Mark Hughes
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Content ArticleThis article provides a brief overview of patient safety issues raised in a debate in the House of Commons on Monday 1 June 2026 during the second reading of the Health Bill 2026-27.
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Content ArticleThe role of the Patient Safety Commissioner for Scotland is to champion safer care across Scotland's health and care system. This site provides information and resources related to this role.
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Content ArticleNon-communicable diseases (NCDs) are the leading cause of death and disability in countries across the 27 European Union (EU) Member States, Norway and Iceland (EU27+2) and in the Organisation for Economic Co-operation and Development (OECD). While all countries are impacted by NCDs, there are substantial cross-country differences in the current burden of NCDs, the contribution of individual risk factors, and the outcomes of prevention and management efforts. This OECD Health Working Paper finds that countries can be clustered into seven distinct groups of countries within the EU27+2, each with a unique NCD profile. In addition, the remaining 14 OECD countries were grouped, providing a broader international benchmark with corresponding comparative analysis. World Patient Safety Day on the 17 September 2026 is focused on the theme “Safe care for non-communicable diseases”
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On the 14 May 2026 the UK Government introduced the Health Bill in the House of Commons, also known as the NHS Modernisation Bill. This new legislation is intended to introduce two significant changes, joining up health information and abolishing NHS England. This article pulls together a number of different reflections shared on this bill as it proceeds through Parliament. -
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The King’s Speech 2026 sets out the programme of legislation that the UK Government intends to pursue in its next parliamentary session. This blog highlights six key takeaways from this speech from a patient safety perspective. -
Content ArticleThis is the recording of a webinar which took place on the 30 April 2026, hosted by the State Claims Agency, focused on clinical risk, state indemnity, and learning from claims and incidents involving slips, trips and falls. Delivered by the Agency's Clinical Risk Unit, this webinar provided an updates on the unit’s work and share clinical risk snapshots, answered common questions about the Clinical Indemnity Scheme and shared learning from slips, trips and falls incidents and claims. The State Claims Agency is the name given to the National Treasury Management Agency in managing personal injury and third-party property damage claims against the State and State authorities, as delegated by Government, in the Republic of Ireland.
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Content ArticleThis Patient Safety Supplement, issued by the Health Service Executive in the Republic of Ireland, aims to raise awareness among patients and healthcare staff of the risk of paracetamol-induced hepatotoxicity (harm to the liver) from standard doses of paracetamol in some adult patients. Paracetamol-induced hepatotoxicity may result in acute liver failure, the need for liver transplantation and/or death. Symptoms can include stomach pain, nausea (feeling sick) or vomiting, jaundice (skin or eyes look yellow), confusion, drowsiness or sleepiness and not urinating as much as normal.
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Content ArticleThis study, published in JAMA Network Open, considered how often and what types of patient safety events are reported by paediatric home health care staff. Researchers undertook a multistate cohort study of paediatric home health care data of 2,901 children, more than 1 in 10 children had an incident reported by agency staff. In this cohort it found that more than 1 in 10 had a reported incident, of which approximately half were patient safety related. This work provides new data about paediatric home health safety, with the authors suggesting that further work should explore factors contributing to and preventing health care related harms to children at home and include parent perspectives.
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Content ArticleThis Patient Safety Supplement aims to raise staff awareness of the risk of self‑harm with people using plastic bags as ligatures in Health Service Executive (HSE) and HSE‑funded services, including emergency care, in the Republic of Ireland. A ligature is an item used for tying or binding something tightly. To help prevent the risk of self-harm from bin bags or liners, this supplement shares alternative product options, including for sanitary bins. These options are based on learning from a number of our mental health services across the country.
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This online session will look at the essential role of robust data and learning from audit in helping identify risks, prevent harm, and build safer systems of care. Drawing on practical examples, the session will explore how data from audits and registries can be used to detect safety signals, understand where harm is occurring, and support action to reduce risk and improve patient safety. This session includes: Welcome from the Chair: Dr Jacqueline Andrews, Executive Medical Director, Harrogate and District NHS Foundation Trust and HQIP Trustee Using data for safety – A perspective from the Patient Safety Commissioner: Professor Henrietta Hughes OBE, Patient Safety Commissioner The role of the National Joint Registry in patient safety: Chris Boulton, Director of Operations, National Joint Registry Using national maternity data to drive patient safety improvement: Faith Sheils, Director of Midwifery, Northern Care Alliance NHS Foundation Trust From incident to improvement: using Epilepsy12 data to commission a safer first seizure pathway: Dr Colin Dunkley, Consultant Paediatrician, Sherwood Forest Hospitals, Epillepsy12 Clinical Lead Update from Patient Safety Learning: Clare Wade, Director, Patient Safety Learning Register here. -
Content ArticleIn June 2024, Martha’s Rule was introduced into 143 NHS Trusts. This rule allows patients, families and staff to quickly request an urgent review from an independent medical team if they’re worried a patient is worsening and feel their concerns aren’t being heard. It also requires hospitals to regularly check in with patients and families about how the patient is doing. This interim report presents findings from an independent evaluation of Martha's Rule carried out between November 2024 and February 2026. This was undertaken by the patient safety arm of the National Institute for Health and Care Research (NIHR) Policy Research Unit in Quality, Safety and Outcomes for Health and Social Care to understand how the first rollout of Martha’s Rule is working for patients, families and healthcare staff. It draws on a prospective in depth case study across three hospital trust pilot sites, involving observations, interviews and documentary analysis, accompanied by a systematic review of literature and a public awareness survey, which was conducted in collaboration with Picker.
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EventThis the next session of the JCI Patient Safety Grand Rounds will highlight global perspectives on how investing in patient safety generates measurable operational and economic value. You will hear from internationally recognised experts as they examine the economic value of patient safety and its impact on health systems, hospitals, patients, and society. Featured speakers include: Dr. Shankar Prinja, MD, DNB, MSc - Professor of Health Economics, Postgraduate Institute of Medical Research, Chandigarh, India Katherine de Bienassis, MPH - Health Policy Analyst, Organisation for Economic Co-operation and Development (OECD), France Dr. Rachel A. Elliott, PhD, FRPharmS - Professor of Health Economics, University of Manchester; and Lead, Manchester Centre for Health Economics, United Kingdom You can register your place here. JCI-GrandRounds-June26-Flyer-Final.pdf
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The 2025 review of patient safety in England, chaired by Dr Penny Dash, proposed changes intended to coordinate and rationalise patient safety roles and responsibilities. In this long-read article Patient Safety Learning reflects on NHS England’s proposals to implement one of these changes, the abolition of the National Guardian’s Office, which was introduced following Sir Robert Francis‘s 2015 review Freedom to Speak Up.[1] -
Content ArticleArtificial intelligence (AI) is ushering in a new era, with the potential to reshape the world as we know it. In healthcare, it’s already starting to have an impact. AI can support earlier diagnosis and reduce the administrative burden on clinicians, giving them more time to focus on patient care. For patients, this could mean faster answers, more personalised treatment, and a healthcare system that responds better to their needs. In this blog, the Patient Safety Commissioner for England, Professor Henrietta Hughes, reflects on the ongoing work of the National Commission into the Regulation of AI in Healthcare and the need to work with partners across the system to explore both the opportunities and the challenges this brings. She also shares details of an upcoming Ask Me Anything webinar on these issues that she will be hosting on Wednesday 20 May 2026.
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The National Commission into the Regulation of AI in Healthcare are hosting a live Ask Me Anything on how artificial intelligence (AI) is being regulated in healthcare. This is your opportunity to hear directly from the National AI Commission and ask questions about what this means for you. Register now and submit your questions in advance. In this session, you can: Learn more about the Commission’s work Ask questions about how AI is regulated and how this may develop Hear open and honest responses You can ask about anything relating to the work of AI Commission , including: Patient safety How the Commission makes decisions What AI could mean for your care -
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Despite decades of national efforts, non-communicable diseases (NCDs) continue to rise. NCDs are long-lasting health conditions, that typically develop slowly and progress over time. They include cardiovascular diseases (such as heart attacks and strokes), cancers, chronic respiratory diseases and diabetes. NCDs affect far more than health outcomes: they influence how people live and work, strain families and communities, and impose a growing burden on health systems and economies. This report from the Organisation for Economic Co-operation and Development (OECD) assesses the health and economic benefits of tackling NCDs. It highlights how countries that succeed in reducing key health risks such as obesity and tobacco use can save lives, ease pressure on health budgets and unlock substantial economic gains. World Patient Safety Day on the 17 September 2026 is focused on the theme “Safe care for non-communicable diseases”. -
Content ArticleFollowing a recommendation from the Review of patient safety across the health and care landscape, the National Guardian’s Office will close on the 30 June 2026. Subsequently, NHS England will deliver some activities previously undertaken by this body. This will be accompanied by increased reasonability and accountability for embedding effective Freedom to Speak Up arrangements sitting with individual healthcare organisations. This document sets out the revised responsibilities for Freedom to Speak Up across the NHS.
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In healthcare, developing a culture of psychological safety is essential to ensuring patient safety; a priority identified in the NHS Patient Safety Strategy. In the context of 10 Year Health Plan for England and healthcare leaders' commitments to psychological safety across all developed nations, it is essential that the safety of patients and staff is at the core of its design and delivery to avoid harm and reduce incidents. If the healthcare system is to truly be transformed over the next decade, matters of culture need to be addressed. At this event, attendees will: Meet experts in culture, clinicians, patient safety who will be highlighting why changes need to be made and how individual healthcare professionals can apply good practice to address the challenges. Gain a deep understanding of what psychological safety is and why it is essential to promote and deliver a safety culture in healthcare. Comprehend the actions needed to improve psychological safety in healthcare - what does good look like? Be provided with an opportunity to make personal commitments for better patient safety. Opportunity to engage with key note presentations, panel session discussions, and listen to personal experience of those than have been damaged by poor culture. Learning outcomes will include: Attendees will be able to identify what psychological safety is, how it shows up in team behavior, and how it differs from trust, comfort, or simply being “nice. Be able to apply practical strategies to build psychologically safe environments by learning specific behaviors - such as framing work as learning, modeling vulnerability, and responding productively to patient safety incidents and risk. Identify, evaluate, and address barriers to psychological safety. Attendees will be able to spot common organizational, cultural, and interpersonal obstacles and use structured approaches to reduce fear, friction, and silence. Find out more and register here. -
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The renewed Women’s Health Strategy sets out how the UK Government will improve women’s health and healthcare over next 10 years. -
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On Tuesday 19 May, a new toolkit to support adults at risk of self-harm or suicide will be launched at The University of Manchester’s Whitworth Art Gallery, as part of a free and interactive event open to all. Jay’s Personalised Safety Planning Toolkit, co-designed by researchers, people with lived experience, and healthcare professionals, is an evidence-based, practical guide that offers a more personalised approach to safety planning within health and care settings, offering meaningful support to help save more lives. The Safety Planning Toolkit can be used by: Individuals themselves Families, friends, and wider support networks Health and social care professionals The launch event is open to anyone with an interest in safety planning for self-harm and suicide prevention, including practitioners from across health and social care, as well as individuals who may use safety planning themselves, along with family, friends and other support people. Book your place here. -
Content ArticleOn 25 February 2026, healthcare leaders and stakeholders gathered in London for the Patient Safety Forum, organised by Public Policy Projects (PPP) in partnership with Patient Safety Learning. At this event a panel session took place which considered the potential for artificial intelligence to transform patient safety, weighed against growing questions around risk, regulation and readiness. Read the full article from PPP via the link below.
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Content ArticleThe Infected Blood Inquiry (2024), the 10 Year Health Plan for England and the Department of Health and Social Care’s Review of patient safety across the health and care landscape (2025) have all highlighted the need for more systematic approaches to safety management in healthcare. This statement summarises NHS England’s position on the potential for safety management systems to improve patient safety.
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Content ArticlePublished by NHS Wales Performance and Improvement, this plan is intended to guide and drive patient safety improvements throughout Wales over a five-year period. It aims to reduce avoidable harm and build a culture where learning and improvement are at the heart of everything the NHS does.
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Content ArticleOn 25 February 2026, healthcare leaders and stakeholders gathered in London for the Patient Safety Forum, organised by Public Policy Projects (PPP) in partnership with Patient Safety Learning. Panellists at this event investigated multifaceted impacts patient safety measures are having on wider system operations. From avoiding duplicated processes and failure demand, to cross-disciplinary learning and efficiency gains, this blog summarises discussions from two panels which highlighted the Patient Safety Incident Response Framework and productivity as focuses for a reforming healthcare system. Read the full article from PPP via the link below.
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Content ArticleResearch is crucial to making improvements in healthcare during and after a pregnancy. It can help women make informed decisions about their pregnancy care. This includes identifying treatments to keep both mother and baby safe from infection. This article highlights five key findings related to this from studies funded and supported by the National Institute for Health and Care Research (NIHR).
