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News Article
NHS waiting list rises for third month in row
Mark Hughes posted a news article in News
The hospital waiting list in England has risen for the third month in a row with experts warning the government's key NHS priority - tackling the backlog - is at risk. At the end of August the waiting list for routine treatments hit 7.41 million – in May it was 7.36 million. The proportion waiting longer than the target time of 18 weeks has also risen. Experts said the government was facing a significant challenge reducing waits, but ministers said its investment in the NHS would pay off. The government has promised that by the end of this parliament it will hit the 18-week waiting time target – something that has not been done for a decade. Read full story. Source: BBC News, 9 October 2025 -
News ArticleIn a statement made to The Pharmaceutical Journal, Henrietta Hughes has urged the government to provide a full response to recommendations made in her February 2024 report. The Hughes Report, published in February 2024, called on the government to set up a two-stage redress scheme, including a possible £100,000 for each patient harmed as a result of valproate use, followed by a main scheme payout, based on the individual needs of each patient. Hughes’ exclusive statement to The Pharmaceutical Journal follows a letter written by campaigners from the Independent Fetal Anti-Convulsant Trust and Fetal Anti-Convulsant Syndrome Association to the government calling for compensation and clarity. The letter, addressed to Keir Starmer, UK prime minister, and Rachel Reeves, chancellor of the exchequer was written by Janet Williams and Emma Murphy, both of whom are mothers of children with foetal valproate syndrome. Read full story. Source: The Pharmaceutical Journal, 9 October 2025 Related reading The Hughes Report: Options for redress for those harmed by valproate and pelvic mesh (Patient Safety Commissioner for England, 7 February 2024) Reflections on The Hughes Report: Pelvic mesh, sodium valproate, hormone pregnancy tests and options for redress (a blog from Patient Safety Learning) A year on from The Hughes Report: Urgent action needed on redress (Patient Safety Learning, 7 February 2025)
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Content ArticleThis report shares learning and insights from Health Services Safety Investigations Body's (HSSIB) education and investigation teams about patient safety incident investigation under the Patient Safety Incident Response Framework (PSIRF). It is intended for national and local organisations and policymakers to help inform future work to support staff in system-based investigation across the NHS in England. You can read Patient Safety Learning's response to this report here. Summary of learning and insights about patient safety incident investigation under PSIRF identified in this report: Applying investigation tools, templates and guidance The shift to a system-based approach to investigation, which avoids blaming individuals when incidents happen, has been positively received by staff. Using system-based tools is a skilled activity. Expertise builds over time with practice, support and guidance from those with existing expertise and experience. Currently there is a gap between staff’s awareness that there are tools and guides in the PSIRF toolkit and having the necessary support and expertise to be able to use them in practice. Training for staff has provided limited opportunities for them to practically apply and discuss using the tools and guides in the toolkit. The current design of some PSIRF tools and guides may limit staff’s ability to use them in practice. Feedback indicates staff find it particularly challenging to apply the tools and guides in investigations about mental health care. Engaging and involving those affected by patient safety incidents The principle of greater engagement and involvement in investigations is welcomed by staff and seen as the right thing to do. Progress towards greater engagement is variable depending on the organisational support available to enable this work. Time pressure was the main reason given for continuing to rely on statements from those involved in incidents rather than gathering information through interviews and discussions as recommended by PSIRF. Conversations which involve apologising to a patient, family or carer for harm caused during their care require specific knowledge, skills and attributes as detailed in the PSIRF patient safety investigation standards. Specific challenges in engaging with patients, families and carers were highlighted in investigations in mental health organisations. Organisational support for patient safety incident investigation Organisational support and informed oversight are fundamental and essential conditions to enable the shift to a system-based approach to investigation with meaningful involvement of those affected. Boards and senior leaders have a powerful influence on the approach and practice of investigations. Some organisations have invested in implementing PSIRF and have provided the organisational support needed, for example by establishing safety teams with dedicated investigators and engagement leads, which also provide a space for sharing and learning. Some organisations have not invested in implementing PSIRF and progress has been limited by the lack of dedicated roles and resource. For example, some staff have attended PSIRF training in their own time as their organisation has not provided protected learning time. External influences on investigation practice The lack of central funding for PSIRF implementation may have contributed to the variation in support provided within organisations to implement it. Greater oversight of PSIRF implementation in organisations is needed to help ensure consistency in how PSIRF is understood and applied in NHS trusts. Investigations involving multiple providers are difficult for a single organisation to co-ordinate. Integrated care boards have not always been able to provide the support and co-ordination needed for cross-provider investigations as expected under PSIRF. This means investigations often focus on one element of a patient’s journey, missing valuable learning and meaningful improvement opportunities. Coroners’ expectations can influence an organisation’s choice of learning response to an incident. Other PSIRF learning responses Staff value having the flexibility to choose a range of learning responses to patient safety incidents. After action review is the chosen learning response to many incidents that previously would have triggered an investigation. It is important that facilitators are appropriately trained and that the governance processes for this learning response are robust. There is interest in and an aspiration to use thematic analysis but there are challenges with applying this method which mirror those of applying system-based tools.
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Content ArticleThis report by the Office of Inspector General at the US Department of Health and Human Services looks at the implementation of the Patient Safety Organization (PSO) programme in the United States. Its findings suggest that although the PSO has helped some hospitals and health systems improve, it has fallen short in facilitating patient safety learning and improvement on a national scale. Key findings are highlighted below. In response to these findings, the Office of Inspector General recommends: Increase alignment of the PSO program with other Department of Health and Human Services patient safety efforts Promote opportunities to involve patients and families in PSO activities Clarify cybersecurity protections and data use limitations for patient safety work product submitted to the Network of Patient Safety Databases Take steps to harness technologies and new data sources that could help address barriers facing the Network of Patient Safety Databases
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Content ArticleJess’s Rule is a primary care initiative to encourage GPs teams to rethink a diagnosis if a patient presents three times with the same symptoms or concerns, particularly if symptoms unexpectedly persist, escalate, or remain unexplained. It is led by the Department of Health and Social Care and NHS England and is supported by the Royal College of General Practitioners. Jessica Brady passed away due to cancer in December 2020 at the age of 27. In the 5 months leading up to her death, Jess had 20 consultations with her GP practice, and her cancer had not been diagnosed. Jess was then admitted to hospital with stage 4 adenocarcinoma and passed shortly afterwards. Since then, Jess’s family have campaigned for primary care staff to elevate a patient’s case for review after their third appointment with their practice about a condition or symptom. Jess’s Rule asks GP teams to ‘reflect, review and rethink’ if a patient presents three times with the same or escalating symptoms. Below is a poster for displaying in GP consultation rooms in relation to this, which you can also find attached as a PDF at the bottom of this page.
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Content Article
In February 2024 NHS England launched a consultation to collect views on the effectiveness of its Never Events policy and framework. This article summarises the findings of the consultation and sets out next steps for revising the definition of and process for Never Events. Never Events are defined as patient safety incidents that are “wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers”. NHS England held a 12 week consultation that ran from February to May 2024 asking, via an online survey, ‘on balance do you think the Never Events framework is an effective mechanism to support patient safety improvement and based on the evidence provided in the supporting consultation document which one of the following options do you prefer for its future?’ Option 1: no change; continue with the current framework Option 2: abolish the Never Events framework and list Option 3: revise the list of Never Events to only include those with current barriers that are ‘strong, systemic, protective’ Option 4: revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’ Key findings There were 854 responses to the online survey, 86% (744) from individuals and 14% (120) on behalf of an organisation Only 8% of consultation respondents felt the current Never Event framework was effective 66% of consultation respondents considered the current framework unfit for purpose 48% of respondents advocated for an alternative approach Feedback highlighted the ‘Never Event’ terminology creates unintended negative effects on staff morale and blame culture The majority of respondents shared the view that the current framework has limited impact on driving safety improvements Future direction and next steps NHS England state that as a result of these findings Option 4 is the preferred way forward, revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’. Reflecting the consultation's findings, they state that a new framework should: Focus on learning rather than meeting a definition based on strength of barriers Reflect the patient safety events that are of significant concern to patients and the NHS Be better at including patient safety events across sectors and settings, including mental health and primary care Align with Patient Safety Incident Response Framework (PSIRF) principles of proportionate learning and response Support a just culture where staff feel confident to report and learn Direct resources toward activities that have the greatest potential for improvement Better recognises the complexity of healthcare delivery To take this forward, NHS England had said they have launched a ‘discovery phase’ to explore and test alternatives to the Never Events framework. This will be done in collaboration with stakeholders, including patients and NHS staff. They state that they will aim to complete this next phase within six months and will then set out further plans after that. While an alternative process is in development, the existing Never Events framework will remain active. Related reading NHS England, Detailed findings from the 2024 consultation on the Never Events framework, 16 September 2025. Dr Aiden Fowler, Evolving our approach to patient safety: the future of Never Events, 16 September 2025. Patient Safety Learning, Never Events: The Big Debate, 2 May 2024. -
Content ArticleIn early 2025, the Oregon Patient Safety Commission partnered with a local research firm to conduct a statewide survey seeking to understand how medical harm affects Oregonians and in what ways the response they receive shapes their experience. The survey findings reinforce that medical harm is not uncommon in Oregon, and when harm does happen, Oregonians expect transparency. Key findings include: 30% of Oregonians have had experience with medical harm in the last 5 years; this includes direct experience of harm or harm experienced by someone close to them. Oregonians expect transparency about medical harm—more than 9 in 10 of those surveyed agreed that healthcare providers should be required to tell patients if a medical error is made during their care. Oregonians want to be informed right away about medical harm, and they want an apology for what happened; however, only 31% of Oregonians who experienced harm got this type of response from the healthcare provider or facility. The more serious the health consequences of the harm, the less likely Oregonians were to be informed or to get an apology.
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Content ArticleDementia is the UK’s leading cause of death, and by 2040, 1.4 million people are expected to be living with the condition. Yet one in three go undiagnosed - denying them vital support, the chance to plan, and the opportunity to join research that could find a cure. Across 2024 and 2025, Alzheimer’s Research UK surveyed more than 500 people affected by dementia and over 160 healthcare professionals to understand the realities of diagnosis. This report shares findings from this process and considers what works, what gets in the way, and what needs to change. Key findings Alzheimer’s Research UK highlight in this report are as fololows: Diagnosis matters Nine in 10 (91%) healthcare professionals agreed a formal diagnosis benefits patients, and almost all (98%) said it benefits families and carers. Respondents recognised the need for an early diagnosis “so that treatment can start”, even in the absence of a cure. For people with dementia and their loved ones, gaining insight into the changes in behaviour also helped with their own feelings about the situation. The ability to put a “name to it” and have a clear understanding of the condition was seen as crucial for managing the situation effectively. But the system isn’t working as it should Fewer than a third (27%) of healthcare professionals felt current diagnostic pathways are fit for purpose. Respondents described the system as “appalling”, “shameful” and “broken”, with many people “left to come to terms with the diagnosis alone.” They consistently highlighted a lack of funding and staff, describing services as “under-resourced”, with “not enough staff to run clinics due to a massive rise in referrals.” Staff are struggling to provide the care they want to give Fewer than half (43%) of healthcare professionals feel able to provide patients with the best level of care. Respondents spoke of a lack of “seamless communication between health and social care services” which often leaves people to “fall through the cracks” and leads to “delays in diagnosis, inconsistent care, and confusion for families who are left trying to coordinate everything on their own.” Families face disjointed and confusing journeys People living with symptoms of dementia described a gradual and often confusing journey. One in three said their symptoms had been present for more than a year before help was sought. Respondents described feelings of frustration and a “loss of control” over their lives, with guilt and fear of “becoming a burden.” Somone living with a dementia diagnosis described the wait as “tedious” and “worrying” as they recognised their symptoms were increasing in frequency and severity. People wait too long for a diagnosis Sadly, one in five people (22%) were still waiting more than two years for a diagnosis after visiting their GP for help. One respondent, who is still seeking a diagnosis, said: “My mum is struggling with day-to-day life, and there is nothing we can do about it. We can’t even officially put a name to it. It’s devastating watching what is happening with no answers, no support. We desperately need the reassurance of a diagnosis, so at least we know.” Based on these insights, the report outlines five key priorities to build a diagnosis pathway that is efficient, equitable, and supportive for everyone: Earlier, faster and more accurate diagnosis: cognitive assessments, imaging, diagnosis and support should be provided together during a single visit to a “one-stop shop” clinic – reducing fragmentation and speeding up care. Consistent and integrated diagnosis: diagnostic pathways should be standardised across regions, with shared digital patient records. Where appropriate, memory assessments should be provided in the community, via home visits, outreach clinics and virtual consultations. Improved pre- and post-diagnostic support: dedicated support services should sit alongside clinical appointments, to help guide people through the diagnosis process and beyond. Investment in people and infrastructure: the Government and NHS leaders must commit to targeted investment for more staffing, infrastructure and training in dementia services. Improved access to advanced diagnostics: diagnosis is being held back by outdated assessment methods and limited access to technology – services need to be future-proofed and made ready to rollout promising next-generation tests on the way, such as blood tests to detect Alzheimer’s disease.
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Content Article
This report explores the important topic of dementia rehabilitation, combining expert essays and real-world case studies from multiple countries globally to examine how the concept is defined and implemented, as well as practical considerations of how to best adapt rehabilitation practices for people living with dementia in different contexts. The report is divided into five parts. The introduction defines dementia rehabilitation, explaining why it is vital for people living with dementia, and issues around accessibility. Section 1 looks into the core components of rehabilitation, namely person-centred, goal-oriented, and collaborative approaches. Section 2 delves into strategies and methods to support the attainment of rehabilitation goals, providing practical techniques to implement a rehabilitation goal. Section 3 tackles the implementation of rehabilitation across various environmental settings and stages of dementia. Section 4 discusses system readiness for rehabilitation, taking a critical look at what can and should be done for rehabilitation to become a more mainstream part of post-diagnostic care for dementia in various contexts The report also makes the following recommendations: Rehabilitation should be embedded within national dementia plans (NDPs) – and implemented. Encouragingly, 65% of current national dementia plans mention rehabilitation, but with 75% of World Health Organization (WHO) member states yet to develop national plans, Alzheimer’s Disease International (ADI) calls on all governments and stakeholders to recognise, embed, and implement rehabilitation into their strategic responses to dementia, in alignment with Action area 4 of the WHO’s Global action plan on the public health response to dementia, namely ‘diagnosis, treatment, care and support’. Rehabilitation should be a right. Dementia is recognised as a disability under the Convention on the Rights of Persons with Disabilities (CRPD), and rehabilitation is generally recognised as supportive care for disabilities. ADI calls on governments to fully embed rehabilitation for dementia in their policies and to start to report on progress at the annual Conference of State Parties (CoSP). Rehabilitation should be embraced as part of ‘precision care’. Recent scientific innovations, such as blood-based biomarkers, have enabled the dementia community to focus more on precision medicine and personalised care. The new dialogue is around ‘precision diagnosis’, ‘precision treatment’, and ‘precision risk reduction’. Now we need to ensure that rehabilitation is more consistently included as part of ‘precision care’ – personalised and focused on the needs of the individual. Good rehabilitation is on a continuum. While this report aims to paint a picture of the golden standard of rehabilitation care, there is a whole continuum of good practices that can be tailored to varying resource contexts. While specialised healthcare professionals can – and should – play an important role in supporting people living with dementia with their rehabilitation goals, this report provides many resources that people living with dementia, their doctors, families, friends, and other informal carers can use at little to no cost. This can be implemented when the general health and care workforce, as well as the public, are equipped with dementia rehabilitation literacy. We need more implementation research and evaluation. Rehabilitation is an emerging field of practice and, as such, there is a paucity of longitudinal data. What is needed is implementation research that evaluates the benefits of integrating rehabilitation for people with dementia into health systems in different contexts. We need to explore real-world practice – how rehabilitation can fit into a case management model of care that integrates the needs of the whole person, as opposed to a ‘one-off’, task-based model. We need to measure economic impact. Improving functionality through rehabilitation should extend independence, enabling people with dementia to remain in work, live at home, stay active in the community, and delay hospital and residential care admissions for as long as possible. Economic impact measurement and cost saving, including for carers is needed alongside further research to substantiate the argument for investment in rehabilitation as a cost-effective measure. Quality of life and ageing well don’t have to be a luxury. We need to normalise rehabilitation and encourage governments to invest in healthcare systems that integrate rehabilitation as part of the regular care pathway. Healthcare professionals need to be trained and encouraged to discuss and undertake rehabilitation with dementia patients. Interventions need to be timely to make the greatest impact – we cannot wait until it’s too late. Carers should be actively involved in the rehabilitation process. The benefits of rehabilitation are not just felt by the person living with dementia but also their carers, improving their own wellbeing and caregiving experience. Carers should be educated about the importance of rehabilitation, its principles, and the role they can play, and supported throughout the process as essential actors in the dementia journey. -
Content Article
On 23 June 2025 the Secretary of State for Health and Social Care announced a rapid, national, independent investigation into NHS maternity and neonatal services. Chaired by Baroness Amos, this document sets out the terms of reference for the investigation. The aims of the investigation are to: develop and publish one set of national recommendations to: drive the improvements needed to ensure high-quality and safe maternity and neonatal care across England reduce inequalities and promote health equity in the delivery of those services help bereaved and harmed families to receive justice and accountability in the future ensure that the lived experiences of women, babies and families, including fathers and non-birthing partners, are fully heard and used to inform the development of the national recommendations conduct and publish 14 local investigations of maternity and neonatal services in NHS trusts and use these alongside other sources of data and evidence gathered by the investigation to inform the development of the national recommendations The individual trusts to be reviewed are: Blackpool Teaching Hospitals NHS Foundation Trust Bradford Teaching Hospitals NHS Foundation Trust University Hospitals of Leicester NHS Trust Leeds Teaching Hospitals NHS Trust Sandwell and West Birmingham Hospitals NHS Trust Gloucestershire Hospitals NHS Foundation Trust Somerset NHS Foundation Trust Oxford University Hospitals NHS Foundation Trust University Hospitals Sussex NHS Foundation Trust Barking, Havering and Redbridge University Hospitals NHS Trust Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust University Hospitals of Morecambe Bay NHS Foundation Trust East Kent Hospitals NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust The investigation started work in summer 2025. Some initial findings will be published in December 2025 ahead of further findings in spring 2026. -
Content ArticleThis report presents the findings of the 2025 Freedom to Speak Up Guardian survey. It providers a timely and insightful snapshot of how the Guardian role is being delivered across healthcare organisations. It highlights both encouraging progress and ongoing challenges. Guardians continue to be vital to fostering a culture of openness, safety, and accountability, but their ability to do so effectively depends on the support structures around them. Key findings included: Time allocation: Inconsistent access to ring-fenced time limits effectiveness. Many reported lack sufficient time to engage proactively, manage caseloads, and maintain visibility. Resources and infrastructure: Lack the funding, space, and communications support needed to carry out the Guardian role effectively. Confidentiality and trust are compromised without dedicated budgets or private meeting areas. Recognition and remuneration: Concerns persist the minimum pay band recommendation, Band 7 or equivalent does not reflect the leadership and strategic influence required. Respondents seek better alignment between responsibilities and pay. Support from the National Guardian’s Office: While valued, respondents call for more timely, practical, and tailored resources. With the Dash review’s changes, future support and functions are currently being discussed with Department of Health and Social Care, NHS England and Care Quality Commission, and remains to be defined at the time of report writing. Influence and engagement: Respondents are seeking a stronger, more visible national presence with the authority to challenge poor practice, support complex cases, and hold organisations accountable. With the transition following the Dash review, NHS England and Department of Health and Social Care will need to consider how best to meet these expectations. Role satisfaction: Nine out of ten guardians would recommend the role. Despite its emotional demands, especially in NHS trusts, many find it deeply rewarding, reinforcing the need for robust support to sustain their wellbeing and impact.
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EventuntilDespite progress in healthcare delivery, newborns and children remain vulnerable to preventable harm, especially in low- and middle-income countries. This webinar will highlight the critical importance of patient safety and explore the role of health system strengthening, policy frameworks, and intersectoral partnerships in reducing newborn and child mortality. The session aims to foster dialogue and share actionable insights to advance safe, high-quality, and equitable care for every child. This event has been organised by the Patients for Patient safety Network India, as part of the observance of World Patient Safety Day 2025, under the WHO theme “Safe Care for Every Newborn and Every Child”. Key Discussion Areas: Burden and causes of preventable newborn and child deaths, with emphasis on patient safety and quality of care. Global commitments such as SDG 3.2 and their role in guiding action. Systemic gaps in public health systems that hinder safe and equitable care. Successful strategies and interventions to improve outcomes through multisectoral collaboration and capacity-building. The role of partnerships between governments, NGOs, academia, and communities in ensuring safe maternal and child health services. Register here.
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Content ArticleThis report from the Northern Ireland Public Services Ombudsman relates to the care and treatment the Southern Health and Social Care Trust provided to the patient between 2016 and 2018. The patient’s GP made an urgent referral to the Trust’s Breast Clinic on 15 February 2016. The Trust triaged the referral and downgraded it to routine. The patient attended the clinic in September 2016, seven months after the GP’s referral. In October 2016, the Trust diagnosed the patient with a probable grade II infiltrating duct carcinoma in her left breast The investigation found the Trust failed to appropriately triage the GP referral. It also did not communicate its decision to downgrade the referral to the patient or her GP. The investigation found the failure caused the patient to experience a seven-month delay before she received her diagnosis and treatment.
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Content ArticleThis 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 April to June 2025. Count of Event Types in LFPSE – based on patient safety event records from April 2025 to June 2025 LFPSE brings the feature to record patient safety event types beyond incidents. Recorders can now 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 the current period, 833,136 events were recorded to LFPSE, the majority of which were recorded as patient safety incidents (96.81%). Count of patient safety incidents by maximum physical harm – based on patient safety incident records from April 2025 to June 2025 Grading the degree of harm to a patient resulting from a patient safety incident can be a challenge for recorders, but by grading patient safety incidents according to the harm they cause patients, local organisations can ensure consistency and comparability of data. This consistent approach locally will enable LFPSE to compare, analyse and learn from data nationally. This grading can also be used to “triage” incidents for review both locally and nationally, ensuring the most serious events are looked at first. 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.
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Content Article
PHSO: Prioritising patient safety (Summer 2025)
Mark Hughes posted an article in PHSO investigations
Prioritising patient safety is a quarterly blog series from the Parliamentary and Health Service Ombudsman (PHSO). Each month, PHSO publish between 70 to 100 of their casework decisions as a way to share learning that will help organisations improve their service and prevent mistakes happening again. This blog explores how findings from PHSO casework can help colleagues across the NHS harness the power of complaints. -
EventuntilIAPO, the International Alliance of Patients’ Organizations, and the Patients for Patient Safety Observatory warmly invite you to the global webinar: “Engaging Families and Communities, Protecting Every Newborn and Every Child”. This webinar is being organised to mark World Patient Safety Day 2025 aligned with the theme ‘Safe care for every newborn and every child – Patient safety from the start!’. Date: Tuesday, 16 September 2025 Time: 13:30-14:30 CEST This 60-minute session brings together international experts to share proven practices and amplify family and community voices in creating safer healthcare systems for newborns and children worldwide. Webinar panellists include: Dr Neda Milevska-Kostova - Patients for Patient Safety Observatory [Moderator] Dr Ayda Taha - Patient Safety and Quality of Care Unit, World Health Organization [Moderator] Dr Neelam Dhingra-Kumar - Joint Commission International Ida Ferdinandi - Early Childhood Development, UNICEF Montenegro Leanne West - International Children's Advisory Network Register here. IAPO-P4PS WPSD 2025 Webinar_Banner.pdf
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Content Article
This report sets out the work that has been undertaken by the Patient Safety Commissioner for England at the end of their first three year term. It outlines the strategic impact of the role and its influence in areas such as policy, medicines safety and medical device safety. It concludes by looking ahead to the delivery of the 10 Year Health Plan for England and the future Patient Safety Commissioner strategy. -
EventuntilTo mark World Patient Safety Day, this interactive session, hosted by the Association of British Paediatric Nurses, will explore the role of childhood immunisations as a cornerstone of safe care for newborns and children. The diverse panel brings together expertise from emergency care, public health nursing, and hospital-based practice to share practical insights, challenges, and strategies for promoting vaccine uptake. It is designed for children’s nurses and student nurses and will include short presentations followed by discussion and Q&A. Chair & Presenters: Kath Evans Director of Children’s Nursing, Barts Health; Babies, Children & Young People’s Clinical Lead, North East London Integrated Care Board; CYP Participation champion at NHS England (London). Becky Platt, Children’s Nurse and Advanced Clinical Practitioner, Emergency Department, Royal London Hospital Helen Donovan, Independent nurse consultant and immunisation specialist nurse. Josephine Bakar, Ward Manager, Rainbow Ward, Newham Hospital Register here.
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EventuntilEnsuring safe care for patients is a fundamental priority, yet newborns and children remain especially vulnerable to patient safety risks. To bring attention to this critical issue, “Safe care for every newborn and every child” has been selected as the theme for World Patient Safety Day 2025. This is especially relevant when it comes to medical imaging and radiation safety where an understanding of benefits and risks is important. The webinar aims to raise global awareness of safety risks in paediatric and newborn care in all health care settings, emphasizing the specific needs of children, families and caregivers when using radiation for diagnosis and treatment. It will bring together a number of Non-State Actors in official relations with World Health Organization (WHO) involved in radiation safety and medical imaging to discuss strategies for improving patient safety and radiation protection in paediatric and newborn care. Agenda Welcoming remarks – Dr Rüdiger Krech, Director a.i., Environment, Climate Change One Health and Migration (WHO) World Patient Safety Day 2025 – Dr Ayda Taha, Technical Officer (WHO) DG recorded message WHO activities on radiation protection of children and newborns – Dr Ferid Shannoun, Scientist (WHO) Paediatric Imaging in newborns and children - why radiation protection matters from day one – Dr Elaine Kan and Dr Kevin Fung (WFPI) Panel discussion with Non-State Actors in official relations with WHO on: Their role in enhancing radiation protection for newborns and children; and Their collaboration through a multidisciplinary approach to strengthen radiation protection for paediatric and newborn care across different regions. Conclusion and closing remarks – Dr Emilie van Deventer, Unit Head (WHO) Register here.
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Content Article
WHO: Patient safety from the start! Protecting every child’s health journey
Mark Hughes posted an article in WHO
Every child deserves safe, quality health care — right from the very start. But for many newborns and young children, a hospital visit can carry risks that no child should face. This video, produced by the World Health Organization for World Patient Safety Day 2025, looks at the unique challenges children face in health care through the story of six-year old Amiya. From subtle symptoms to the impact of living conditions, discover why children aren’t just small adults — and why their care must be tailored, thoughtful, and collaborative. Further reading on the hub: Patient Safety Learning: World Patient Safety Day 2025 Patient safety for babies and children: key resources World Patient Safety Day 2025 at the Royal College of Surgeons of Edinburgh -
Content ArticleThe video, produced by Homerton Healthcare NHS Foundation Trust, presents a clinical scenario supporting SEIPS training by highlighting human factors that contribute to clinical incidents. It demonstrates how communication lapses, prioritisation challenges, and procedural delays can affect patient care, emphasising the importance of effective teamwork, thorough documentation, and timely responses to ensure patient safety and prevent medical errors.
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Content ArticleThe video, produced by Homerton Healthcare NHS Foundation Trust, serves as an instructional resource for nursing students and healthcare professionals on the correct procedure for verifying the placement of a nasogastric (NG) tube, troubleshooting common issues, and managing potential complications, including emergency response to a suspected anaphylactic reaction.
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Content ArticlePeople with attention deficit hyperactivity disorder (ADHD) often face long waiting times to get their diagnosis. In this blog, Healthwatch England highlight from their research that even after diagnosis, people face another wait to get the medication they need to help them manage their condition. The blog includes several recommendations to improve care for people living with ADHD: Publish official data on titration waiting times. There are no official targets or data collected on waiting times for titration. External research shows variation in waiting times for some, and a totally hidden wait for others. Our research shows publication of this data would provide people with clarity, particularly after long waits for assessment. Fix shared care commissioning so people can get the medication they need. Whether discharged from a hospital team with a prescription or sent back to GPs from independent providers, we have heard from people who struggle to access the medicine they need following an ADHD assessment. Clarity over shared care commissioning and follow-up arrangements is needed, which will require collaboration between NHS England, the General Medical Council (GMC), and the Care Quality Commission (CQC). Improve communication and signposting to help people understand the process to accessing ADHD medication. This should be via NHS information shared when people are referred, and from independent providers including those who offer assessment-only services. The government should also look at how to address issues from unregulated and unregistered independent providers conducting assessment-only services. Pilot the prescription of ADHD medicine by GP and pharmacy teams. In the long term, we have called for ADHD assessments to move from hospital teams, where there are long waits, to primary and community care teams who work closer to people’s homes. As part of this shift, earlier prescription of preventative medication should be explored, to better help people while they wait for an assessment. Act to mitigate the impact of medication shortages. The government must continue to find solutions to medicine shortages while doing more to keep the public up to date. This includes producing clear and official information to support people experiencing a shortage to understand timelines and next steps. Related reading Healthwatch England, Recognising ADHD: How to improve support for people who need it (28 May 2025) Long waits for ADHD diagnosis and treatment are a patient safety issue (Lotty Tizzard, 15 May 2023) NHS England: Report of the independent ADHD Taskforce: Part 1 (20 June 2025)
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Content ArticleIn this article Suzette Woodward shares her views on the findings and recommendations in the Review of patient safety across the health and social care landscape in England. She talks about the lack of substantive commentary about the review from those who work in patient safety, and reflects on the factors that may explain this. She also provides a detailed commentary on the review report itself, considering its findings and recommendations
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Content ArticleIn this article, published in The Pharmaceutical Journal, Emma Wilkinson reflects on the findings and recommendations of the Review of patient safety across the health and care landscape chaired by Dr Penny Dash. She focuses on its proposals to streamline oversight and reduce duplication around the patient voice, specifically plans to abolish Healthwatch England and bring its functions in-house within a new Patient Experience directorate in the Department of Health and Social Care.
