Mark Hughes

This report, produced by NHS Resolution in collaboration with the Royal College of Obstetricians and Gynaecologists, analyses Obstetric Anal Sphincter Injuries (OASI) claims made by claimants between 2011/12 and 2021/22. It highlights common themes in OASI claims and provides guidance to help healthcare professionals prevent OASI where possible. It also identifies key areas of care that can be improved, ensuring better support for women affected by OASI. This report identifies the following areas for improvement in the prevention, diagnosis, and management of OASI: Safer assisted vaginal births – Ensure all obstetricians are trained on the basic principles of assisted instrumental delivery, including avoidance of excessive force so that gentle traction is applied with a uterine contraction and appropriate use of ventouse and forceps with episiotomy when required. This should also include how to assess for OASIs. Supervision of trainee clinicians – Provide adequate support and supervision of both midwives and non-consultant grade doctors when performing complex deliveries such as assisted births, particularly rotational deliveries. Promote and encourage perineal protection, especially during difficult deliveries. Diagnosis of OASI – Focus on appropriate clinical training to ensure clinicians can perform a systematic bimanual vaginal and rectal examination to identify an OASI. This should include using the pill rolling technique to identify OASI at the time of birth so that the injury can be repaired, as this gives the best outcomes. Education – Educate clinicians on the symptoms that can affect women who sustain OASIs, as well as the social, psychological, and economic impact of these injuries. This includes supporting clinical teams to consider underlying risk factors during pregnancy, follow the appropriate pathway of assessment, and escalate concerns about potential OASIs, supported by greater awareness of the significant impact these injuries can have on women. We must also ensure that clinicians are appropriately trained and supervised to repair OASIs. Awareness of rectovaginal fistula (an undetected or repaired fourth degree tear) – This remains a rare complication of OASIs but has a devastating impact on women. Clinicians should be aware of this potential complication, its presenting symptoms, and how to assess for this in a multidisciplinary context. Pathway for management of women with missed OASIs – Management remains very variable across units, depending on local facilities and expertise available, and further guidance is urgently needed to improve consistency and long-term outcomes. NHS Resolution have also produced a one page poster that summarises the key messages at a glance which clinicians are encouraged to print and display this poster on notice boards within clinical areas. You can find this here.

From the 4 September to 16 October 2023 the Department of Health and Social Care held a public consultation seeking views on the possible introduction of regulations mandating the disclosure of industry payments to the healthcare sector. This report sets our the UK Government's formal response to the findings of this consultation. The Government response is stated as follows: The government wishes to express its gratitude to all of those who contributed to this consultation, and their patience while the analysis and response was finalised. It is clear from the majority of responses that there is a need for better transparency regarding payments made between industry and: registered healthcare professionals healthcare provider organisations organisations connected to the provision of healthcare The government fully supports this sentiment, recognising the importance in enabling patients to make informed decisions about their own care and improving the transparency of industry payments. In response to this consultation, the government will develop and publish clear guidance in relation to disclosing payments made by the medicines and medical devices industries to the healthcare sector. This guidance will set out best practice for industry to follow, which will advise on: which payments should be reported the format of the reporting the frequency of the reporting The government will monitor the uptake of this forthcoming guidance. While the government acknowledges that a number of stakeholders favoured a legislative approach to payment disclosures, this guidance-based approach will allow patients to benefit from industry reporting more quickly, without further delays that could have followed the introduction of legislation and the establishment of a government reporting and compliance system. This positive step towards transparency will add clarity to the relationship between industry and healthcare professionals, assisting patients in making informed decisions about their care. Over the coming months, officials will work with stakeholders to develop a robust set of guidelines, with careful consideration given to the range of valuable suggestions provided by respondents to the consultation. This will ensure that the guidance is comprehensive and captures all relevant payments to healthcare-related professionals. To date, no formal government guidance has been available for industry to follow and against which patients can hold the sector to account. This step will provide certainty for industry and stakeholders, as well as a clear path to improve transparency and improve public safety. This decision is also aligned with the government’s commitment to reduce regulatory burden on industry. It will provide industry with the space to show leadership and a commitment to transparency, while minimising regulatory requirements that could be especially detrimental to small and micro businesses.

In this blog Fredrik Matre considers the connection between patient safety and productivity, challenging the assumption that safety measures block productivity improvements. He makes the case for putting safety at the core of productivity planning. This blog has been published ahead of the Patient Safety Forum 2026, an event jointly hosted by Public Policy Projects and Patient Safety Learning, which features a panel session on “Aligning patient safety with productivity”.

The National Audit of Eating Disorders (NAED) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England as part of the National Clinical Audit and Patient Outcomes Programme. In 2025 the NAED team conducted a comprehensive mapping of eating disorder service provision across England. This report provides an in-depth overview of NHS-funded and independent sector services for children, young people, and adults. Key findings in the report include: Nationally, adult community teams have 1.89 people on their caseload for every 1 patient open to children and young people (CYP) teams. This means adult community teams face an 89% higher demand. The national median wait for CYP community care is 14 days for assessment and 4 days for treatment, with waiting times of up to 450 days. The national median wait for adult community care is 28 days for assessment and 42 days for treatment, with waiting times of up to 700 days. 15% of community adult teams accept self-referrals compared to 62% of CYP teams.

In this short discussion Professor Henrietta Hughes, Patient Safety Commissioner for England, speaks to ABHI Patient Safety Group Chair Greg Quinn and Vice Chair Steffanie Russell, following the publication of ABHI’s new report, Patient Safety System Foundations: A Call for Action. The conversation explores the role of system foundations in strengthening patient safety across healthcare.

This update presents statistics from the Learn from Patient Safety Events (LFPSE) service, a national NHS system for the recording and analysis of patient safety events that occur in healthcare. The LFPSE definition of a patient safety incident is something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm for one or more person(s) receiving healthcare. This report shares the patient safety incident data from July to September 2025. Count of Event Types in LFPSE – based on patient safety event records from July 2025 to September 2025 LFPSE brings the feature to record patient safety event types beyond incidents. Recorders can now also upload patient safety risks, outcomes, and instances of good care. This is to ensure the database contains more instances of care that the healthcare system can learn from instead of only detailing errors involving patients. In the current period, 834,454 events were recorded to LFPSE, the majority of which were recorded as patient safety incidents (96.96%). Count of patient safety incidents by maximum physical harm – based on patient safety incident records from July 2025 to September 2025 Sometimes a problem in care can affect more than one patient, or none at all. To capture this, as a new feature of LFPSE, recorders can submit information for multiple patients per incident, meaning there can be multiple degrees of harm per incident. The following table we takes the highest harm level per incident. During this quarter, 747,487 incidents had recorded a degree of harm. The majority of these incidents (94.09%) recorded low or no physical harm to patients. LFPSE has a new variable for grading of the psychological harm associated with the recorded patient safety incidents. This is an experimental field which seeks to explore if responses to safety incidents need to be different if psychological harm is considered separately from physical harm, rather than rolling them together into one measure, as was done in the National Reporting Learning Service (NRLS). Currently, there is low confidence in the grading of psychological harm, as users familiarise themselves with its use, and as such, it is excluded from this report.

In this short discussion, Greg Quinn, Chair of ABHI’s Patient Safety Group, and Helen Hughes, Chief Executive of Patient Safety Learning, introduce ABHI Patient Safety System Foundations: A Call for Action. Together, they discuss the report’s key themes, the persistence of avoidable harm, the need for system learning and shared accountability, and the vital role of HealthTech as a trusted partner in improving safety for patients and healthcare workers.

The term ‘corridor care’ is inclusive of any non-designated clinical space. NHS England considers the delivery of corridor care in departments or wards experiencing patient crowding to be unacceptable and should never be considered standard. Patients should only be placed in corridors in extremis and for the shortest possible duration, to ensure the time patients are cared for in this environment is kept to a minimum. These principles have been developed to support point-of-care staff in delivering the safest and highest quality care possible when corridor care has been deemed unavoidable.

The Faculty of Intensive Care Medicine have developed this guidance in response to recurrent safety incidents concerning the connection and reconnection of both invasive and non-invasive breathing circuits. This was created to act as a resource to help in the design of local guidance and visual aids and is intended to be easily adaptable for use by individual units. It was subsequently recommended for this purpose in NHS England's National patient safety alert – risk associated with adult breathing circuits lacking a patent exhalation route, published on the 11 December 2025.

This national patient safety alert has been issued by the NHS England National Patient Safety team, in collaboration with the Faculty of Intensive Care Medicine. The alert is directed at organisations caring for patients on invasive and non-invasive breathing circuits who are required to develop local guidance and visual aids for circuit assembly, implement training on specific safety checks, and establish clear communication processes. All actions should be completed by 12 June 2026. This alert has been issued in response to the risk of harm from incorrectly assembled breathing circuits lacking proper exhalation routes for patients receiving invasive or non-invasive ventilatory support. A review by the of the national patient safety databases over a 3-year period identified 102 safety incidents describing the absence of an exhalation route because of incorrect assembly or selection of equipment. As a result the patient could not effectively exhale. 2 patients were reported as peri-arrest when exhalation routes were missed from their breathing circuits. In multiple reports describing the physiological deterioration of a patient, the potential for serious harm was mitigated when staff placed the missing exhalation port into the circuit. Actions required Organisations should identify a clinical lead and form a working group to develop local guidance and visual aids for the assembly, connection and reconnection of breathing circuits. The guidance and associated training must include the following recommendations: 1) Before connection to the patient, check the breathing circuit includes an exhalation route, and that there are no obstructions within the circuit 2) Perform the following checks when there is any change in the configuration of any breathing circuit: observe the patient, checking chest movement (inspiration and expiration), to ensure patient is ventilating normally, and check flow, volume, pressure, saturations and capnography. ensure alarm parameters and volume are set appropriately. ensure expiratory vents, ports or valves on NIV masks are not occluded. Organisations should: 3) Ensure the clinical lead (or deputy) oversees any revision to the local guidance 4) Establish a clear process to ensure all updates to the guidance, checklists or visual aids are communicated to all relevant team members 5) Establish a clear process for communicating any urgent changes to local guidance and practice when, for example, a supply chain disruption means standard consumables are unavailable and replacements are provided. The Faculty of Intensive Care Medicine (FICM) has published a resource to help in the designing of local guidance and visual aids to support the safe set up of invasive and non-invasive breathing circuits. This can be used as a template for organisations to produce local guidance.

In this blog Professor Henrietta Hughes, Patient Safety Commissioner for England, considers the publication of the new report ABHI Patient Safety System Foundations: A Call for Action, which sets out a blueprint for how industry can contribute to this transformation. She reflects on this report and the importance of recognising that patient safety is not simply a clinical issue, but is a system issue.

The Maternity and Newborn Safety Investigations (MNSI) programme has published its 2025–27 strategy, building on its approach to improving maternity and newborn safety. The strategy focuses on supporting NHS trusts to spot risks sooner and act quickly to prevent harm, especially for communities that experience the worst outcomes. MNSI's Mission We conduct independent safety investigations into maternity and newborn events. We listen to and learn from families and healthcare professionals, and we work in partnership to prevent future harm and improve care. MNSI's Vision A safer future for maternity and newborn care built on listening and learning through independent safety investigations. MNSI's Strategic Priorities 2025-2027 Excellence - We will strengthen MNSI’s foundation by improving governance, developing our analytical capacity and supporting our people, while maintaining the investigation quality that underpins our credibility. This focus ensures we can respond effectively to evolving safety challenges and take on an expanded role. Impact - Building on our investigatory experience, we will support the national system in identifying and reducing maternity and newborn safety events before they occur. By harnessing predictive intelligence and proactive safety insights, we will enable NHS trusts to anticipate and prevent future harm, while continuing to develop robust ways to demonstrate MNSI’s impact across the healthcare system. Relationships - We will build meaningful partnerships with families, healthcare professionals and system partners to drive sustained improvements in safety and equity, ensuring that all communities benefit.