Mark Hughes
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Everything posted by Mark Hughes
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Content ArticlePrioritising patient safety is a blog series from the Parliamentary and Health Service Ombudsman (PHSO). Each month, PHSO publish 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 shares two cases involving patients with disabilities and the improvements one Trust has made, highlights key themes emerging from PHSO casework and provide updates on patient safety work from NHS Resolution, the Freedom to Speak Up Guardian and the Health Services Safety Investigations Body (HSSIB).
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Content ArticlePatients 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
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Content ArticleThe 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.
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Content ArticleIn 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.
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Content ArticleIn 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.
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Content ArticleIn 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.
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Content ArticleProduced 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.
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Content ArticleThe 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.
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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. -
EventAntimicrobial 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.
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Content ArticleIn 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.
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Content ArticleThis 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.
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Content ArticleThis 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.
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Content ArticleSusan 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.
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Content ArticleAdam 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.
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Content ArticleThis 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.
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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. -
Content ArticleThis 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.
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Content ArticleIn 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.
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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. -
Content ArticleTransitions in care are high-risk moments for patient safety; whether from hospital to home, mental health settings to community, or across specialties. In this episode of the Voices for Safety podcast, research experts Dr Natasha Tyler, Dr Richard Keers, and Professor Tom Blakeman dive into why transitions in care can present patient safety challenges and the emotional toll on patients and carers. From medication errors to emotional readiness for discharge, they explore research insights that could reshape the future of safer care transitions.
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Content ArticlePatient safety is a central pillar of healthcare quality. However, with repeated examples of failure emerging across healthcare, there is an ongoing need to better understand how the safety of care can be improved for patients. Evidence suggests that some population groups are more likely to inequitably experience healthcare harm. This article provides an overview of a new review which will look at what evidence exists on understanding patient safety harm and its causes and impact on different population groups and particularly those from marginalised backgrounds. It will also focus on what actions can be taken to address patient safety disparities and service improvements, including with patient and public involvement.
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Content ArticleThe Maternal Care Bundle (MCB) sets best practice standards across five areas of clinical care, for implementation by NHS providers and commissioners across England. Venous thromboembolism (VTE) – reducing thrombotic events in early pregnancy by risk assessing all pregnant women at the earliest opportunity before antenatal booking and providing rapid access to thromboprophylaxis for those identified as at high risk. Pre-hospital and acute care – ensuring unwell pregnant women receive the right care at the right time through improving access to urgent obstetric and maternal medicine care; and implementing a common approach to the monitoring, identification and management of maternal deterioration across all care settings. Epilepsy in pregnancy – improving control of seizures by ensuring timely access to specialist multidisciplinary epilepsy care during and after pregnancy. Maternal mental health – improving the identification and response to perinatal mental health concerns through the consistent use of National Institute for Health and Care Excellence (NICE) recommended screening tools and timely referral to appropriate specialist support. Obstetric haemorrhage – improving the management of haemorrhage through standardised approaches to timely identification, escalation and response to obstetric bleeding, along with ongoing multidisciplinary review and learning. The aim is to reduce maternal mortality and morbidity and reduce inequa
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Content ArticleThe NHS Primary Care Patient Safety Strategy sets the ambition and vision for patient safety in primary care and encourages discussion and exploration across all primary care platforms. In February 2025, NHS England informed general practices that having regard to the primary care patient safety strategy and signing up for an administrator account with the Learn From Patient Safety Events (LFPSE) service would become a contractual requirement in 2025/26. This maturity matrix is a tool that is intended to help general practices understand where they are on their patient safety journey and what actions they can take to improve. It is also designed to aid Integrated Care Boards (ICBs) in understanding what might be considered as evidence of practices having taken due regard. Please note the full document at the link below can only be accessed when logged into the NHS Futures Collaboration Platform.
