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Mark Hughes

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  1. Event
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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.
  2. News Article
    A major teaching trust was forced to close its maternity services to new births twice in two days, due to unsafe staffing levels, HSJ can reveal. Leeds Teaching Hospitals Trust temporarily closed suites at St James’s Hospital and Leeds General Infirmary sites on 16 and 17 August. All new patients were diverted to neighbouring hospitals as a result of the closures, which ran from 4pm on Saturday to 7am on Sunday, and from 2.30pm on Sunday to 6.30am on Monday. Read full article. (Paywalled) Source: Health Service Journal, 22 August 2025
  3. News Article
    A new technology could reduce NHS waiting lists for prosthetic legs by half, a study has found. The software personalises prosthetic leg fittings based on data from previous patients. The data-driven fittings for below the knee prosthetics were, on average, as comfortable for patients as those created by highly skilled prosthetists, the NHS trial suggested. Technology developed by Radii Devices and the University of Southampton is hoping to halve the number of clinical visits for the fitting from an average of four to two using the software. Nearly 100 people have now had a prosthetic leg designed this way, across multiple centres in the UK and the USA. The study has now moved into its final stage where the new software is developed alongside clinicians to see how it can be best incorporated into their practices. Read full article. Source: The Independent, 22 August 2025
  4. Content Article
    More information about "Failing to learn? The NHS is losing its capacity for system-wide safety investigation (11 August 2025)"
    Published in July 2025, Dr Penny Dash’s Review of patient safety across the health and care landscape made a number of recommendations intended to streamline and consolidate patient safety functions in England. One of these was that the Health Services Safety Investigations Body (HSSIB), currently a independent arm’s length body of the Department of Health and Social Care, should have its functions transferred into the Care Quality Commission (CQC), though continue to operate as a discrete branch within the regulator. In this article Carl Macrae argues that this change risks potentially risks setting back progress in the systematic improvement of quality and safety, removing the health system’s nascent capacity for independent system-wide safety investigation. You can read the full article in the Journal of the Royal Society of Medicine here. Related reading Review of patient safety across the health and care landscape (7 July 2025) Review of patient safety across the health and care landscape: Patient Safety Learning's response (15 July 2025) Suzette Woodward's opinion piece on the Patient Safety Review by Dr Penny Dash
  5. Event
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    The Healthcare Improvement Scotland webinar aligns with World Patient Safety Day on Wednesday 17 September. The theme for World Patient Safety Day is “Safe care for every newborn and every child” This event is for staff working in maternity and neonatal services, and those looking to learn more about Quality Management Systems in action. The webinar will look at Scotland’s evolving approach to perinatal safety through a quality management lens. This session offers an opportunity to: hear about our first year of maternity inspections and the development of national standards explore learning from emerging perinatal safety intelligence and improvement design hear from leads shaping the quality management approach contribute to a shared vision for safer, more equitable maternity care across Scotland The aims of our webinar are: Aligning the HIS Perinatal Quality Management System (QMS) with World Patient Safety Day 2025 – Patient Safety from the Start! Promoting an understanding of the HIS Perinatal QMS. Building an environment of collaboration between perinatal stakeholders. Register here.
  6. Content Article
    More information about "HSSIB Investigation Report: An exploratory review of maternity and neonatal services (19 August 2025)"
    This report is a summary of information the Health Services Safety Investigations Body (HSSIB) collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved meetings with 17 stakeholders and a review of 35 safety concerns submitted to HSSIB and one report published in 2021 by the Healthcare Safety Investigation Branch (HSIB), the precursor organisation to HSSIB. Themes arising from stakeholder interviews identified in this report including: Some improved outcomes - some progress has been made in maternity and neonatal outcomes, staffing levels and governance arrangements. Complex national infrastructure - national maternity and neonatal systems are overly complex. Collaboration and information sharing between national organisations - national collaboration efforts are inconsistent and variable. Development, oversight and implementation of recommendations - too many recommendations exist, with limited implementation. Local governance arrangements - local governance of maternity services often operates in isolation from the wider organisation Risk awareness - services still lack the consistent ability to identify and respond to clinical risks. Potential for learning in maternity and neonatal services - there is limited potential to learn from harms that happen to women and babies during pregnancy, labour and birth. Compounding patient harm - patients experience compounded harm due to issues within the wider healthcare system, particularly the way local investigations are carried out or the way complaints/concerns are managed. Compounding staff harm - staff are also affected by cumulative stress and harm. Inequalities - disparities in care and outcomes persist because of health inequalities. Training and standards - there are concerns about the standards set in undergraduate and postgraduate education and whether these can be adhered to in practice.
  7. Content Article
    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 on 12 April 2023 in relation to the treatment of grade two haemorrhoids. The investigation established two main failures in the complainant’s care and treatment. The first was the failure to provide the complainant with pain relief on discharge. The second was the failure to discuss with the complainant the risk and benefits of the proposed surgery during the outpatient appointment to enable her to make a fully informed decision.
  8. News Article
    The U.S. Department of Health and Human Services (HHS) said on Thursday it is reinstating a federal task force for safer childhood vaccines after 27 years. The original task force was created by Congress under the National Childhood Vaccine Injury Act of 1986 to improve the safety, quality and oversight of vaccines administered to American children. It was disbanded in 1998 and has been inactive ever since. HHS said the task force will be led by Jay Bhattacharya, the National Institutes of Health director, and represented by senior leaders of the Food and Drug Administration and the Centers for Disease Control and Prevention. Read full article Source: Reuters, 14 August 2025
  9. Content Article
    Non-traumatic cardiac arrest is a critical condition, and errors and safety incidents during resuscitation reduce patient survival rates. Systematic investigations of patient safety incidents during resuscitation are limited. This systematic review examines the characteristics and nature of patient safety incidents during real and simulated resuscitation. This review identified a range of types of patient safety incidents that occur during non-traumatic cardiac arrest resuscitation which can be categorised thematically to support work to address the potential for latent safety issues effecting resuscitation.
  10. Content Article
    This report from the Northern Ireland Public Services Ombudsman relates to the care and treatment the Belfast Health and Social Care Trust provided to the complainant, a woman of 80 years of age, on 23 August 2023 when she had a CT Coronary Angiogram. The investigation established the Trust failed to provide appropriate aftercare to the complainant after she experienced extravasation during the procedure. It was unclear from the records how long the patient was monitored after this incident, as it was not recorded, but the Ombudsman stated that this was clearly less than the minimum hour required by the guidance. Further, the report states that the Trust did not provide the complainant with reassurance and explanation of what had happened.
  11. News Article
    NHS England is launching a recruitment campaign to attract trust and integrated care board non-executive directors (NEDs) in the face of an increasing number of retirements and resignations. A tender notice published by NHS England says the service has “experienced difficulty in recruiting NEDs” and therefore needs to “refresh” its “talent pipeline”. It adds this is particularly important as “a large number of NEDs are coming to the end of their terms of office”, while others are “stepping down” for other reasons. Read full article (Paywalled). Source: Health Service Journal, 15 August 2025
  12. News Article
    Artificial intelligence has invented two new potential antibiotics that could kill drug-resistant gonorrhoea and MRSA, researchers have revealed. The drugs were designed atom-by-atom by the AI and killed the superbugs in laboratory and animal tests. The two compounds still need years of refinement and clinical trials before they could be prescribed. Researchers have previously used AI to trawl through thousands of known chemicals in an attempt to identify ones with potential to become new antibiotics. Now, the MIT team have gone one step further by using generative AI to design antibiotics in the first place for the sexually transmitted infection gonorrhoea and for potentially-deadly MRSA (methicillin-resistant Staphylococcus aureus). Read full article. Source: BBC News, 14 August 2025
  13. News Article
    Patients who use social media to help plan cosmetic procedures will now be able to access more reliable trustworthy information thanks to a landmark new initiative between the government and TikTok. More people are using social media apps like TikTok to research potentially risky operations - like hair transplants and dental work - abroad as they are often cheaper or more readily available than in the UK but are often presented with slick marketing campaigns that do not highlight the dangers of the surgery. To help keep these patients informed, TikTok and the government have partnered with medical influencers, like Midwife Marley and Doc Tally to create content to show the risks, help carry out thorough research and provides advice on how to make trips as safe as possible. The Foreign Office will also provide more detailed travel advice for those seeking to travel abroad for ‘tweakments.’ Read full article. Source: Department of Health and Social Care, 15 August 2025 Related reading: Crackdown on unsafe cosmetic procedures to protect the public
  14. News Article
    A vulnerable 14-year-old girl was unlawfully killed when an agency support worker failed to keep her under observation at a secure psychiatric unit, an inquest jury has concluded. The worker, who used a false identity, left Ruth Szymankiewicz alone even though she had complex mental health issues and was judged to need constant watching because she was a suicide risk. Ruth was able to slip back to her room and harmed herself at the privately run Huntercombe hospital near Maidenhead on 12 February 2022. She died two days later. During the inquest it emerged that the worker, who went under the stolen identity Ebo Acheampong, had never worked at any hospital before the day he was put in charge of observing Ruth and did not receive an induction before his shift. Read full article. Source: The Guardian, 14 August 2025
  15. Content Article
    This is the video of a online event hosted by The Patients Association that considered what needs to be done to ensure patient partnership is in the foundations of the 10 Year Health Plan for England. The session explored what meaningful patient agency looks like in practice, drawing on real-life insights from the Patients Association helpline and focus groups. Chaired by Julie Thallon, former nurse and Chair of the Patients Association, you’ll hear from: Ellie Howe, patient advocate and founder of A Note of Hope, Ellen Tutton, patient advocate, Professor Alf Collins, former NHS England National Clinical Director for Personalised Care and trustee, the Patients Association.
  16. Content Article
    More information about "Department of Health and Social Care: Managing a robust and resilient supply of medicines (11 August 2025)"
    While at any one time the vast majority of medicines are in good supply, medicines shortages continue to present challenges to patient care at a global scale. This paper sets out the actions being taken by the Department of Health and Social Care and NHS England to protect patients from medicines shortages. This policy paper has three main objectives: To provide greater transparency of the supply chains the UK relies on and the action the Government is taking to protect patients from medicines shortages when they occur. To outline the steps they plan to take to further enhance processes for mitigating medicine shortages and to strengthen long-term resilience. These include: tangible measures around earlier identification of potential disruption enhanced reliability and timeliness of supply across the whole supply chain improving communication and guidance to different sectors strong international partnerships. To invite all partners across the health system and medicines supply chain to continue to work with the Government and the NHS to co-design and provide the changes needed to ensure a consistent and reliable supply of medicines to patients. Related reading on the hub There are a number of resources available on the hub on how medication shortages are affecting staff and patients, including: Medication supply issues: A pharmacist’s perspective - a interview with Darren Powell, Clinical Lead for NHS England and Community Pharmacist Medicines Shortages Policy: Solutions for empty shelves - a report from the Royal Pharmaceutical Society Medicines shortages: minimising the impact on patients - a blog by Catherine Picton All-Party Parliamentary Group on Pharmacy inquiry into medicines shortages in England
  17. Event
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    World Patient Safety Day (WPSD), which takes place annually on 17 September, was launched by the WHO in 2018 to raise public awareness, foster collaboration between stakeholders and mobilise global action to improve patient safety. This year's theme is Safe Care for Every Newborn and Every Child, with the slogan “Patient safety from the start!”, recognising the vulnerability of this age group to risks and harm caused by unsafe care. The WHO calls for urgent action to eliminate avoidable harm in paediatric and newborn care, driving meaningful improvements and reaffirming every child's right to safe and quality care. To help celebrate this year’s WPSD, the Royal College of Surgeons of Edinburgh (RCSEd) are hosting this webinar on the importance of system design in helping to ensure safety for neonates and children. This will feature a panel of paediatric surgery consultants, innovators and human factors experts discussing how we can best design systems and built environments to help ensure safety in paediatric surgical care. The importance of creating a simulated environment to allow people to fail safely and of ensuring appropriate psychological support when they do will be discussed. How to troubleshoot a build as a clinician to identify and ameliorate potential risks will also be covered. Also how we can adopt a multi-factorial system based approach to improving paediatric surgical care will be considered. The principles discussed will be transferable across all surgical specialties. Aims The aim of this webinar is to celebrate World Patient Safety Day and to help participants provide safe surgical care for every newborn and every child. Learning Objectives By the end of this webinar, participants will: Have a better understanding of World Patient Safety Day and the RCSEd’s commitment to patient safety. Appreciate the importance of simulation in learning and innovation, together with the value of being able to fail safely. Recognise the importance of appropriate support for staff when developing new services. Be better able to identify and ameliorate potential patient safety risks in any new infrastructure build. Be more confident in adopting a system wide, human factors approach when designing surgical services for neonates and children. Register here.
  18. Content Article
    This consultation seeks views on the following proposed changes affecting 4 professional groups: extending the list of medicines that paramedics can administer in emergency situations using exemptions within medicines legislation extending the list of controlled drugs that physiotherapist independent prescribers are legally able to prescribe enabling operating department practitioners to supply and administer medicines using patient group directions enabling diagnostic radiographer practitioners working at an enhanced, advanced or consultant practitioner level to become independent prescribers of medicines These proposals aim to make it easier for patients to get the medicines they need when they need them, while maintaining patient safety. This consultation closes at 11:59pm on 28 October 2025.
  19. Content Article
    Wearable smartwatches present a novel approach to continuous patient monitoring in ICU settings. This study evaluated the impact of smartwatch use on alarm response rates and clinical outcomes in a 27-bed intensive care unit (ICU). Nurses in the ICU wore smartwatches in wards and researchers evaluated their response to alarms and the efficiency of their nursing work. Their findings suggest that using wearable smartwatches can significantly improve alarm response rates, reduce alarm response times and the number of alarms, and decrease alarm fatigue and adverse events.
  20. Content Article
    Large language models (LLMs) are being used to reduce the administrative burden in long-term care by automatically generating and summarising case notes. However, LLMs can reproduce bias in their training data. This study evaluates gender bias in summaries of long-term care records generated with two state-of-the-art, open-source LLMs released in 2024: Meta’s Llama 3 and Google Gemma. Its findings reveal notable variation in gender-based discrepancies was observed across summarisation LLMs.  In this study, gender-swapped versions were created of long-term care records for 617 older people from a London local authority. Summaries of male and female versions were generated with Llama 3 and Gemma, as well as benchmark models from Meta and Google released in 2019: T5 and BART. Conclusions from this studies findings included: Llama 3 showed no gender-based differences across any metrics, T5 and BART demonstrated some variation, and the Gemma model exhibited the most significant gender-based disparities. Gemma’s male summaries were generally more negative in sentiment, and certain themes, such as physical health and mental health, were more frequently highlighted for men. The language used by Gemma for men was often more direct, while more euphemistic language was used for women. In the Gemma summaries, women’s health issues appeared less severe than men’s and details of women’s needs were sometimes omitted. While this study provides evidence of gender bias in LLM-generated summaries for long-term care, the findings are based on one specific domain and dataset. Further research is needed to assess whether similar patterns arise in other health and care settings, such as hospitals or mental health, where documentation styles and service models may differ.
  21. Content Article
    The Maternity and Neonatal Independent Senior Advocate (MNISA) role is being piloted across England following a series of high-profile maternity reviews. The role is designed to support families who have experienced the death or serious injury of their baby, or of a mother during NHS care, to help families navigate processes following the incident, ensure they are listened to, and ultimately influence system change. This report summarises the findings of the National Institute for Health and Care Research Rapid Service Evaluation Team’s assessment of the implementation, impact, and value of the role.
  22. Content Article
    The internet can be a great place to find out more about your health condition and find support. But it is crucial to make sure the information you find is trustworthy. Anyone can post anything online, including false health information. There are no laws stopping this. This page from the Patients Association is designed to help you find trustworthy information online.
  23. Content Article
    Researchers in this study sought to understand whether chatbots would repeat incorrect medical details embedded in a user’s question, and whether a brief prompt could help steer them toward safer, more accurate responses. Its results found that AI chatbots are highly vulnerable to repeating and elaborating on false medical information, indicating a need for stronger safeguards before putting these tools into use in health care. In this study the researchers created fictional patient scenarios, each containing one fabricated medical term such as a made-up disease, symptom, or test, and submitted them to leading large language models. In the first round, the chatbots reviewed the scenarios with no extra guidance provided. In the second round, the researchers added a one-line caution to the prompt, reminding the AI that the information provided might be inaccurate. Without that warning, the chatbots routinely elaborated on the fake medical detail, confidently generating explanations about conditions or treatments that do not exist. But with the added prompt, those errors were reduced significantly.
  24. Content Article
    The NHS Constitution states that people have a right to be involved in the NHS. By properly listening to people who use and care about services, the NHS can understand their diverse health needs better and focus on what matters. This helps to improve the quality of services, tackle health inequalities and make better use of public resources. The policy sets out how NHS England aims to meet its commitment to working in partnership with people and communities, including through roles such as patient and public voice partners.
  25. Event
    Continuing with the JCI Patient Safety Pathways Grand Rounds, the next session of the Grand Round on "Pediatric Patient Safety”. This session is being organized to commemorate World Patient Safety Day 2025 aligned with the theme ‘Safe care for every newborn and every child’. This upcoming session will feature a compelling conversation between internationally recognized leaders in the fields of Pediatrics and Patient Safety - Dr. Sara L. Toomey, Senior Vice President, Chief Safety and Quality Officer & Chief Experience Officer, Boston Children’s Hospital, Associate Professor, Harvard Medical School, United States; Dr. Ashok Kumar Deorari, Pro Vice-Chancellor, Swami Rama Himalaya University, Former Professor & Head, Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India; Dr. Marwa Ezz El Din, Patient Safety and Quality, Certified Patient Experience Professional, International Physician Surveyor, Joint Commission International, Dubai, United Arab Emirates; and Dr. Neelam Dhingra, Vice President and Global Chief Patient Safety Officer, Joint Commission International, Former Head, WHO Patient Safety and Blood Safety (2000-2024), Geneva, Switzerland. JCI invites you to register now to be part of this important initiative and share this information with your networks and social media channels. The registration is complimentary. Register

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