Mark Hughes
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Everything posted by Mark Hughes
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Content Article
On the 23 June 2025 the Secretary of State for Health and Social Care announced a rapid, national, independent investigation into NHS maternity and neonatal services. In this report the investigation’s Chair, Baroness Amos, provides an update on its progress since the publication of its Terms of Reference in September 2025. She outlines the activities undertaken as part of the investigation to date and her initial reflections from engagement with families, staff, community organisations and Members of Parliament. The investigation's interim report, published on the 26 February 2026, can be found here. -
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This webinar unites paediatric hospital leaders, clinical teams, patient safety, and risk experts who share a common goal—transforming the future of paediatric IV therapy. More than a webinar, this is a collaborative space for paediatric experts to connect, exchange experiences, and explore a more holistic and safer approach to IV care. Find out more and register here. Save the Date_PEDS_Coalition.pdf -
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Join an exclusive group of healthcare leaders for a webinar exploring the latest advances in IV therapy, vascular access safety, and proven strategies to reduce risk and improve patient outcomes. This session will focus on practical, cost-effective approaches to elevating care quality across adult populations—while offering actionable insights you can apply immediately within your organisation. Topics of discussion Hidden Risks Revealed: How seemingly routine IVs can cause evolving injuries with devastating outcomes. Vesicant Exposure: The silent threat of tissue destruction from common IV medications/fluids. When Minutes Matter: Why delayed recognition turns minor leaks into catastrophic harm. Risk and Responsibility: The clinical, legal, and financial impact of extravasations and infiltrations — and how to protect patients and providers. A Patient’s Story: One person’s journey from IV extravasation to amputation — and the lessons it leaves behind. From Insight to Action: Proven strategies to reduce risk, strengthen governance, and stop preventable injuries. Find out more and register here. Save the Date_ADULT_Coalition.pdf -
Content ArticleBetween 2018 and 2024, 59 people died in women’s prisons in England and Wales, more than a third (39%) of these deaths were self-inflicted. In the next four years, self-inflicted deaths across all prisons in England and Wales are expected to rise by 21%. In this report the charity Inquest examines the circumstances of seven recent deaths in women’s prisons, situating them within broader systemic issues that have persisted for decades.
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Content ArticleThe NHS Friends and Family Test (FFT), introduced nationally in 2013, was designed to provide a simple mechanism for gathering patient feedback across health services in near real-time. Today its use is mandated across the NHS, and provider organisations are encouraged to focus on the unstructured comments that it gathers from patients. This report, explores the historical context of the FFT, its current structure, strengths, and weaknesses, and sets out a case for reform. It draws on stakeholder engagement, a published literature review, and wider analysis to assess the FFT’s effectiveness and future potential against the wider current political and economic context.
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Content ArticleInfections are ubiquitous – over the course of our lifetimes we will all experience multiple episodes of infection. In his annual report for 2025 the Chief Medical Officer for England, Professor Chris Whitty, focuses on recent trends in infections and changes to the health system, laying out current challenges and considering what comes next.
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Content ArticlePatient safety culture is crucial to ensuring the quality and safety of healthcare. Assessing safety culture raises awareness of patient safety, identifies areas for improvement, and supports tracking changes over time. Given the increasing growth of home care, the complexity of care, and its unique characteristics, understanding safety culture in home care is essential to informing practice and guiding further research. This study aimed to identify instruments used to measure patient safety culture in home care, including its associated factors and outcomes.
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Content ArticleThis report from the Northern Ireland Public Services Ombudsman relates to the care and treatment the Belfast Health and Social Care Trust provided to a patient during the period of 7 February to 21 September 2022. The complainant believed the Trust misdiagnosed her Temporomandibular Joint Dysfunction1 as muscular, rather than Disc Displacement without Reduction2 and consequently did not provide appropriate treatment. The investigation identified the Trust failed to carry out appropriate radiological investigations in diagnosing the complainant’s condition and clearly communicate the diagnosis in accordance with relevant standards.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines, medical devices and blood components for transfusion in the UK. This roundup provides a summary of their latest safety advice for medicines and medical device users. It includes details of medicine recalls, medical device field safety notices and details of how to report drug reactions and device incidents.
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Content ArticleSimulation is a well-established tool for clinical education and has been used to uncover latent safety threats (LSTs) in healthcare settings. However, the extent to which systems theory underpins efforts to detect and mitigate LSTs remains unclear. This scoping review explores how healthcare simulations have been used to identify and address LSTs, with particular attention to the visibility and application of systems theory in study design, implementation, and analysis. It concludes that simulation is a valuable method for identifying LSTs, but inconsistent application of systems theory and variable methodological transparency limit learning and generalisability. The authors suggest that future research should make theoretical underpinnings explicit, define terminology clearly, and align simulation design with both educational and organisational improvement goals.
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Content ArticleEvery year in Australia, an estimated 140,000 people experience a diagnostic error. For 21,000 people, it causes serious harm. For 4,000 people, it’s fatal. In this blog, the authors make the case for a national policy that puts diagnostic safety on the agenda, and drives real change to prevent errors before more patients are harmed.
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Healthcare-associated infections (HAIs) remain a major, yet largely preventable, burden across all countries—contributing infection in 7% of hospital patients in high income settings, and 15% in Low and Middle-Income Countries thereby imposing significant costs on health systems and society. Environmental cleaning is a critical component of infection prevention and control strategies. However, it is often overlooked in terms of staffing, funding, and research investment. Over the past five years, a coalition of leading organizations—including WHO, ICAN, WaterAid, UK-PHRST, and LSHTM—has worked to raise awareness of this missed opportunity to reduce infection transmission. Join this event on 11 December, where speakers will highlight the collaborative efforts to strengthen the evidence base for environmental cleaning in healthcare settings. The event will mark the publication in Lancet Microbe of findings from a recent cluster randomized trial conducted in Cambodia which evaluates the effectiveness of the WHO training package on environmental cleaning. The programme will feature presentations, a panel discussion, and a Q&A session, followed by a networking reception. Find out more here. -
Content ArticleThe Maternity Outcomes Signal System (MOSS) was developed by NHS England in response to the East Kent Reading the signals report. This recommended the development of a safety signal system capable of monitoring routinely collected maternity and neonatal outcomes to detect potential declines in safe care in a timely way. MOSS operates at trust site level. It is a near-real time safety signal system that supports early detection and rapid responses to potential safety issues in intrapartum care service delivery. These standard operating procedures explain the responsibilities of trust boards and maternity services, Integrated Care Boards, regions and the national team in relation to MOSS.
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Content Article
On the 27 November 2025, the Health Services Safety Investigations Body (HSSIB) published a new report looking at patient safety issues associated with electronic patient record (EPR) systems. It is a thematic review which draws on findings from investigation reports by HSSIB and its predecessor organisation – the Healthcare Safety Investigation Branch (HSIB). In this article, Patient Safety Learning sets out its reflections on the report’s findings. -
Content ArticleThis report is a thematic review of investigation reports by HSSIB and its predecessor organisation – the Healthcare Safety Investigation Branch (HSIB) – that included consideration of electronic patient record (EPR) systems. Its intention is to identify themes arising from these investigations and to share any additional safety learning. You can read Patient Safety Learning's response to this report here.
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Content ArticleArtificial intelligence (AI) is transforming health systems, reshaping how care is planned, delivered and governed. This report presents the first assessment of AI integration into health systems across the whole of the World Health Organization (WHO) European Region, based on findings from the 2024–2025 survey on AI for health care. It examines national strategies, governance models, legal and ethical frameworks, workforce readiness, data governance, stakeholder engagement, private sector roles and the uptake of AI applications. Drawing on insights from 50 Member States, the report explores how countries are navigating opportunities and challenges, highlighting emerging trends, gaps and practices to guide policy-makers towards coherent, ethical and people-centred approaches to AI in health care.
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Content ArticleThis infographic is from the Health Service Executive (HSE), the publicly funded healthcare system in the Republic of Ireland. The graphic is intended to share learning on choking incidents in the HSE and or HSE funded services, complementing their Patient Safety Supplement on ‘Reducing and managing the risk of choking in adults’.
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Content ArticleThis letter from Jeremy Hunt MP, Chair of the All-Party Parliamentary Group (APPG) for Patient Safety, to Dr Penny Dash, Chair of the National Quality Board (NQB), sets out the APPG's views on how the NQB can help to create a more coherent and systematic approach to managing patient safety recommendations across the NHS. It suggests what recommendations the NQB could consider as part of this, how it could approach prioritisation and how it could measure and monitor the implementation of these actions.
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Content ArticleThis patient safety podcast episode from the Royal College of Paediatrics and Child Health (RCPCH) focuses on psychological safety in healthcare settings. This is the condition in which you feel safe to learn, safe to contribute and safe to challenge the status quo. The discussion features Dr Dal Hothi, a paediatric nephrologist at Great Ormond Street Hospital and Dr Jess Morgan, a paediatric doctor and Dinwoodie RCPCH Fellow.
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Content ArticleThis hub page links to an open access chapter of the book Safer Healthcare: Strategies for the Real World which considers that different challenges and different types of work require different safety strategies. It reflects on three broad approaches to the management of risk, which each have their own characteristic approach that can give rise to an authentic way of organising safety and possibilities for improvement.
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Content ArticleThis national patient safety alert has been issued by the NHS England National Patient Safety team. This alert is for action by acute, community and mental health providers, health and justice services, primary care including nursing and care homes, general practice and community pharmacy. All actions should be completed as soon as possible but no later than 20 November 2026.
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This document sets out the government’s 10-year strategy for men’s health in England. It details the government’s vision for men’s health over the next 10 years and actions they are taking now to improve the health and wellbeing of all men and boys in England. -
Content ArticleIncident 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.
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Content ArticleCoroners 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.
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Content ArticlePaediatric 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.
