Mark Hughes

Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In an article in the June issue (page 22), Patient Safety Learning's Helen Hughes talks about how Patient Safety Learning and the Royal College of Surgeons of Edinburgh are working together on a new wave of education, resources and support to empower surgical teams to embed safety into every aspect of their practice.

On the 19 March 2025 the Department of Health launched a consultation on the introduction of a new Regional Framework for Learning and Improvement from Patient Safety Incidents and supporting documentation to replace the current Serious Adverse Incident (SAI) Procedure in Northern Ireland. As part of this process, the Patient & Client Council held a public engagement event on this issue. This included members of the public with lived experience of the current SAI process, those with a general interest, members of the voluntary and community sector, health and social care staff and leaders, healthcare regulation and Patient & Client Council members. This report summarises the views expressed in this event and follow-up written responses shared with Patient & Client Council. They heard from a range of views and experiences, and we have collated these under key themes arising from the engagement conversations. Some of these themes were reflected in the answers to more than one question.

At the start of 2025, the NHS Race and Health Observatory sponsored an infographic, explaining how healthcare professionals can spot the signs of jaundice in babies with dark skin tones. This infographic below, designed by Dr Helen Gbinigie and Dr Oghenetega Edokpolor, in collaboration with FiveXMore and Bliss, serves as a guide for parents' for recognising jaundice in Black and Brown babies, including where and how to seek help.

‘The Month’ is a new publication from NHS England which provides a strategic update for health and care leaders. This edition includes details of the 100 day plan for Sir Jim Mackey’s first few months as NHS England Chief Executive, information about the new Urgent and emergency care plan 2025/26 and highlights of other recent healthcare publications and developments.

The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines, medical devices and blood components for transfusion in the UK. This roundup provides a summary of their latest safety advice for medicines and medical device users. It includes details of medicine recalls, medical device field safety notices and details of how to report drug reactions and device incidents.

Prioritising patient safety is a quarterly blog series from the Parliamentary and Health Service Ombudsman (PHSO). Each month, PHSO publishes 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 highlights how the PHSO is working with NHS England to improve NHS imaging services and looks at cases that show how organisations are making complaints count by listening, learning and putting things right.

Each year since May 2023 the Sands & Tommy’s Joint Policy Unit have published an annual report setting out the extent of pregnancy and baby deaths across the UK. This year’s report argues that progress made to date falls short of what is needed to stop babies dying every day in the UK, and that unacceptable inequalities in pregnancy and baby loss persist despite continued calls for change. It estimates that at least 2,500 fewer babies – the equivalent of around 100 primary school classrooms - would have died since 2018 if the government had achieved its ambition of halving the 2010 rates of stillbirth, neonatal and maternal deaths in England. The report draws on the latest data from MBRRACE-UK, which shows that the gap continues to grow between neonatal death rates in the most deprived areas and those in the least deprived areas of the UK. It highlights that the stillbirth rate among babies of Asian ethnicity has risen sharply, and Black babies are still twice as likely as White babies to be stillborn. It includes 10 key actions for policymakers Renew commitments to save babies’ lives. Specifically, a stillbirth rate of 2.0 stillbirths, and a neonatal mortality rate of 0.5 neonatal deaths for babies born at 24 weeks’ gestation and over (per 1,000 live births). A preterm birth rate of 6.0%. Count miscarriages in the UK. The number and rate of miscarriages are not reported across the UK or for any individual nation. All UK governments should set up routine data collection on miscarriage. Take coordinated and meaningful action to eliminate inequalities. There are a range of policy areas where specific action is needed, including: understanding whether current efforts to reduce inequalities are working, and a comprehensive review of translation and interpreting services in maternity and neonatal care. Strengthen national leadership to make progress on the safety of maternity and neonatal services. Clarify the workforce needed to deliver safe care. Future development of the workforce must move away from a binary debate focussed on whether we do or don’t have enough staff and focus on the staffing requirements needed to deliver safe care, in line with nationally-agreed standards. Put the resources needed in place to deliver safe care. More investment is needed to improve the safety and quality of services if the government is going to deliver on its commitments to reduce rates of stillbirth and neonatal death and eliminate inequalities. Make informed choice a reality. Everyone should receive personalised care, know what they are entitled to, such as their birth choices, and services need the resources and operational capacity to provide this. Address unwarranted variation in care. Too often babies are dying because of care that is not in line with nationally-agreed standards. We need clarity on how national guidance is applied and clear national standards to improve the consistency of service provision. Ensure lessons are learned when babies die. The NHS is still not properly learning lessons when babies die or listening to the experiences of bereaved families to improve care in the future. There must be more robust oversight of the implementation of actions that are identified by reviews and investigations. Prioritise pregnancy and baby loss in research. This requires a broad range of research topics, the involvement of bereaved parents and communities, and a strong connection with policy and practice.

This framework sets out 5 principles to reduce patient safety healthcare inequalities across the NHS. It outlines opportunities for implementation that local teams and Integrated Care Boards (ICBs) can take up, as well as the work NHS England is taking nationally to support and enable this. These principles align with the aims of NHS England’s Patient safety strategy and Core20PLUS5 approach for adults and for children and young people to address healthcare inequalities. Principle 1 – All staff, patients, service users, families and carers have access to information, translation and interpretation services when needed. National actions: Publish a framework for community language, translation and interpretation. Opportunities for local implementation: Improve every interaction between patients and healthcare staff. Make communication at all levels culturally and linguistically appropriate. Make information clear and accessible. Minimise the risk of digital exclusion. Reduce communication barriers. Principle 2 – All healthcare staff receive undergraduate patient safety training, ongoing training, and accessible resources that improve their awareness and understanding of healthcare inequalities related to patient safety risks. National actions: Co-develop and publish a patient safety healthcare inequalities reduction handbook to provide guidance and ‘top tips’ for use by individual clinicians, organisations, patients and communities. Opportunities for local implementation: Improve training. Develop a repository of accessible resources. Principle 3 – Accurate and complete diversity data are collected for protected characteristics and inclusion health groups on digital platforms. This work includes making disaggregated data available so evaluation can drive improvements in patient safety and healthcare inequalities. National actions: Clarify the requirements for reducing healthcare inequalities related to patient safety at the provider, ICB, regional, and national levels through the delivery of quality functions in the ICSs document on the ICS Quality Hub FutureNHS Collaboration Platform. Develop the LFPSE service to record the protected characteristics of those involved in patient safety events to identify when patient harm is more common in specific groups of patients, and whether there is case selection bias in patient safety incident investigations (PSIIs). Opportunities for local implementation: Use data on health inequalities to improve safe care. Principle 4 – Representatives of diverse communities are involved in the design and delivery of improvements aimed at reducing patient safety healthcare inequalities. This co-production involves drawing on the knowledge and experience of patients, service users, carers, families, communities and staff. National actions: Promote the recruitment of diverse Patient safety partners (PSPs) and their value in co-production in all areas of patient safety improvement work by providing information, guidance, surveys and tools for support. Opportunities for local implementation: Involve patients and diverse communities in developing patient safety improvements. Principle 5 – Improve the understanding of patient safety healthcare inequalities and drive improvement through identifying priority areas for research. National actions: Submit proposed patient safety healthcare inequalities reduction research questions to the next round of NIHR funding opportunities. Opportunities for local implementation: Identify and enable research.

In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations. The aim of this report is to examine patient safety risks identified across the following HSSIB investigations: Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024) Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024) Mental health inpatient settings: out of area placements (21 November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024) Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025) Findings Safety, investigation, and learning culture There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations. System integration and accountability The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness. The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned. Physical health of patients in mental health inpatient settings There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness. The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes. National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely. Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness. There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs. There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place. Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity. Caring for people in the community Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations. Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement). Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care. Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed. There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients. Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country. Staffing and resourcing Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care. In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’. Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services. There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model. Digital support for safe and therapeutic care A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers. Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure. Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots). Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones. Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe. Suicide risk and safety assessment ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this. Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them. Safety recommendations HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems. Safety observation National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.

Jacqueline Anne Potter, known as Anne, was a 54 year old teacher who died by suicide following a decline in her mental health. Anne died during overnight leave from an acute psychiatric unit in Somerset, where she was being looked after because of mental health issues exacerbated by menopause. In this report, the coroner raises concerns about her care and the lack of importance given to menopausal care in the NHS. Coroner's matters of concern Overnight leave arrangements When Anne was sent on her first overnight leave there was no codified ‘risk’ and ‘safety planning’ document. While in Anne’s case the report notes that it was widely accepted that her husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, the Coroner noted that this may not apply in other cases. The report said that whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained. The Coroner suggests that this could help equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones while they are in the community. Internet access in mental health settings The report notes that it found that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide. The Coroner noted that workplace organisations do have the ability to block sites if they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content, etc). The report states that by allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths. Menopausal care The Coroner noted several areas of concern about menopausal care available on the NHS: Menopausal training is not mandatory in any area of clinical practice or specialism. The Coroner expressed concerns that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as mental health practice, obstetrics and gynaecology, and oncology, or even general as a general GP. The Coroner noted that she was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations. Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist. She also noted that: “I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms. If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.” Concluding, the Coroner referenced being told in a response to a previous Prevention of Future Deaths report where she raised similar concerns about a roll-out of specialist menopausal care and upskilling of GPs. She stated that from reviewing this case there was little evidence that this has happened/is happening and said that women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing.

Antimicrobial resistance (AMR) a critical global health threat that undermines the safety of routine medical procedures and reverses many advancements in modern medicine by making antimicrobials ineffective to treat infections. Inappropriate use of antimicrobials is a major driver of AMR. This Global Antimicrobial Resistance and Use Surveillance System (GLASS) report describes global progress in antimicrobial use surveillance and antibiotic use in 2022, reported by 60 countries.

This guidance offers high-level information to assist those adopting ambient scribing products that feature Generative Artificial Intelligence (AI), for use across health and care settings in England. These products are sometimes referred to as ambient scribes or AI scribes and include advanced ambient voice technologies (AVTs) used for clinical or patient documentation and workflow support. The guidance is intended for settings aiming to implement a specific product or function of an existing product. 

Samuel Brookes was discharged home from Russells Hall Hospital, Dudley, on the 8 April 2024 where he had been admitted following a fall and long lie at home. The hospital arranged his transportation without rearranging his required care of two carers, four times a day. Mr Brookes, who was immobile and lived alone, was transported to his bed where he could not reach his pendant alarm nor his mobile phone, which was in another room. Mr Brookes was left unattended for two weeks, until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall. An ambulance was called, sadly on arrival paramedics confirmed that Mr Brookes was deceased and his death was declared at 11:37 hours. The Coroner in his report highlighted the following matters of concern: The hospital arranged for Mr Brookes transportation home without rearranging the required care. There was no record or documentation or process to show or demonstrate that the care had been rearranged. The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner. Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help.

Effectively tackling the challenge of antimicrobial resistance (AMR) requires a co-ordinated and strategic approach across healthcare settings. Antimicrobial stewardship (AMS) is an important element of this work. This publication outlines the functionalities that clinical digital systems need to support optimal antimicrobial stewardship (AMS) in primary and secondary care. It should be read alongside the Digital framework for antimicrobial stewardship – what good looks like, which sets out an organisational and system approach to ensuring good digital functionality for antimicrobial stewardship.