Mark Hughes

This report sets out the findings of the independent review which looked at the response of NHS England to the service failures in children’s hearing services. It found that the failed or late identification of deafness has had a profound impact on many affected babies and children, and their families, and that initial estimates that nearly 300 children (as of May 2025) have come to harm is an underestimation. The review makes 12 key recommendations grouped into 3 themes: addressing the immediate areas for improvement with the NHS England’s Paediatric Hearing Services Improvement Programme placing services on a secure footing looking at commissioning, staffing, data, research and deaf awareness lessons for similar at-risk services to mitigate future crises, including workforce and culture changes Key findings of this review The failed or late identification of deafness has had a profound impact on many affected babies and children, and their families. The NHS England Paediatric Hearing Services Improvement Programme that was established in 2023 has not met the target it set for recalling affected babies and children and has lost the confidence of external stakeholders. Communication between NHS England and the Department of Health and Social Care (DHSC) about the service issues in children’s hearing services did not follow expected practice and there was no dedicated DHSC lead. There has been no assurance of quality, as measured by safety, effectiveness and patient experience, in children’s hearing services in England, for some time. Service delivery is highly varied and so it follows that outcomes are unacceptably variable. Children’s hearing services are rarely on anyone’s radar - regionally, at ICB and at provider level - nor among regulators, for example the Care Quality Commission. The audiology workforce has been neglected for years, their status and profile is low. There is little professional governance and fragmented professional representation. There is a lack of coherent workforce planning and little investment in research. The findings of this review are highly relevant to any service which attracts little attention, investment or scrutiny, but has the potential to cause lifelong harm when quality standards are not upheld. Summary of recommendations Theme 1 – Understanding the scale of the problem The role and remit of the current Paediatric Hearing Services Improvement Programme needs urgent review to focus on completing review and recall. Theme 2 – Placing these services on a secure footing for the future Children’s hearing services should be commissioned using a modern service framework and model commissioning contract. Professional registration of audiologists must be a requirement in the NHS and relationships between national organisations and organisations representing audiologists should be reset and formalised. Children’s hearing services should be delivered by a network model, rather than a ‘hub and spoke’ model. NHS trusts and Integrated Care Boards (ICBs) should implement improved governance arrangements for audiology and apply these to other healthcare sciences. Improved data on individual children’s hearing services should be used by NHS trusts and ICBs to monitor service quality and outcomes. Undergraduate and postgraduate training pathways for audiologists working in children’s hearing services need wholescale review and redesign, as does the approach to CPD. National research funding bodies should invest in research activity and capacity in audiology. Children’s hearing services should be setting the standard for deaf awareness and improve processes for seeking feedback from patients and their families. Theme 3 – Applying the lessons learning to similar services The next NHS Workforce Plan should include workforce modelling and recommendations specific to the healthcare science workforce, including audiology, and action should be taken to improve workforce culture and morale in children’s hearing services. A regional incident response process should be formalised to enable a more structured response to service issues which do not meet NHS emergency preparedness, resilience and response (EPRR) criteria, including clear guidance around public communications and action should be taken to improve early identification of emerging issues. Written guidance should be provided for all officials regarding how and when to raise service issues with ministers and horizon-scanning processes should be subject to review.

This study, published in BMC Nursing, used in-depth qualitative methods to explore the concept of patient safety culture and its dimensions from the perspectives of nurses working in the neonatal intensive care unit (NICU). Data was collected through in-depth semi-structured interviews with 15 NICU nurses working in Riyadh, Kingdom of Saudi Arabia. The study’s findings consider the influence of systemic barriers (staffing shortages, workload, communication gaps) and facilitators (teamwork, leadership support, peer mentoring). Furthermore, it brings out emotional and ethical dimensions of safety such as fear of blame, moral distress when unable to deliver optimal care.

In this blog, Fiona Garín McDonagh reflects on a conversation with Helen Hughes, Chief Executive of Patient Safety Learning, about the persistence of avoidable harm in health and care. She reflects on why progress in reducing this has been slow, how the implementation gap continues to undermine safety efforts, and why we must reframe patient safety as a system-wide priority, not just a frontline concern.

This report summarises the outcome of an unannounced maternity services inspection to the Royal Infirmary of Edinburgh, NHS Lothian on Monday 23 and Tuesday 24 June 2025. This inspection resulted in five areas of good practice, two recommendations and 26 requirements. Healthcare Improvement Scotland summarised their key findings as follows: Throughout the inspection they observed staff working hard to provide compassionate and responsive care in very challenging circumstances. The multidisciplinary team within maternity services spoke highly of the clinical working relationship. In some areas staff were complimentary and described their line manager as supportive. However, the majority of the multidisciplinary team they spoke with expressed feeling frustrated at staffing levels which they believe left areas short staffed and staff unsupported. Staff told them this presented a safety risk for women, babies and families within their care which they raised on multiple occasions with managers. The majority of the staff they spoke with shared their concerns and feelings of being overwhelmed, described feeling unsupported and believed they were not being listened to. Staff informed inspectors this has impacted staff confidence to escalate staffing concerns due to lack of feedback and resolution when concerns are raised. They observed delays to the induction of labour process of up to 29 hours and other delays to women who required ongoing care within the labour ward due to lack of staff availability, capacity and increased acuity. Staff they spoke with described suboptimal skill mix, low staffing levels and high acuity resulting in challenges in providing and maintaining one-to-one care for women within the labour ward. Staff also described staffing impacting on timely care such as delays in undertaking maternity early warning score (MEWS) observations or escalation of clinical concerns. Women told them of mixed experiences within Royal Infirmary of Edinburgh maternity services. In some areas women were highly complimentary of the care they experienced, describing it as exceptional; however, other women described their experience leaving them feeling alone and vulnerable. Whilst some women were complimentary of their care, they also informed inspectors of poor communication, leaving them feeling uninformed and with no ‘voice’ in their care. Their inspection has highlighted gaps in incident reporting and what appears to be a reluctance to submit incident reports with staff describing a culture of mistrust. These are concerning issues that may have significant impact on the learning from adverse events within the system, reducing opportunities to improve safety. During the course of this inspection, Healthcare Improvement Scotland escalated serious concerns with NHS Lothian through the Healthcare Improvement Scotland and Scottish Government Operating Framework. These concerns related to culture, oversight of patient safety and staff wellbeing within Royal Infirmary of Edinburgh maternity services. Other areas for improvement have been identified within maternity services within Royal Infirmary of Edinburgh. These include fire safety requirements, safe storage of cleaning products and required improvements to the environment.

This annual report contains information on NHS England’s work in 2024/25. It highlights their achievements, challenges and how the organisation has performed against its priorities. It also incudes financial statements for 2024/2025.

This report from the Northern Ireland Public Services Ombudsman relates to the care and treatment the Northern Health and Social Care Trust provided to a patient. The patient, who was 85 years old at the time, has now sadly passed away. The complainant is the patient’s son. He said the Trust provided his father with substandard care, causing him severe bed sores. He found his father in a wet state on several occasions, indicating staff did not meet his toileting needs for extended periods of time.   The investigation founding several failings in pressure damage care and treatment in this case. This included a failure to reassess the patient’s pressure ulcer risk appropriately; a failure to reposition the patient appropriately on several occasions; and a failure to develop an appropriate care plan for managing the patient’s incontinence. Its recommendation is that the Trust apologises to the complainant for the failures and injustice identified and that it provides refresher training on certain aspects of pressure damage care and treatment to relevant staff and reviews its protocol for managing patients’ incontinence.

Smart digital technologies are rapidly transforming perioperative care through tools such as clinical decision support systems, wearable sensors, and electronic checklists. Despite growing adoption, their specific impact on patient safety in the operating room remains insufficiently understood. This narrative review, published in the journal Patient Safety in Surgery, explores recent advancements in perioperative digital health and examines how innovations like AI-assisted systems, electronic WHO checklists, and physiological monitoring wearables contribute to safer surgical care. The evidence suggests that these tools can enhance complication detection, protocol adherence, and team communication. However, their effectiveness is tempered by challenges including alert fatigue, fragmented data systems, and added digital workload for healthcare staff.

This report is intended for healthcare organisations, healthcare staff, policymakers, higher education institutions and the public to help improve patient safety in how 12-lead electrocardiograms (ECGs) are carried out in ambulance services. It shares findings and recommendations from an investigation that considered the use of ECGs to help identify ST elevation myocardial infarction (a type of heart attack) and the support available to ambulance crews in making this identification. This report focuses on the equipment and support systems that are used by and assist ambulance crews in diagnosing a STEMI. The findings highlight key issues concerning not only the ECG equipment’s ability to recognise a STEMI, but also the ambulance crews’ recognition and the level of clinical support available to them during interpretation. HSSIB heard from ambulance crews that it was easy to interpret an obvious or “barn door” STEMI from a 12 lead ECG. However, it was more challenging to identify one where patients had less obvious signs and symptoms. Safety recommendations HSSIB recommends that NHS Supply Chain reviews and amends the procurement framework for monitors/defibrillators to help ambulance services ensure they are fully considering the defibrillation/monitoring and cardiac diagnostic functions of the device when making purchasing decisions, to better reflect how these devices are used in practice. HSSIB recommends that NHS England/Department of Health and Social Care reviews and amends the service specification for primary percutaneous coronary intervention (PPCI) centres, to include a requirement for a function enabling two-way communication with ambulance crews for shared decision making about patients with a suspected STEMI. This is to ensure that patients are taken to the correct place of care and PPCI teams are responding to confirmed STEMI cases. Safety observations Regulatory bodies can improve patient safety by supporting standardisation across manufacturers in how information from ECG traces is displayed. Manufacturers can improve patient safety by identifying the potential design barriers and enablers for ambulance crews entering information about a patient’s age or sex into a monitor/defibrillator. This could inform future device design to increase the likelihood that this information is entered when carrying out a 12-lead ECG using auto-interpretation. Algorithm developers can improve patient safety by collecting data from different ethnic groups across different geographical locations to help increase the global representation and accuracy of auto-interpretation algorithms for STEMI. Ambulance services can improve patient safety by informing regulators and manufacturers of instances where the use of monitor/defibrillators has impacted on patient safety.

This short animation from the National Guardian's Office highlights the unique role that Freedom to Speak Up champions can play in fostering a speaking up culture, alongside Freedom to Speak Up Guardians. It is designed for organisations to use for in internal communications, onboarding, and awareness campaigns to embed the Champion role effectively and ensure every voice is heard. In the video, you’ll learn: How Champions contribute to a culture where workers feel safe to raise concerns. How Champions and Guardians work together to provide support. Practical ways organisations can use Champions to strengthen Freedom to Speak Up arrangements.

High-reliability organisations (HROs), such as nuclear power plants, petrochemical plants, or aviation are complex systems in which safety is a critical component when it comes to achieving success and preventing catastrophic accidents. The WHO Global Patient Safety Action Plan identifies building high-reliability health systems and health organisations as a key objective in seeking to protect patients from avoidable harm. In HROs, upward voice (the willingness and ability of lower-status or frontline personnel to speak up about concerns, errors, near misses, or potential safety threats to those in higher authority) contributes to a proactive approach to safety and allows the early identification of potential problems before they cascade into tragic consequences. This study responds examines the relationship between upward voice and safety performance, and the mediating role of team learning in this relationship, looking at a sample composed of 617 workers from two nuclear power plants of the same organisation.

Artificial intelligence (AI) is changing health and health care on an unprecedented scale. Though the potential benefits are massive, so are the risks. This article summarises issues discussed at The JAMA Summit on AI concerning how health and health care AI should be developed, evaluated, regulated, disseminated and monitored. Key observations: Health and health care AI is wide-ranging, including clinical tools (e.g, sepsis alerts or diabetic retinopathy screening software), technologies used by individuals with health concerns (e.g, mobile health apps), tools used by health care systems to improve business operations (e.g, revenue cycle management or scheduling), and hybrid tools supporting both business operations (e.g, documentation and billing) and clinical activities (e.g, suggesting diagnoses or treatment plans). Many AI tools are already widely adopted, especially for medical imaging, mobile health, health care business operations, and hybrid functions like scribing outpatient visits. All these tools can have important health effects (good or bad), but these effects are often not quantified because evaluations are extremely challenging or not required, in part because many are outside the US Food and Drug Administration’s regulatory oversight. A major challenge in evaluation is that a tool’s effects are highly dependent on the human-computer interface, user training, and setting in which the tool is used. Numerous efforts lay out standards for the responsible use of AI, but most focus on monitoring for safety (e.g, detection of model hallucinations) or institutional compliance with various process measures, and do not address effectiveness (i.e, demonstration of improved outcomes). The paper notes that ensuring AI is deployed equitably and in a manner that improves health outcomes or, if improving efficiency of health care delivery, does so safely, requires progress in 4 areas. Multistakeholder engagement throughout the total product life cycle is needed. This effort would include greater partnership of end users with developers in initial tool creation and greater partnership of developers, regulators, and health care systems in the evaluation of tools as they are deployed. Measurement tools for evaluation and monitoring should be developed and disseminated. Beyond proposed monitoring and certification initiatives, this will require new methods and expertise to allow health care systems to conduct or participate in rapid, efficient, and robust evaluations of effectiveness. The creation of a nationally representative data infrastructure and learning environment to support the generation of generalizable knowledge about health effects of AI tools across different settings should be a priority. An incentive structure should be promoted, using market forces and policy levers, to drive these changes.

On the 8 September 2023 Keith James Hankin was admitted to Goring Hall Hospital for an elective surgical optical urethrotomy for long standing urethral strictures. Shortly after the procedure Mr Hankin developed sepsis and was transferred to Worthing Hospital later that afternoon. Despite supportive intensive care management Mr Hankin died at the hospital on the 11 September 2023. The Coroner’s report into his death identifies failings in the community management, pre-operative assessment, intra-operative and post operative care at Goring Hall Hospital on a background of poor clinical governance of the Community Urology Service (CUS) materially contributed to his death. She states that there was a gross failure to provide basic medical attention to Mr Hankin when he was dependent on it and concludes that Mr Hankin died from a recognised complication of a surgical procedure contributed to by neglect. The report identifies the following matters of concern: Lack of clinical governance of the Community Urology Service (CUS) by the Integrated Care Board (ICB) who commissioned the service and Sussex Medical Chambers (SMC) who were responsible for providing the service. The Coroner states that neither the ICB nor SMC were able to provide any evidence of robust clinical governance or multi-disciplinary team processes to ensure best practice of urology services from inception to date. Lack of Integration of the CUS with NHS Hospital Urology Services. The Coroner said that the ‘silo’ effect of these two services was such that they effectively worked independently of each other. There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. The Coroner notes that this case gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practicing privileges to work independently outside of the NHS to the potential detriment of patient care. The lack of an independent review prevented any proactive learning and changes in practice following the death of Mr Hankin. The Coroner stated that this gives rise to a concern that the system within the ICB and SMC are insufficiently robust and could – as it was with Mr Hankin – prevent transparency and openness as to the circumstances of his death and limit any learning and or necessary changes in practice to prevent future deaths. There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co- morbidities rendered him unfit to have his operative procedure at the hospital.

In this article Jeremy Hunt MP, who served as secretary of state for health, later secretary of state for health and social care, from 2012 to 2018, reflects on maternity safety in the NHS at the start of Baby Loss Awareness Week. He highlights the different rates of maternal deaths in the UK compared with other high-income countries and how significant numbers of staff don’t feel comfortable speaking up about safety concerns. He also talks about the potential benefits of the NHS adopting a system of no-fault compensation following medical error, similar to the one operated in Sweden.