Mark Hughes

The Independent review of maternity services at Nottingham University Hospitals NHS Trust was commissioned in June 2022 and looks at the provision of maternity and neonatal care at the Trust between 2012 and 2025. More than 2,500 families and over 800 staff have contributed to this review. It concluded that there were potentially avoidable outcomes relating to 444 maternity cases examined up to May 2025, alongside 76 neonatal cases. Key issues identified in this report include insufficient staffing and funding across perinatal care settings; the inability of staff to undertake even basic (often, mandatory) training; a persistent failure to listen to and believe mothers and fathers; and a corresponding failure to investigate, and therefore learn from, mistakes. The Review identifies 18 immediate and essential actions to improve care and safety in maternity services across England, which are summarised below: 1. Strengthening women-centred communication and informed choice All women must be provided with clear, consistent and accessible information throughout pregnancy to support informed decision-making. This should include information about labour and birth, pain relief options in labour, anaesthetic care for operative delivery, and the potential benefits and risks of different interventions. 2. Support a nationally agreed perinatal workforce planning methodology as a critical enabler of perinatal improvement at pace and scale Investment should be made in the development and implementation of a robust, evidence-based workforce planning tool across perinatal services. The tool should move beyond birth rates alone to reflect population complexity, including factors such as maternal age, co-morbidities, deprivation, acuity and service configuration. 3. National immediate and essential actions labour ward coordinator (LWC) role Implement a nationally recognised LWC programme for all Band 7 LWC midwives undertaking the LWC role. Provide structured opportunities and support to achieve the competencies and standards outlined across the six domains of the national LWC Framework. Introduce 360-degree feedback for all LWCs to support reflection, performance development and understanding of the impact of behaviour on the multidisciplinary team. 4. All trusts must support training for midwives in the use of speculum examination All Trusts must ensure that midwives are supported to achieve local training competencies to perform speculum examinations for women at any gestation of pregnancy, with clear escalation pathways for women in pre-term labour or those requiring immediate ongoing care. 5. Enhanced maternal care All staff caring for pregnant women must receive regular, structured multidisciplinary training to ensure timely recognition and effective management of the deteriorating woman. Training must equip midwives, obstetricians, anaesthetists, critical care teams and outreach services with the skills, knowledge and confidence to deliver safe, high-quality enhanced maternal care. National education programmes must cover key areas of maternal care and include the recognition and management of lesser-known but clinically important conditions, such as maternal ketosis, to ensure consistent, safe and excellent care across all maternity services. 6. Delivering safe, personalised and equitable maternity care through early risk recognition, coordinated care and responsive services All Trusts must ensure women receive the appropriate ‘safety-netting’ within their care, enabling them to access services and treatments, including the consideration of reducing barriers to enable to the provision of safe maternity care. 7. National standard for standardisation and recording of fetal growth risk assessment There must be standardisation of fetal growth risk assessment, management and audit across RCOG, SBLCB and NICE guidance, with clear concise recommendations on the choice of pathways and charts to ensure consistency of the approach to the reduction in stillbirth. All practitioners performing ultrasound growth scans should have training to undertake and report examinations to meet the standardised methods used in the recommended charts. 8. There must be a national standard and documentation for maternity triage and record keeping in maternity care provision Trusts must develop a robust method of training for midwives providing triage care. This must include minimum competency standards for telephone risk assessment, agreed pathways for mandatory attendance for review and a holistic review of physical, mental and social wellbeing assessment. Suppliers of Electronic Patient Record (EPR) systems must ensure there is a standardised national maternity handover tool that addresses interoperability gaps between Trust systems. All Trusts must implement the standardised national Maternity Early Warning System (MEWS) with clearly defined escalation pathways wherever they are being cared for. 9. Support the development and implementation of a structured assessment framework for the latent phase of labour, ensuring clarity when the ‘latent phase of labour’ becomes abnormal requiring escalation Develop and implement a structured assessment framework for the latent phase of labour, incorporating maternal and fetal wellbeing, the woman’s preferences and narrative, social circumstances, potential barriers to accessing care (e.g. language or socioeconomic factors), time of day, and distance from the unit when determining the appropriateness of admission. 10. All Trusts must define criteria for the safe use of telephone postnatal follow-up, indicating when telephone follow-up is acceptable or when face-to-face follow-up is mandatory The first risk assessment for this should be documented in the woman’s notes in the antenatal period (by 34 weeks gestation), and the risk assessment reviewed before postnatal discharge from the hospital, and after every postnatal community visit. 11. National standard for obstetric anaesthetic record-keeping All Trusts must introduce and use standardised approaches to key areas of maternity anaesthetic care to reduce variation and improve outcomes. An agreed minimum standard for obstetric anaesthetic documentation must be implemented. This should include routine recording of intra-operative pain scores and accompanying narrative log, particularly during unexpected or critical events. 12. Safe, accessible and comprehensive maternity anaesthetic documentation All Trusts must strengthen maternal anaesthetic and critical care documentation, ensuring it is clear, contemporaneous and readily accessible, ideally within a single unified electronic patient record. Documentation must capture all relevant multidisciplinary discussions and care plans, and be woman centred, reflecting the woman’s needs, preferences, and involvement in decisions. 13. Department of Health and Social Care/NHS England (DHSC/NHSE) should introduce and support access to coordinated multidisciplinary debrief and psychological support. DHSC/NHSE must support Trusts to ensure that maternity services provide timely, accessible psychological support for women and families following traumatic events. This must include clear referral pathways, adequately resourced specialist provision, and processes that proactively identify and respond to unmet emotional and psychological needs 14. Funding for implementation of maternity Patient Safety Incident Reporting Framework (PSIRF) DHSC/NHSE must provide adequate funding to address the systemic resource gap that prevents Trusts from operationalising new national policy, enabling women and families to experience safer, more consistent care, with improvement demonstrated through full implementation, audit compliance, and sustained delivery of required standards. DHSC/NHSE should develop clear maternity-specific definitions and guidance on patient-safety incidents to resolve national inconsistency in interpretation, ensuring women and families receive transparent and accurate reporting of harm, with improvement evidenced by nationally standardised grading and reliable national data. 15. Strengthened multidisciplinary governance and learning All Trusts must ensure protected time for multidisciplinary governance, review and learning. This must include learning from both adverse events and examples of good practice to support continuous improvement in the quality and safety of care provided to women. Learning from neonatal PSIRF investigations should be considered alongside maternity investigations, recognising the opportunities for shared learning across perinatal services. 16. Foster a compassionate, psychologically safe, and learning culture All Trusts must actively foster a culture of safety, compassion and respect across all maternity services. Staff must feel supported to speak up and raise concerns without fear of reprisal. Women must feel listened to, respected, and fully involved in decisions about their care. Trusts must promote compassionate leadership, a civil and kind workplace, and the use of positive feedback as a tool to reinforce good practice and drive continuous improvement. A psychologically safe and learning culture is essential to improving clinical outcomes, supporting staff wellbeing and enhancing the experiences of women and their families. 17. DHSC/NHSE should recommend and support recruitment processes and implement a consistent onboarding package for new starters Trusts must streamline recruitment processes and implement a consistent onboarding package for all staff involved in the delivery of perinatal care with named supervision and support during initial shifts. 18. All Trusts to ensure compliance, audited annually, with the NHS Records Management Code of Practice post-death care The report also notes that in post-death care, Trusts should cease the practice of conducting post mortem examinations anywhere except the mortuary. They should ensure all investigations or reviews into after-death care include an independent post-death care specialist. Nationally there should be statutory regulation of Anatomical Pathology Technologists introduced.

The long-awaited report into maternity failures at Nottingham University Hospitals NHS trust, the largest investigation of its kind in the UK, involving about 2,500 families, will be published shortly. Led by the senior midwife Donna Ockenden, the inquiry investigated stillbirths, neonatal deaths, maternal deaths and babies or mothers who suffered brain damage and other injuries between 2012 and 2025. In this article some of the families affected share their stories about what happened to them in Nottingham, and explain why this is such a landmark moment.

Healthcare organisations have experienced a steady rise in data breaches, many of which expose large amounts of patient information. This analysis reviewed more than 7,300 reported incidents to identify the factors linked with the most extensive breaches. Cyberattacks involving hacking were most frequently associated with large‑scale events, particularly when attackers accessed network servers. Breaches that involved business associates, such as external vendors, also tended to affect more individuals. Hacking became increasingly common over time and now represents the majority of breaches. These results highlight critical weaknesses in healthcare systems and emphasize the need for stronger security practices and tighter oversight of third‑party partners.

Following revelations in 2017 of the abuse of patients by staff at Muckamore Abbey Hospital, the Minister for Health in Northern Ireland ordered a public inquiry be held into that abuse and related matters. The Inquiry, chaired by Tom Kark KC, and heard from 235 witnesses, including a number of service users, and over 90 relatives of service users. It found that patients had been abused and systematically bullied by staff members at Muckamore Abbey Hospital whose job it was to look after them. The report includes 106 recommendations. The Inquiry heard extensive evidence concerning injuries sustained by patients, particularly bruises, unexplained marks and signs consistent with physical abuse. Some patients were verbal and were able to express that they had been assaulted by staff, but such direct evidence was very limited. Relatives reported being informed by staff that injuries were caused by self-harm, behavioural incidents or peer-on-peer violence. They were told their relative was clumsy or may have fallen in the night. Over time, many families lost confidence in these explanations, especially where injuries were located on areas of the body difficult to self-inflict or appeared repeatedly in similar patterns. Sometimes injuries were unexplained even when a patient was supposed to be under supervision. The Inquiry also heard evidence of physical abuse captured on CCTV, including forceful handling, dragging, pushing and inappropriate restraint. These incidents provided confirmation that unexplained injuries reported by families over many years could not be attributed solely to patient behaviour or peer-on-peer violence. The presence of injuries alongside incidents captured on CCTV demonstrated that earlier concerns had been justified and should have prompted urgent intervention. The Inquiry notes that families’ concerns were exacerbated by the lack of communication from staff at the hospital about when patients had been injured, and many complained of significant delays in injuries being reported to them. The Panel concluded that injuries such as bruises and marks were not isolated or incidental; they were visible indicators of systemic failure. Dealing with each incident individually resulted in the inability of the organisation to recognise patterns, escalate concerns and protect patients, and allowed physical abuse and neglect to continue unchecked, causing lasting harm to patients and profound distress to their families. Key themes Key patient safety issues highlighted in this report include: Information sharing and co-production Families described not being informed of their rights when relatives were detained under the Mental Health (NI) Order 1986. Many believed decisions were made without consultation, leaving them feeling excluded from their loved one’s care. The Inquiry repeatedly heard that families were informed of decisions rather than involved in making them. Families reported not being able to visit during early stages of admission, removing opportunities to share crucial information. Many families struggled to identify a consistent point of contact or key worker. Restrictive practices The Panel identified serious and persistent concerns regarding the frequency, rationale, recording and governance of restrictive practices over a prolonged period. Seclusion was a particular area of concern. Although policies on seclusion became increasingly prescriptive over time, including requirements for monitoring, the Inquiry heard evidence that implementation was inconsistent, sometimes inadequate and not effectively audited. The use of PRN medication as a form of restrictive practice was also problematic. Although guidance emphasised that PRN medication should only be used with a clear therapeutic rationale and as a last resort, families frequently described experiencing their relatives as sedated, disengaged or ‘zombified’. The Panel accepted that this was not necessarily an indication of overmedication by use of regularly prescribed drugs but may have reflected the use of PRN medication to control behaviour when other non-medical approaches had either not been available or not been attempted. Governance and oversight of restrictive practices were inadequate. Although data on restraint, seclusion and incidents was collected and reported internally, the Inquiry found limited evidence of effective senior management challenge, trend analysis or sustained action to reduce use. Complaints and concerns Evidence revealed widespread confusion, fear and mistrust among families, alongside systemic weaknesses in complaint handling, oversight and organisational learning. Many family members found the complaints system opaque and difficult to navigate, with little clarity about how complaints were investigated, how decisions were reached or what outcomes, if any, resulted. Many families reported finding out about injuries, assaults or significant incidents only during visits, or after long delays. Others described communications they perceived as defensive, dismissive or designed to protect the institution rather than investigate the facts. Some believed that staff were effectively ‘investigating themselves’, creating perceptions of bias and eroding confidence in outcomes. Even when complaints were upheld in part, families often felt responses lacked empathy, apology or accountability. Fear was a major barrier to complaint-raising. Witnesses described explicit or implicit warnings suggesting that complaining could affect their relative’s care or future admissions. Patients themselves were sometimes frightened to speak up. Governance and oversight arrangements were also found wanting. Although complaints data was presented in dashboards and discussed at Muckamore Abbey Hospital management meetings, there was limited evidence of robust analysis, challenge or sustained organisational learning. Previous concerns, previous investigations and warning signs The Panel concluded that Muckamore Abbey Hospital exhibited multiple, persistent and well-documented warning signs long before 2017: sustained understaffing; inadequate specialist supports; unsafe environments; escalating violence and restraint; frequent safeguarding referrals; family complaints; and a geographically and culturally closed institution. While individual allegations were often investigated, the system failed to connect the dots. No single mechanism brought together incident reporting, safeguarding intelligence, complaints and workforce pressures in a way that would have revealed the scale of risk Safeguarding The Panel found that safeguarding systems were fragmented and insufficiently integrated with the Trust’s wider clinical governance and risk management arrangements. Safeguarding investigations were structurally separated to preserve independence, but this separation limited organisational learning. Staff and ward management The Panel concluded that staffing challenges at Muckamore Abbey Hospital were long-standing, well-documented and increasingly severe, yet were never adequately resolved. These systemic workforce failures significantly increased patient vulnerability and contributed to the conditions in which abuse was able to occur and persist. Staffing shortages were persistent from at least 2009 onwards and worsened significantly after 2012, when recruitment freezes and temporary contracts became common due to the anticipated closure of Muckamore Abbey Hospital. The ratio of registered nurses to healthcare assistants was frequently below safe levels, and in some wards fewer than half of staff were registered nurses. Healthcare assistants, who provide the majority of direct patient care, had no specialist training requirements and relied heavily on informal learning. Supervision of healthcare assistants inconsistent, and clinical supervision arrangements fell far below what would be expected in a high-risk inpatient setting. This created a task-focused culture where staff prioritised basic physical care over personal and therapeutic engagement. Throughout this period, senior leadership and the Trust Board repeatedly reassured themselves and external bodies that staffing was safe, even as the regulator and whistleblowers raised escalating concerns. Leadership While extensive governance structures existed, they consistently failed to work to bring relevant information to the Board of Belfast Health and Social Care Trust, and to translate information into understanding of risks or into an active response. There was a resulting lack of insight by the Board into the difficulties faced at Muckamore Abbey Hospital. A central failure identified by the Inquiry was the Trust’s focus on governance processes rather than outcomes. Reports to the Board emphasised the existence of policies, action plans and committees but rarely demonstrated whether these arrangements were effective in protecting patients or improving care. Incident reporting, safeguarding referrals, complaints and staff intelligence were routinely aggregated at Trust level, masking significant variation at hospital level and thus obscuring sustained patterns of harm at Muckamore Abbey Hospital. Risks from Muckamore Abbey Hospital were often downgraded or removed as they ascended the risk register hierarchy, even when underlying conditions persisted or deteriorated. Risks affecting specific services were smoothed out through aggregation and failed to reach the Board as Principal Risks. Even after external regulators raised serious concerns, including the issuing by the Regulation and Quality Improvement Authority (RQIA) of Improvement Notices in 2019, the Board continued to accept assurances that care was safe, often disputing regulators’ findings without providing robust supporting data. Senior leaders failed to reconcile contradictory evidence from inspections, incidents, safeguarding reviews and staffing data. Crucially, the Board did not adequately address structural risk factors such as chronic staffing shortages, excessive use of untrained agency staff and inappropriate ward mixes. Reassurances provided by executive directors were not properly scrutinised for any underlying supporting data. External agencies inspection and oversight The Inquiry concluded that, although multiple agencies were involved with Muckamore Abbey Hospital over many years, none succeeded in identifying, preventing or stopping abuse before it was revealed, exposing significant limitations in the external oversight framework. Between 2009 and 2019, RQIA conducted over 100 inspections of Muckamore Abbey Hospital, initially at ward level and later using a whole-hospital approach. These inspections frequently identified problems such as staffing shortages, safeguarding weaknesses, excessive restrictive practices and governance failings. However, the inspection methodology relied heavily on documentation review and there was limited involvement with staff, patients and families, providing only a snapshot of practice. Inspectors acknowledged that staff behaviour changed when inspectors arrived on the wards and that therefore they were unlikely to observe ‘normal’ ward culture. Despite having statutory powers to do so, RQIA did not review CCTV footage at Muckamore Abbey Hospital, even after CCTV was viewed by the Trust and by Police Service of Northern Ireland and serious concerns were raised. Evidence to the Inquiry suggested that families repeatedly raised concerns through various routes but felt unheard, contributing to a loss of confidence in advocacy and oversight mechanisms. Overall, the Panel concluded that external inspection and oversight failed to operate as an effective safety net. Warning signs, including staffing instability, increased violence, high use of restrictive practices and repeated complaints, were visible and known but not interpreted as indicators of potential abuse. Oversight was reactive rather than preventive. The central lesson is that external regulation and investigation must extend beyond procedural compliance and episodic inspection. For services caring for highly vulnerable people, effective oversight requires proactive, risk-based approaches that: examine culture; triangulate multiple data sources, including where appropriate the use of CCTV; engage directly with families and, where possible, patients; and act decisively when conditions associated with abuse are present. Planning and funding of learning disability services Overall, the Inquiry found there was a failure to align policy, funding, workforce planning and accountability that prevented meaningful transformation of learning disability services. The absence of a coherent, long-term, system-wide approach contributed directly to sustained institutionalisation of individuals at Muckamore Abbey Hospital and to risks in care quality and safety. Redress There is no doubt that patients did suffer as a result of abuse within Muckamore Abbey Hospital but to try to assess the extent of such abuse in relation to individual patients or the nature of the harm caused was deemed as beyond the Inquiry’s capacity. In relation to direct redress, including the consideration of financial compensation, however, our recommendation would be that the Department of Health should set up a small working party to consult with patients, service user groups and individuals connected to those who have suffered abuse at Muckamore Abbey Hospital in relation to what form redress might properly take.

This report from the Men's Health Forum examines the role of community pharmacy in improving men’s health in the UK, the theme of Men’s Health Week 2026. The report sets out a five-point plan that pharmacies should adopt to become a male-friendly pharmacy, which encourages more men to engage. This report’s findings are Based on a survey from a UK-wide poll in 2025 exploring men’s evolving attitudes to health and pharmacy. The report highlighted the following key themes emerging from this: Privacy as a prerequisite: Without genuinely private, professional spaces, men are unlikely to open up. Environment and culture matter: Pharmacies often still feel feminised and transactional, deterring men from engagement. Trust is built through relationships: Men respond to respectful, non-patronising interactions and consistent positive experiences. Meet men where they are: Outreach in community settings and constructive engagement with online and AI-based health information are essential. Services, not sales: The future of community pharmacy might well lie in healthcare services commissioned by the NHS, not retail.

These two reports summarise findings from the National Commission into the Regulation of Artificial Intelligence (AI) in Healthcare’s research and engagement activities and call for evidence. The Commission’s purpose is to advise the Medicines and Healthcare products Regulatory Agency (MHRA) on improving its regulatory framework and to accelerate safe access to AI in healthcare and across the NHS. You can read a summary of Patient Safety Learning’s response to this call for evidence here. The work brought together evidence from patients and the public, healthcare professionals, industry, academics and wider health system stakeholders through public polling, surveys, stakeholder engagement, deliberative research, an open call for evidence, a public Ask Me Anything session and insights from the MHRA’s AI Airlock programme. Thorough analysis of this evidence, 10 key findings have been identified. The report summarises these as follows: 1. There is a clear call for a proportionate, lifecycle-based approach to regulation Stakeholders noted that the current framework, which is designed for more static medical devices, is not well suited to iterative and adaptive AI systems. Across groups, stakeholders called for a proportionate approach that is risk-based, considers patients’ safety and fairness, with clear practical guidance and addresses existing duplication and fragmented oversight. Stakeholders also underlined the importance of strengthening clinical evidence requirements, with strong support for enhancing post-market surveillance and improving coordination. With a more proportionate approach seen as essential for balancing innovation with patient safety. 2. There is strong consensus for significant regulatory reform Across respondent groups of healthcare professionals, healthcare providers and industry, most people said that the existing regulatory framework needed “significant reform” but did not need a “complete overhaul”. Amongst patients and the public, the number of respondents calling for “significant reform” and a “complete overhaul” were similar, with 34% asking for “significant reform”, and 35% for a complete overhaul. 3. There was broad consensus that AI systems will increasingly require continuous post-market surveillance and monitoring Several stakeholders highlighted the need to upgrade current approaches to post market surveillance and monitoring, so they are better suited to AI systems. There was strong consensus that performance and risk cannot be adequately assessed through one-off approvals alone but instead require ongoing, real-world oversight across the lifecycle. Through qualitative evidence, stakeholders called for a more continuous and ongoing approach which helps track performance, monitor safety, and manage compliance across the AI system lifecycle. They also suggested that upgraded approaches need to help manage performance drift, validate performance in real world settings, and track changes in performance over time. 4. Responsibility should be shared across the system, with each individual and institution understanding their essential role and responsibilities There was strong consensus that accountability should not rest with a single person or institution, with respondents favouring a model which better distributes liability across the lifecycle. Patients and members of the public called for a comprehensive approach to accountability that addresses current gaps, healthcare professionals stressed that clinical accountability should be maintained whilst healthcare providers emphasised the need for robust governance structures and clear organisational responsibility. Stakeholders also highlighted uncertainty in how roles, responsibilities, and liability are defined and applied in practice. There were differing views on where liability should sit when an AI system causes or contributes to harm. Some respondents believed that liability should sit with the healthcare professional using the AI system. Another group of respondents argued that liability should sit with the healthcare provider who deploys the AI system. Others suggested that liability should sit with manufacturers, given their role in developing the technology and then maintaining their AI system’s performance. Across responses, there was a consistent emphasis on the need for greater clarity and consistency in how liability is allocated. Many respondents called for structured approaches to distributing liability that reflect the roles of different actors, including manufacturers, healthcare providers, and healthcare professionals. Suggested approaches included shared or distributed liability models that apportion responsibility based on specific circumstances. Stakeholders noted that clearer and more consistent frameworks would help address uncertainty and support the safe use of AI systems in healthcare. 5. Human oversight and responsibility for clinical judgment should be retained There was strong consensus from respondents that AI systems should continue to augment the work of professionals and should not be fully responsible for clinical decision making. Patients and the public emphasised the importance of human involvement in their care, including expectations that clinical decisions involving AI should be checked and validated by a human clinician. Healthcare professionals and professional bodies highlighted the risk of over-reliance on AI outputs at the expense of professional judgement. Industry respondents were supportive of ‘human-in-the-loop' safeguards. 6. Transparency and explainability will be key for the ongoing deployment of AI systems The ability to easily understand how an AI system works and to interpret its outputs will be key for building trust, enabling deployment, and ensuring the safety of an AI system. Patients, public and professionals advised that explanations of AI system outputs need to be clear, and providers called for greater transparency in the procurement process for sourcing AI systems. Industry organisations commented on the need for clearer and more structured regulatory documentation. 7. Data access and use is central to the role of AI in healthcare moving forward Respondents to the Call for Evidence noted that healthcare data is simultaneously an enabler and a barrier to the development and deployment of AI systems in healthcare. Patients and public expressed strong concerns about current approaches to consent for data access and how data is used by commercial entities. Some respondents cited governance and compliance burdens and fragmented data infrastructure as key barriers to development and deployment. Industry respondents called for clear and robust frameworks for accessing data including shared data governance templates and clearer guidance on data standards. 8. There is a need for robust training and improved AI literacy The Call for Evidence found a clear view that robust, ongoing training and clear understanding of AI in healthcare is critical for safe adoption. Healthcare professionals highlighted the risks of a lack of AI-specific training can bring such as increased risk of automation bias. Healthcare providers called for more structured workforce training on AI moving forward. Industry respondents advised that training is also needed for individuals who oversee the governance of AI systems in healthcare. 9. There is a need to improve incident reporting and learning mechanisms There were widespread calls for standardised reporting mechanisms for AI systems. Patients and public called for greater transparency and accountability over where AI is involved in care, including clearer communication when things go wrong. Healthcare professionals raised concerns about underreporting of safety incidents in healthcare more broadly, noting that workload pressures are a significant contributing factor. Responses also suggested limited awareness amongst some healthcare professionals that the existing Yellow Card scheme already applies to medical devices, including AI enabled devices. Healthcare providers highlighted the operational challenges of implementing incident reporting consistently across different settings. Industry respondents called for clearer guidance on how incident reporting should work within AI specific post-market surveillance frameworks. Several respondents also proposed improvements to surveillance and monitoring approaches, including establishing a national reporting system for AI incidents and providing guidance for healthcare professionals on what to report. 10. Patient and public engagement, trust, and communication will continue to be key for the deployment of AI systems. Through the Call for Evidence, trust emerged as a core enabler of AI adoption in healthcare. Patients and the public called for consistent involvement, consent, and clarity over the role of AI systems, whilst professionals highlighted the need to take a proportionate approach to explaining how AI is being used to patients. Providers advised that clear and consistent transparency and communication frameworks are needed whilst industry respondents recognised that trust is key for the uptake of AI systems in healthcare.

This update presents statistics from the Learn from Patient Safety Events (LFPSE) service, a national NHS system for the recording and analysis of patient safety events that occur in healthcare. The LFPSE definition of a patient safety incident is something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm for one or more person(s) receiving healthcare. This report shares the patient safety incident data from January to March 2026. Count of Event Types in LFPSE – based on patient safety event records from January to March 2026 LFPSE brings the feature to record patient safety event types beyond incidents. Recorders can also upload patient safety risks, outcomes and instances of good care. This is to ensure the database contains more instances of care that the healthcare system can learn from instead of only detailing errors involving patients. In this period, 829,300 events were recorded to LFPSE, the majority of which were recorded as patient safety incidents (96.96%). Count of patient safety incidents by maximum physical harm – based on patient safety incident records from January to March 2026 Sometimes a problem in care can affect more than one patient, or none at all. To capture this, as a new feature of LFPSE, recorders can submit information for multiple patients per incident, meaning there can be multiple degrees of harm per incident. For the following figure and table NHS England have taken the highest harm level per incident. NHS England identified and removed 64,223 incidents where the number of patients affected was unknown. Preliminary analysis suggests that these records likely represent incidents with no patients involved. NHS England will continue further data quality checks to validate these figures. During this quarter, 739,846 incidents had recorded a degree of harm. The majority of these incidents (94.2%) recorded low or no physical harm to patients. LFPSE has a new variable for grading of the psychological harm associated with the recorded patient safety incidents. This is an experimental field which seeks to explore if responses to safety incidents need to be different if psychological harm is considered separately from physical harm, rather than rolling them together into one measure, as was done in the National Reporting Learning Service (NRLS). Currently, there is low confidence in the grading of psychological harm, as users familiarise themselves with its use, and as such, it is excluded from this report. Related reading – previous quarterly data publications NHS England: Patient Safety Event Data Quarterly Publication – Quarter 3 2025/26 (October to December 2025) NHS England: Patient Safety Event Data Quarterly Publication – Quarter 2 2025/26 (July to September 2025) NHS England: Patient Safety Event Data Quarterly Publication – Quarter 1 2025/26 (April to June 2025) NHS England: Patient Safety Event Data Quarterly Publication – Quarter 4 2024/25 (January to March 2025) NHS England: Patient Safety Event Data Quarterly Publication – Quarter 3 2024/25 (October to December 2024)

This article provides a brief overview of patient safety issues raised in a debate in the House of Commons on Monday 1 June 2026 during the second reading of the Health Bill 2026-27. The Health Bill 2026-27, also known as the NHS Modernisation Bill, is a piece of legislation introduced by the UK Government. It is intended to bring forward two significant changes, joining up health information and the abolition of NHS England. Below is a summary of some of the key patient safety issues raised in the second reading of the Health Bill in the House of Commons. The second reading is the stage of the UK legislative process where Members of Parliament (MPs) debate the general principles and main purpose of a proposed piece of legislation. Single Patient Record The Health Bill establishes the purpose of the single patient record - to bring together patient information from existing separate sources and make it available to patients and their relevant health and care providers such as GPs, hospital doctors, social care providers or others involved in their direct care. MPs expressed broad support the concept of a Single Patient Record, though some did raise concerns about safeguards and privacy around this proposal, emphasising the: Need for extra care concerning data that relates to children. Importance of having new privacy protections alongside this. Need for robust measures around any secondary uses of data. Healthwatch England Multiple MPs raised concerns about the Bill's proposals to abolish Healthwatch England and Local Healthwatch. The legislation proposes the introduction of a new patient experience directorate within the Department of Health and Social Care will bring patient voice ‘in house’ and take over the statutory functions of Healthwatch England. Issues highlighted in the debate included: That this may result in a loss of independent scrutiny in the health system. MPs commenting positively on the contributions made by their Local Healthwatch organisations. Questions about whether a new patient experience directorate will genuinely be able to hold the health system to account. Comments that without Healthwatch the remaining checks and balances in the health system will come only from the medical professional. and existing healthcare stakeholders, while patients would be left without a clear advocate. The importance of retaining Healthwatch’s reporting and insights function in some form. Health Services Safety Investigations Body (HSSIB) The Health Bill includes provisions to abolish HSSIB, proposing its functions are transferred into the Care Quality Commission (CQC). Points raised by MPs in relation to this included: Like the abolition of Healthwatch, this change may result in a loss of independent scrutiny in the health system. There is a conflict between CQC carrying out its functions as a regulator and compliance enforcer against HSSIB’s functions as an investigator. The importance of retaining both the independence, and appearance of independence,, of the patent safety investigation function of HSSIB. Related reading The King’s Speech 2026: Six key takeaways for patient safety Perspectives on the NHS Modernisation Bill

The role of the Patient Safety Commissioner for Scotland is to champion safer care across Scotland's health and care system. This site provides information and resources related to this role. This website includes: Patient Safety Charter - this sets out what the Commissioner expects of health care providers in terms of standards and good practice. Key principles - this statement of the principles informs the exercise of the Commissioner’s functions. Contact information - detailing how patients and the public can get in touch with the Commissioner.