Mark Hughes
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Everything posted by Mark Hughes
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Content ArticleIn 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.
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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.
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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.
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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.
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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. -
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.
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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.
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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. -
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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. -
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.
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Despite 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. -
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.
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Content ArticlePrioritising 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.
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IAPO, 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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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. -
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To 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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Ensuring 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. -
Content ArticleEvery 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.
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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.
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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.
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The World Health Organization (WHO) and the Partnership for Maternal Newborn and Child Health (PMNCH) are holding this webinar to mark World Patient Safety Day 2025 under the slogan “Patient safety from the start!”. The event will bring together patient representatives, health leaders, frontline health workers and international partners to shed light on the preventable harm children face in health care, share experiences and innovations from around the world, launch the campaign materials and World Patient Safety Day 2025 Goals, and mobilize collective action to make care safer for every newborn and child. Programme highlights include: Opening addresses from WHO and PMNCH leadership Keynote by WHO Envoy for Patient Safety, Sir Liam Donaldson Voices of patients and frontline health workers Launch of the WPSD 2025 campaign materials and Goals Commentaries from experts and partners Closing reflections Register here.
