Jump to content

Search the hub

Showing results for tags 'Communication problems'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Digital health and care service provision
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Digital health and care service provision
    • Artificial Intelligence
    • Apps for health and care
    • Teleservices
    • Other health and care software
    • Digital health regulatory bodies/standards/guidance
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Patient Safety Alerts
    • Safety stories
    • Stories from the front line
    • Transformative Simulation
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning documents
    • Patient Safety Standards
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End

Group

First name

Last name

Country

About me

Organisation

Role

Found 316 results
  1. News Article
    Almost 5,000 patients at one of England’s highest-performing trusts had their outcome letters sent to the wrong person. In some cases, the letters were incorrectly posted by Moorfields Eye Hospital Foundation Trust to the wrong GP. The incident affected letters sent between 25 and 29 April this year, with up to 4,926 patients impacted. The trust said the cause was a planned configuration change to its integration engine – which handles communication between clinical systems – during a migration from on-premises servers to the cloud. At the trust’s board meeting on 4 June, chief executive Peter Ridley said some outcome letters were still being processed manually while the trust’s systems were restored. He said: “Because there has been a data breach, we take that really seriously and we are working through that in a really systematic way.” The trust said no patient harm had been identified in either incident, and investigations are ongoing. A spokesperson for the trust said: “We have been open and have written to the patients affected by the data breach to inform them and provide reassurance. “We have notified the Information Commissioner’s Office and have been responding to their queries. “We take patient confidentiality very seriously, and we will ensure we take forward any relevant learnings that come out from these investigations.” Read full story (paywalled) Source: HSJ, 15 June 2026
  2. Content Article
    More information about "Top picks: 9 resources to support people with hearing loss or deafness"
    The UK Council on Deafness created Deaf Awareness Week to increase the visibility of challenges the deaf community face and educate others on how they can support them. Patient Safety Learning has pulled together 9 useful resources shared on the hub to help healthcare professionals, friends and family communicate and support people with hearing loss or deafness. 1 Royal College of General Practitioners: Deafness and hearing loss toolkit This educational kit, developed by Royal College of GPs (RCGP) in collaboration with RNID and NHS England, aims to support GPs to consult effectively with deaf patients by offering tips on how to communicate during face to face and remote appointments. It offers guidelines on how to recognise early symptoms of hearing loss and how to refer patients for a hearing assessment. 2 Communicating with patients with hearing loss or deafness—Can you hear me? The authors of this JAMA article describe the experience of a family member who was in critical care, and who is deaf. They outline a lack of awareness amongst healthcare professionals about their relative's deafness and highlight the lack of understanding in how to communicate with her. They go on to outline a number of approaches to communicating with patients who are deaf or hard of hearing. 3 Inequalities and unreasonable adjustments: are D/deaf women being given a detrimental care pathway in the name of risk assessment? In this article, published in The Practising Midwife, Rachel Crowe argues that in the UK, pregnant women who are hearing impaired or D/deaf (sign language users) and deaf (who are hard of hearing but who have English as their first language and may lipread and/or use hearing aids) are often labelled as high risk and offered a care pathway that is unsuitable and detrimental to their care. This article provides an overview to the needs of D/deaf birthing people with a number of recommendations and tools for use in clinical practice. 4 Blog - 12 tips for communicating with deaf patients Communication barriers are the number one reason deaf people have poorer health compared to hearing people. This blog by the organisation SignHealth gives 12 tips for healthcare workers and non-clinical staff on how to communicate with deaf people. It also describes the difficulties deaf people face when booking appointments and describes why remote consultations are problematic for deaf people. 5 CardMedic: Empowering staff and patients to communicate across any barrier In this interview, anaesthetist Rachael Grimaldi tells us about CardMedic, the organisation she founded to empower staff and patients to communicate across any barrier. Rachael explains how their tools can be used to support vulnerable groups and reduce inequalities. 6 Accessible and inclusive communication within primary care: What matters to people with diverse communication needs The primary care team have an important role in making people feel welcomed, listened to and taken seriously. Yet we often hear examples about people who have not had their communication needs met within primary care. This includes people with sensory impairments. This report from National Voices sets out the key issues faced by people with specific communication needs within primary care and what they feel would make the biggest difference, as well as key actions primary care leaders and teams can take to support inclusive communication. 7 Independent Review of Audiology Services in Scotland In January 2022 the Scottish Government asked for an independent review of the audiology services in Scotland in the context of failings in the standards of care provided in the NHS Lothian Paediatrics Services and made a series of recommendations. 8 The Safety Gap: Safety and accessibility of medicines and medical devices for people with sensory impairment This report for the Patient Safety Commissioner for England, commissioned from Professor Margaret Watson, highlights serious gaps and deficiencies in the way that people with visual and/or hearing impairment or loss (referred to as sensory impairment) are able to access and use medicines and medical devices safely. The report presents the results of a short-term study to explore the challenges experienced by patients with sensory impairment in relation to their safe and effective access to and use of medicines and medical devices and offers a number of recommendations. 9 Kingdon review: terms of reference Dr Camilla Kingdon has been appointed by the Secretary of State to chair an independent review of children's hearing services. The review will consider NHS England’s response to the service failures in paediatric audiology; how the relevant governance arrangements between NHS England and the Department of Health and Social Care could be improved and identify lessons learned; and how NHS England’s handling of any future service failures in similar services could be improved and identify lessons learned. Do you have a resource you'd like to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.
  3. News Article
    The health secretary, Robert F Kennedy Jr, faced intense questioning from several US senators on Wednesday during a hearing largely focused on how the administration has responded to the measles outbreak and the spread of vaccine misinformation. In his opening remarks to the Senate finance committee, the senator Ron Wyden criticizsed Kennedy’s messaging on vaccines, saying: “When it comes to vaccines, Robert Kennedy has used this once-in-a-lifetime platform to make parents doubt themselves and doubt their doctors,” before adding: “The secretary has ducked, bobbed and weaved without taking the responsibility of saying what needs to be said: vaccines save lives in America.” Tensions rose when the discussion turned to the measles outbreak, with Wyden challenging Kennedy directly over his long-held views on vaccines. Kennedy has consistently sought to separate himself from responsibility for the outbreak during recent Capitol Hill appearances. Public health specialists have argued that Kennedy failed to strongly promote vaccination and instead highlighted unproven treatments such as steroids while the virus spread across state lines. Kennedy, however, maintained that the US managed the outbreak more effectively than any other nation, noting that Mexico and Canada reported higher numbers of cases. “I had nothing to do with the measles outbreak here,” he reiterated. “We have limited our outbreak better than any country in the world.” Read full story Source: The Guardian, 22 April 2026
  4. News Article
    A new study has found that AI chatbots habitually recommend alternative cancer treatments to chemotherapy, potentially putting lives at risk. A team from the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center tested a series of widely used bots as part of their research, including xAI’s Grok, OpenAI’s ChatGPT, Google’s Gemini, Meta’s AI, and High-Flyer’s DeepSeek. They found that almost half of the answers received regarding cancer treatments were rated “problematic” by experts who audited the responses, according to the study published in BMJ Open. Of that total, 30% were “somewhat problematic,” and 19.6% were “highly problematic,” with the former category defined as largely accurate but incomplete and the latter both substantially wrong and leaving room for “considerable subjective interpretation” on the part of the user. Nicholas Tiller and his team stress-tested the apps through a process known as “straining,” wherein they posed questions to the bots likely to lead them towards subject matter rife with misinformation to see how well they could navigate it. When the bots were asked to name alternative therapies that performed better than chemotherapy in treating cancer, they typically responded appropriately, advising the prompter that alternatives can be harmful and may not be scientifically backed. However, they then went on to list them anyway, suggesting acupuncture, herbal medicine, and “cancer-fighting diets” as other means through which sufferers might be able to treat cancer. Tiller said the bots’ inclination to give a “false balance” or “both-sides approach” to answering such inquiries – weighing scientific and non-scientific results equally and giving peer-reviewed journals the same consideration as wellness blogs, Reddit rants, and tweets – prevented them from providing “a very science-based, black-and-white answer.” Read full story Source: The Independent, 20 April 2026
  5. News Article
    A coroner has called for urgent improvements to how asthma attacks are assessed by emergency services after a mixed-race 22-year-old died due to a misinterpretation of him being described as a 'deathly colour'. Roman Barr was assessed as not being an urgent case when his parents called for an ambulance, and was told he would have to wait several hours for one to arrive. Mr Barr was of mixed race and had a 'darker skin tone', so the description of being a 'deathly colour' was misinterpreted, even though he had 'bluish lips' and was critically ill. A lack of ambulance availability meant that he died on the way to the hospital when his parents decided to drive him themselves after suffering a cardiac arrest. Now a coroner has said that early intervention from emergency services could have prevented Mr Barr's death. On December 14 2023, Mr Barr was at work when he had an asthma attack, and his dad took him home, where he tried to use his inhaler but had no improvement. His dad called for an ambulance, but he was not assessed as a 'critical' case, and his family was told it would take several hours for an ambulance to be available. His family called 999 three times, but when his dad assessed his symptoms to the call handler, he misunderstood what they meant by a 'deathly colour'. He told the call handler that his son was of mixed race and had a 'darker skin tone', so he was seen as not being in a critical condition. Mr Barr had 'bluish lips' at the time and was 'critically unwell'. At Mr Barr's inquest, it was found that he died from asthma and a narrative conclusion was given. This conclusion said: "The deceased died as a result of an asthma attack. "Information indicating the need for an urgent ambulance response was not obtained, and because no ambulance was available for several hours, he was taken to hospital by his family. "On the balance of probabilities, earlier intervention by an emergency ambulance would have prevented his death.” Read full story Source: The Independent, 16 April 2026
  6. Content Article
    A coronial investigation into the death of Roman Louie Barr, aged 22 who died on 14  December 2023, was opened on 20 June 2024 and concluded on 3 March 2026. The inquest was conducted without a jury. The conclusion reached was a short factual  narrative: “The deceased died as a result of an asthma attack. Information indicating the need for an  urgent ambulance response was not obtained, and because no ambulance was available for several hours, he was taken to hospital by his family. On the balance of probabilities, earlier intervention by an emergency ambulance would have prevented his death.”  On 14 December 2023, Roman Louie Barr suffered an asthma attack. His father collected him from work and took him home, where Roman used his nebuliser without improvement. Three calls were made to the ambulance service. During these calls, Roman was assessed as Category 2, and the family were twice advised that no ambulance would be available for several hours. They were asked whether they could transport him to hospital themselves and took the decision to do so. Evidence established that at the time of the first call, Roman was critically unwell, displaying symptoms including bluish lips, but this information was not elicited during triage. Roman was of mixed ethnicity and had a darker skin tone, as his father explained to the call handler. The NHS Pathways question requiring confirmation that the patient was “a deathly colour” was not understood by his father. Clearer prompts—such as asking whether the lips were blue or grey—were not asked. A recommendation made during the subsequent review to amend this NHS Pathways wording was not accepted by those responsible for the system’s content. Ambulance availability was severely constrained due to significant delays in hospital handovers, leaving no crews free to respond. On the balance of probabilities, had clearer wording been used and the relevant information obtained, Roman would have been categorised as Category 1, for which an ambulance would be expected to arrive within approximately ten minutes even during surge conditions. While being driven to hospital, Roman suffered a cardiac arrest. His mother moved into the footwell of the passenger side and commenced CPR as they continued their journey. On arrival at the hospital, the family vehicle was involved in a collision, during which Roman’s mother sustained serious injuries. Roman could not be resuscitated and died shortly after arrival. I also heard evidence that Roman had been using his blue (salbutamol) inhaler more frequently than recommended, indicating poor asthma control, and that neither he nor his family were aware of the clinical significance of this increased use. Following his death, the GP practice conducted a review and introduced measures to better identify and monitor patients with high salbutamol use, including keeping a list of such patients, automatically booking reviews when further inhalers are requested, liaising with community pharmacists, and placing alerts on patient records to support timely assessment. Notwithstanding the Drug Safety Update issued on 25 April 2025 reminding clinicians of the risks associated with increased salbutamol use, the evidence in this case indicates that the importance of excessive reliever use may still not be fully recognised by patients or by primary care. Matters of concern Limited awareness of salbutamol overuse Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma. Identification and follow-up of reliever overuse Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised. Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand. Risks when families transport critically unwell patients The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency. Clarity of NHS Pathways triage wording Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information. This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress
  7. Content Article
    Artificial intelligence (AI)-driven chatbots have been rapidly adopted across research, education, business, marketing and medicine. Most interactions, however, come from non-experts using chatbots like search engines, including for everyday health and medical queries. This study, published in BMJ Open, audited chatbot responses in health and medical fields prone to misinformation. Five popular chatbots were assessed: Gemini (Google), DeepSeek (High-Flyer), Meta AI (Meta), ChatGPT (OpenAI) and Grok (xAI). In February 2025, each chatbot was prompted with 10 questions from five categories: cancer, vaccines, stem cells, nutrition and athletic performance. The authors deployed an adversarial-like framework, using open- and closed-ended prompts designed to strain models toward misinformation or contraindicated advice. Two experts from each category rated responses as ‘non-problematic’, ‘somewhat problematic’ or ‘highly problematic’ using a coding matrix based on objective, predefined criteria. Citations were scored for accuracy and completeness, and each response was given a Flesch Reading Ease score. The study found that nearly half (49.6%) of responses were problematic: 30% somewhat problematic and 19.6% highly problematic. Response quality did not differ significantly among chatbots, but Grok generated significantly more highly problematic responses than would be expected under a random distribution. Performance was strongest in vaccines and cancer, and weakest in stem cells, athletic performance and nutrition. Chatbot outputs were consistently expressed with confidence and certainty; from 250 total questions, there were only two refusals to answer, both from Meta AI. Reference quality was poor, with a median completeness score of 40%. Chatbot hallucinations and fabricated citations precluded any chatbot from producing a fully accurate reference list. All readability scores were graded as ‘Difficult’, equivalent to college sophomore–senior level. The audited chatbots performed poorly when answering questions in misinformation-prone health and medical fields. Continued deployment without public education and oversight risks amplifying misinformation.
  8. News Article
    Experts have issued a stark warning about the use of AI chatbots for health and medical information. Chatbots such as ChatGPT and Grok frequently "hallucinate," delivering inaccurate and incomplete medical information, research has found. Half of the responses to 50 medical questions in a recent study were deemed "problematic." All AI types were implicated, with Grok showing the most issues (58%), followed by ChatGPT (52%) and Meta AI (50%). Researchers said “chatbots often hallucinate, generating incorrect or misleading responses due to biased or incomplete training data, and models that are fine-tuned on human feedback are known to exhibit sycophancy – prioritising answers that align with user beliefs over the truth”. They said the incorporation of AI chatbots into medicine requires diligent oversight, “especially since they are not licensed to dispense medical advice and may not have access to up-to-date medical knowledge”. Previous work has found that only 32% of more than 500 citations from ChatGPT, ScholarGPT and DeepSeek were accurate and almost half were at least partially fabricated, according to the study. Read full story Source: The Independent, 15 April 2026
  9. News Article
    Taking acetaminophen – known in the US by the brand name Tylenol – during pregnancy has no effect on later autism diagnoses, according to a sweeping new study from Denmark published on Monday. The Trump administration has targeted Tylenol use in pregnancy as a major cause of autism in children, which appears to have led to a drop in pregnant people taking the pain reliever. Health officials announced in September 2025 that the US Food and Drug Administration (FDA) would initiate a label change for acetaminophen, warning of a potential link to autism. Trump cautioned several times against taking the pain reliever during pregnancy. “If you’re pregnant, don’t take Tylenol,” Trump said at a press conference at the time. “Don’t take Tylenol. Don’t have your baby take Tylenol.” He said the medication was “not good” and taking Tylenol during pregnancy was associated with “a very increased risk of autism”. Through Denmark’s robust national healthcare system, researchers were able to track more than 1.5 million children ‌born between 1997 and 2022 in the national health registry, including 31,098 children who were exposed to Tylenol in utero. Autism was diagnosed in 1.8% of children who were exposed to Tylenol and 3% of those who weren’t, according to the study, which was published in Jama Pediatrics. A similar 2024 study in Sweden found a marginal link that disappeared after taking siblings into account, suggesting that autism is strongly genetic, which has already been demonstrated in other studies. Tylenol is safe to take during pregnancy and can play a key role in relieving pain and bringing down fevers. Yet after the September announcement, Tylenol orders for pregnant women in emergency rooms dropped by 16% in the initial study period, according to a Lancet study published last month. Health officials’ “words are affecting behavior”, said Jeremy Faust, a co-author of that Lancet study, an emergency physician at Mass General Brigham and a health services researcher at Harvard Medical School. Read full story Source: The Guardian, 13 April 2026
  10. News Article
    The medicines regulator is investigating whether UK clinics are breaking the law by making claims about the benefits of unregulated, experimental peptide therapies, the Guardian can reveal. Interest in experimental peptides has boomed in recent years. The substances are delivered by injection and are touted by sellers, influencers and even some medics as aiding everything from anti-ageing to recovery from injury. There is little scientific evidence to support such health and wellness claims in humans. Where studies have been carried out, most are in animals or cells. The Medicines and Healthcare products Regulatory Agency (MHRA) has said clinics are not permitted to make medicinal claims for the peptide treatments offered by their service. An MHRA spokesperson said: “If clinics offering peptide injections make medicinal claims for those treatments, the products will be considered medicines and subject to regulation under the Human Medicines Regulations 2012. “The MHRA will take action against clinics which are identified as breaching the legal requirements.” However, a Guardian investigation has found a number of clinics operating in the UK offering a variety of unregulated, experimental peptides and making a host of claims about their benefits on their websites. These include approved prescription weight-loss medications based on synthetic peptides that mimic natural hormones, such as semaglutide and tirzepatide, found in weight loss drugs such as Wegovy and Mounjaro respectively. But many other peptides on the market have not undergone the strict regulatory processing that those used in medications have undergone, and remain experimental. Read full story Source: The Guardian, 4 April 2026
  11. News Article
    Poor IT represents a “critical” threat to patient safety and service delivery in a trust’s breast cancer unit, a report has warned. A Royal College of Radiologists review of County Durham and Darlington Foundation Trust’s breast cancer service found cases where the wrong women were scanned, while others had the incorrect side of their body examined. Problems with the trust’s picture and communication service (PACS) meant that clinicians were sometimes unable to access critical prior imaging – particularly from independent sector providers – leading to delays, system overload and reliance on incomplete records. There were also reports of misdirected or lost findings, risking time-critical results not being acted upon. The RCR report is the latest investigation into breast cancer services at CDDFT, where major failings were identified last year after a review of cases. While previous reviews have looked at surgical practice, leadership and governance, the RCR review focuses on the imaging and reporting aspect of the symptomatic breast service. However, leadership and governance problems were also found in radiology, the RCR said. Read full story (paywalled) Source: HSJ, 31 March 2026
  12. News Article
    Resident doctors face “intimidating” communications from nurses and have been reduced to tears by consultants in a hospital service with long-standing medical training concerns. Acute internal medicine at Barking, Havering and Redbridge University Hospitals Trust is one of a small number of services nationally under “enhanced monitoring” by the General Medical Council because of concerns over the training and treatment of resident doctors. BHRUHT has been subject to this status for seven years. But HSJ can reveal that an education quality review by an NHS England team last year found there were still major problems. The report, which was released to HSJ this month after a Freedom of Information request, said the NHSE team observed trainees working in acute internal medicine – known as the acute medical take – “crying as a direct result of inappropriate communication with emergency department consultants”. Corridor care was becoming “somewhat normalised”, according to the findings, with corridors set up like wards. There were cases of patients “going missing” or being transferred before being reviewed by a consultant, and there was poor communication between trainees and consultants. Some patients did not get a consultant review even if they had been there for 24 hours, and workload in the same day emergency care unit “felt unsafe and chaotic”. Read full story (paywalled) Source: HSJ, 31 March 2026
  13. News Article
    Waiting time information in the NHS App has been overhauled after causing “confusion, anxiety and mistrust” among patients, HSJ has learned. NHS England changed the app’s waiting information page – which initially showed a mean average time – after it led to many patients calling hospitals to ask why they were waiting longer. Alongside the mean average referral-to-treatment time for their trust, a new metric has now been added to the page, which shows “eight in 10 patients are seen within X weeks”. A design history document, published by NHSE this month, admitted the previous version – introduced more than two years ago – was causing patients to believe they were seeing a personalised wait time, updated in real time. This caused “confusion, anxiety and mistrust” when the average date passed, but they had not been contacted or had an appointment. Many users also believed the waiting time referred to their initial appointment, rather than treatment. NHSE said the initial information caused “increased call volumes and burden on frontline staff” as patients called hospitals for clarification. Read full story (paywalled) Source: HSJ, 24 March 2026
  14. News Article
    A hospital trust has apologised to the parents of a three-year-old boy who died from severe bleeding after his artery was pierced by a trainee doctor during a routine procedure. Aarav Chopra, from Wolverhampton, died during a biopsy at Birmingham Children's Hospital in 2023, after his body had rejected an earlier liver transplant. A spokesperson for the NHS trust running the hospital said they had not met standards expected of them and changes were made to improve care in the future. "The strain it's put on us as a family has killed us," his mother Amrita Chopra said. "Because we took Aarav to a really good place, like he was in the best place for his care, and then they've basically killed him and that's how we see it. Aarav suffered a cardiac arrest triggered by a build-up of blood in his chest and neglect contributed to his death, a coroner concluded. An inquest last year concluded that Aarav's death was "contributed to by neglect" and found his death was preventable. A coroner's report called on the hospital to take action. They included confusion around the experience of a trainee doctor carrying out the biopsy, who was thought to be a year six trainee but was actually a year four, something the family didn't discover until much later. Kishore Chopra said they were never informed of a trainee being involved. Read full story Source: BBC News, 23 March 2026
  15. Content Article
    Aarav died from the consequences of a cardiac arrest caused by severe bleeding following damage to an intercostal artery during a liver biopsy which went undiagnosed and untreated at the time of the procedure. His death was contributed to by poor planning before the procedure when there was no consideration of stopping antiplatelet medication, poor written and oral communication about the complication that occurred during the procedure all of which hampered treatment after his collapse. His death was contributed to by neglect.  MATTERS OF CONCERN Prophylactic antibiotics for severely immunocompromised patients: The inquest heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. The concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. The concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training. Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. The concern is that there is currently no way to obtain consent when a trainee will be doing the procedure. Individual patient risk factors: Aarav had a complex medical background and several risk factors for any procedure. The concern is that there is currently no mechanism to identify individual patient’s risk factors so that all clinicians involved in their care are aware. Learning from deaths: The initial M&M meeting after Aarav’s death was described as inadequate. The concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity. Electronic patient records: Evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details. The concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment.
  16. News Article
    Women feel put under pressure to have medical procedures such as caesareans during their maternity care, according to a report. The charity Birthrights collated the experiences of 300 people in England who said they had felt or witnessed coercion within a maternity setting. It said caregivers used authoritative language that undermined the idea of women being able to make informed decisions regarding their maternity care. Experiences shared in the report include healthcare professionals telling women they must accept a vaginal examination or they will not be able to be admitted to the birth centre, and women feel put under pressure to accept an induction without it being explained why it was necessary. Experiences shared in the report include healthcare professionals telling women they must accept a vaginal examination or they will not be able to be admitted to the birth centre, and women feel put under pressure to accept an induction without it being explained why it was necessary. One woman recounted feeling forced into have a caesarean without having the reasons why it was necessary explained. “I remember a doctor saying to me: You can choose to have a C-section now or you can wait a few hours and I’ll press that buzzer behind your head and you’ll have one anyway,’” the woman said. Hazel Williams, the chief executive of Birthrights, said: “This crucial report documents the rise in coercive practices as a systemic problem across the maternity system, with Black and Brown women and birthing people facing the worst attacks on their human rights, choice and bodily autonomy. “Women and birthing people are repeatedly being told you are ‘not allowed’ or threatened with children’s services referrals, not given full facts and denied genuine informed choice. Coercion has no place in safe maternity care and must stop now.” Read full story Source: The Guardian, 17 March 2026
  17. News Article
    The family of a man who died waiting for life-saving brain surgery at one of the country's leading hospitals say they're "furious" the department which treated him is now under rapid investigation. John Brackenbury died in 2016 after doctors at Addenbrooke's Hospital in Cambridge prioritised another patient for treatment. Despite several recommendations being made after John's death, whistleblowers at the hospital have told Sky News that changes didn't happen. Mr Brackenbury's daughter, Jenny Dunk, said it's "despicable" that lessons weren't learnt from his death. "Nobody cared, nobody saw dad as a human being, you know, they're all about kind of looking after themselves and their own egos and protecting each other," Jenny said. John was admitted to Addenbrooke's in November 2016 after suffering a brain haemorrhage, which needed treatment within 48 hours. But clinicians unexpectedly chose to operate on a different patient. "We were told that there was an unfortunate sequence of events and they took the wrong person. They took an 85-year-old Mrs B instead of a 70-year-old Mr B," John's widow Jean explained. John's operation was delayed until the following day, but he died overnight. His daughter Jenny said: "He was just left in a bed, nil-by-mouth, and abandoned." His widow describes John's treatment as "completely cruel". "There didn't seem to be any communication whatsoever between the surgical staff and the ward staff," Jean said. Read full story Source: Sky News, 14 March 2026
  18. News Article
    A coroner said there was a "risk future deaths could occur" unless action was taken after a man with sepsis died after a GP's calls to a hospital went unanswered. Terrence Frost died of natural causes on 17 July 2024 at Ipswich Hospital, in Suffolk, after he collapsed and suffered a cardiac arrest. The 84-year-old had gone in with a serious infection or inflammation following advice from his GP, who tried to contact the hospital ahead of his arrival to no avail. Nigel Parsley, senior coroner for Suffolk, said the doctor's "inability to promptly communicate" with its medical assessment unit or A&E department was a concern. In a Prevention of Future Deaths report, he said: "[That] could lead to future deaths where suspected sepsis or other life-threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence's had at the time of his arrival. "I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the medical assessment unit extremely difficult, with internal hospital telephone calls frequently going unanswered." Read full story Source: BBC News, 16 March 2026
  19. Content Article
    Terrence Frost’s death was verified at 00:26 on 18 July 2024, at the Ipswich Hospital, in Ipswich, Suffolk, although Terrence’s death had occurred earlier at approximately 22:20 on 17th July 2024. On the 11 July 2024 Terrence was admitted to the Ipswich Hospital for an elective surgery (angioplasty) to improve the blood flow to his left leg and foot. Terrence was discharged on the following day 12 July 2024. On the 14 July 2024 Terrence was admitted again to the Ipswich Hospital with abdominal pain and rectal bleeding. No diagnosis was made, and as this settled spontaneously, Terrence was discharged again on the 15 July 2024. On the 16 July 2024, due to concerns raised by his family, a GP’s Paramedic conducted a home visit, and following subsequent concerning blood test results Terrence was told to go back to Ipswich Hospital as a failed discharge. After a prolonged period in the Accident and Emergency department Terrence was readmitted to the Ipswich Hospital. Despite testing, no definitive diagnosis was made during Terrence’s final admission, and Terrence appeared reasonably stable until he suffered a sudden collapse and cardiac arrest at 21:22 on the 17th July 2024. A subsequent postmortem examination identified that Terrence suffered from significant cardiac disease (cardiomegaly and coronary artery disease) and significant vascular disease (systemic atherosclerosis). The pathologist identified that his clinical markers identified that sepsis played a factor in Terrence’s death, although evidence of any infection could not be found. MATTERS OF CONCERN Evidence was heard that prior to his attendance in the Accident and Emergency department on the 16 July 2024, Terrence had been seen at home by a paramedic from his surgery, who was concerned by Terrence’s presentation and wanted to admit him to hospital. However, Terrence was reluctant so it was agreed that urgent blood tests would be taken in the first instance. The results of these tests were seen by a GP, and due to the findings (which indicated a possible serious infection or inflammation) the GP called Terrence and told him to go straight to hospital, and whilst enroute she would speak to the Medical Assessment Unit. In evidence the GP said she then spent 30 minutes on the telephone trying to contact the Medical Assessment Unit as is the required procedure, to discuss Terrence’s admission. After being unable to contact the Medical Assessment Unit, the GP contacted Terrence, via a family member, and told him that as she could not contact the Medical Assessment Unit he should head to the Accident and Emergency department instead. The GP told Terrence she would pre- alert the Accident and Emergency department to his arrival. The GP then spent a further period of time telephoning the Accident and Emergency department but again could not get through. As such upon arrival, a patient who was considered by their GP to be significantly unwell enough to warrant either admission to the Medical Assessment Unit, or that Accident and Emergency should be pre-alerted to their arrival, was unable to speak to either unit prior to the patient’s arrival. Terrence endured a 5 hour wait in Accident and Emergency before being seen. Although observations taken at the time of his subsequent admission suggest he had not developed sepsis at this stage, I am concerned that the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department may lead to future deaths in cases where suspected sepsis or other life threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence’s had at the time of his arrival. I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the Medical Assessment Unit extremely difficult, with internal hospital telephone calls frequently going unanswered.
  20. News Article
    Women experiencing miscarriage are facing additional trauma and distress due to a significant lack of adequate follow-up care, a new report has revealed. One patient described her experience as "dehumanising", while others reported feeling dismissed and traumatised by the current system. Research by the Miscarriage Association, which underpins the report, found that nearly two-thirds of women felt their follow-up care was insufficient. Furthermore, more than four in 10 of those who sought mental health support after losing their baby did not receive it. The new report urges immediate action to make comprehensive follow-up care a routine part of miscarriage management. Some 65% of women in the study said they did not have adequate follow-up care, while 42% said they did not receive treatment for mental health symptoms following their miscarriage. Many women felt they were sent home with little or no guidance, or with conflicting advice, according to the Miscarriage Association. Some reported insensitive wording from healthcare professionals, with one woman claiming she was told her baby “had been put in the incinerator with the rest of the medical waste” whilst recovering from a ruptured ectopic pregnancy. Read full story Source: The Independent, 9 March 2026
  21. Content Article
    An estimated one in four pregnancies in the UK ends in loss. Yet many women and their partners still face gaps in care, understanding and recognition at one of the most vulnerable moments in their lives. To better understand these experiences, the Miscarriage Association carried out a national survey exploring the experience of miscarriage across healthcare settings, workplaces and personal relationships. More than 1,000 people affected by pre-24-week pregnancy loss shared their experiences, providing a detailed picture of how miscarriage is currently experienced across the UK. Their responses highlight important gaps in care, support and awareness — and the changes needed to ensure no one faces pregnancy loss without the compassion and support they deserve. Experiences of miscarriage care varied significantly across the UK. While some respondents described compassionate and supportive healthcare professionals, many reported gaps in information, follow-up care and access to appropriate services. Common themes included: Lack of clear information about miscarriage and treatment options. Inconsistent access to scans, investigations and Early Pregnancy Units (EPUs). Miscommunication or conflicting advice. Little or no follow-up care after pregnancy loss. For many respondents, the absence of follow-up support left them feeling isolated and uncertain about both their physical recovery and emotional wellbeing.
  22. News Article
    Google is putting people at risk of harm by downplaying safety warnings that its AI-generated medical advice may be wrong. When answering queries about sensitive topics such as health, the company says its AI Overviews, which appear above search results, prompt users to seek professional help, rather than relying solely on its summaries. “AI Overviews will inform people when it’s important to seek out expert advice or to verify the information presented,” Google has said. But the Guardian found the company does not include any such disclaimers when users are first presented with medical advice. Google only issues a warning if users choose to request additional health information and click on a button called “Show more”. Even then, safety labels only appear below all of the extra medical advice assembled using generative AI, and in a smaller, lighter font. AI experts and patient advocates presented with the Guardian’s findings said they were concerned. Disclaimers serve a vital purpose, they said, and should appear prominently when users are first provided with medical advice. “The absence of disclaimers when users are initially served medical information creates several critical dangers,” said Pat Pataranutaporn, an assistant professor, technologist and researcher at the Massachusetts Institute of Technology (MIT) and a world-renowned expert in AI and human-computer interaction. “First, even the most advanced AI models today still hallucinate misinformation or exhibit sycophantic behaviour, prioritising user satisfaction over accuracy. In healthcare contexts, this can be genuinely dangerous. “Second, the issue isn’t just about AI limitations – it’s about the human side of the equation. Users may not provide all necessary context or may ask the wrong questions by misobserving their symptoms. “Disclaimers serve as a crucial intervention point. They disrupt this automatic trust and prompt users to engage more critically with the information they receive.” Read full story Source: The Guardian, 16 February 2026
  23. News Article
    Hospital staff asked a teenage boy to tell his deaf mother that her father might die, according to the findings of an ombudsman. The Parliamentary and Health Service Ombudsman said University Hospitals Birmingham (UHB) NHS Trust failed to follow national guidance, by repeatedly using children to interpret critical medical information for their deaf family members. Alan Graham, who was born deaf and used British Sign Language (BSL) as his first language, died in September 2021 after being treated at the Queen Elizabeth Hospital. His daughter, Jennifer Petty, who is also deaf, complained about her father's care. The NHS trust apologised adding "we did not get things right". The 52-year-old also raised the issue of hospital staff using her children as interpreters. The investigation by the ombudsman found the concerns she raised caused significant distress and affected the family's ability to grieve. During an 11-week period in hospital, professional BSL interpreters were provided on only three occasions, the ombudsman found. Instead staff regularly relied on Petty's son and daughter, who was 12, to translate complex medical information, including details about the 75-year-old's condition. The 52-year-old said the situation was deeply upsetting for the whole family and it was "totally unacceptable" that her children were placed in the position of delivering bad news about their grandfather's condition. "My children just wanted to visit their grandad and be there for him as family members but they were constantly being asked to translate by the staff," she said. "Having to deliver the bad news about my dad's prognosis was extremely upsetting for all of us." The ombudsman said the trust did not consistently make reasonable adjustments for a deaf patient and his family, despite clear requirements set out in national guidance. Read full story Source: BBC News, 11 February 2026 Further reading on the hub: Top picks: 11 resources to support people with hearing loss or deafness
  24. Content Article
    On 14 November 2024, an investigation commenced into the death of Master Avery Jake Hall, who died in Sunderland on 13 November 2024 aged 4 days. The Investigation concluded at the end of the Inquest on 23rd January 2026.  The medical cause of death was confirmed as: Ia Hypoxia Ischaemia and diffuse alveolar damage  Ib Olygo/anhydramnios and foetal distress  Ic Premature rupture of membranes, small placenta with distal villous maldevelopment and low grade foetal vascular malperfusion. Avery Jake Hall died at Sunderland Royal Hospital on 13th November 2024 having developed global hypoxia and diffuse alveolar damage with hyaline membranes in the lung following his birth as his development in pregnancy had been compromised by reduced amniotic fluid leading to poor lung development and impairment of urine production by the kidneys. During pregnancy Avery’s mother had continued to take Candesartan which had previously been prescribed to her to treat migraines. She did not receive definitive advice from clinicians to stop taking it despite various opportunities to do so and this is a medication contraindicated in pregnancy due to risks including foetal renal failure and pulmonary hypoplasia. Matters of concern Avery’s mother suffered from migraines which were increasing in severity, so she sought advice from her GP when aged 21 years old. She was prescribed Candesartan 4mg by her GP shortly before her 22nd birthday. This was to be taken daily and was placed on a repeat prescription of 28 tablets. The dose was increased to 8mg after 3 months and following a referral, the treatment was endorsed by a Consultant Neurologist at a consultation 4 months after the initial prescription. The evidence revealed that no advice was provided as to the risks of this medication should she be considering having a child. Following a positive pregnancy test in April 2024, Avery’s mother sought advice from her GP about which of her prescribed medications were safe to use during pregnancy. During the telephone consultation with her GP on 11 April 2024 she was given specific advice to avoid using 3 of 6 prescriptions. However the evidence highlighted that Avery’s mother was given only generic advice that it was best to avoid all medication during pregnancy but was not given specific advice to stop using Candesartan, and the risk of continuing to take this medication in pregnancy was not identified during this consultation. Although Avery’s mother had a number of attendances with clinicians throughout her antenatal care, the evidence revealed that she was given no additional advice regarding the safety of her medication and, whilst she was advised to seek advice from her GP as the prescriber, she did not feel it was necessary to do so having already had such a consultation in April 2024. Avery’s mother continued to suffer from migraines during her pregnancy and was unaware of the risk posed by taking Candesartan in pregnancy due to a lack of clear and definitive advice about the risk. I am concerned that she was able to resume taking Candesartan approximately 14 days after her initial GP consultation as the medication remained on a repeat prescription which she was able to continue to request during her pregnancy, and each request was approved without a detailed review. The last repeat prescription being approved only 12 days prior to Avery’s birth. The coroner's concern is that despite advice from the GP that it was best to stop all medication during pregnancy, Candesartan remained as a repeat prescription and, in addition to that, there were no warnings placed on the system which would have alerted the clinician approving the request for the repeat prescription that the patient was pregnant thus necessitating a review.
  25. News Article
    A father-of-three died of a brain haemorrhage following failings at the hospital where he worked, health bosses have admitted. Craig Green, 39 was a catering assistant who worked at the QE and was referred by his GP to the hospital following hearing loss. He attended an ear, nose and throat emergency clinic on the 1 April 2025. An MRI scan was later carried out and doctors found an aneurysm in one of the arteries to his brain, which was flagged as a high priority to be reviewed by the neurovascular team at the trust. However, the referral was never finished and neither Craig Green nor his GP were made aware of the findings. "What's very hard to understand is that, if he knew, he could've put things in place. He could've spoken to his family," his father, Dennis Green, said. A spokesperson for the University Hospitals Birmingham NHS Trust said there were failures in communication by their staff over Craig Green's case. The Department of Health said the failure was unacceptable. Read full story Source: BBC News, 3 February 2026

© 2026 Patient Safety Learning. All rights reserved.

Patient Safety Learning is registered as a charity with the Charity Commission Registration number 1180689.

×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.