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This NHS England case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. Through its core work to review recorded patient safety events, the National Patient Safety Team identified issues with the assessment and management of brain injury following an inpatient fall, leading to delays in diagnosis and treatment. A targeted review of falls reported to the National Reporting and Learning System (NRLS) over a one-year period identified deviation from NICE guidance on ‘Head injury: assessment and early management’ and variation in clinical assessment. This included differences in how neurological observations were taken, and delays in diagnostic interventions, including computerised tomography scans. Subsequent treatment and management were also impacted by these delays. Reports also suggested significant deviation from NICE guidance on ‘Falls in older people’ regarding safe retrieval of patients from the floor, exacerbating patient discomfort and risk of further injury. As a result of the review, it was highlighted that management of suspected traumatic brain injury following an inpatient fall should be an area of improvement focus for frontline clinical staff. NHS England worked with the Royal College of Physicians to successful apply to the Healthcare Quality Improvement Partnership (HQIP) to extend the scope of the National Audit of Inpatient Falls to include traumatic brain injury assessment and early management. This will help organisations to ensure they are meeting national best practice standards and allow the national programme to develop targeted resources.

During the period March 2007 to June 2011 there were six homicides committed by service users who had received care and treatment from South West Yorkshire Partnership NHS Foundation Trust. External investigations have been carried out for all six cases three by The Health and Social Care Advisory Service (HASCAS) and three by Verita. Verita were also commissioned to consider any thematic similarities between the six cases.

The Patients Association wants to hear your views on AI (Artificial Intelligence) in health and care settings, how AI is currently being used in your health and care, and how you think AI should be regulated in the UK. Your feedback will support the Patients Association in responding to a call for evidence by the Medicines and Healthcare products Regulatory Agency (MHRA). It is carrying out a consultation on how AI should be regulated when used in health and care settings to help inform the work of the recently established National Commission into the Regulation of AI in Healthcare. This survey will take around 10 minutes to complete.

The State of Care is the Care Quality Commission’s (CQC) annual assessment of health and social care in England. The report looks at trends, shares examples of good practice and highlights where care needs to improve. Access and demand for care Demand for services is growing. People cannot always access the care and treatment they need when they need it, and the system often fails to deliver effective, joined-up care, resulting in long waits and unmet needs. Over 700,000 more patients were registered with a GP on average in 2024/25 compared with 2023/24, and the number of appointments has risen by nearly 10% over the last 2 years. In adult social care, the demand for support funded by a local authority continued to rise – new requests for care were 4% higher in 2023/24 than in the previous year, and 8% higher than in 2019/20. In 2024/25, people were still waiting too long for mental health care and were unable to access the care they need when they needed it. During the year, there was an average of 453,930 new referrals to secondary mental health services every month – an increase of 15% from 2022/23. Workforce and capacity Issues with recruitment, retention and understaffing in some areas are affecting people’s care. Despite an 11% growth in the sector during the last year, the CQC have expressed concern that some homecare providers have said they are handing back local authority contracts due to rising costs. The CQC also note concern about the burden on unpaid carers. District nursing services are an important part of shifting care from hospital settings into the community, but the number of qualified district nurses per 10,000 people aged 65 and over has dropped by 50% in the last 14 years. People’s experiences The health and care system remains fragmented and pressure in the system has an impact on people’s experiences of care. There are significant challenges around funding and system working, as poor communication and collaboration between services, and problems with shared care protocols can have a negative impact on people’s experience of care, the co-ordination of their care and transitions between care pathways. Navigating the care system remains challenging, especially for people with needs that are more complex to meet or who have limited advocacy – this includes people living with dementia, autistic people and people with a learning disability and people living in more deprived areas. Inequalities and concerns for specific groups of people The CQC have stated that they continue to see significant unwarranted variation and inequalities in care. This persists in how people access and experience care, and their outcomes from it. Variation at both a regional and ICS level is leading to inconsistent quality across the country. Signs of improvement and innovation Although the system is under serious pressure, we have seen evidence of innovation and improvement making a difference for people. In CQC assessments, they state that they continue to see how good leadership can promote a culture of openness and learning. Deprivation of Liberty Safeguards The number of applications to authorise the deprivation of a person’s liberty have continued to increase significantly over the last decade – far beyond the levels expected when the safeguards were designed, which often results in lengthy delays. Issues with the Deprivation of Liberty Safeguards (DoLS) system continue to disproportionately affect certain groups of people. Our survey of Mental Capacity Act leads in hospitals highlighted particular concerns around older people, including those with dementia.