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Mark Hughes

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  1. Content Article
    This article provides an overview of a Parliamentary reception, hosted by Carolyn Harris MP, as part of the Safety for All campaign. The event was attended by over 50 guests including MPs, Peers, frontline healthcare professionals, patients and representatives from NHS organisations, regulators, charities, unions and industry.
  2. Content Article
    On the 18 April 2023 the Women and Equalities Select Committee published a report on Black maternal health. This analysed Government and NHS activities to date in this area and made a number of recommendations for further action needed to end disparities in maternal deaths. This paper sets out the UK Government’s response to the recommendations in this report.
  3. Content Article
    On the 23 January 2023 the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, announced the commencement of a rapid review into patient safety in mental health inpatient settings in England. The review Chair, Dr Geraldine Strathdee, was asked to consider how improvements could be made to the way that data and information is used in relation to patient safety in mental health inpatient care settings and pathways, including for people with a learning disability and autistic people. This report contains the findings of this review and an associated set of recommendations.
  4. Content Article
    This is the transcript of an oral statement to the House of Commons by Steve Barclay MP, Secretary of State for Health and Social Care, on improving safety in mental health in-patient services across England.
  5. Content Article
    This is an overview of the role and responsibilities of the National Patient Safety Committee. This was established in 2021 to bring key national healthcare organisations together to address complex patient safety issues that require cross-organisation effort and input to make care safer within the NHS.
  6. Content Article
    David Wilson was admitted to Pinderfields Hospital on 27 December 2022 and subsequently underwent a CT scan which indicated an inflammation in the distal section of his colon. To identify the cause of this he underwent a flexible sigmoidoscopy, during which there was a colonic perforation which resulted in his death the following day.
  7. Content Article
    In this blog Aiden Fowler, the National Director of Patient Safety in England and a Deputy Chief Medical Officer at the Department of Health and Social Care, reflects on progress made in implementing the NHS Patient Safety Strategy, four years on from its publication. He outlines some of the main programmes of work associated with this and considers their impact on avoidable harm in the NHS.
  8. Content Article
    The NHS Staff Survey is an essential tool for assessing the experiences and opinions of NHS workers in Trusts in England. It also provides valuable insights to help understand the speaking up culture in the NHS. In this report the National Guardian’s Office analyse the results of the 2022 NHS Staff Survey, focusing on questions relating to speaking up.
  9. Content Article
    This article highlights three questions tabled in the House of Commons relating to the Yellow Card Scheme, the system for recording adverse incidents with medicines and medical devices in the UK.
  10. Content Article
    The Global Patient Safety Action Plan was formally adopted at the World Health Assembly on 28 May 2021. It provides a 10-year roadmap and actions to work towards its vision of a world in which no one is harmed in healthcare and every patient receives safe and respectful care. This report provides a snapshot of progress made in achieving the strategic objectives and strategies of the global action plan based on the WHO Member State survey coordinated by the secretariat. This interim report will be replaced by a final Global Patient Safety Report 2023 later in the year.
  11. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the investigation into the death of Elizabeth Dixon in respect of the failures of care she received from the NHS.
  12. Content Article
    A formal diagnosis of dementia can help people living with the condition and their families gain a better understanding of what to expect and help to inform important decisions about treatment, support and care. Alzheimer’s Society estimate that in England, Wales and Northern Ireland there are over 300,000 people living with dementia who do not have a diagnosis. In this report they highlight barriers to accessing a timely and accurate dementia diagnosis and advocate for practical changes and tangible solutions to overcome them.
  13. Content Article
    Safe and Sound is a podcast produced by the Barts Health Education Academy which aims to have honest, informative and educational discussions about patient safety and how it can be improved. In this episode, Dr Charlotte Hopkins, an HIV consultant who works in patient safety and Dr Annie Hunningher, a consultant anaesthetist and patient safety specialist, discuss the pros and cons between two different approaches to patient safety, Safety 1 and Safety 2.
  14. Content Article
    This Strategy is based on a vision of Finland being a model country for client and patient safety in 2026. It is divided into four strategic priorities, each of which have three corresponding objectives aimed at strengthening patient safety. It is accompanied by an Implementation Plan so that these objectives can be translated into everyday activities. It was published by the Finnish Ministry of Social Affairs and Health, supported by preparatory work by the Finnish Centre for Client and Patient Safety.
  15. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, chaired by Professor Ted Baker, to consider ‘what does safety look like at a system level?’ and discuss the key issues and help support the development of Integrated Care Systems. This report captures the key themes covered in this discussion.
  16. Content Article
    In this report, the Public Accounts Committee, which examines the value for money of UK Government projects, programmes and service delivery, looks in detail at the implementation of NHS England’s three-year recovery programme for tackling the Covid-19 backlog of elective care.
  17. Content Article
    In this blog, the Healthcare Safety Investigation Branch (HSIB) reflects on the recent publication of the new National Safety Standards for Invasive Procedures (NatSSIPs 2) by the Centre for Perioperative Care. It outlines how these standards can help NHS organisations provide safer care and reduce the number of patient safety incidents, including a comment on this from Deinniol Owens, Associate Director of National Investigations at HSIB.
  18. Content Article
    In this article, John Tingle, Assistant Professor at the University of Birmingham Law School, discusses recent developments in patient safety in the context of possible reform of the clinical negligence system in the UK.
  19. Content Article Comment
    I don't think there has been anything similiar to the Nuffield analysis quoted here specific to mental health beds but its definitely an area that needs greater investigation. There was some analysis last year about the decrease in mental health beds more generally across the system (Guardian coverage here) and current occupancy levels remain above the recommended level (Royal College of Psychiatrists analysis here) but suspect that picture is more complicated regionally, you would imagine some areas are under much more strain than others. Also today's new National Audit Office report looking more broadly at mental health performance highlights bed occupancy issues.
  20. Content Article
    This report provides an overview of speeches, presentations and panel sessions held at the inaugural Safety for All conference, which took place at the Royal College of Physicians in London on Wednesday 7 December 2022. It has been published by the Safety for All campaign, which calls for improvements in, and between, patient and healthcare worker safety to prevent patient safety incidents and deliver better outcomes for all. The campaign is supported by Patient Safety Learning and the Safer Healthcare and Biosafety Network.
  21. Content Article
    This is a brief summary of a Westminster Hall debate in the House of Commons on the 31 January 2023 concerning the Essex Mental Health Independent Inquiry.
  22. Content Article
    This is a written statement to the House of Commons by the Parliamentary Under Secretary of State (Minister for Mental Health and Women’s Health Strategy), Maria Caulfield MP, on behalf of the UK Government. In this she provides an update on how £150 million of capital investment in NHS mental health urgent and emergency care infrastructure is being used and announces the commencement of a rapid review into patient safety in mental health inpatient settings in England.
  23. Content Article
    In a blog for National Voices, the leading coalition of health and social care charities in England, Patient Safety Learning’s Chief Executive Helen Hughes discusses an independent report written by risk expert Tim Edwards that highlights serious and widespread safety concerns around the misdiagnosis of pulmonary embolism.
  24. Content Article
    This study, published in The New England Journal of Medicine, looks at the frequency, preventability and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during 2018. From this sample, it identified adverse events in nearly one in four admissions, approximately a quarter of which were deemed as preventable.
  25. Content Article
    This is an Adjournment Debate from the House of Commons on Wednesday 7 December 2022 on fatalities relating to foetal valproate spectrum disorder.
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