Patient_Safety_Learning

Corridor care is increasingly being used in the NHS as demand for emergency care grows and hospital departments struggle with patient numbers. In a series of blogs for the hub, we shine a light on some of the key patient safety issues surrounding corridor care. Corridor care can broadly be defined as care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity. Documenting the experiences of more than 5,000 nursing staff, a recent report from the Royal College of Nursing has set out in stark terms how corridor care has become normalised in the NHS. Almost 7 in 10 (66.8%) of those surveyed said they were delivering care in over-crowded or unsuitable places. More than 9 in 10 (90.8%) of those surveyed said patient safety is being compromised. Corridor care has now become so normalised that in September 2024 NHS England published new guidance setting out principles for providing safe and good quality care in what it describes as ‘temporary escalation spaces’ (TES). Key patient safety concerns At Patient Safety Learning we will continue to raise awareness of the significant patient safety concerns relating to corridor care, including: Delayed treatment. Inadequate monitoring. Compromised infection control. Patient dignity not being supported. Relatives not being able to support patients who may not otherwise be closely monitored. Moral injury and impact on staff delivering poor standards of care. Manual handling safely. Trip hazards and obstructions. Blocked evacuation routes in the case of fires of other major incidents. Corridor care blogs In a series of blogs for the hub, we shine a light on some of the safety concerns surrounding corridor care. The crisis of corridor care in the NHS: patient safety concerns and incident reporting On the 16 January 2025, the Royal College of Nursing (RCN) published a new report presenting the findings of a survey of nursing staff outlining the extent of corridor care across the UK. This blog sets out Patient Safety Learning’s response to this report. The crisis of corridor care in the NHS: patient safety concerns and incident reporting In this blog, Patient Safety Learning’s Director Clare Wade reflects on the challenges that growing prevalence of corridor care poses to reporting and acting on patient safety concerns in the NHS. How corridor care in the NHS is affecting safety culture: A blog by Claire Cox Patient Safety Learning’s Associate Director Claire Cox looked at how corridor care within the NHS is affecting safety culture and examined its implications for both healthcare professionals and patients. Corridor care: are the health and safety risks being addressed? Patient Safety Learning’s Associate Director Claire Cox writes about the associated health and safety risks, questioning whether these are being properly addressed. Claire draws out key areas for consideration and suggests practical measures that can help protect patient safety in such challenging working environments. A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces In this blog, an anonymous nurse reflects on the recent NHS England (NHSE) guidance on the use of "temporary escalation spaces" and why this is so far removed from 'work as done' on the frontline. A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift In this anonymous account, a nurse shares their experience of corridor nursing, highlighting that corridor settings lack essential infrastructure and pose many safety risks for patients. They also outline the practical difficulties providing corridor care causes for staff, as well as the potential for moral injury. Using the System Engineering Initiative for Patient Safety (SEIPS) framework, they describe the work system, the processes and how that influences the outcomes. Share your insights Do you have experience of corridor care either as a patient or a healthcare professional? What impact have you seen on patient safety? You can comment below (sign up here for free first) or email the editorial team at [email protected]

The Parkinson’s Excellence Network have released a series of resources to support UK healthcare professionals in hospitals to improve the delivery of time critical medication for people with Parkinson’s. Parkinson's UK time critical medication dashboard. The new dashboard estimates the benefits of improving time critical medication management for people with Parkinson's in hospitals in England, Scotland and Wales. The dashboard estimates the direct cost for hospitals and impact on patient outcomes of delayed or missed medication doses. Audit and awareness: how staff at Hexham General Hospital improved the delivery of time critical medication. This case study details how a staff nurse's dissertation led to an increase in Parkinson's medication delivered on time on a ward at Hexham General Hospital. Webinar: Driving improvement on time critical Parkinson's medication. In February our fully subscribed webinar included a session on practical benchmarking against the 10 recommendations. Watch the webinar recording and read the Q&A document now. Time critical medication patients' stories: in their own words. In these new short films, people with Parkinson’s share their experiences of receiving their Parkinson's medication in hospital and how this impacted on their health and well being. These films have been developed to raise awareness and support education and training of health professionals. Read more in the latest time critical medication blog by former nurse Patsy Cotton. Access all of the time critical medication resources.

*Trigger warning: content related to suicide Rachel Gibbons is the Vice Chair of the Psychotherapy Faculty at the Royal College of Psychiatrists. In this opinion piece she draws on personal and professional experience to explore the complex relationship between patient safety and inpatient suicide. Rachel argues that fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved. I'm a consultant psychiatrist whose professional trajectory was profoundly shaped by a harrowing experience early in my career. In 2009, during my first 18 months as a consultant, four of my patients died by suicide. The intense aftermath—serious incident inquiries, coroner's court appearances, and the emotional fallout—fundamentally changed who I was, both personally and professionally. Before this, I was someone different; afterward, thoughts about suicide dominated my consciousness. Since then, I've dedicated my professional life to deeply understanding suicide, it’s devastating impact on those bereaved, and the complex interactions involved in patient safety. Central to my work is the question of truth in patient safety—how to engage honestly and realistically with this complex subject. Too often, safety is driven by fantasies of control rather than by realistic expectations and honest acknowledgment of uncertainty. When our expectations are unrealistic, it harms clinicians and bereaved families alike. The profound trauma of inpatient suicide When suicide occurs within inpatient settings, its impact can be especially devastating. These tragedies unfold in two distinct scenarios: deaths occurring off the ward, and those taking place directly on the ward itself. Deaths on the ward can be especially traumatic—sometimes violent and occurring in the immediate presence of staff and other patients. I have personally been involved in such cases, witnessing first-hand the traumatic ripple effect across an entire organisation. The sudden, shocking nature of an inpatient death reverberates, intensifying every response, from the serious incident inquiry to appearances at the coroner’s court. Unfortunately, we don’t often give sufficient attention to the profound trauma staff and patients experience when exposed to inpatient suicide. If not effectively addressed, this trauma can linger unresolved for years, manifesting repeatedly in patterns of care—a phenomenon Freud described as "repetition compulsion". Unprocessed trauma can harm staff and affect the safety and wellbeing of future patients. The double-edged sword of patient safety investigations It’s essential that every inpatient death prompts a thorough patient safety investigation. However, the issue isn’t the investigation itself; it’s how easily the concept of patient safety can become distorted following a traumatic death. When a suicide occurs, intense emotions and destructive forces are unleashed within an organisation. This often results in attempts to create a simplistic causal narrative for the tragedy—a narrative that can never truly capture the complexity of suicide. In the aftermath of suicide, people’s ability to mentalise—to think clearly and compassionately—is severely compromised. The intense emotional turmoil often triggers a search for blame. As the deceased patient’s agency is often discounted, blame shifts rapidly towards clinicians. I've seen distressing examples where clinicians become scapegoats, absorbing an organisation’s collective anxiety and guilt. Organisations can behave almost like sentient beings, attempting self-preservation by shifting blame onto individual staff, often with devastating personal and professional consequences. Improving support for bereaved families The anxiety surrounding inpatient suicides can make it challenging for organisations to engage compassionately and openly with bereaved relatives. Defensive postures, though understandable given potential repercussions, ultimately harm those grieving. One proven way to mitigate confrontation and provide genuine support is appointing Family Liaison Officers. These dedicated individuals advocate for bereaved families, offering emotional support, clarity, and careful communication, thus alleviating confrontational dynamics. Supporting staff in caring for the bereaved Staff must not be left unsupported in their interactions with grieving families. Effective engagement with bereaved relatives requires thoughtful, organisational leadership and strategic planning. I've witnessed harmful situations where clinicians, driven by guilt, rush prematurely to communicate with bereaved families. Such impulsive actions, however well-intentioned, can cause unintended harm. Again, Family Liaison Officers are instrumental in mediating this delicate and emotionally charged communication, providing guidance and helping staff navigate difficult interactions more safely. Creating reflective spaces for staff Mental health work, particularly in inpatient environments, is intensely emotional and psychologically demanding. In the aftermath of a patient suicide, it becomes vital for organisations to provide reflective spaces—dedicated times and places where clinicians can safely process traumatic experiences. Without such spaces, unprocessed trauma can manifest as "acting out," leading to harmful patterns in care delivery and clinician burnout. Embedding regular reflective practice is essential, enabling staff to maintain their psychological wellbeing and enhancing patient safety through thoughtful, compassionate care. Final thoughts: seeking truth and compassion in patient safety Throughout my career, my core interest remains the truthful engagement with suicide and patient safety. We need honest, realistic frameworks that acknowledge limitations, complexity, and uncertainty. Fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved. True safety comes from authentic, reflective practice, compassionate communication, and careful systemic support.

Patient and family voices play a critical role in understanding patient safety issues, learning from incidents and managing risk. In this Top picks, we’ve pulled together resources from the hub that highlight the value in involving patients and the public in patient safety.  1. The role of simulation-based education, co-design and co-delivery in improving patient safety Dr Kirsten Howson, Specialist Education Lead at SimComm Academy, discusses the role Simulation-Based Education (SBE) can have in patient safety. Kirsten highlights some of the techniques used in SBE, the benefits for staff and patients, and the importance of involving people with lived experience in the design and delivery of SBE. 2. Working with bereaved parents for safer and more equitable care Julia Clark and Mehali Patel from the Sands Saving Babies’ Lives research team, draw on their recent Listening Project to illustrate the value of working with bereaved parents. Julia and Mehali argue that hearing and amplifying these unique insights is vital to developing safer, more equitable neonatal and maternity care. 3. Integrating patient and public involvement into co-design of healthcare improvement: a case study in maternity care (March 2025) Despite recognition of the importance of patient and public involvement (PPI) in healthcare improvement, compelling examples of “what good looks like” for PPI in co-design of improvement efforts, how it might be done, and formalisation of methods and reporting are lacking. The authors of this study sought to address these gaps through a case study. 4. Patient safety and lived experience Anthony O'Connor works primarily in the areas of lived experience and in co-production and strives to have both of these concepts better understood, and more effectively utilised wherever possible. In this blog he focuses on lived experience, its definition, its usage, and its impact. 5. Patient safety and co-production Anthony O’Connor talks about the benefits of co-production and why it is essential to patient safety. Anthony gives examples of how co-production can be used more in healthcare and encourages everyone to develop their knowledge of co-production and start embedding it into their work. 6. Providing patient-safe care begins with asking and listening... really listening! Dan Cohen talks about how patient-safe care is all about collaborating and listening to your patients to find out what really matters to them. He illustrates this in a case study of his own personal experience whilst working as a clinician in the USA. 7. Catching cancer early: what more can we do as GPs? GP, Amelia Randle sets out a number of ways clinicians can develop their daily practice to improve cancer diagnosis at an early stage. Amelia talks about involving patients in questioning symptoms, deep listening and learning from patients and families. 8. “Listening to a patient’s history for longer can help doctors make the right diagnosis” Mary Dahm and Carmel Crock tell us more about their research to explore the relationship between communication and diagnostic accuracy. The findings highlight how critical it is to spend time listening to the patient, and for doctors to communicate uncertainties well. Share your insights Have you been involved in safety improvements as a patient? Or perhaps you’re a healthcare professional who has made safety improvements that were informed by the patient voice? Could you share your insights on the value of the patient voice in patient safety? You can comment below (sign up first for free) or email our editorial team at [email protected].

World Health Day, celebrated on 7 April, kicks off a year-long campaign on maternal and newborn health. This year's campaign, titled ‘Healthy beginnings, hopeful futures’, will urge governments and the health community to ramp up efforts to end preventable maternal and newborn deaths, and to prioritise women’s longer-term health and well-being. It is led by The World Health Organization.  The Motherhood Group focuses on creating supportive spaces where Black mothers can find community, resources, and advocacy. In this interview Sandra Igwe, Founder and CEO of the Motherhood Group, reflects on this year’s theme and the continuation of disparities in Black maternal mental health. Sandra highlights key areas for action and explains how a greater focus on lived experience leads to better outcomes for women and babies.  What does a ‘healthy beginning and hopeful future’ look like for Black maternal mental health? A healthy beginning means Black mothers receiving respectful, dignified care where their voices are heard and their concerns taken seriously. It means having access to culturally competent mental health support without stigma. Drawing from our "Interconnecting Themes" framework, a hopeful future includes: Community and Connection: Strong support networks both online and in-person Advocacy and Voice: Black mothers empowered to speak for themselves and be heard Education and Knowledge: Better information for both mothers and healthcare providers Healthcare Transformation: Systems that acknowledge cultural differences and provide equitable care Safe Spaces: Environments where Black mothers can be vulnerable without judgment This vision requires reframing Black maternal health as a human rights imperative and addressing it through an anti-racist approach, as highlighted by speakers at our conference. What are the big issues that need addressing? The most pressing issues include systemic racial disparities in maternal healthcare, lack of cultural competency among healthcare providers, insufficient mental health support for Black mothers, and the dismissal of Black women's pain and concerns. Our training workshops highlight specific challenges including: Mental health stigma within Black communities Barriers to effective engagement with healthcare services Language and cultural barriers affecting quality of care The "Strong Black Woman" myth that prevents many from seeking help Black mothers being less likely to be identified with perinatal depression due to inadequate screening tools The difficulty many Black mothers face expressing emotional distress in a system that applies western/eurocentric labels These issues disproportionately affect Black women, who in the UK are four times more likely to die during childbirth than white women and consistently report poorer experiences throughout their maternity journey. What results have you seen for women and their babies when they receive good mental health support? When Black mothers receive appropriate mental health support, we see transformative outcomes: stronger maternal-child bonding, better parenting confidence, improved family dynamics, and children who thrive emotionally and developmentally. Mothers report feeling more empowered to navigate healthcare systems and build supportive networks. Our initiatives like the NICU, Early Life and Loss panel discussions reveal how proper support can help mothers through the most challenging circumstances. The community-led initiatives showcased at our conference demonstrate that when Black mothers are supported appropriately, they often become powerful advocates and create solutions for others facing similar challenges. What more needs to happen by who? We need coordinated action across multiple fronts: Policy: Implementation of culturally sensitive care standards and mandatory training on racial bias for all healthcare workers. Funding: Greater investment in community-based maternal support services and grassroots solutions. Training: Healthcare professionals need comprehensive education on recognizing and addressing racial disparities and implicit bias. Healthcare Providers: Maternity services should collect and act on ethnicity data to identify and address disparities. GPs and Midwives: Need to create safe spaces where Black mothers feel heard and validated, with better screening for mental health concerns that considers cultural context. Community Organizations: Continued development of diverse focus groups, patient forums, and support groups (both digital and face-to-face). Our conference demonstrates the multi-stakeholder approach needed, bringing together NHS leadership, politicians like MP Florence Eshalomi and Rt Hon Diane Abbott MP, medical professionals, community groups, and most importantly, mothers with lived experiences. Final thoughts? The conversation around Black maternal health must move beyond statistics to recognize the lived experiences of Black mothers. As our conference theme "Building Better Futures: Community-Led Solutions" suggests, the most effective approaches center on the voices of those most affected. Initiatives like our project work with Genomics England and "Avoiding Brain Injury in Childbirth" (ABC) show that when Black mothers' perspectives are included in research and service design, the outcomes improve for everyone. This World Health Day theme aligns perfectly with our mission of creating healthy beginnings through community, connection, education, and advocacy. We believe that rest, as highlighted in our "Rest as Revolution" conference session, is also a critical component of maternal wellbeing that is often overlooked for Black mothers. True progress requires not just acknowledging disparities but actively dismantling the systems that create them and building new, more equitable approaches. Related hub content Addressing critical gaps in Black maternal mental healthcare: a new partnership project is launched (interview with Sandra Igwe) Working with bereaved parents for safer and more equitable care Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies Women who experience high-risk pregnancies are too often forgotten when their babies are born Mums with babies in NICU: postnatal maternal mental health support Top picks: Key resources for maternity safety

In this interview, researcher Zara Ward tells us about her latest project looking at adverse experiences of intrauterine device (IUD) fittings, removals and cervical smear tests.  Zara is seeking volunteers to take part in the research to help develop understanding of lived experiences. Find out what’s involved and how to take part…   Can you tell us a little bit about yourself? I’m a second- year counselling psychology doctorate trainee at the University of the West England. I work within a community mental health service for those with additional needs. I have a background of working within women's services for those who have experienced sexual abuse both online and offline. I have published research relating to so-called "revenge porn" and the effects this can have on those affected. I am incredibly passionate about exploring understudied areas, especially relating to the reproductive and sexual experiences of women and marginalised groups. What is the focus of your research and what led you to this area? The research focus is the adverse experiences of intrauterine device (IUD) fittings, removals and cervical smear tests. I was led into this area from my conversations with others following an adverse experience myself and being slightly floored by the lack of research and support in this area. The experiences shared within the Patient Safety Learning hub and social media were indicative that more work needed to be done. Who can take part? I am looking for adults based within the UK who have had an adverse experience relating to an IUD fitting, removal or smear test within the last two years. What would the process involve? The process would be an interview with myself via a Teams video call and would allow time for exploration of areas important to the individual. Once an interview has been completed, I shall transcribe, anonymise and analyse the interview to bring together themes across the people I interviewed. Is it confidential? It is. All information will be anonymised at the point of myself transcribing. How can people get in touch if they are interested? Anyone interested is welcome to e-mail me on: [email protected] and I would be happy to speak with them more about the process before any expectation of participation. What is your hope for the research findings? My hope for the research is to understand the lived experiences of those having adverse experiences during IUD fittings, removals and cervical smear tests and provide recommendations relating to mental health support. Related reading on the hub My experience of an IUD insertion: frozen with shock - no one was asking if I was OK Gynaecology procedures: patient survey example One hour with a women's health expert and finally I felt seen Fitting coils: developing a safe and supportive service Medical trauma from IUD fitting: it’s not just five minutes of pain for five years of gain