning disabilities are less likely to access cervical and breast cancer screening when compared to the general population. In this study, the Social Ecological Model (SEM) was used to examine the inequalities faced by women with learning disabilities in accessing cervical and breast cancer screening in England. The study highlights key barriers to access for women with learning disabilities. 4. “We’re not taken seriously”: Describing the experiences of perceived discrimination in medical settings for Black women Black women continue to experience disparities in cervical cancer despite targeted efforts. One potential factor affecting screening and prevention is discrimination in medical settings. This US study in the Journal of Racial and Ethnic Health Disparities describes experiences of perceived discrimination in medical settings for Black women and explores the impact of this on cervical cancer screening and prevention. The authors suggest that future interventions should address the poor quality of medical encounters that Black women experience. 5. Top tips for healthcare professionals: Cervical screenings This article by the Royal College of Obstetricians & Gynaecologists and the My Body Back Project offers tips for healthcare professionals to make cervical cancer screening attendees feel as comfortable as possible during their appointments. Cervical screening can be very daunting for some women, and for those who have experienced sexual violence it can be triggering and cause emotional distress. The article provides tips on communication, making the environment calm and safe, sharing control and building trust with women. 6. Cervical screening uptake: supporting positive patient experiences is key In this blog, Steph explains why Cervical Cancer Prevention Week is an opportunity to validate and help improve patient experiences. She calls for more information to be shared with both patients and doctors that helps to increase compassion, understanding and accessibility. 7. Cervical screening for people with learning disabilities: Learning resource for sample takers This learning resource from the NHS Wessex Cancer Alliance explains the misconceptions and barriers to cervical screening, the consent and best interest decisions, and the role of the sample taker and the reasonable adjustments that can be made. 8. The Eve Appeal: What adjustments can you ask for at your cervical screening? The Eve Appeal want to raise awareness of what adaptations women and people with a cervix can ask for during their screening to make the appointment more comfortable. 9. How can reframing women’s health improve outcomes? An interview with Dr Marieke Bigg Dr Marieke Bigg is the author of a 2023 book, This won’t hurt: How medicine fails women. In this interview, Marieke discusses how societal ideas about the female body have restricted the healthcare system’s approach to women’s health and describes the impact this has had on health outcomes. She also highlights areas where the health system is reframing its approach by listening to the needs of women and describes how simple changes, such as allowing women to carry out their own cervical screening at home, can make a big difference. 10. Having a smear test. What is it about? This download A4 Easy Read booklet from Jo's Cervical Cancer Trust uses simple language and pictures to talk about smear tests. It explains what a smear test is, has tips for the person having the test and has a list of words they might hear at their appointment. 11. Health Improvement Scotland: Cervical screening standards Published by Healthcare Improvement Scotland in March, the new cervical screening standards include recommendations to ensure women receive accessible letters and information about screening and healthcare professionals are trained to support women to make informed choices. 12. Cervical cancer screening in women with physical disabilities This US study explored how the cervical cancer screening experiences of women with physical disabilities (WWPD) can be improved. Interviews with WWPD indicated that access to self-sampling options would be more comfortable for cervical cancer screening participation. The authors highlight that these findings that can inform the promotion of self-sampling devices for cervical cancer screening. 13. Cervical screening - a guide for survivors of rape, sexual assault and sexual abuse This guide by The Eve Appeal and The Survivors Trust gives information about attending cervical screening for survivors of rape, sexual abuse or assault. It offers tips that may help patients feel more comfortable about their appointment. It is part of the #CheckWithMeFirst campaign to help raise awareness of the challenges survivors of rape, sexual abuse and sexual violence may face when accessing cervical screening. Have your say Are you a healthcare professional who works in women’s health or cancer services? We would love to hear your insights and share resources you have developed. Perhaps you have an experience of cervical screening or cervical cancer that you would like to share? We would love to hear from you! Comment below (register as a hub member for free first) Get in touch with us directly to share your insights

World Hospice and Palliative Care Day takes place on 11 October 2025.  Patient safety in hospice and palliative care involves ensuring that every patient is able to access the services, support and pain relief that they need when they reach the end of life. It is also vital that families and carers are given relevant and timely support and information by healthcare services during their loved one’s hospice or palliative care, and following their death. Patient Safety Learning has pulled together 15 useful resources shared on the hub about hospice and palliative care. They include reports into the current state of hospice and palliative care in the UK, families’ reflections on how end of life care can be improved and resources related to palliative care for people with learning disabilities. 1. NHS Confederation: Collaborating to provide care at home for terminally ill patients A collaborative programme between Marie Curie and Bradford Teaching Hospitals NHS Foundation Trust is keeping patients with terminal illnesses out of the hospital and providing care in the comfort of their own homes. 2. Bringing care closer to home: Improving palliative care in remote, rural and island communities People living in remote, rural and island communities face unique and significant challenges accessing health and care services. Long distances to travel, poor public transport and a chronic shortage of health and care staff leave people struggling to get the care they need. In some rural areas, a lack of services means that people’s basic human rights, including their right to health, are not being met. For those at the end of life, these challenges are even greater. This report is the first comprehensive policy report addressing the palliative care needs of adults and children in remote, rural, and island communities across the UK. 3. "We were completely unprepared for the challenges and disruption that lay ahead" — A family share their experience of taking a loved one home for end of life care In this anonymous blog, a hub member shares how unprepared she and her family were for the challenges and disruption that lay ahead when her husband was discharged from hospital for end of life care at home. 4. "What matters to you today?" How this simple question can improve patient care Physiotherapist Ann Bryan and occupational therapist Ines Brito are part of the therapy team working at the Marie Curie hospice in Hampstead. In this blog, they look at how asking a simple yet powerful question: "what matters to you?" can give healthcare professionals vital insights into the lives of patients that aren't always captured in routine assessments. 5. End of life care – 2024 State of the Nations report The National Audit of Care at the End of Life (NACEL) is a comparative audit of the quality and outcomes of care experienced by the dying person and those important to them during the last admission to hospital before death. The aim of NACEL is to improve the quality of care of adults (18+) at the end of life in NHS-funded hospital inpatient settings in England, Wales and publicly-funded care in Jersey. 6. The Worldwide Hospice and Palliative Care Alliance The Worldwide Hospice and Palliative Care Alliance (WHPCA) is an international non-governmental organisation focusing exclusively on hospice and palliative care development worldwide. The WHPCA website hosts a wide variety of resources relating to hospice and palliative care including advocacy resources, standards and clinical guidelines and country reports. 7. Dying well at home: commissioning quality end-of-life care (King's Fund) This King’s Fund report explores what we know about commissioning end-of-life care, the inequalities experienced by particular groups, and how NHS and social care commissioners in England are measuring and assuring the quality of care people receive. 8. Seeking Excellence in End of Life Care UK (SEECare UK): a UK multi-centred service evaluation The Association of Palliative Medicine coordinated the first ever prospective evaluation of end of life care against set standards in 88 hospitals across the UK. It found that people dying in UK hospitals without specialist palliative care input frequently have “significant and poorly identified unmet needs” —93% of people assessed having demonstrable unmet need. 9. Interview with Dr Elena Mucci, Consultant Geriatrician at East Sussex Healthcare NHS Trust In this video interview, consultant geriatrician Dr Elena Mucci talks about patient safety in geriatrics and end of life care. She describes the importance of taking a whole-person approach to caring for older people, reviewing medications regularly, equipping patients to manage their own health, and engaging patients and their families in planning for end of life care at an early stage. 10. Palliative Care for People with Learning Disabilities Network (PCPLD Network) The Palliative Care for People with Learning Disabilities (PCPLD Network) is a charity created to ensure that patients with learning disabilities receive the coordinated support they need throughout their life. The PCPLD Network website has some interesting webinars on a range of different topics which have already taken place for you to watch as well as useful resources. 11. Sarcoma UK: Family insights from Dermot’s experience This article from Sarcoma UK was written by the family of Dermot, who was diagnosed aged 77 with myxofibrosarcoma in March 2020. They reflect on the issues Dermot faced in accessing effective palliative care and make recommendations linked to the recent publication of the Healthcare Safety Investigation (HSIB) report, Variations in the delivery of palliative care services to adults. 12. Mind the gaps: understanding and improving out-of-hours care for people with advanced illness and their informal carers For patients living at home with advanced illness, deterioration in health can happen at any time of the day or night. This research report funded by the charity Marie Curie looks at issues faced by people with advanced illness and their informal carers in accessing out-of-hours care. 13. Lessons not learned: A family's lengthy efforts to turn complaints into improvements In this blog, a family describe the lengthy efforts they had to take to try to ensure their complaints about their loved one's end of life care would result in improvements at the hospital. 14. Final guidance on visiting and accompanying in care homes, hospitals and hospices - Care Quality Commission (CQC) Following consultation, the Care Quality Commission have now published final guidance to help providers understand and meet the new fundamental standard on visiting and accompanying in care homes, hospitals, and hospices. The guidance (on Regulation 9A: visiting in care homes, hospitals, and hospices) also sets out what people using health and social care services and their families, friends or advocates can expect. 15 NCEPOD: Planning for the end. A review of the quality of care provided to adult patients towards the end of life Approximately 70% of people die from long-term health conditions that often follow a predictable course, with death anticipated well in advance of the event. The annual number of deaths in the United Kingdom is predicted to rise to 736,000 by mid-2035. Therefore, the provision of care at the end of life must meet the needs of the population. NCEPOD reviewed the quality of care provided towards the end of life for adults with a diagnosis of dementia, heart failure, lung cancer or liver disease and have made a number of recommendations. Have your say Are you a healthcare professional who works in hospice or palliative care? We would love to hear your insights and share resources you have developed. Perhaps a family member or someone you care for has received palliative care - what was your experience like? We would love to hear from you! Comment below (register for free first) Get in touch with us directly to share your insights

In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, emergency medicine doctor Chelcie Jewitt describes why and how she co-founded Surviving in Scrubs, a campaign that shares survivor stories of sexism, harassment and sexual assault in the healthcare workforce. She outlines the work the campaign is doing with professional regulators to set clear behavioural standards that will more effectively hold perpetrators to account. She also describes the training and support that Surviving in Scrubs offers healthcare staff and organisations on how to respond to harassment and abuse. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series

At the beginning of 2025 we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive.  In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life. They share their story and their reflections on what needs to be done to improve organisational cultures so that when staff raise patient safety issues, their concerns are responded to appropriately and not dismissed because they are inconvenient to address. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. In this blog, Helen and Peter look at some of these themes and outline their implications for people who speak up or whistleblow. We are now three months into the series, which seems like a good time to stop and reflect on what we have learned so far. Our introductory blog about ‘Speaking up for patient safety’ explains why we launched the series and what we hope it will achieve. It also explains in more detail what we mean when we talk about speaking up and whistleblowing. Briefly, speaking up in healthcare is when a member of staff raises concerns about something that is worrying them to a manager or someone else within, or outside of, their organisation. In some cases—but not all—when someone speaks up, it is also defined as ‘whistleblowing’. Whistleblowing always involves a concern that is in the public interest and might relate to a criminal offence, health and safety risks, failures to carry out legal obligations, a miscarriage of justice, or an attempt to conceal and cover up any of these things. Three key themes from the interviews so far These are the top three recurring themes we have noticed coming up in the interviews so far. Other issues we have noticed include the lack of clarity about who should take responsibility for whistleblowing and the reality of threats and bullying, and we will continue to explore these issues going forward. 1. “I didn’t realise I was speaking up, I was just doing my job!” Perhaps the comment we have heard most frequently is that people didn’t realise they were formally speaking up or whistleblowing—they just thought they were doing their job. Every healthcare profession has a set of professional standards which all practitioners are expected to keep to. For example, the General Medical Council (GMC) states that all doctors have a duty to take action by raising concerns if they believe patient care or safety are at risk.[1] In addition, each healthcare organisation has a code of conduct, which will include requirements for staff to be honest, open and accountable for their work. For the interviewees we spoke to, to not raise their concerns would be a failure to fulfil their duty to both their patients and their organisation. When people speak up, they often find themselves in the middle of a process that they had no idea they were entering. This can be very disorientating and leave them unprepared for the path ahead of them. At the end of this blog, we share some advice from our interviewees about what to do if you find yourself in this position. 2. There is a whistleblowing ‘playbook’ Most organisations have policies and support in place to listen to staff members who raise concerns, including access to a Freedom to Speak Up Guardian. We have interviewed Jayne Chidgey-Clark, the National Guardian, who described the good practice that many are developing. However, we are hearing about several common tactics that some organisations use when dealing with people who speak up or blow the whistle. The experiences of our interviewees suggest that these approaches may be deliberately designed to disadvantage the individual throughout the process—from investigation through to employment tribunals. Some of the key activities we have heard about include: Organisations not responding—or responding at the very last minute—to communications from the staff member. Interviewees said they received emails with key information at 5pm on a Friday, which left them with no opportunity to ask questions or respond until the next working week. They expressed their belief that this may be a deliberate tactic to exert pressure on the individual speaking up, which amounts to emotional bullying. The use of occupational health as a way to cast doubt on the mental state of the person. Occupational health providers are often very supportive, but we are concerned that organisations are fishing for reasons to question the believability and motives of staff who speak up. Over-focus on HR issues, rather than focusing on the patient safety issues someone has raised. Mandated isolation from colleagues while investigations take place. This can have a very damaging effect on the person’s mental health as well as restricting their ability to source evidence from other staff in support of the concerns they have raised. We have heard examples of colleagues agreeing to provide supportive testimony, but then feeling pressurised to withdraw this support. Retaliatory referrals against the person speaking up to professional regulators, such as the General Medical Council and Nursing and Midwifery Council, which can have a detrimental effect on a healthcare professional’s reputation and career. Regulators are aware of how such referrals can be used to intimidate whistleblowers and discourage them from raising concerns. Some have approaches to ensure that fitness to practice concerns are appropriately addressed without unfairly impacting doctors who have raised whistleblowing concerns. To highlight these tactics we have created 'The whistleblower playbook' infographic, illustrating how some organisations respond to staff raising concerns about patient safety. We believe it is important to identify and call out these tactics so that people raising concerns are aware of them and can seek support and advice. Organisational leaders need to look at their own practice and recognise the ethics of their approaches and whether their actions match their stated organisational values. They need to be aware of the significant damage these tactics cause to people who raise concerns and the chilling impact it might have on their organisational culture, effectively preventing others’ raising concerns. 3. Employment tribunals are unfit, unfair and imbalanced Every person we spoke to who had attempted to pursue justice at an employment tribunal commented that the process was unfit for purpose and not the right place for whistleblowing cases to be heard. Employment tribunals take no interest in the safety issues being raised. The main issue we keep hearing is that the tribunal system is weighted in favour of whichever side has the most financial resources—which will almost always be the employer. A single individual who has lost their employment can rarely succeed against the millions of pounds that organisations are willing to spend on highly specialised lawyers who have tried and tested ways of winning. The playbook we identified above also runs into employment tribunals, with whistleblowers reporting: The employer and their legal advisers withholding key documents, and emails, minutes, notes and other vital information going missing. Key witnesses, often in senior leadership positions, being unable to recall events. Receiving last minute threats from their former employer to come after them for costs and often being given a limited time to consider signing a non-disclosure (NDA) to settle a case. If rejected, often the NHS organisation will seek the full costs from the whistleblower, including expensive external legal costs and internal staff costs, which can amount to thousands of pounds—few whistleblowers can afford to take this financial risk, even if they and their advisers think they have a strong case. Advice from our interviewees if you find yourself speaking up Reflecting on their experiences, our contributors have made some observations about how you can protect yourself when speaking up, should the issue escalate. Try to resolve issues locally first. This is not always possible, but if a concern can be raised and dealt with within a team or with a manager, in some cases this will prevent the situation from escalating to a formal process. Keep a record of concerns and events as they happen. This means you will have some facts and clear observations to refer back to, if the situation does escalate. Don’t go to meetings alone. Take a trusted colleague with you so that every conversation is witnessed. Get your union involved if you are called to meetings about your concerns or receive counter-complaints or accusations. Regulation of NHS managers Some of the interviewees highlighted that regulating NHS managers may be a potential means of tackling some of these issues. The Department of Health and Social Care recently held a public consultation on proposals that could see managers who use misconduct to silence whistleblowers barred from working in the NHS. Patient Safety Learning has formally responded to the consultation, stating that there is a clear case for the regulation of NHS managers, for the protection and benefit of both staff and patients. Everyone in healthcare should be honest and transparent when something goes wrong. Patient Safety Learning’s response expressed support for a professional register of NHS managers and the requirement for individuals in NHS leadership to have a professional duty of candour. These measures would be a positive step in increasing accountability for healthcare organisations in how they respond to staff raising patient safety concerns. But this is only one part of a much wider set of changes needed—significant cultural change also needs to take place in tandem with these reforms. Staff across many organisations are still afraid to speak up, as indicated by the most recent NHS staff survey results. Thank you to our contributors, and an invitation to get involved We’d like to take this opportunity to express our gratitude again to each person who has been willing to share their experiences and insights with us—it can be very difficult to retell traumatic events that have changed the course of your life. We are also aware that there are many other individuals who have experienced unjust treatment because they have spoken up for safety. If that’s you, thank you for your commitment to standing up for safe, ethical care. We invite everyone with experience in this area to contribute to this vital conversation. We would particularly like to hear from: Allied health professionals. Staff from Black and minority ethnic backgrounds Staff in non-clinical roles such as administration. If you would like to share your story, you can: Contribute to our community conversation (you’ll need to sign up first). Comment on any hub post (you’ll need to sign up first). You can find information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub. Watch the interviews Helené Donnelly Martyn Pitman Jayne Chidgey-Clark Gordon Caldwell Bernie Rochford Beatrice Fraenkel Chelcie Jewitt References General Medical Council. Professional Standards: Raising and acting on concerns about patient safety, 13 December 2024

In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Beatrice Fraenkel, ergonomist and Non Executive Director at Stockport NHS Foundation Trust discusses the importance of understanding the issues that lead to poor culture and harm in healthcare organisations. She describes the Board's radical approach to establishing a Just Culture during her time as Chair of Mersey Care NHS Foundation Trust and the huge investment needed to build trust between healthcare staff and their employers. She also talks with Peter and Helen about the importance of understanding the needs, views and emotions of people in the wider community that each trust serves. They discuss the universal impact of fear and anxiety on human behaviour and the need to ensure lessons are really understood before attempting to put solutions in place to tackle issues, on any scale. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series

DeNPRU Exeter is a Policy Research Unit in Dementia and Neurodegeneration based at the University of Exeter. This webinar will share learning from DeNPRU Exeter's policy research project on reducing inequalities for minority ethnic communities living with dementia, Parkinson's disease, motor neurone disease or Huntington's disease. The United Kingdom is composed of diverse range of ethnic and cultural groups. However, people from minority ethnic communities living with dementia or other neurodegenerative conditions often face significant inequalities in accessing healthcare. This can result in delayed diagnoses, poorer health outcomes and a reduced quality of life. This project has: identified and examined community campaigns aimed at raising awareness and/or reducing stigma around neurodegenerative conditions in minority ethnic populations. reviewed existing research on the barriers and facilitators influencing access to care and support for people from minority ethnic communities. learned from people with lived or professional experience about raising awareness of neurodegenerative conditions and addressing barriers to accessing services. Join the DeNPRU Exeter Reducing Ethnic Inequalities Project Team to hear about the findings. Deputy Director of DeNPRU, Professor Jan Oyebode Research Fellow, Dr Maria Caulfield There will be a chance to ask questions of the speakers. Register for the webinar

In this blog, Justean Winter shares her experience of working as an agency nurse in the NHS. She describes how she was told not to report patient safety issues she witnessed. After raising concerns about patient care, Justean received several accusations and was eventually blocked from working in the NHS. She outlines why she continues to try and raise awareness of the patient safety and organisational issues she witnessed. Patient safety issues and reporting I have been a nurse for 33 years, and worked for an NHS Health Board via an agency for a number of years. In the Autumn of 2022, I was working in the A&E department when we were told not to submit Datix reports without checking them with managers first. Datix is the incident reporting software widely used in the NHS for reporting patient safety issues. We weren’t able to report anything we saw, including short staffing, bullying and patients being left without treatment. When I or another member of staff asked about why we couldn’t report what we witnessed, we were told by the managers to stop asking and just get on with our job. Later that year, I was asked to work in paediatric A&E, but knew I wasn’t up to date with all the relevant training. I raised this but was told to go and do the shifts anyway. The atmosphere in the wider A&E department was one of keeping quiet about any concerns. If you raised concerns you were seen as a trouble maker. Some examples of issues I raised were patients being denied end-of-life medication, patients with diabetic ketoacidosis being left without treatment and nurses wearing name badges that didn’t belong to them. There were also some issues with staff conduct that could pose a threat to patient safety that I was told not to mention if I wanted to keep my job. At this point, I started reporting incidents anyway, as I was seeing patient safety issues that I just couldn’t ignore. Accusations and suspension In October, I was told by my agency that there had been a complaint against me, dating from that July. I asked to see the details, but they wouldn’t show me anything. I also asked why it hadn’t been raised with me sooner, but was just told there would be no statement needed and there would be no investigation. Then in March 2023, my agency contacted me to tell me about another complaint they had received against me. It turned out to be the same one they had mentioned before, but now the Health Board wanted a statement from me. I did the statement and nothing came of it again. I felt that something underhand was going on. Then in April, one of the nurse managers pulled me into an office and accused me of stealing cash from one of the patients. At this point, I felt I was being bullied because I was refusing to keep quiet about issues on the ward. There were other incidents of intimidation, such as being squared up to in the corridor by another nurse about whose care I had concerns. I was on holiday in May when I received a series of texts from my agency telling me all my shifts had been cancelled. When I came back I realised I was unable to book any shifts, and it turned out that I had been totally suspended by the Health Board. My agency then told me that I had been accused of stealing morphine back in January. Five months had passed and I was only being told about it now! I vigorously defended myself against these accusations. In June, I was called to a Zoom meeting to discuss my suspension. I wasn’t allowed to see any of the complaints or any evidence, but the accusation was used as the reason for my suspension. I asked them to check the CCTV and was told that there was no CCTV in the department. My contact at the agency told me they would be collecting more statements and coming up with a plan for a way forward. When I asked about what the process was, I received no response. After the meeting, I wrote a long email to the Health Board detailing all my concerns, including about the inability to submit Datix reports and inadequate care standards I had witnessed . I later wrote a further letter to 18 members of the Health Boards as well as the Senedd and Healthcare Improvement Wales (HIW), sharing my patient safety concerns but heard nothing back. The Senned Minister for Health and Social Services said that the concerns I had raised were employment concerns rather than safety ones but that they would keep the letter on file for 10 years. At this stage, life was really difficult. I couldn’t get any work—there was a red flag against my name so I was basically unemployable. I asked the agency what was going on, but again got no response. My career and life were being ruined and I hadn’t done the things I was accused of. The same day I delivered the letters, my agency phoned to tell me I had been referred to the Nursing and Midwifery Council (NMC). It wasn’t until December 2023 that I heard from the NMC. The referral stated that I lacked insight to reflect and had refused to do a communication course—no missing money or morphine had ever been mentioned in the referral. I was cleared by the NMC in January 2024. I later found out through court documents relating to my employment tribunal that seven managers and an entire health board were responsible for referring me to the NMC—ostensibly on the grounds of communication issues. It just doesn’t add up. Employment tribunals When I contacted ACAS in September 2023, they told me that I was within the timeframe for an employment tribunal. But three judges since then have told me I am out of date and have refused to read my evidence bundle because it was too long. One judge told me I should “Stop criticising the NHS” and accused me of having a personal vendetta. But all I want is for the truth to come out and to be able to resume my career. I am now on my fourth appeal to try and get my case heard at tribunal. I’ll continue to do everything I can to pursue justice. Vulnerability as an agency nurse I believe that my status as agency staff made me vulnerable to repercussions. There is no support mechanism or process to follow as an agency nurse when raising concerns, and as I wasn’t employed directly by the Health Board, I was more easy to falsely accuse and get rid of. The personal cost of my experience has been huge. We have had to put our home up for sale because I’ve been unable to work since May 2023. I have developed post-traumatic stress disorder and a fear of the NHS because of what I have witnessed. I believe patients are dying because they aren’t receiving the care they need, and that it is being covered up. There are so many issues that the public need to be aware of and that NHS organisations need to deal with to keep patients safe and protect staff. Related reading My experience as an agency nurse A dropped instrument, washed in theatre and immediately reused: a story from a theatre nurse Speaking up for patient safety: A new interview series about raising concerns and whistleblowing My experience of speaking up as a healthcare assistant in a care home Share your speaking up story If you have spoken up about unsafe care or have been a whistleblower in healthcare or social care, we would love to hear from you about your experience. You can: contribute to our community conversation (you’ll need to sign up first) comment on any hub post (you’ll need to sign up first) contact us at [email protected] and we can share your story anonymously. You can find information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub.

This webinar will look at how we can collaboratively and effectively utilise clinical audit to continuously improve patient safety, prevent avoidable harm and work together within our patient safety systems. The Clinical Audit Hero Award for Patient Safety will be announced and there will be the opportunity to hear the winner present their project for wider learning for us all. The event is hosted by the National Quality Improvement (inc. Clinical Audit) Network (N-QI-CAN) and the Healthcare Quality Improvement Partnership (HQIP). Register for the event