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Mark Hughes

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  1. Content Article
    More information about "Patient safety and the regulation of AI in healthcare"
    In this blog, Patient Safety Learning highlights the key issues included in its response to the Medicines and Healthcare products Regulatory Agency’s (MHRA) call for evidence on the regulation of artificial intelligence (AI) in healthcare. At Patient Safety Learning we recognise the potential of the use of AI to improve patient care and outcomes. However, we believe it is vital that patient safety considerations are hardwired into the implementation of these solutions. One of the key ambitions of the UK Government, set out in its 10 Year Health Plan, is to “make the NHS the most AI-enabled care system in the world”.[1] In support of this goal, in September 2025 the MHRA announced the creation of a new National Commission into the Regulation of AI in Healthcare.[2] The Commission’s purpose is to advise the MHRA on improving its regulatory framework and to “accelerate safe access to AI in healthcare and across the NHS”.[3] To inform its work, in January the MHRA launched a call for evidence on the regulation of AI in healthcare. Below we summarise the key points included in our response to this. Improving the regulatory framework The NHS should adopt a systems approach to patient safety with this at the heart of the initial procurement, design and configuration of new technological solutions provided by AI. This approach should also be reflected in the framework for regulating these technologies. Existing regulations are designed around traditional medical devices, which range from surgical instruments to diagnostic scanners. We believe these regulations need a significant update to respond effectively to the growing use of AI in healthcare and the adaptive nature of this technology. In our response to the call for evidence, we have highlighted several areas which we think should be considered when updating this. Developing and testing AI In our response, we stated that there should be a single “front door” regulating AI as a medical device. By this, we mean there should be a standardised process for regulating these technologies, in terms of guidance, requirements and approval processes. This should bring together the MHRA, NHS England and the National Institute of Health and Care Excellence (NICE). We also have suggested that there should be an expansion of targeted sandboxes and testbeds, so AI developers can generate real world evidence with NHS data and workflows, under MHRA oversight. A sandbox is a controlled environment where AI can be developed, tested and experimented with safely, without affecting real individuals or sensitive data. The outcomes of these tests could subsequently be linked to clinical safety cases that manufacturers and healthcare providers have to complete. A clinical safety case is a current regulatory requirement for digital solutions. It sets out, with supporting evidence, an argument that a digital system is safe for use in healthcare. How regulation interacts with professional competency While an AI tool may be safe when properly implemented and used by a well-trained healthcare professional, it could be potentially dangerous if such training and support is absent. As such technologies are increasingly used, ensuring staff have adequate levels of digital literacy will be vital. Without this, an overreliance on automated systems and algorithms could create new patient safety risks. Ensuring inequalities are not embedded in new systems Data accuracy, completeness and representativeness is key to ensuring safe AI systems in health and care. As we increase the use of AI health technologies, it is important we avoid reproducing historic biases, particularly relating to groups with protected characteristics. Steps should be taken to ensure the data used to train and develop AI models reflects this. Cybersecurity Cyber attacks present a significant risk to patient safety; one which will only grow with the increased digitalisation of health services. In our response to this call for evidence, as also noted in our response to the 10 Year Health Plan last year, we set out the need for a greater focus on cybersecurity in the regulatory framework.[4] Patient engagement In our response, we posed the question of how patients and families will be informed and engaged in the use of AI. The public needs to be confident that they can trust their healthcare providers to use AI safely and there needs to be mechanisms that inform and support this. There also needs to be consideration on how the public will be guided on their own use of AI if they directly access information and guidance and not via regulated health and care professionals. AI that is not a medical device When considering the future regulation of AI in healthcare, a yet unresolved issue we highlighted in our response concerns how technologies that do not meet the specific requirements to qualify as a medical device will be regulated. There may be new tools used in healthcare settings that could have a significant impact on patients’ safety, experience and outcomes but are not covered by the existing definitions. Who regulates these? Monitoring AI health technologies in use The call for evidence asked for views on how regulation should approach the post-market surveillance of AI health technologies. Post-market surveillance refers to requirements on manufacturers of medical devices to monitor their products once they are being used by healthcare providers. In our response, we suggested that a different approach to this may be needed when it comes to AI, because these technologies have significant scope to evolve and change over time. For example, an AI system may initially work well in a single site but subsequently fail when rolled out in a more complex health and care setting. Or it may, over time, change in terms of its capabilities, role and risk profile as it processes more data, significantly changing the way it operates. Further to this, there may be a need to reassess AI tools when they undergo significant version upgrades or model changes. Therefore, new regulation needs to carefully consider the level of ongoing evaluation that will be required to account for these systems evolving and changing over time. This may be for significantly longer than for other medical devices and change at significant pace. We also noted the need to consider oversight of AI as part of the ongoing review of the existing clinical assurance standards and processes in the NHS: DCB0129 and DCB160.[5] These standards provide essential requirements for manufacturers of health IT systems and healthcare providers in assessing and managing clinical risks to ensure the safety of digital solutions in the NHS. We highlighted various issues around the importance of ongoing monitoring and sharing learning during post-market surveillance, including: The importance of having in place sustained and transparent feedback loops between developers, regulators and care providers. The need to encourage continuous monitoring to be standard practice. Automated dashboards and audits should be employed to detect safety issues and initiate regulatory review where needed. The value of having effective means of sharing information about patient safety incidents and risks between providers and manufacturers. This should be supported and aided by regulators. Considering how the patient voice is incorporated into post-market surveillance and how patients’ experiences inform this. Shared responsibility for delivering safer care In our response, we set out that we believe everyone involved in healthcare – national bodies, individual providers, healthcare professionals, industry and patients – has a role in ensuring patient safety. Responsibility for the safety of such systems should be shared over the full life cycle of an AI health technology. In its final question, the call for evidence asked about where liability would lie in the case of where an adverse patient outcome involved an AI tool. There is currently significant ambiguity around this, and few legal test cases. It is also potentially complex, tying into the previous point we mentioned earlier about the boundary between appropriate training and support and professional accountability and regulation. This is an area where we think national leadership is required to establish these boundaries, from the Department of Health and Social Care and MHRA. In our view, there should be collaborative working to convene key stakeholders to provide clarity and guidance in this area, including NHS Resolution, professional regulators such as the General Medical Council, and system regulators such as the Care Quality Commission. This is a matter that should be considered UK wide, as the issues relate equally to England, Northern Ireland, Scotland and Wales, and should be informed by discussions in European and internationally. References Department of Health and Social Care. 10 Year Health Plan for England: fit for the future, 3 July 2025. MHRA. National Commission into the Regulation of AI in Healthcare. Last accessed 2 February 2026. MHRA. New Commission to help accelerate NHS use of AI. 26 September 2025. Patient Safety Learning. 10 Year Health Plan: Patient Safety Learning’s Response, 14 August 2025. NHS England. Review of digital clinical safety standards: DSC0129 and DCB0160. Last accessed 2 February 2026. Related reading Artificial intelligence and patient safety in healthcare: Insights and recommendations from HETT 2025 roundtable (10 November 2025) Clive Flashman. Copilot has arrived in the NHS — But no one told us how to fly it! 25 November 2025 Patient safety and the role of AI in a cautiously optimistic future: A blog by Ian Fearnley. 19 August 2025. Professional regulation and patient safety systems: parallel planets or partners in improvement? (5 November 2025)
  2. Content Article
    Patients and families often raise concerns long before serious harm occurs — but too often those early warnings are missed. In this blog, Paul Whiteing, Chief Executive of the Action Against Medical Accidents (AvMA), looks at why curiosity about what patients and families say and report is vital to effective safety
  3. Content Article
    The Patient Safety Commissioner for England, Professor Henrietta Hughes, has announced she will approach Number 10 directly to secure financial redress for those harmed by pelvic mesh and the medicine valproate, following a Government update that provides no timetable for decisions on financial compensation. The announcement comes nearly two years after the publication of the Hughes Report in February 2024, which examined options for redress for patients and families affected by these interventions. The report followed earlier advice provided to the Department of Health and Social Care in October 2023. In October 2025, Professor Hughes wrote to Dr Zubir Ahmed MP, Parliamentary Under-Secretary of State for Health Innovation and Safety, using her powers under Schedule 1, paragraph 3 of the 2021 Medicines and Medical Devices Act. This legislation authorises the Patient Safety Commissioner to access information, documents or records considered necessary for the exercise of her functions. Professor Hughes sought information about the steps that had been taken by Ministers and officials to respond to her report and its ten recommendations on redress. She subsequently received two responses to this: Letter from Dr Zubir Ahmed MP, dated 28 November 2025 Letter from Dr Zubir Ahmed MP, dated 30 January 2026 Commenting on this on the 2nd February 2026, the Patient Safety Commissioner issued the following statement: “I welcome Minister Ahmed’s acknowledgement that financial redress is part of the Government’s thinking. However, acknowledgement alone does not provide justice to the thousands of patients and families who have been harmed. What is starkly absent from this update is any commitment to a timetable for action. Nearly two years after publishing my report, patients are still waiting for action and financial redress. Patients’ lives don’t grind to a halt while Government departments debate jurisdiction and timelines. I am grateful for the Minister’s personal commitment and the progress on non-financial aspects. But the reality remains that the Department of Health and Social Care does not have the agency to deliver financial compensation. That authority sits with the Treasury and Number 10. I will now be approaching Number 10 directly, using the power to request information under the 2021 Medicines and Medical Devices Act if required. This is very much unfinished business and I will not stop holding Government to account until this is resolved for the patients and families harmed.” Related reading First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review (8 July 2020) The Hughes Report: Options for redress for those harmed by valproate and pelvic mesh (Patient Safety Commissioner for England, 7 February 2024) A year on from The Hughes Report: Urgent action needed on redress (Patient Safety Learning, 7 February 2025)
  4. Content Article
    In this report the Public Accounts Committee states that, although the as UK government’s liability for clinical negligence quadrupled over 20 years, the Department of Health and Social Care (DHSC) is unable to show any meaningful action taken to address this. They also argue that the NHS has not done enough to tackle the underlying causes of patient harm. This report was published as part of an inquiry by the Public Accounts Committee looking specifically at the costs of clinical negligence claims. The Committee examines the value for money of UK Government projects, programmes and service delivery. Key conclusions and recommendations in the report are as follows: DHSC has failed to tackle the rising costs of clinical negligence despite repeated warnings. The report notes that the government’s liability for clinical negligence has quadrupled in real terms since 2006–07, reaching £60 billion in 2024–25. Annual settlement costs have tripled to £3.6 billion in 2024–25 with forecasts suggesting the cost of clinical negligence will continue to rise significantly in coming years. It recommends that: Alongside its Treasury Minute response to this report DHSC should write to the Committee explain its operational plan to tackle clinical negligence, including key milestones for achieving reductions in claim costs and volumes. DHSC should also publish David Lock KC’s review of clinical negligence within six months of it being completed. This should include all supporting analysis and the Department’s response to any recommendations made by the review. The NHS has not done enough to tackle the underlying causes of harm to patients. The report states that DHSC and NHS England’s (NHSE) approach to patient safety lacks coordination and that patients often pursue legal action to get answers and accountability due to a confusing and unresponsive complaints system. It recommends that: DHSC must set a national framework for improving patient safety with clear targets for annual improvement. DHSC must review the NHS complaints system and improve the number of cases that are resolved without recourse to litigation. DHSC should estimate and track the costs to the NHS of treating avoidable harm. DHSC should write to the Committee to set out progress in implementing the Dash Review and its assessment of the impact of abolishing the Health Services Safety Investigations Body (HSSIB) on patient safety. DHSC and NHSE should have a clear system of accountability for patient safety, learning from mistakes and sharing what works, implementing best practice across the NHS streamlining patient safety alerts and recommendations from national bodies. We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. The report states they are disappointed that neither the Department nor NHS England could adequately explain how the NHS uses its extensive data on patient harm to identify and address the underlying causes of clinical negligence. It recommends that: DHSC should establish a national system for sharing data between trusts and analysing trends. If there are barriers to sharing protected data, it should develop analysis on an anonymised basis to pull out lessons and provide early warning alerts to trusts DHSC, NHSE and NHS Resolution should explore the use of artificial intelligence to analyse live data, detect discrepancies and outliers quickly, and improve the speed of early warning systems. The Department’s failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. It recommends that: DHSC and the organisations it funds need to learn lessons from its failure to improve maternity care in England. Where problems arise the Department and the wider NHS should look for systemic failings in care and tackle these problems at their cause. DHSC should publish the Amos Review within two months alongside its response and set out how it plans to reduce the incidence of harm and the costs of claims in maternity care. Legal costs in clinical negligence claims are disproportionate for medium and low volume claims. It recommends that: DHSC should develop alternative dispute mechanisms to speed up decisions and reduce costs for less complex cases. As part of this, the Department should look at international examples (such as in New Zealand and Sweden) of non-adversarial and ombudsman models and assess how our ombudsman system could be improved. DHSC should clarify its position on a fixed recoverable costs scheme for lower-value clinical negligence cases at the earliest opportunity. Clinical negligence claims are settled on the basis of costs of care in the private sector and yet there is nothing to stop the claimant using the NHS or publicly funded social care in the future, potentially inflating the costs of claims. It recommends that: DHSC should develop, within six months, proper estimates of the impact of assuming health and social care for clinical negligence victims will be provided exclusively by the private sector. It should by the same deadline set out additional measures—including any requiring changes to legislation—which it judges would effectively guard against the risk of paying twice for the care of those it has harmed and an indicative timeline for their potential implementation.
  5. Content Article
    In 2022 concerns were raised about the practice of a Consultant Orthopaedic Surgeon, Mr Yaser Jabbar, who worked at Great Ormond Street Hospital NHS Foundation Trust from 2017 to 2022. The Trust commissioned the Royal College of Surgeons (RCS) to review both his work and the broader Orthopaedic Service. The RCS recommended a detailed review of approximately 200 of Mr Jabbar’s patients. The Trust expanded this to include all patients he had seen, initiating a full recall of 721 individuals in February 2024. This review found 98 patients (12.4%) experienced some level of harm, and 94 of these cases were linked to specifically the care provided by Mr Jabbar. Harm gradings ranged from mild, such as an unnecessary general anaesthetic, to severe gradings for situations like delayed diagnosis of complications or surgery that did not achieve the intended outcome.
  6. News Article
    Nearly 100 children were harmed by a Great Ormond Street Hospital limb reconstruction surgeon, a review has found. The investigation, published by the world-famous London hospital into Yaser Jabbar, found widespread evidence of unacceptable practice in the botched operations he carried out. Jabbar worked at the hospital between 2017 and 2022, providing care to 789 children – 94 of them came to harm, GOSH's report concluded. Most of those – 91 – were patients he did surgery on. He specialised in limb-lengthening and reconstruction for children with complex problems. Read full article. Source: BBC News, 29 January 2026
  7. Content Article
    In this blog Greg Quinn, Director of Public Policy & Advocacy for BD UK & Ireland, reflects on the need for a systems-based approach to patient safety, set out in the recent report Patient Safety System Foundations: A Call for Action. He explores the critical role health technology can play as a partner in building safer, more resilient health systems for patients and healthcare professionals alike.
  8. Content Article
    Produced by Patient Safety Watch in partnership with the Institute of Global Health Innovation at Imperial College London, this report considers the current state of patient safety around the world. The report compares patient safety performance across 38 Organisation for Economic Co-operation and Development (OECD) countries, using four internationally comparable indicators: Maternal mortality Neonatal disorders Treatable mortality Deaths due to the adverse effects of medical treatment On this basis, Norway ranks first in the world for patient safety, while the UK ranks 21st, unchanged since their previous report in 2023. Based on its findings, the report updates and expands on the three recommendations made in their 2023 report: To create a more comprehensive set of global patient safety indicators, they encourage international organisations focused on safety and quality to develop a roadmap to improve data coverage in LMICs. The example of maternal and neonatal safety data shows how collective action can lead to global coverage, supporting safety improvement efforts. To support improved adoption of best practice in patient safety, they advise countries to use our patient safety dashboard, international insights, and ambitions for national patient safety systems to learn from best practice in core aspects of patient safety. These tools complement emerging resources, including the WHO Global Knowledge Sharing Platform for Patient Safety. To help ensure patients, families and carers become active partners in the delivery of safe care, they advocate national and international action to address the inequities in safe care identified in this report. Their case studies demonstrate how patients and the public can become part of the solution, helping to design and inform national policies and interventions for safer care.
  9. Content Article
    The National Health Service (NHS) in England boasts one of the largest and longest running suites of patient and workforce experience surveys anywhere in the world. Its various national surveys have tracked changes in people’s experiences of care for a quarter of a century and have provided a blueprint for similar collections internationally. Although the NHS gathers feedback from patients, service users, and staff across a broad range of health and care settings, the results of these surveys tend to be viewed separately and in isolation. This report brings together the results from nine national patient and staff experience surveys that Picker coordinated across 2024 and 2025 on behalf of the Care Quality Commission and NHS England. It maps the results against the Picker Principles of Person Centred Care to give an overview of the state of person centred care in the NHS in England. Key findings highlighted by this report include: Quality of care Patient perceptions of the overall quality of NHS care are largely positive, although variations in the level of positivity occur dependent on the setting. In particular, adult and child cancer care was viewed positively, while mental health services and accident and emergency (A&E) services1 have clear room for improvement. Substantive NHS staff largely reported that they would be happy with the standard of care provided by their organisation if their friends or relatives needed treatment – however, only a small proportion ‘strongly agree’ with this statement Fast access to reliable healthcare advice Patients reported concerns about waiting times, with variation across different care pathways. Patients experienced long waits for care in urgent and emergency and adult inpatient care, and reported that long waits have negatively impacted their health in community mental health and inpatient care settings. Effective treatment by trusted professionals People generally told us that they felt confident in the staff that were treating them. However, results were more mixed when parents of children and young people receiving hospital care were asked this question, and people receiving maternity care reported that their confidence in staff varied at different points along the pathway. There is room for improvement in the support offered to patients with pre-existing medical conditions, who require access to their regular medication while in a healthcare setting. The proportion of staff reporting that their team regularly meets to discuss effectiveness has improved in recent years, but there remains room for improvement. Continuity of care and smooth transitions Patients and their families/carers generally reported poor experiences when asked whether staff seemed aware of their medical history, particularly in community mental health services and children’s cancer care. However, collaboration between staff and teams was perceived to be strong in adult cancer care. Just over half of staff reported that teams in their organisation work well together to meet their objectives. Clear information, communication and support for self-care Patients tend to understand the information they receive about their health and care: however, this is less likely in A&E departments. People would also like to receive clearer information about next steps, particularly when leaving hospital after receiving inpatient or urgent and emergency care. People’s experiences of being informed about holistic support varies; adult cancer patients felt well-informed, but those accessing community mental health services did not. Staff reported high levels of pressure on their time while at work, which is likely to impact the ability of patients and their families/carers to ask questions Emotional support, empathy and respect The majority of people felt that they are treated with dignity and respect by healthcare staff. However, results from the community mental health and maternity surveys showed poorer patient experiences compared to other patient surveys. While most staff reported positive interactions with patients, their families/carers, and the public, we know from the NHS Staff Survey results related to discrimination, abuse, bullying and harassment that some interactions can result in staff experiencing unacceptable behaviours. Most staff agreed that they are treated with respect by their colleagues, and that their colleagues are polite, understanding and kind. Involvement in decisions and respect for preferences National surveys showed that patients currently lack opportunities to feel fully engaged in decisions about their health and care, while only half of staff reported being involved in decisions that affect their work. These results suggest there is room for improvement in wider culture around involvement and decision-making, for both staff and patients. Involvement and support of families and carers People receiving maternity care reported positive experiences of family involvement, but there are challenges in involving families in urgent care and in crisis mental health support. Attention to physical and environmental needs Patients generally felt they were given enough privacy when accessing health care, with the exception of urgent and emergency care where there is room for improvement. Patient and staff feedback shows that there is a need to address access to food and amenities in care settings. Considering the aspirations for digital transformation outlined in the Ten Year Plan, the lack of access to reliable Wi-Fi suggests there is a fair way to go to improve NHS digital capabilities.
  10. Event
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    Picker published its first State of Person Centred Care report on 29th January 2026, which brings together the findings from the nine national experience surveys they are commissioned to deliver on behalf of the Care Quality Commission (CQC) and NHS England and mapped them against their eight Principles of Person Centred Care. Their report also includes examples of existing best practice and a set of recommendations to strengthen patient voice in the NHS of today and tomorrow. This webinar will explore the report and its findings in more detail, with presentations from members of the Picker team, and an opportunity for audience questions. Register here.
  11. News Article
    The NHS has reduced the use of physician associates after a government review found that they were being used as a “substitute” for doctors, a survey has suggested. The number of physician associates (PAs) averaging more than 11 patient interactions — including consultations, follow-ups, results and referrals — per shift, has dropped since publication of the Leng review in July. More than three-quarters (76 per cent) of PAs said their scope of practice had been restricted in recent months. The findings come from a survey of 457 associates by United Medical Associate Professionals (UMAPs), the physician associates union. Read full article (paywalled). Source: The Times, 29 January 2026
  12. News Article
    As an increasing number of people turn to mental health apps and technologies for support, the Medicines and Healthcare products Regulatory Agency (MHRA) has published guidance on how to use the tools safely. Not all digital mental health technologies are regulated as medical devices – some are instead classed as wellbeing or lifestyle products, which means they may not have been through the same checks. MHRA and NHS England have developed free online resources for the public, parents, carers and professionals which use short animations and real-world examples to show what safe, well-evidenced digital mental health technologies look like, and explain how to report concerns through the MHRA Yellow Card scheme. Read full article. Source: Digital Health, 28 January 2026
  13. News Article
    Surgeons can safely perform two common operations from distances of up to 1,700 miles, a new study has found. New research delved into telesurgery, a cutting-edge technique that allows medical professionals to operate on patients remotely using a surgical robot connected via a secure video-link. Academics in China initiated the study, highlighting that robust evidence on this method has previously been "scarce". Their primary aim was to ascertain whether telesurgery could achieve results comparable to, or "non-inferior" to, those from robotic-assisted surgery performed locally. Some 72 patients were randomly assigned to be given telesurgery or local surgery, with the main measure of success the outcome of the surgery. The researchers found telesurgery “was not inferior to local surgery in terms of the probability of surgical success”. Read full article. Source: The Independent, 29 January 2026
  14. Event
    Antimicrobial resistance (AMR) is a growing threat to global health. Misuse of antibiotics, limited awareness, and gaps in infection prevention make common infections harder to treat and place patients at increased risk. The World Patients Alliance works with patient groups across regions that face rising impacts of AMR, including delayed treatment, higher treatment costs, and preventable complications. In this webinar they will focus on the shared roles of patients and healthcare providers in addressing AMR. It will open with an overview of current AMR trends and why everyday decisions by patients and provider’s matter. The session will then highlight how patient education, responsible prescribing, and effective communication can reduce unnecessary antibiotic use and support safer care. A panel discussion will bring together patient leaders and clinicians to share practical actions that strengthen awareness, prevention, and stewardship. The webinar aims to show that reducing AMR requires coordinated effort, informed choices, and strong engagement from both patients and providers. Key Objectives Explain the current burden of antimicrobial resistance and its impact on patient care. Highlight the role of patients in preventing AMR through responsible antibiotic use and infection prevention practices. Describe how healthcare providers support stewardship through accurate diagnosis, appropriate prescribing, and clear communication. Present practical examples of patient–provider collaboration that improves awareness and reduces unnecessary antibiotic use. Encourage patient organizations to promote education and community engagement that supports AMR prevention efforts. Register here.
  15. Content Article
    In this article Jeremy Hunt argues that closing the UK’s patient safety gap must become a core national priority. He reflects on new data highlighted in the Institute of Global Health Innovation and Patient Safety Watch report, Global State of Patient Safety 2025, which shows tens of thousands of deaths could be prevented by matching the performance of leading health systems.
  16. Content Article
    This plan sets out new actions to address health inequalities faced by women and girls in Scotland. Building on the first Women’s Health Plan, these actions seek to advance the Scottish Government's ambition that all women and girls in Scotland enjoy the best possible health throughout their lives. The Plan identifies four priority programmes as part of this second phase of the Women’s Health Plan. These programmes are in addition to, and complement, the 40 actions with the aim of driving forward progress in women’s health. Transformation of Gynaecology Services - The Scottish Government will develop, and NHS Boards will implement, a National Plan for Gynaecology. This programme of service transformation will ensure the timely provision of high-quality gynaecological care which is sustainable for the future. Elimination of Cervical Cancer - The Scottish Government will develop, publish and implement an Action Plan for the Elimination of Cervical Cancer. Women’s Brain Health - Women’s Brain Health will be an early priority for the work of the Brain Health and Dementia Risk Group, led by the Chief Medical Officer (CMO), which is setting national priorities in response to emerging evidence around risk factors for dementia. Innovation to Support Women and Girls - We recognise the transformative impact of innovation and its pivotal role in ensuring women and girls have access to the best-quality care. To support the testing, adopting and scaling of innovations to support women and girls we will explore the innovation opportunities, working with our three NHS Scotland Innovation Hubs and partners across Scotland, around three key priority areas: menopause care and support, gynaecological care and support and data to enable effective design and development of innovation.
  17. 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 in the Emergency Department of Antrim Area Hospital. The investigation found the Trust’s decision to act to prevent the complainant leaving the hospital grounds for her own safety was reasonable and appropriate and that the actions it took to restrain the patient and prevent her leaving were disproportionate and contrary to relevant standards. The investigation also identified maladministration in the Trust’s handling of the complaint. In particular, the Trust failed to conduct a sufficiently robust and comprehensive investigation into the complaint in a fair impartial manner. It placed too much emphasis on the Nurse in Charge’s statement about the incident, without taking steps to gather other potentially relevant evidence to corroborate or refute her statement. As a result, the Trust failed to give sufficient consideration to the complainant’s account of events, and failed to provide an appropriate response.
  18. Content Article
    Susan Gilby, the former chief executive of the Countess of Chester Hospital NHS Foundation Trust, was awarded £1.4m in damages after a tribunal found she was unfairly dismissed by the Trust. It is one of the largest settlements of its kind in NHS history. In this interview with the British Medical Association she talks about her case and how in 2022 she was offered a 16-month ‘non-job’ to walk away quietly from the concerns she had been raising. She emphasises the importance of doctors feeling confident to blow the whistle when they have patient safety concerns and not be deterred if they face barriers.
  19. Content Article
    Adam Hussain died from complicated appendicitis with perforation and peritonitis on 16 May 2025. This illness developing over a three day period, with worsening abdominal pain, vomiting and clear evidence of sepsis on the day prior to his final admission, which followed a cardiac arrest at home. The Coroner in their report states that there were many opportunities missed by the East Midlands Ambulance Service (EMAS) and by the Nottingham Emergency Medical Service (NEMS) to recognise the severity of his illness, and to ensure a face to face assessment, most particularly and obviously on 14 May, the day prior to his collapse at home on 15 May. No organisation with whom there was contact, recognised that there were repeated calls for assistance over the days prior to his death. The Coroner lists matters of concern in this case as follows: The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response. There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff, when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS. Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS.
  20. Content Article
    This data brief shares key statistics concerning maternal mortality in the UK from 2022 to 2024. During this period, the overall rate of maternal death in the UK was 20% higher than it was in 2009-11 when the government set an ambition to halve the rate of maternal mortality in England. Key points highlighted in this data brief include: Exclusion of maternal deaths due to COVID-19 has a minimal impact on the increase in the overall rate of maternal death in the UK compared to 2009-11, emphasising the importance of renewed efforts to tackle maternal mortality. The was no statistically significant difference in the overall maternal death rate in the UK between 2021-23 and 2022-24 but rates remained higher than the last complete triennium of 2019-21. The number of deaths due to COVID-19 dropped significantly with only six women dying from COVID-19 complications in 2022-24. When these deaths due to COVID-19 were excluded, rates of overall and indirect maternal deaths remained statistically significantly increased in 2022-24 compared to the corresponding rates in 2019-21, the last complete triennium. Thrombosis and thromboembolism remained the leading cause of maternal death in 2022-24 in the UK during or up to six weeks after the end of pregnancy. Cardiac disease was the second most common cause of maternal death followed by psychiatric causes. Maternal suicides remained the leading cause of maternal death occurring between six weeks and one year after the end of pregnancy. As a whole, deaths from psychiatric causes accounted for 33% of maternal deaths in this period. Inequalities in maternal mortality persisted in 2022-24. Compared to women aged 25-29, women aged 35 or older were nearly two times more likely to die. There was a nearly three-fold difference in maternal mortality rates for Black women compared to White women and Asian women's risk of maternal death was also slightly higher compared to White women. Women living in the most deprived areas continued to have a maternal mortality rate twice that of women living in the least deprived areas.
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    The second victim phenomenon – emotional distress experience by healthcare workers after adverse events – has profound implications for wellbeing, patient safety and organisational culture. This session will outline core concepts of the second victim phenomenon and how it influences patient care. It will then introduce A-SHIELD, a Malaysian anaesthesia-led peer support initiative established to provide structured, confidential support after adverse events, and move to systems away from blame towards learning and compassion. The session will also looking at lessons from incident reporting and how this relates to support for second victims. Register here.
  22. Content Article
    This open letter to the World Health Organization (WHO), signed and endorsed by a group of global health experts, makes the case that surgical masks provide inadequate protection against airborne pathogens. It calls on the WHO to take a lead in establishing respirators as the universal default for all healthcare encounters. The letter includes a seven-step plan outlining how the WHO should implement this change. The signatories urge the WHO to act now to address the threat of airborne transmission, and take the following steps: Update IPC Guidelines to recommend respirators (e.g., N95, FFP2/3, elastomeric) in all healthcare settings — not just during outbreaks or high-risk procedures, but as a baseline occupational safety standard. The Guidelines could recommend locally-determined off-ramps based on precautionary interpretations of current local and establishment-specific conditions. Revisit prior statements about how SARS-CoV-2 is transmitted, and unambiguously inform the public that it spreads via airborne respiratory particles (a term subsuming both “aerosols” as well as “droplets”). Restoring public trust begins with transparency and accountability. To close the knowledge gap, provide comprehensive training and education on risk reduction for airborne hazards. Leverage WHO’s partnerships and procurement infrastructure to support equitable access to certified respirators globally — particularly for healthcare systems in low- and middle-income countries. Over time, surgical masks should be produced in progressively smaller quantities, as safer, more effective respirators have been and remain readily available. Launch global campaigns normalizing the use of respirators as a basic tool of infection prevention — not as emergency gear, but as modern personal protective equipment. Integrate universal respiratory protection into pandemic preparedness frameworks, including the forthcoming WHO Pandemic Accord. Respirators must no longer be treated as optional, nor as luxury items. Convene multidisciplinary experts, including industrial hygienists, aerosol scientists, social scientists, healthcare workers, disease transmission modelers, and patient advocates, as well as infectious disease modelers, to advise on implementation and adherence. Clearly, publicly, and regularly reinforce the message that while WHO had stopped referring to SARS-CoV-2 as a Public Health Emergency of International Concern in 2023, the pandemic is still ongoing. This will make countries accountable for mitigating the ongoing risks or covering the ongoing costs of inaction.
  23. Content Article
    In this blog Roger Kline outlines findings and recommendations set out in a new report, Investigating the Investigators. The report examines why (and when) formal investigations are authorised, how they are conducted and their impact on staff well-being, staff behaviours, workplace culture and patient care.
  24. News Article
    A renewed campaign to end the practice of treating patients in hospital corridors has been launched across Wales, as pressure mounts on political parties ahead of the May Senedd elections. The BEDS – End Corridor Care in A&E campaign has warned that corridor care remains widespread in Welsh NHS hospitals, putting patient safety, dignity and staff wellbeing at risk. Campaigners say the issue has become a major concern for voters, with growing frustration that repeated warnings from frontline clinicians have not yet led to meaningful change. Read full article. Source: The Bangor Aye, 8 January 2025 Related reading Corridor care: Patient Safety Learning’s response to the latest HSSIB report
  25. Event
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    This is a free, 1-hour, live online webinar, hosted by MedLed and delivered by Ben Tipney. This session will cover the following: Explore what we mean by Human Factors For Healthcare, and why does it matter? Discuss the benefits and limitations of comparing healthcare with other industries. Should healthcare simply be more like aviation?- Does does 'safety' look like in practice across different healthcare services? Register here.

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