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Mark Hughes



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Profile Information

  • First name
  • Last name
  • Country
    United Kingdom

About me

  • About me
    I am Patient Safety Learning's Business and Policy Manager. Prior to this I worked in a range of different roles for Alzheimer's Society and two Members of Parliament. I have a strong interest in reforming the social care system and improving patient safety.
  • Organisation
    Patient Safety Learning
  • Role
    Business and Policy Manager

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  1. Content Article
    In late 2023, the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner for England to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. This report sets out the outcome of this project and is designed to help the government understand the options available for providing redress to those patients harmed by pelvic mesh and valproate.
  2. Content Article
    On 26 January 2023, University Hospitals Sussex NHS Foundation Trust contacted the Royal College of Surgeons of England to request an invited service review of the Trust’s general surgery department, with a specific focus on upper gastrointestinal surgery, lower GI surgery and emergency general surgery. The request highlighted that the general surgery department was a service which had been under scrutiny for many years, with a history of internal reviews, and concerns being raised by consultant surgeons as well as other members of staff within the department. This report sets out the findings of this review.
  3. Content Article
    On the 24 October 2023 the Health and Social Care Select Committee announced that its independent Expert Panel would be undertaking an evaluation of government progress on implementing accepted recommendations to improve patient safety. As part of this review, the Committee wrote to the Secretary of State for Health and Social Care requesting a list of key independent public inquiry and review recommendations pertaining to patient safety and whistleblowing in the NHS that that the Government has accepted since 2010. This letter sets out the response to this request from Maria Caulfield MP, Parliamentary Under Secretary of State.
  4. Content Article
    In this article, Claire Brader summarises the recent findings on the performance of NHS maternity services in England, as well as recent government and NHS policies aimed at improving the quality of maternity care.
  5. Content Article
    Elizabeth Roberts was severely frail and bedbound, supported by visits from care agency carers four times per day and her local District Nursing Team. She had ischaemic and hypertensive heart disease and developed a large sacral sore with associated sepsis. She was admitted to Tameside General Hospital on 19 May 2023 where despite treatment, she died the same day of Sepsis with congestive cardiac failure. In this report the Coroner notes concerns about the her case and the capacity of the District Nursing Team providing here care.
  6. Content Article
    Pressure ulcers are a significant challenge for the patients who develop them and the healthcare professionals involved in their prevention and management. They can result in serious complications and avoidable harm, with patients with mobility difficulties at particularly risk from this. This guidance is designed to help practitioners and managers across health and care organisations to provide caring and quick responses to people at risk of developing pressure ulcers.
  7. Content Article
    Morgan-Rose Hart died after she was found unresponsive while being detained under section 3 of the Mental Health Act at the Derwent Centre at the Princess Alexandra Hospital in Essex. Morgan-Rose was last clinically observed at 14.06 on 6 July 2022 and in between the last observation and when Morgan-Rose was discovered the Coroner notes that multiple failings in her care took place, including consecutive hours observations being incorrect and falsified.
  8. Content Article
    Andrew Guillaume was admitted to Warwick Hospital on the 6 June 2023. Following a review, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team. However, no referral was made as the Consultant was unable to get through to the switchboard at UHCW, so Mr Guillaume remained at Warwick Hospital. Subsequently his condition worsened and on the 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite his surgery, but again they were unable to reach the team through the switchboard. Mr Guillaume was admitted to the unit on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition.
  9. Content Article
    In this article for the Journal of Eating Disorders, Alykhan Asaria considers the criteria used in a paper by Guadiani et al. (J Eat Disord 10:23, 2022) to define ‘terminal anorexia nervosa’ and outlines concerns about this new term from a lived experience perspective. The author highlights issues about the ambiguities around how the criteria can be applied safely and the impact of labelling anorexia nervosa sufferers with terms. Further articles on the hub from Alykhan Asaria: ‘Terminal anorexia’: a lived experience perspective
  10. Content Article
    Produced by the Institute of Global Health Innovation at Imperial College London, and commissioned by the charity Patient Safety Watch, this report considers the current state of patient safety around the world, through analysis of publicly available data from the last two decades. It includes an interactive data dashboard, case studies of patient safety excellence and a ranking of patient safety in OECD countries.
  11. Content Article
    The review into the statutory duty of candour has been established by the Department of Health and Social Care to consider the design of operation of this requirement, assess its effectiveness and make advisory recommendations. The duty of candour is about people’s right to openness and transparency from their health or care provider. It means that when something goes wrong during the provision of health and care services, patients and families have a right to receive explanations for what happened as soon as possible and a meaningful apology.
  12. Content Article
    The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This website provides information about inquiry team, terms of reference and publications relating to this.
  13. Content Article
    This report summarises the findings arising from a comprehensive study of antibiotic ‘line flushing’ and disposal practices in NHS organisations across Great Britain. It argues that is a need for concerted, UK-wide action on antibiotic line flushing policies.
  14. Content Article
    Homecare medicines services deliver medicines and provide medicine-related care to patients in their homes, for example, teaching them to self-inject, and delivering medicine that might need special transport. In this report, the House of Lords Public Services Committee highlights concerns about multiple reports of delays and errors by homecare providers, resulting in patients receiving care later than scheduled. The report states that this key service is not working the way it should and, in some cases, is causing patients serious harm.
  15. Content Article
    Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021.
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