Mark Hughes

Incident reporting systems are key components of a health systems patient safety infrastructure. Whilst widely implemented in the NHS, engagement with these systems varies across professional roles and settings. This study seeks to explore how healthcare professionals in the UK engage with incident reporting systems, identify perceived barriers, and gather suggestions for improvement.

Coroners in England and Wales have a duty to write Prevention of Future Deaths (PFDs) reports when they believe that action should be taken to prevent similar deaths. This article sets out the findings of a systematic case series study of the reports involving maternal deaths. It sought to characterise these deaths in terms of demographics, explore the concerns raised by the coroners and understand what actions were reported by organisations in their responses to the coroner. Key findings The median age at death was 33.5 years and three-quarters (75.9%) of deaths occurred in hospitals. The most common cause of death was haemorrhage. Coroners frequently voiced concerns around the failure to provide appropriate treatment (48.2%) and failure of timely escalation (37.9%). Specific lessons highlighted include gaps in national guidance, failure to follow national protocols, communication issues and lack of resources or staff cover. Only 38% of PFDs had published responses from the organisations they were sent to. When organisations did respond to the coroner 80% reported that they implemented changes, including publishing new local policies, increasing training or committing to increased staffing. There is no mechanism to follow-up on missing responses or ensure that reported actions are implemented. Related reading Preventable deaths tracker Independent maternity and neonatal investigation: terms of reference

Paediatric emergency departments (PEDs) are high-risk environments where patient injury can result from delays, unclear diagnoses, and poor communication. This systematic review and meta-analysis evaluated how safety culture and quality improvement (QI) initiatives impact clinical and functional outcomes in PEDs. Its findings suggest that QI techniques can significantly improve the quality and efficiency of care when supported by a strong safety culture.

Martha’s Rule is a patient safety initiative empowering patients, families and carers to raise concerns if their loved one’s condition is getting worse and their concerns are not being responded to. As the implementation partner for Martha’s Rule, the Health Innovation Network supports its delivery through the regional Patient Safety Collaboratives. In this blog looks at this in practice, with Elaine and Diane sharing their experience of calling Martha’s Rule into action.

The report analyses spending, demand, staffing and performance across the NHS, specifically in relation to hospitals and general practice. It is intended to provide a comprehensive stocktake to date of the inheritance left by the previous Conservative government and the decisions made since the Labour Party came to power in the UK in 2024. Key findings General practice There are 2,219 more salaried GPs* in September 2025 than in June 2024 (+20.5%). That monthly growth is almost 6x faster than Conservative governments achieved between 2015 and 2019. Between June 2024 and September 2025, the number of GP partners declined by 4.1% – and by 17.0% among partners under the age of 40. Though there are more GPs overall, the number of GP appointments has flatlined – meaning the number per GP was 2.7% lower in the 12 months to September 2025 compared to 2019. A record 8.6% of appointments in September 2025 were online, compared to just 0.7% in April 2023. But this is not widespread: three in 10 practices carried out no online appointments in the year to September 2025 (29.8%). Hospitals Health spending growth is due to be only slightly higher than under the last Conservative government for the rest of this parliament (at 2.8% per year in real terms compared to 2.7%). 32 of 42 integrated care boards (76%) are forecasting a deficit in 2025/26, up from 18 in 2024/25. The growth of staffing has slowed since the start of 2024. There has been almost no change in the number of non-clinical staff in that time, while clinical staff have increased by 5%. Leaver rates have fallen to record lows (excluding the pandemic), with particularly low rates among consultants. In 2025 the NHS is recruiting more UK than overseas staff – reversing a trend seen between 2021 and the start of 2025, where more recruits came from overseas.

To be authorised for use in the National Health Service (NHS) in England, digital health technologies (DHTs) must meet two mandatory clinical risk management standards, DCB0129 and DCB0160. Meeting these standards is intended to demonstrate that risks from design and use have been assessed and mitigated. NHS organisations must not procure a DHT without DCB0129 assurance and must not deploy one without DCB0160 assurance. Despite legal requirement, no public data exist on how many DHTs are in use in the NHS or how many are assured. This study, published in the Journal of Medical Internet Research, aimed to determine the number of DHTs in use in the NHS in England and assess their assurance status against mandated clinical safety standards. Its findings indicated that more than 10,000 DHTs currently in use lack documented assurance against clinical safety standards, and that in a typical NHS trust, 3 out of 4 digital tools influencing patient care do not demonstrate compliance with minimum legal or clinical safety requirements.

The US National Aeronautics and Space Administration (NASA) will be familiar to most across the world. Leading highly dangerous and innovative space travel, NASA has gone from a blame culture in the 1960s to an environment that keeps safety at the forefront and a top priority. NASA culture aims to ensure that staff work safely through balancing challenges and risks, feel comfortable communicating safety issue sand learn from both successes and error. This article, published in The Annals of The Royal College of Surgeons of England, outlines NASA’s safety journey considers what surgeons can learn from this in seeking to improve both patient safety and culture.

The risk that sleep deprivation and fatigue among healthcare staff pose to patient safety is often overlooked, which can be detrimental to patient safety and outcomes. Prolonged shifts, night duties, and inadequate rest all contribute to fatigue, impair clinical judgment, and increase the likelihood of errors. This research article aims to assess the prevalence of sleep deprivation and fatigue among healthcare professionals, examine its association with patient safety incidents, and provide recommendations to mitigate fatigue-related risks in high-acuity clinical settings.

This report sets out the findings of new research conducted by Healthwatch England to inform the Government’s first-ever men’s health strategy for England. They commissioned a nationally representative poll of 3,575 men aged 18+ in June 2025 and also drew on local Healthwatch engagement, with men from diverse backgrounds, spanning a wide range of ages, ethnicities, occupations, and areas.  NHS Health ChecksKey findings Only 37% of eligible men (aged 40 to 74 and with no long-term conditions) said they had ever been invited to an NHS Health Check.56% of men who’d attended a check had made lifestyle changes.92% of men who’d gone for a check would take up a future invite.Key recommendations Provide stronger direction and oversight to improve the number of invites issued, uptake rates and consistency across local authority areas.Collect and publish demographic-specific uptake data, to track how many men attend and analyse which characteristics affect uptakeLaunch an awareness campaign about the Check and encourage tailored outreach to underserved men and those at higher risk of cardiovascular disease.Prostate cancer screeningKey findings 79% of all men (including 81% of Black men) said they would be likely to attend prostate screening if the NHS introduced it routinely.Only 36% of men aged 50 and over had asked their GP for a PSA testSeven per cent of those who’d asked for a PSA test had been refused (though caution is advised on this statistic given it is a low sample)Key recommendations Policymakers should consider men’s views, alongside clinical and economic evidence, when deciding on whether to introduce a national prostate cancer screening programme.Issue clear, consistent guidance for the public and GPs on whether asymptomatic men aged 50 and older can receive, or only request, a PSA test.Mental HealthKey findings 52% of men said they would visit their GP, and only one-in-five (20%) would self-refer to NHS Talking Therapies if they experienced mental health issues.Men were significantly less likely than women to turn to their friends and family for mental health support (38% vs 45%).Key recommendations Mental health support should remain varied with a ‘no wrong door’ approach to suicide prevention and improve referrals pathways from the third sector.Improve awareness of NHS talking therapies, including clearer information on how data is handled. Data should also be disaggregated between self- and GP referrals, to understand where to target changes in behaviour to improve uptakeHealth literacyKey findings One in 10 men use AI, like ChatGPT, for health information; but mostly used the NHS.Men mostly want to receive information from the NHS via email and the NHS App.Key Recommendations Create a men’s health page on the NHS website, raise awareness of spotting and avoiding online misinformation and develop health literacy from a younger age.Priorities for changeKey findings Better GP access is the top priority for change in the NHS for men; they want to see the same GP for new and ongoing physical and mental health problems and would wait longer for an appointment to do so.Key recommendations The new strategy should focus on continuity of care, where clinically appropriate

In this blog John Tingle, Associate Professor at Birmingham Law School (University of Birmingham), discusses the concept of blame in relation to patient safety. He considers how this relates to the current NHS patient safety policy framework and clinical negligence litigation , outlining tensons between the two.