Patient_Safety_Learning

Dita Aswani and Fulya Mehta are both consultant paediatricians and NHS England national advisors for Children and Young adults’ (CYA) diabetes. In this blog, they outline racial inequalities that persist in paediatric diabetes and present five key areas for change. In summary they talk about what healthcare professionals can do to reduce inequalities through their own practice.  This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. Racial inequalities – stark and persistent A key objective of the Children and Young adults’ diabetes programme at NHS England is to reduce unwarranted variation in diabetes care and outcomes. Children of all ages, regardless of where they live, the colour of their skin, or the economic circumstances of their family, should receive equitable care in order to thrive, and live well with their diabetes. Racial inequalities in paediatric diabetes are stark and persistent, with multiple data highlighting disparities in outcomes, access to technology, and care experiences. Disparities in glucose levels HbA1c is a blood test that reflects your blood glucose levels over the past two to three months. It is used to diagnose and manage diabetes. Higher readings indicate worse blood sugar control. Children and young people of Black ethnicity with type 1 diabetes consistently have higher average HbA1c levels than their White peers, even when using the same diabetes technologies and with similar mean glucose levels. Data also shows that Black children in the least deprived areas have similar HbA1c levels to White children in the most deprived areas. These gaps have persisted for years despite overall National improvements. These disparities increase the likelihood of long-term complications—including retinopathy, kidney disease, and cardiovascular issues—especially when combined with systemic delays in intervention. Children and young people with type 2 diabetes are more likely to come from ethnic minority backgrounds or live in more deprived areas (six times as likely if living in most deprived quintile versus least deprived).[1] Preventable medical emergencies Hybrid Closed Loop systems (sometimes known as an artificial pancreas) help to keep blood glucose levels in target range by automatically adjusting insulin levels using real time sensor readings. Better blood glucose levels lead to improved HbA1c outcomes. Access to this technology is lower among Black and Asian children, independent of socioeconomic status. If children don’t have equal access to diabetes technology like Hybrid Closed Loop systems, episodes of hypoglycaemia or ketoacidosis may go unnoticed until they become emergencies. [2] Diabetic ketoacidosis (DKA), where a lack of insulin causes harmful substances to build up in the blood, can be life threatening and needs urgent treatment. DKA at diagnosis is a preventable medical emergency—it’s a symptom of delayed recognition, reduced access, and missed opportunities for earlier intervention. DKA at diagnosis follows the lines of social and racial inequality with the following comparative rates; White 39.6%, Asian 42.7% and Black 48.6%. [2] Barriers to equitable, safe care There are genetic and biological factors which predispose individuals or groups to certain health conditions, and these cannot be altered. However, these risks are compounded by discrimination within healthcare systems. When services are not equitably accessible, culturally responsive, or designed to meet diverse needs, existing vulnerabilities are intensified. What begins as a biological risk can escalate into a systemic injustice—where people aren’t just more likely to get sick, but less likely to be cared for appropriately when they do. If services aren’t inclusive or fail to adapt to local needs, early signs of problems—like psychosocial distress or erratic blood glucose—may be overlooked. Structural factors like bias, cultural mismatch, and systemic barriers, contribute to disengagement from services and reduced trust in healthcare professionals. Reduced trust undermines shared decision-making. When families experience bias or feel culturally misunderstood, they may disengage from services, making it harder for clinicians to tailor treatment or catch safety concerns early. Inconsistent communication. Language barriers, unconscious bias, or lack of culturally safe care can lead to miscommunication about insulin dosing, sick day rules, or when to seek help—all of which raise safety risks. Five key areas for change 1. Equity-focused commissioning This means allocating resources not based on equal distribution, but in proportion to need. For example, targeting investment in areas of deprivation or in communities with poorer health outcomes can close the gap over time. Metrics should measure fairness as well as overall performance. 2. Data transparency and granularity Gathering and disaggregating data by ethnicity, socioeconomic status, geography, and age uncovers patterns that aggregate figures hide. There are still big gaps in ethnicity data. But the real impact comes when this data is complete and drives local action—such as redesigning pathways that currently disadvantage certain groups. 3. Co-production and community leadership Communities affected by inequality must be central in designing solutions. That doesn’t just mean “feedback,” but real influence over priorities, language, and delivery—especially in populations historically underserved or blamed. 4. Workforce representation and cultural safety A healthcare system that reflects the diversity of the population and fosters safe, inclusive environments is more likely to build trust and reduce disparities. That includes tackling racism, both interpersonal and systemic. 5. Narrative change We need to replace deficit-based narratives (“non-compliant families,” “hard-to-reach groups”, “poor attender”, “frequent flyer”, “lack of motivation”) with systemic ones with full understanding of what they mean (“health inequities”, “institutional racism”, “under-resourced systems,” “barriers to access”, “structural vulnerability”, “cumulative disadvantage”) and shift responsibility to where it belongs. What can healthcare professionals do? On a personal level we should develop genuine and compassionate curiosity of lives by trying to imagine being in someone else’s shoes to understand what they experience and how that feels. This means questioning your own bias, building relational safety by asking questions to listen, and having a trauma-based approach in order to consider structural barriers, not just clinical ones. Document the context of a person, and not just their behaviour. Wider than that: collect and use data with purpose use the data as a mirror, not a defence, and let the data speak even when it is uncomfortable understand the structural determinants of your organisation understand how other systems intersect with health (eg education, immigration, housing) name and acknowledge racism for what it is, not just ‘inequality’ or ‘diversity’. Engage in Poverty Proofing training with your teams and managers, seeking to identify, challenge, and remove the structural barriers that perpetuate disadvantage, ensuring that no child, young person, or family is excluded, stigmatized, or underserved due to financial hardship. Use tools such as YoungType2 (by DigiBete), a dedicated platform and app for young people up to age 25 living with type 2 diabetes or at risk of it, co-produced with families and communities. It includes culturally sensitive content which is accessible and easy to understand, and translated in other languages, on food, activity, sleep, relationships, emotional wellbeing, school and work and school life—especially relevant for communities disproportionately affected by early-onset type 2 diabetes. Diabetes Africa is doing some standout work, especially when it comes to equity in diabetes technology access for Black, African, and African-Caribbean populations in the UK. Their Technology Equity Toolkit is particularly relevant for paediatric and young adult care, and highlights awareness to promote culturally responsive solutions. References [1] National Paediatric Diabetes Audit (NPDA) spotlight audit, 2025. [2] National Paediatric Diabetes Audit Admissions report (NPDA) 2015-2020, July 2023.

NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing PSIRF resources, tools and templates to support one another as the approach is implemented. In this ‘Top picks’, we’ve selected some to share with you. Click on the title to access each full content piece. 1. NHS England: Patient safety incident response standards NHS England has provided a complete list of patient safety incident response standards that organisations need to uphold to ensure they meet the minimum expectations of PSIRF, which cover policy, planning and oversight; competence and capacity; engagement and involvement of those affected by patient safety incidents; and proportionate responses. 2. PSIRF templates: AAR, SWARM, Rapid Review (Liverpool Heart and Chest Hospital, 2023) Three templates developed by Liverpool Heart and Chest Hospital for use in After Action Review, SWARM and Rapid Review toolkit responses. 3. PSIRF infographic: A new era in patient safety for the NHS and healthcare A simple, eye-catching poster to explain PSIRF, created by Stephen Ashmore and Tracy Ruthven. 4. Four PSIRF learning response tools Judy Walker, iTS Leadership, summarises four tools that can be used for PSIRF, explaining what they are and the strengths and weaknesses of each. 5. Suffolk and North East Essex's SOP – Patient Safety Incident Response Framework (PSIRF) ICB sign off process for smaller independent providers Suffolk and North East Essex NHS Foundation Trust share their Standard Operating Procedure on PSIRF Integrated Care Board sign-off process. 6. Applying the After Action Review for the PSIRF – some real life examples Judy Walker describes some real-life examples of After Action Reviews to illustrate some of its many applications. 7. PSIRF planning – Pressure ulcer example scenario This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups. 8. Example of a PSIRF preparation guide A Patient Safety Specialist in the North East of England has shared their 'plan on a page’ with the hub to help others prepare for the implementation of PSIRF. 9. PSIRF tool: Themed review template (August 2022) Dr Sam Machen shares her thematic review template. 10. Learn Together - Supporting involvement after safety events in healthcare Learn Together is a resource website that equips patients and families with the knowledge and resources to be involved effectively in patient safety investigations. 11. HSIB: Learning Response Review and Improvement tool Development of this tool was informed by a research study from Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), identified ‘traps to avoid’ in safety investigations and report writing. The 'Learning Response Review and Improvement Tool' is intended to be used by those writing learning response reports following a patient safety incident or complaint, to inform the development of the written report; and peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. 12. PSIRF Risk Register and Risk Management Plan: Free tool to help you transition To help organisations develop their plans and transition to this new way of working, Patient Safety Learning has published a template PSIRF Risk Register and Risk Management Plan. *Please note, that many of these will be under continuous development so please check with the related organisation or individual if you require the latest version. 13 NHS England: Applying the Patient Safety Incident Response Framework outside of NHS trusts NHS England has provided FAQs based on the questions that have been asked about applying PSIRF in non-NHS trust organisations. They should be read in conjunction with the wider PSIRF guidance and help clarify how PSIRF principles can be applied proportionately across the variety of services and commissioning structures within the NHS. 14 Self-Assessment Framework for Event Response (SAFER) Oversight: A tool for effective Patient Safety Incident Response Framework (PSIRF) governance The introduction of the Patient Safety Incident Response Framework (PSIRF) has removed traditional oversight targets, requiring practitioners to take a flexible, improvement-focused approach. While this shift is intended to improve patient safety, it has also created uncertainty for those in oversight roles, who must navigate new responsibilities without the comfort of prescriptive performance metrics. This article provides practical guidance on PSIRF oversight and introduces the Self-Assessment Framework for Event Response (SAFER) Oversight tool. The article outlines the mindset and functions needed to support effective, improvement-focused governance. It explores three aspects of oversight mindset: systems thinking, improvement focus, and compassion - as well as three oversight functions: demonstrating and assuring improvement, supporting and collaborating, and facilitating learning across the system. 15 Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF) The Health Services Safety Investigation Body (HSSIB) have published three reports that model investigation of sepsis under PSIRF, to boost local learning and help improve investigation quality across the NHS. These three investigations explore issues associated with sepsis in healthcare settings that span GPs, hospitals, ambulance services and nursing homes. Each report examines an individual case of sepsis relating to different conditions: a patient with a urine infection a patient with abdominal pain a patient with diabetes and a foot infection. Related content Top picks: PSIRF insights and opinions Top picks: 8 Swarm resources Join our community If you would like to join our hub community or become a member of the Patient Safety management Network, you can register for free here. Read our '7 reasons to join the hub' to get a flavour of how our community might help you. Share your views If you have insights, tools or knowledge to share relating to PSIRF why not comment below or get in touch with us at [email protected]. At Patient Safety Learning we are also always keen to share good practice, challenges and training resources that could help support safe care more widely. If you sign up to become a member of the hub, you can upload resources to the site, receive our monthly newsletter and engage with other members.

Angela Hayes, is a Nurse Fellow and Project Lead at The Centre for Sustainable Healthcare. In this blog, she tells us more about the Green Maternity Challenge and draws on three case studies to highlight it’s success in delivering low carbon, equitable and safe maternity care: local screening for newborn developmental hip dysplasia supporting breast-feeding reducing health-inequalities for Albanian-speaking women. This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. Background With births totalling over 673,000 in 2022, maternity services contribute significantly to the overall carbon footprint of the NHS, and therefore, to the environmental crisis. Pregnant women and infants are particularly vulnerable to climate change, which exacerbate existing health complications. Women from ethnic minorities or disadvantaged backgrounds are disproportionately affected so significant health inequalities persist. The Green Maternity Challenge was delivered in partnership with the Centre for Sustainable Healthcare, The Royal College of Obstetricians and Gynaecologists, The Royal College of Midwives and The Sustainable Healthcare. It aimed to: address the environmental impact of maternity care improve health outcomes create a more sustainable, equitable healthcare system. Nine clinical teams in the UK were chosen and supported by CSH to develop a Sustainable Quality Improvement project (SusQi) and measure its impact. Examples of impact Local screening for newborn developmental hip dysplasia - Orkney Due to geographical limitations, access to advanced equipment and specialist care and skills can be limited. Presently, families need to travel to Aberdeen with their newborns for the Ultrasound Newborn Screening for Hip Dysplasia. This has the potential to negatively affect clinical outcomes for patients, particularly those from peripheral areas such as Orkney Island, due to increased travel time and delay in travel owing to unpredictable weather, longer waiting periods and inconvenience to families. Local screening programmes can reduce waiting times and increase access to healthcare. It can also allow for early management and intervention in newborns. A team in Orkney introduced local screening facilities for newborn developmental hip dysplasia and eliminated the need for travel to the mainland. The programme has created increased job satisfaction for staff and reduced stress, travel and delays for patients. The environmental savings projected are around 22,500 miles and costs savings rising to £17000/year. Supporting breast-feeding - Great Western Hospitals NHS Foundation Trust Breastfeeding is important because it improves the long-term health of both mothers and babies. Between 74-86% of birthing people start breastfeeding in the first 48 hours. Around 8% stop breastfeeding by the time they go home from hospital and a further 20% stop during the first two weeks at home. There are several reasons for this, but a lack of infant feeding support is a major contributor. Lack of support also contributes to 5-20 mothers and babies a month requiring readmission for jaundice, weight loss and tongue tie. Staff on the post-natal ward at the Great Western Hospitals NHS Foundation Trust hoped to improve breast-feeding rates through the implementation of daily feeding support groups. They demonstrated improvements in effective person-centred care, staff satisfaction and patient confidence. With breast-feeding rates up by 5%, they projected yearly savings over £4600, reductions in re-admissions and outpatient appointments, and environmental savings equivalent to driving almost 5000 miles. Reducing health-inequalities for Albanian-speaking women - Kingston Vulnerable groups such as migrants and ethnic minorities, face various barriers in accessing healthcare, and as a result, face poorer clinical outcomes. One such example is that of Albanian speaking women in Kingston. Comprising of 1% of all maternity care bookings at Kingston (as compared to the 0.2% national population), Albanian women face various challenges such as language barriers, asylum seeking status, poor socio-economic status, lack of support, histories of human trafficking and sexual abuse, and pre-existing mental health conditions. They are also subject to discrimination and culturally insensitive care. All these factors contribute to underutilisation of healthcare services, limited access to high quality care, concerns about confidentiality as well as lack of faith in healthcare system. Delay in getting timely and appropriate care can lead to poorer health outcomes, often necessitating more intensive and resource heavy treatments. The Olive Clinic in Kingston & Richmond midwifery team arranged for an interpreter to support their ante-natal clinic for Albanian-speaking women to support them during and after pregnancy. Impact studies are yet to be measured but qualitative data shows encouraging results from women and midwives. Summary There are many more examples and case studies but these three particularly highlight how green initiatives can be aligned to patient safety improvements to make sure every newborn and every child receives safe care. With projected annual savings of £860,669, and carbon savings equivalent to 778,978 disposable nappies, they made a huge impact on sustainable and equitable maternity. Share your insights Do you have insights to share around balancing patient safety with sustainability? What are the challenges and opportunities? Contact the editorial team at [email protected] to share your ideas.

Trigger warning: This blog contains themes that may be triggering for some people.  Hope Virgo is an author, a multi award winning mental health campaigner, and secretariat for the All-Party Parliamentary Group (APPG) for eating disorders. In this blog, she explores the patient safety issues affecting children with eating disorders and their families. Hope highlights how lack of investment and understanding is leading to avoidable harm and shares five key actions for change.  This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. My campaigning work was born out of wanting to fight the injustices that so many people affected by eating disorders go through. Having lived with anorexia from the age of 12-17 before being admitted to a mental health hospital where I began my journey to recovery, I know first-hand just how awful eating disorders are. I have spent huge amounts of life feeling frustrated by how many people get turned away from services for not having that “particular stereotypical look” and with how much neglect is taking place in treatment across the UK. Patient safety concerns Often people still think someone with an eating disorder will be underweight or have been labelled with anorexia. Eating disorders are so much more than that. During my campaign work and the APPG evidence sessions, I’ve met hundreds of people who have been denied treatment for not looking that way. We have spoken to parents who have children with avoidant restrictive food intake disorder (ARFID), who have not been able to access treatment and support. The reality is, there is a postcode lottery and a lot of children and their families aren’t being given the best chance of life. Many carers also tell me how often their concerns are dismissed as silly worries. This cultural dismissiveness across eating disorder services and the lack of training and funding, is leading to huge issues for patient safety. It is causing people to die. It can feel so hard to speak up when support is so limited, but as a parent or carer, learning to push for support is crucial. I’d also recommend looking at the amazing resources for carers produced by the organisation FEAST. Stigma, misunderstanding and dangerous narratives Eating disorders are an illness that is massively stigmatised and misunderstood. Contrary to many assumptions, people with an eating disorder: are not making a lifestyle choice are not being difficult are not all white females. Eating disorders can impact people of any age, size, gender or race. Stigma and misunderstanding leads to so many people being denied treatment for an eating disorder. Marked as ‘untreatable’ One narrative that we have seen in the last two years is an increasing amount of people with eating disorders being marked as untreatable, too complex and in some cases as terminal and moved to palliative care. This dangerous narrative is causing many people to be discharged from services too soon and given inadequate care. If they are discharged prematurely and still have a malnourished brain they are not being given the chance for it to fully rewire - leading them at high risk of relapse. Time for change For too long eating disorders have been stigmatised and underfunded, with very little specific staff training. For children’s services, whilst there has been some investment, it has been very limited. Five key changes to support patient safety The APPG published a report in January 2025 calling on the government for five key things: Develop a national strategy for eating disorders. Provide additional funding for eating disorder services. This funding should address the demand for both adult and children’s services. Launch a confidential inquiry into all eating disorder deaths. Increase research funding for eating disorders: The aim is to enhance treatment outcomes and ultimately discover a cure for eating disorders. Ensure non-executive director oversight for adult and children's eating disorder services. This oversight and accountability should be implemented in all NHS Trusts and Health Boards in the UK. Recovery When you have an eating disorder, it completely consumes you. It takes over every area of your life. And it consumes your family life too. The research shows that people can and do recover at any age, severity of illness or length of illness. So why are we allowing so many to remain stuck living with an eating disorder and denying them the care they need? Over the last few years. we have seen pockets of good practice in services from the development of integrated enhanced cognitive behavioural (I-CBTE) therapy, to areas where GPs have quickly referred patients or supported families to recover. With the right support and treatment in place for people with eating disorders we will not only save lives but also money. Through early intervention we can prevent hospital admissions and prevent begin becoming more malnourished thus leading to quicker recovery times. Final thoughts Eating disorders are a serious mental health issue. They have the highest mortality rate of any other psychiatric illness yet are often hidden in plain sight. It doesn’t have to be this way. People with eating disorders can and do make full recoveries, we just need to do better to enable this to happen. This growing epidemic can only be reversed by investing into prevention, early intervention, and timely, high-quality treatment. Access to services needs to be free from discriminating criteria and bias. The current inpatient treatment approach results in poor outcomes and 40-50 percent relapse rates. Without a cultural shift and a complete reformation of services nothing is going to change. Campaigners, clinicians and others need to work together to make this change happen. March with us On 21 June, 2025, we’ll be taking to the streets of London for the third consecutive year to march for those we love, for those we have lost, and for the future generations affected by eating disorders. This march is not just a walk — it’s a statement to demand better services and put an end to the neglect faced by those struggling with eating disorders across the UK. Find out how you can join.

In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. The tool was designed by Chris and Nicki Pusey, Maternity Investigation Team Leader at MNSI. This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. Why was COMPASS developed? COMPASS was created based on work carried out by the Patient Experience Library who conducted a literature review of over 10 years’ worth of avoidable harm enquiries, which included the reports on the maternity services at East Kent and Morecambe Bay. The work has been collated into a report called ‘Responding to Challenge’¹. The review demonstrated that poor organisational culture is a recurrent theme in avoidable harm, with significant impact on patient safety. Their work highlights how organisational culture remains challenging to quantify and articulate which hampers external bodies’ ability to provide insight to providers. Through our safety investigations it became evident that MNSI did not have a way to record and analyse cultural observations in a structured and evidence-based format. This inhibited us from feeding back our observations to organisations to help them see how their organisational culture might be impacting on patient safety. What are the aims of COMPASS? We developed COMPASS for two key reasons: To provide MNSI staff with a standardised process to record observations around organisational culture, empowering MNSI staff to articulate their observations to trusts in a structured and evidence-based manner rather than based on personal experience or individual interpretation of certain situations. To highlight to trusts areas where their organisational culture is contributing positively to patient safety, and areas where enhancing their focus will support and improve safer care to be delivered. There is already significant work being done to help trusts to improve culture and leadership within maternity services, and COMPASS is a tool designed to complement this by focussing on how organisations respond to and learn from patient safety events. How is COMPASS being used? COMPASS is currently being piloted in partnership with 12 NHS trusts in England and is due to finish at the end of May. MNSI staff are using COMPASS to gather observations about organisational culture that may have impact on patient safety, in a structured manner that reflects the findings from the ‘Responding to Challenge’ report. The findings are then collated and reviewed to determine how frequently these types of observations are occurring so we can assess the overall level of impact to patient safety that may be occurring within each of the specific areas. These findings are then shared with trust leadership teams to flag areas that may require attention or focus to improve safety and organisational culture and also highlight observations of culture that have had a positive impact on patient safety. What is next for COMPASS? After the pilot, and with the help of feedback from both MNSI staff and trusts who piloted the report, we hope to: Adapt the COMPASS tool to match the needs of both MNSI and organisations we work with to maximise the impact of the tool. Showcase the positive impact COMPASS has had on patient safety within maternity and newborn services. Share our learning through the development of COMPASS and explore how this can be utilised in other sectors to improve patient safety across healthcare. If feedback suggests that the tool is of value to both MNSI and trusts, we may seek to use COMPASS on a regular basis to help share our insights into organisational culture with trusts to help improve patient safety. How can people find out more? Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety MNSI has launched a new patient safety tool COMPASS Red Flag Tracker – a tool to help recognise the red flags for harmful healthcare cultures by the Patient Experience Library References 1. The Patient Experience Library's Responding to Challenge report April 2025 Do you have a safety tool or project to share? Are you implementing a change that has had a positive impact on patient safety? Could you share your insights, tools and knowledge to help others? Or perhaps you are at the start of the journey, seeking ways to address a patient safety issue that you've identified. Comment below (sign up for free first) or contact our editorial team at [email protected] to tell us more.

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 become increasingly normalised, with NHS England having issued guidance to support point-of-care staff in delivering as safe and high quality care as possible when corridor care has been deemed unavoidable. 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. Corridor care guidance needs to move beyond what “should” happen and grapple honestly with why it isn’t (a blog by Claire Cox) In this blog, Patient Safety Learning’s Associate Director and nurse, Claire Cox reflects on NHS England's guidance Principles for providing patient care in corridors and sets out the need for national action to tackle this persistent problem. Corridor care: Patient Safety Learning's response to the latest HSSIB report On the 8th January 2026, the Health Services Safety Investigations Body (HSSIB) published a new report looking at patient safety risks associated with the use of temporary care environments, more commonly referred to as corridor care. In this article, Patient Safety Learning sets out its reflections on the report’s findings. 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. Response to RCN report: On the frontline of the UK’s corridor care crisis 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. 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. Poor continence care in overwhelmed emergency departments is leading to avoidable harm A continence nurse highlights the difficulties in delivering toileting support to patients in overwhelmed emergency departments. They explain the challenges staff face, how these impact patient outcomes and experience, and why this needs to be urgently addressed. My experience of the 'Wait 45' policy In this blog, a frontline healthcare worker shares their experience of the 'Wait 45' policy in my trust and the impact it is having. 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. Further reading on the hub: Rethinking suicide prevention: from prediction to understanding

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