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  1. Content Article
    Learning Disability Week is the third week of June every year. The event, organised by the charity Mencap, is an opportunity to raise awareness about different learning disabilities and challenge some of the barriers people who have learning disabilities face. According to Mencap, a learning disability is a person's reduced intellectual ability, meaning they can face difficulty with everyday activities. People with a learning disability can sometimes need extra support to learn new skills, understand complicated information or interact with other people. It can be particularly challenging for people with learning disabilities and their families when accessing healthcare services. To mark Learning Disability Week, we are sharing 16 resources, blogs and reports from the hub for patients, their families and healthcare professionals on breaking down these barriers. 1 Exploring the inequalities of women with learning disabilities deciding to attend and then accessing cervical and breast cancer screening, using the Social Ecological Model Women with learning disabilities are less likely to access cervical and breast cancer screening when compared to the general population. In this study, the Social Ecological Model was used to examine the inequalities faced by women with learning disabilities in accessing cervical and breast cancer screening in England. The authors suggest that multiple methods to reduce the inequalities faced by women with learning disabilities are needed, and that these can be achieved through reasonable adjustments. 2 Pharmacists can do more to bridge the safety gaps for people with learning disabilities People with learning disabilities are more likely to be taking multiple medicines, but labels are not designed with them in mind. This article in the Pharmaceutical Journal looks at a project run by a team at Leeds and York Partnership NHS Foundation Trust. The team ran exploratory workshops to listen to how people with learning disabilities engaged with information on medicines at home, at the doctors and at the pharmacy. The project highlighted that it is time to move away from standard labels and look towards more personalised medicine labels, actively promoting ways to support people with learning disabilities in taking their medicines. 3 Exploring deep sedation at home to support people with learning disabilities to access medical investigations with minimal distress In this blog, Mandy Anderton, a Clinical Nurse specialising in learning disability, explains how they are using shared decision making and reasonable adjustments to implement a new care pathway, where patients with a learning disability needing to undergo a medical investigation can receive deep sedation within their own home. Working with patients, carers, relatives, anaesthetists and others, the aim is to improve access to important medical investigations with minimal distress, where other avenues have been exhausted. 4 NHS England: Ask Listen Do – feedback, concerns and complaints Ask Listen Do resources are designed to support organisations to listen, learn from and improve the experiences of children and adults who are autistic or have a learning disability, their families and carers, and make it easier for people, families and paid carers to give feedback, raise concerns and complain. 5 NHS England: Guidance to support implementation of the Mental Capacity Act in acute trusts for adults with a learning disability This guidance supports trusts and community providers in enabling frontline staff to fulfil their legal requirements under the Mental Capacity Act (MCA) 2005, specifically when supporting people with a learning disability. Leadership within Trusts have been asked to ensure they understand the guidance, take the actions indicated and make these resources available to all frontline staff. 6 Tommy Jessop: Why I investigated hospital care for people like me People with a learning disability are more than twice as likely to die from avoidable causes than the rest of the population. Actor Tommy Jessop and BBC Panorama investigated some of the stories of families who say they were let down by their medical care. 7 How can GP practices help improve health outcomes for people with learning disabilities? In this Patient Safety Learning interview, Mandy Anderton explains some of the barriers people with a learning disability face in accessing safe care and how adjustments can be made within GP practices to improve outcomes. Mandy lists national improvements that she believes would reduce health inequalities in this area. 8 Making reasonable adjustments for patients with a learning disability is G.R.E.A.T. Developed by David Havard, this poster shows a number of ways in which reasonable adjustments can easily be made for patients with a learning disability. 9 HSSIB: Caring for adults with a learning disability in acute hospitals The aim of this investigation and report is to help improve the inpatient care of adults with a known learning disability in acute hospital settings. It focuses on people referred urgently for hospital admission from a community setting, such as a person’s home or residential home. 10 Video: The Oliver McGowan Mandatory Training on Learning Disability and Autism This animation aims to help staff and employers across health and social care understand Oliver's Training and why it is so vitally important. It was co-designed and co-produced with autistic people and people with a learning disability. Oliver McGowan died aged 18 in 2017 after being given antipsychotic medication to which he had a fatal reaction. He was given the medication despite his own and his family's assertions that he could not be given antipsychotics, and the fact that this was recorded in his medical records. The animation tells his story and highlights the increased risks facing people with learning disabilities and autism when accessing healthcare. 11 Palliative Care for People with Learning Disabilities The Palliative Care for People with Learning Disabilities (PCPLD) is a charity created to ensure that patients with learning disabilities receive the coordinated support they need throughout their life. The PCPLD Network brings together service providers, people with a learning disability and carers working for the benefit of individuals with learning disabilities who have palliative care needs. 12 Nobody left behind: Improving the health of people with learning disabilities and reducing inequalities across primary care Mandy Anderton talks in depth about the cross-system programme they launched in Salford to improve the health of people with learning disabilities and reduce inequalities across primary care. Mandy shares their award-winning poster, summarising the programme’s activities and outcomes, and gives her top tips for delivering a successful patient safety improvement project. 13 Reasonable adjustments and designing services for patients and people with learning disabilities Caring for people with learning disabilities in an acute hospital setting can be challenging, especially if that patient has transitioned from children’s services to adult services. The experience in children’s acute care differs to adult acute care; this difference in processes of care can cause great anxiety for the patient and their family and carers. The reasonable adjustments that were perhaps made and sustained in children’s services may now not exist. The purpose of this blog is to demonstrate the importance for services to be designed around patients’ needs with patients, families and carers. If we get this right, the quality of care given will be improved, patient satisfaction increases and, in turn, a reduction in patient harm. 14 Cervical screening for people with learning disabilities: Learning resource for sample takers (NHS Wessex Cancer Alliance) Cervical cancer is preventable. By 2040 the NHS in England is aiming for a cervical cancer incidence rate of below 4 per 100,000 women (elimination status). To achieve this, we need to increase HPV vaccination rates and improve attendance for routine cervical screening particularly in younger people and underserved communities including patients with learning disabilities. This learning resource from the NHS Wessex Cancer Alliance explains the misconceptions and barriers to cervical screening, the consent and best interest decisions, and the role of the sample taker and the reasonable adjustments that can be made. 15 Safety spotlight: Mothers with a learning disability - Maternity and Newborn Safety Investigations (MNSI) Maternity care should be responsive to every woman’s needs. This Maternity and Newborn Safety Investigation (MNSI) safety spotlight focuses on mothers with a learning disability. 16 HSSIB investigation. Insulin: supporting safe self-administration for patients in the community with a disability Many people with diabetes manage and administer their own insulin, either by injection or using a combined monitor/pump device (a hybrid closed loop system). However, a disability or impairment may affect their ability to safely manage their own insulin if they are not supported. This can lead to short-term and long-term health problems, which can be life threatening. This Health Services Safety Investigation Body (HSSIB) investigation explored the the following areas in relation to the patient safety issue: supporting the development of people’s competency – that is, their skills, experience, knowledge and ability – to manage insulin recognising and responding when people’s circumstances change, such as deterioration in a disability assessment of people’s mental capacity to make decisions in relation to insulin. Do you have a resource or story to share about learning disabilities? Could your insights or experiences help improve patient safety? Leave a comment below (join the hub for free first) or contact us at [email protected].
  2. Event
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    This webinar for the Patients Association Patient Partnership Week will explore why many patients still feel unheard, confused, or excluded when communicating with the NHS. The discussion will examine whether NHS communication is truly designed with patients, or simply delivered to them, alongside the growing balance between digital efficiency and meaningful human interaction. Panellists will consider the importance of trust, transparency, and accessibility, and reflect on what good communication actually looks like from a patient perspective — including how services can better support understanding, choice, and partnership in care. Speakers: Chair: Julie Thallon, Chair of Trustees, the Patients Association Dorina Poenaru, patient Saliha Ahmed, Project Manager, Caafi Health Shahnaz Aziz, Head of Health Equalities and Involvement, Health Innovation East Midlands Katie Purbrick-Thompson, Policy Adviser, The King’s Fund Register
  3. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Diabetes is a condition that causes the amount of glucose in a person's blood to be too high. When you have type 1 diabetes, your body can’t make any insulin at all, whereas with type 2, you either can’t make enough insulin, or it can’t work properly. There are also other types of diabetes including gestational diabetes, which some women develop during pregnancy, maturity onset diabetes of the young (MODY) and latent autoimmune diabetes in adults (LADA). It is important that people with diabetes are supported to maintain good blood glucose control through diet, insulin and other diabetes medications, to prevent both acute and long-term complications. We’ve selected our top picks of useful resources about diabetes. Self-management is perhaps the most important aspect of treating diabetes effectively, so we've included some resources aimed at helping patients manage their diabetes too. 1 HSSIB reports The Health Services Safety Investigation Body (HSSIB) has published a series of reports considering the self-administration of insulin by people with diabetes mellitus. Each report focuses on specific groups of people who, due to their circumstances, may be at increased risk of harm because of the way they self-administer insulin. Insulin: supporting safe self-administration for patients in the community with a mental health problem Insulin: supporting safe self-administration for patients in the community with a disability Insulin: supporting patients to safe administration in inpatient settings 2 Decoding diabetes research – an innovative approach that makes scientific knowledge accessible to everyone In this blog, Jazz Sethi, Founder and Director of the Diabesties Foundation and part of the global team that developed D-Coded, discusses the need for the resource and outlines how it will help people living with diabetes to better understand and manage their condition. 3 Leading for patient safety: a conversation with Partha Kar Partha Kar, National Specialty Advisor for NHS England, has led work that has had an enormous impact for patients and for patient safety. In this video podcast, Steph O'Donohue from Patient Safety Learning talks to Partha about his leadership style and how it has helped him drive forward significant change in an often challenging context. 4 Decision support tool: making a decision about managing type 1 diabetes This leaflet from NHS England aims to help people with type 1 diabetes decide between the different technologies available to manage diabetes. It contains summaries of devices available and infographics outlining eligibility criteria for continuous glucose monitors (CGM), insulin pumps and hybrid-closed loop systems. 5 10 Year Vision: For diabetes prevention, care and treatment This report from Diabetes UK sets out a clear plan for the UK government about how it can improve health outcomes and tackle inequality for people living with diabetes by 2035. 6 D1abasics: Equipping staff to care safely for inpatients with diabetes The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital. 7 Improving diabetes care in inpatient mental health settings Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. 8 Diabetes tech: Do national aspirations and local practice align? In this blog, a person with type 1 diabetes describes their recent experience upgrading their insulin pump, a medical device used to continuously deliver insulin instead of taking multiple daily injections. They describe how communication issues and gaps in staff knowledge led to a significant delay in accessing the pump, which caused them significant stress. They also ask whether recent announcements about increased access to diabetes technology over the next few years will match up to the reality experienced by people with diabetes accessing care at local healthcare organisations. 9 NHS England - Language Matters: language and diabetes The language that healthcare professionals use to talk about diabetes can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it. This guidance by NHS England sets out practical examples of language that will encourage positive interactions with people living with diabetes. When people with diabetes feel encouraged and empowered to manage their condition, it has been shown to make a difference to their health outcomes. The examples in ‘Language Matters’ are based on research and supported by a simple set of principles. 10 Key things to remember if you use injectable medication to treat your diabetes This checklist by TREND Diabetes outlines the steps patients should take to ensure they inject their insulin or other diabetes medication correctly. It explains the importance of taking steps such as moving injection sites and changing needles, and outlines how failing to do this can affect blood glucose control. 11 Improving safety for diabetic inpatients: 4 key steps In this video, Partha Kar, National Specialty Advisor for Diabetes, shares four steps to improve safety for inpatients with diabetes, based on information from the National Diabetes Inpatient Audit. He also highlights key resources to help staff improve their knowledge of diabetes and understand how to offer the safest care to people with diabetes when they are staying in hospital. 12 Diabetes technology is life-changing, but we need to be prepared when it fails In this blog, Andrew Stroud talks about his family's experiences supporting their daughter, Bia, to manage her type 1 diabetes. He describes the huge value of technology in improving diabetes management and reducing the mental burden of the condition on people with diabetes and their parents and carers. However, like all technology, medical devices for diabetes can fail, and Andrew highlights the need to be prepared for this situation to ensure the person with diabetes is safe while they cannot use the devices they rely on every day. 13 How safe are closed loop artificial pancreas systems? Closed-loop artificial pancreas systems are self-regulating systems for administering insulin to patients with type 1 diabetes. They allow for tighter blood glucose control and reduce the decision-making burden for people with diabetes. In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, takes a look at the benefits and potential patient safety risks associated with closed-loop artificial pancreas systems (APS). People with diabetes have developed the algorithm that runs these systems and made it freely available to anyone wanting to build their own DIY artificial pancreas. This has spurred the medical tech industry to develop commercial systems, which will make the technology more widely available. But there are challenges in ensuring accessibility to all people with type 1 diabetes who would benefit from the technology, and there are questions about regulation and liability. 14 A systematic approach to insulin safety (video series by Communications PharmSocNI) This video series looks at systematic approaches to insulin safety, including: Human Factors - A Journey of Discovery; SEIPS – The Swiss Army Knife Approach; and Summary & Applying the Learning. 15 System-wide strategies for better diabetes care chapter 1: Evidence approved medicines and chapter 2: Ensuring equitable access to glucose sensing technology for type 2 insulin users Two reports from Public Policy Projects (PPP). Chapter 1 calls for changes in the use of approved medicines to improve diabetes care in the UK and chapter 2 highlights the opportunities and challenges brought by CGM technology to type 2 insulin users and other patient groups. 16 National Diabetes Foot Care Audit 2018 to 2023 Ulceration of the foot in people living with diabetes presents significant challenges, including emotional, physical and financial costs, and is associated with increased risk of both amputation and death. It affects between 1 and 2% of all people with diabetes each year and its management accounts for approximately 1% of the total NHS budget. The aim of the National Diabetes Foot Care Audit is to measure factors associated with increased risk of ulcer onset and adverse ulcer outcomes, and to share information relating to best clinical practice. 17 Diabulimia: what is it and why have so few people heard of it? Type 1 diabetes with disordered eating (T1DE), or diabulimia as some experts call it, is a serious eating disorder that people with type 1 diabetes can develop where the person reduces or stops taking their insulin as a way of managing their weight. The condition can be life-threatening. Although studies are limited, it’s estimated that eating disorders affect more than a third of patients with type 1 diabetes. This episode of the Healthcare Improvement podcast looks at diabulimia and a new toolkit published by SIGN, part of Healthcare Improvement Scotland, which sets out recommendations to raise awareness and provide guidance on how best to support people living with the diabulimia. 18 NHS England: Children and young people diabetes toolkit This toolkit is designed to support integrated care systems (ICSs) to design, plan, and deliver high-quality treatment and care for children and young adults aged 0-25 years with all types of diabetes. 19 Insulin therapy in primary care The management of insulin therapy requires knowledge of the type of diabetes it is being used for and appropriate dosing, as well as correct injection technique, to prevent complications and medication errors. Diabetes nursing specialist Debbie Hicks shares key points on the management of insulin therapy for nurses in primary care. 20 Handbook: Diabetes footcare in dark skin tones Covering essential topics such as physiology, history-taking, assessment techniques, and investigative methods, this handbook has been designed to provide essential information as well as quick tips to healthcare professionals to improve foot care for people with dark skin living with diabetes. Featuring clinical assessments and visual/audio guides, this handbook is the product of a unique collaboration across healthcare professional specialities, and with input from people living with diabetes. 21 Addressing racial inequalities in paediatric diabetes 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. Do you have a resource or story about diabetes to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.
  4. Content Article
    Communication during a medical encounter can be challenging, even when both the patient and their healthcare provider speak the same native language. So, imagine the added difficulty of discussing symptoms, diagnoses, and treatment when there’s a language barrier. Research shows that such communication issues can lead to longer hospital stays, greater risk of falls, delayed diagnosis and treatment, medication errors, and even death. An analysis of safety events reported in Pennsylvania—where more than 1.4 million residents speak a non-English language at home and more than 500,000 have limited English proficiency—reveals that language barriers continue to pose a risk to patient safety, despite policies requiring certified interpreters and translated materials be available to patients who need them. Patient Safety Authority researchers identified 336 events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in 2024 relating to language barriers. The two languages most commonly involved in these reports were Spanish and Nepali, with issues including the lack of a certified interpreter, the lack of translated materials, and materials with inaccurate or incomplete translations. This study closely examines the interpretation and translation challenges faced by Pennsylvania patients and providers, and how they affect patient safety. It also provides strategies and recommendations for facilities to supplement available language services, such as hiring staff bilingual in English and the common languages of the service area and explaining common procedures with visual aids and pre-translated materials.
  5. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked a range of resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices. 1 Alzheimer's Society: Checklist for possible dementia symptoms This checklist has been developed by the Alzheimer’s Society to allow patients to check symptoms that could be a possible sign of dementia. Endorsed by the Royal College of General Practitioners (RCGP), it is a simple tool to help patients and their families clearly communicate their symptoms and concerns to a GP or other healthcare professional. 2 Seeing the unseen: Rethinking dementia diagnosis Across 2024 and 2025, Alzheimer’s Research UK surveyed more than 500 people affected by dementia and over 160 healthcare professionals to understand the realities of diagnosis. This report shares findings from this process and considers what works, what gets in the way, and what needs to change. 3 Health and social care support for people with dementia The Care Quality Commission (CQC) looked at people's experiences of living with dementia when using health and adult social care services, including the experiences of families and carers. It sets out the main themes that influence whether an experience is good or poor, and what health and care services are doing to improve these experiences. CQC will use the findings in this report to help shape their work to define what good care looks like for people with dementia and inform the next phase of CQC’s Dementia Strategy. 4 Keeping patients with dementia safe: an interview with Alison Keizer and Fran Hamilton When people with dementia enter a new healthcare setting, the environment may be confusing and difficult to navigate. They may be unable to use their usual coping strategies and have difficulty communicating their needs and concerns to staff. This can present a wide range of risks to their safety while accessing care. In this interview, Alison Keizer, trust-wide Dementia Lead, and Fran Hamilton, Occupational Therapist and Deputy Dementia Lead at Sussex Community NHS Foundation Trust, describe the patient safety issues affecting patients with dementia and suggest how they can be supported to reduce these risks. 5 World Alzheimer Report 2025: Reimagining life with dementia – the power of rehabilitation This report from Alzheimer's Disease International explores the important topic of dementia rehabilitation, combining expert essays and real-world case studies from multiple countries globally to examine how the concept is defined and implemented, as well as practical considerations of how to best adapt rehabilitation practices for people living with dementia in different contexts. 6 National Audit of Dementia: Spotlight Audit in Memory Assessment Services 2023/24 This report examines waiting times, access to assessments, treatment, and post-diagnostic support for people with dementia in memory assessment services. The results indicate that there is still a great deal of variation between services in key results such as average waiting time for patients, the proportion of patients diagnosed with dementia, and the provision of post diagnostic support and therapy. 7 The role of integrated care systems in improving dementia diagnosis The Alzheimer’s Society commissioned The King’s Fund to explore the development of Integrated Care Systems (ICSs) through the lens of dementia diagnosis—to consider what opportunities ICSs present to approach dementia differently and to improve diagnosis rates by doing so. The research team explored enablers and barriers to improving dementia diagnosis through interviews with stakeholders and people affected by dementia in three case study ICSs. 8 Alzheimer's Society: 'This is me' leaflet This simple leaflet was developed by the Alzheimer's Society for anyone living with dementia, or experiencing delirium or other communication difficulties. It provides a central place where those closest to the person can fill in key information about them, such as their preferred name, cultural background, routines and likes and dislikes. The leaflet can then be shown to health and social care professionals in new and unknown settings to help them better understand the person and deliver care that is tailored to their individual needs. 9 Dementia UK: Making the home safe and comfortable for a person with dementia Dementia can have a significant impact on a person’s daily life, including how well they function within their home. Memory issues or problems recognising and interpreting the objects around them can cause the person frustration or create safety issues. Dementia UK have produced a leaflet with tips and guidance on how to make the home more safe for someone with dementia. 10 Alzheimer's Society: Tips for carers - questions to ask the doctor about antipsychotics Antipsychotic drugs may be prescribed for people with dementia who develop symptoms such as aggression and psychosis. This webpage from the Alzheimer's Society provides information on the prescription of antipsychotic medications for people living with dementia. It describes their potential side effects and includes a list of helpful questions that carers should ask healthcare professionals before the person they care for is prescribed antipsychotic medication. 11 Assessment, diagnosis, care and support for people with dementia and their carers: A national clinical guideline These national clinical guidelines from Health Improvement Scotland, the first to be published in nearly 20 years, provide recommendations on the assessment, treatment and support of adults living with dementia. It calls for greater awareness of pre-death grief for people with dementia, their carers and their loved ones, as they fear the loss of the person they know. To accompany the guidelines, a podcast has been produced by Health Improvement Scotland speaking to professionals, including Dr Adam Daly, Chair of Healthcare Improvement Scotland’s Guideline Development Group and a Consultant in old age psychiatry, and Jacqueline Thompson, a nurse consultant and the lead on pre-grief death for the guideline. 12 Alzheimer’s Society: Improving access to a timely and accurate diagnosis of dementia in England, Wales and Northern Ireland A formal diagnosis of dementia can help people living with the condition and their families gain a better understanding of what to expect and help to inform important decisions about treatment, support and care. This report from the Alzheimer's Society highlights the barriers to accessing a timely and accurate dementia diagnosis and advocate for practical changes and tangible solutions to overcome them. 13 The current state of dementia diagnosis and care in England The current dementia care system remains fragmented, underfunded, and difficult to navigate, leaving many individuals and families unsupported. In response to these systemic challenges, Care England, in partnership with Dementia Forward and care providers, conducted a national survey in January 2025. This initiative aimed to capture the experiences of people living with dementia, their families, and care staff. The findings highlight significant gaps and inequalities in the dementia care pathway and inform a set of urgent policy recommendations. 14 Raising awareness of normal pressure hydrocephalus: an often misdiagnosed condition Normal pressure hydrocephalus (NPH) is a progressive neurological condition that comes under the dementia umbrella. In NPH, the cerebrospinal fluid-filled ventricles within the brain expand and distort the surrounding tissues. This process causes the neurological symptoms of NPH. Unlike other forms of hydrocephalus, NPH does not result in significantly raised intracranial pressure. NPH is often misdiagnosed as it is similar to neurodegenerative conditions such as Parkinson’s disease and other causes of dementia, such as Alzheimer's disease. However, unlike these other conditions, if diagnosed early there is an effective treatment that can significantly slow disease progression and potentially improve, or even reverse, symptoms in some people. 15 The training gap: a hidden injustice in dementia care and how to fix it This report from Alzheimer's UK reveals huge gaps in dementia training across social care: half of staff receive just one to two hours of dementia learning despite 70% of care home residents living with the condition. It argues that these shortfalls in training are leaving social care staff unprepared, unsupported, and putting people with dementia at risk of inadequate care. It calls on the government to build a bold and ambitious dementia plan, which includes mandatory dementia training for care staff. 16 Alzheimer's Society: Unlocking the door to dementia diagnosis and treatments Systems designed to diagnose and support people with dementia are struggling to keep pace, with delays, inequalities and missed opportunities far too common. Too many people have a poor experience, wait too long for a diagnosis and receive less treatment and support than clinical guidance says they should. Everyone with dementia has the right to an early and accurate diagnosis and the best available treatments. Alzheimer's Society’s two 'Unlocking the door' reports lay out a stark reality – and a clear programme of reform for England, Wales and Northern Ireland. For more resources, take a look at our Dementia area of the hub. Do you have a resource or story to share about dementia or a related condition? Could your insights or experiences help improve patient safety? Leave a comment below (join the hub for free first) or contact us at [email protected].
  6. Content Article
    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.
  7. Content Article
    The UK Covid-19 Inquiry has published its fourth report and recommendations following its investigation into ‘Vaccines and therapeutics of the United Kingdom’. It considers and makes recommendations on a range of issues relating to the development of Covid-19 vaccines and the implementation of the vaccine rollout programme in England, Wales, Scotland and Northern Ireland. Issues relating to the treatment of Covid-19 through both existing and new medications were examined in parallel.
  8. News Article
    Nearly half of Americans are somewhat skeptical of vaccines, a new poll has found. Some 46% of U.S. adults who responded to a Public First poll by Politico in March agreed that “facts on vaccines are still up for debate and it is damaging to enforce their uptake.” In contrast, only 39% said that the science on vaccines “is clear and it is damaging to question it.” The results of the survey are in line with the views of Health Secretary Robert F. Kennedy Jr., a longtime vaccine skeptic and founder of the Republican “Make America Healthy Again” movement. “What stands out is that vaccine safety and vaccine choice are no longer fringe issues,” Mary Holland, CEO of anti-vax group Children’s Health Defense, which Kennedy previously led before taking his post in government, told Politico. “People want to be able to make their own medical decisions.” Astonishingly, overall, 39% of respondents to Politico’s survey said they would allow vaccine-preventable diseases to return, rather than force people to have vaccines, in contrast to 47% who said they would rather not. During his tenure as Health Secretary, Kennedy has overseen several major changes within his department and its policies, including the attempted overhaul of the Centers for Disease Control and Prevention and the elimination of Covid-19 vaccine recommendations. Last week, it was reported that the CDC had delayed publishing a report showing the benefits of the Covid vaccine, further sparking concerns that the information conflicted with Kennedy’s views. The CDC insisted that the move followed standard procedure. Read full story Source: The Independent, 14 April 2026
  9. Content Article
    The 'Please, Write to Me' guidance from the Academy of Medical Royal Colleges provides information and advice to encourage and support healthcare professionals to communicate directly with patients in writing.  This guidance was first published in 2018. As a result, many clinicians began writing directly to patients in plain English following outpatient clinic consultations. This has since been recommended as best practice by professional and NHS bodies, the General Medial Council, and the UK Government. This update extends the guidance to include writing a section of discharge summaries directly to patients following a hospital admission. This guidance and governance safeguards should also be applied when developing and using AI systems to create clinical documents for use in training and practice.
  10. Content Article
    Parkinson’s is the fastest growing neurological condition in the world. It can affect young or old, and in the UK, around 153,000 people are living with the condition. With population growth and ageing, this figure is estimated to increase by 20%, within the next ten years. At the moment, there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. People with Parkinson’s face a number of specific patient safety issues when accessing healthcare including communication difficulties and risks associated with medication delays. In this blog, Patient Safety Learning has pulled together 14 useful resources about Parkinson’s shared on the hub. They include guidance for patients and their families about hospital stays and medication, and awareness-raising resources for healthcare professionals about the patient safety issues people with Parkinson’s face. 1. Keeping patients with Parkinson’s safe in hospital: 4 key actions for staff Dr Rowan Wathes, Associate Director of the Parkinson's Excellence Network at Parkinson's UK, recommends four key actions that healthcare workers can take to improve safety for people with Parkinson’s while they are in hospital. 2. Parkinson's UK: Parkinson's Away-From-Home Kit This kit from the Parkinson's UK Excellence Network comes from 3 years of collaboration with people with Parkinson’s and carers to understand the challenges they face when going into hospital and how we can help. People with Parkinson’s can choose from a range of tools to create a kit that works for them. Every item is designed to support them, and those who care for them, to advocate for their Parkinson's medications to be administered on time, every time. 3. Nurses leading the way: enhancing Parkinson's care in nursing homes In this blog published by the Royal College of Nursing, Jean Almond, Programme Manager at Parkinson's UK, discusses improving the delivery of time critical Parkinson’s medication to care home residents. 4. Preparing to go into hospital – tips for people with Parkinson's and their carers In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK, talks about how people with Parkinson’s can prepare their medication to go into hospital. 5. Time-critical Parkinson’s medication: the human cost of delays and mistakes In this blog, Joanne explains how delays to her mother’s time-critical medication in hospital led to her condition deteriorating. 6. Time critical medication guides for health professionals The Parkinson’s Excellence Network has produced three practical guides to support UK health professionals to deliver time critical Parkinson’s medication on time in hospital: a guide for NHS ward staff, a guide for hospital pharmacists and a swallowing guide for the nurse in charge and ward staff. 7. Electronic prescribing: how it can improve the delivery of time critical medications This resource describes how NHS Ayrshire & Arran hospitals improved their rates for administering patients' Parkinson's medications on time, sharing case studies and tips on how other hospitals might be able to replicate their successful e-prescribing system. 8. Improving the delivery of time critical medications at Bradford Teaching Hospitals NHS Foundation Trust A best practice case study showcasing a quality improvement project at Bradford Teaching Hospitals NHS Foundation Trust. 9. Ask the expert: How to spot fake Parkinson’s medicines online Falsified, fake or counterfeit medicines are medicines disguising themselves as authentic, and they can pose significant health risks. This blog highlights the issue of counterfeit Parkinson's medications being sold illegally online. Mike Isles, Executive Director of the Alliance for Safe Online Pharmacy in the EU describes their high prevalence and gives tips for people with Parkinson's on how to stay safe when buying medicines online. 10. My Parkinson's passport This tool from the Parkinson's Association of Ireland allows people with Parkinson's to record their essential medical information in an easy to access format, should they need assistance or medical treatment. 11. Parkinson's awareness: a 15-minute online presentation for ward staff This 15-minute training video by the Parkinson's Excellence Network pulls together the key symptoms and issues that can affect a person with Parkinson's and their care when admitted to a hospital ward. It aims to help ward staff understand the most important considerations when caring for people with Parkinson's. 12. Medication delays: A huge risk for inpatients with Parkinson’s This blog examines the serious health implications of delayed medication in people with Parkinson’s. It highlights evidence that this is a widespread safety issue and outlines the challenges, barriers and solutions to ensuring patients receive their medication on time. 13. Parkinson’s UK Tech Guide Parkinson’s UK created the Tech Guide so that people with Parkinson’s, and their families, friends and carers, can make the right decisions for themselves about all the devices and apps that claim to be able to help improve their quality of life. To do this, they provide trusted reviews based on the lived experience of people with Parkinson’s, and maintain a catalogue of the various products that are on the market. This is backed up with information about Parkinson’s and evidence-based articles that will help you decide what’s right for you, in your unique circumstances. 14. NHS Northumbria Healthcare: Improving the care in hospital for people with Parkinson’s In this blog, consultant geriatrician, Dr James Fisher, talks about a project at NHS Northumbria Healthcare to improve the experience of Parkinson’s patients by focusing on medication. Have your say Are you a healthcare professional who works with people with Parkinson’s? We would love to hear your insights and share resources you have developed. Do you have, or do you care for someone with Parkinson’s? Please share your experience of health and care services with us. We would love to hear from you! Comment below (register for free here first). Get in touch with us directly to share your insights.
  11. Content Article
    Providing performance feedback to staff allows employees to learn and grown in their jobs and to deliver better and higher quality work. For this review, Heine et al. went through 173 studies on performance feedback. They found that there are many different labels and contrasting definitions given to “feedback” and a lack of research specifying feedback valence, which limits our understanding and theory building. Their research indicates that positive feedback consistently enhances performance, whereas negative feedback requires specific moderating variables or a high-quality supervisor–subordinate relationship to be effective. They also found that women consistently receive lower performance ratings than men, especially from male supervisors in traditionally male fields. The authors propose 'Performance Feedback Valence Theory': the supervisor-subordinate relationship is the foundation that makes negative feedback work. Fostering these relationships may be the most critical step organisations can take in ensuring feedback interventions truly enhance employees performance.
  12. News Article
    A hospital trust did not immediately alert health officials about a case of meningitis in Kent. A patient first presented to East Kent Hospitals University NHS Foundation Trust on the evening of Wednesday 11 March, a spokesperson said. But the trust waited until Friday 13 March, once a diagnosis had been confirmed, to notify the UK Health Security Agency (UKHSA), which manages an outbreak of such an illness. Dr Des Holden, acting chief executive of East Kent Hospitals University NHS Foundation Trust, said: “Our first patient presented on the evening of Wednesday 11 March. “We recognise there was an opportunity prior to diagnosis being confirmed on Friday 13 March to notify UKHSA". Health secretary Wes Streeting said that there was a 24-hour window in which hospitals were meant to raise a suspected case with the agency, and that staff had instead done so in 26 hours. He told LBC: “The patient came in on the Wednesday unwell. By mid-morning on Thursday, the staff suspected meningitis. Now at that stage, they had 24 hours within which they should have notified the UKHSA. They did so in 26 hours. “While I can reassure people that it appears in this case that that delay did not have a material impact – we have not found evidence of onward transmission to other people through that delay that we would otherwise have traced faster – nonetheless, we have that 24-hour standard for a reason, and I am taking this seriously.” Read full story Source: The Independent, 25 March 2026
  13. Content Article
    This leaflet produced by the Nursing and Midwifery Council (NMC) can help you decide what you could do if you think a midwife, nurse or nursing associate may have done something wrong. This leaflet explains how we can help if someone has concerns about the care provided by a midwife, nurse or nursing associate during pregnancy, birth or the postnatal period. It covers: what the NMC does and when concerns should be raised with us what happens when someone contacts the NMC where people can go for other types of support, including employers and other organisations that may be better placed to help.
  14. Content Article
    This report presents the findings of a project delivered by the Patients Association and sponsored by Lilly UK to better understand the experience of patients when purchasing medicines from unregulated online sources, including website and social media.  The project aimed to explore why patients turn to unregulated online channels, the role of social media and targeted advertising, the risks patients face, and what public awareness activity could better support people to stay safe. The research involved a desk-based review of existing evidence and two focus groups conducted in August 2025 with patients and carers from across England. Key findings The research identified four key themes shaping patients’ decisions and experiences: 1. Access barriers are the primary driver of unregulated online medicine use. Patients described long waits for GP and pharmacy appointments, difficulty accessing care, and frustration with an overstretched health system. Many felt they had little choice but to seek medicines online to manage their health needs. 2. Social media and targeted advertising strongly influence patient behaviour. Participants reported being exposed to persuasive advertisements and influencer content promoting medicines, as well as relying on online support groups for advice. While these spaces offer emotional support, they can also normalise bypassing clinical oversight. 3. Patients understand the risks but often feel forced to accept them. Unregulated online sources bypass vital safety checks and may supply counterfeit, ineffective or harmful medicines. Although participants were aware of these dangers, many felt compelled to take the risk due to lack of alternatives. 4. Public awareness efforts should inform, not shame. Participants stressed that patients should not be judged for seeking medicines online, particularly when healthcare access is limited. Instead, campaigns should equip people with clear, practical information to help them stay safe and make informed choices. Recommendations Based on these findings, the report makes four key recommendations: Improve patient awareness of the risks of buying medicines from unregulated online sources. Provide clear guidance on how to identify legitimate and safe online pharmacies. Design public awareness campaigns in partnership with patients to ensure relevance, clarity and impact. Address underlying access barriers that push patients towards unsafe alternatives.
  15. Content Article
    Reflecting on a session from last week’s Nuffield Trust Summit on misinformation and polarised views about health, Leonora Merry discusses the growing gap between experts, institutions and the public when it comes to science and healthcare.
  16. Content Article
    Lichen sclerosus is a skin condition that causes itchy white patches, most commonly on the genitals. There's no cure, but treatment can help relieve the symptoms. It is though to affect 1 in 100 women. The Lichen Sclerosus Guide was awarded first place in the 'Communicating effectively with patients and families' category of the 2025 Picker Experience Network (PEN) Awards. The guide has been written by people with vulval lichen sclerosus and expert healthcare professionals and researchers from the University of Bristol, University of Nottingham, East Lancashire Hospitals NHS Trust, and Nottingham University Hospitals NHS Trust. Since its launch earlier this year, the guide has been viewed by over 25,000 people in more than 50 countries. The Lichen Sclerosus Guide led by Dr Sophie Rees and Dr Caroline Owen combines clinical expertise with lived experience of vulval lichen sclerosus, offering clear, accessible information through written content, videos, animations, and downloadable tools. It contains information about symptoms, diagnosis, treatment, and support, and includes videos explaining what happens to the skin in lichen sclerosus, vulval anatomy and self-examination, and how to apply treatment to the vulva. The judging panel praised the guide for its inclusive, evidence-based approach to tackling stigma and improving health literacy. They commented that: “It empowers patients, supports clinicians and bridges gaps in care, making it a model for effective communication and partnership in healthcare.”
  17. News Article
    More than 400 lives may have been saved as a result of Martha’s rule, which lets NHS patients request a review of their care, official figures reveal. Helplines received more than 10,000 calls in the first 16 months of the scheme after its introduction in England in 2024, according to data seen by the Guardian. Thousands of patients were either moved to intensive care, received drugs they needed or benefited from other changes as a direct result of the calls. The system is named after Martha Mills, 13, who died in 2021 from sepsis after a bicycle accident. A coroner found she would probably have survived if she had been moved to the intensive care unit at King’s College hospital in London when she began deteriorating. Martha’s rule helplines received 10,119 calls between September 2024 and December 2025 from patients, relatives or staff who were worried about care, the figures show. That led to 446 people receiving improvements to their care that may have saved their life. One in three calls (3,457) identified a rapid worsening of a patient’s condition, helping raise the alarm more quickly and enable crucial interventions to be made. The NHS England data shows 1,885 patients had their treatment changed as a result. In addition, about 6,000 calls had addressed clinical, communication or coordination concerns, which led to “meaningful improvements” in care or navigating the healthcare system for patients and their families, health officials said. Read full story Source: The Guardian, 8 March 2026
  18. Content Article
    Advances in home diabetes management technologies have transformed how millions of people manage their condition outside of traditional clinical settings. Devices such as insulin pumps, continuous glucose monitors (CGMs), and integrated systems that combine the two have enabled tighter glucose control, fewer manual interventions, and greater independence for patients. Closed-loop systems, in particular, represent a major step forward—automating insulin delivery based on real-time glucose data and significantly improving quality of life. Yet as these technologies become more sophisticated and widely adopted, they also introduce new safety risks—especially when critical recall information, software updates, or safety warnings fail to reach patients and caregivers in a timely or understandable way. When recall communications break down, the consequences can be severe. This ECRI article looks at why recall communication matters more than ever, the clinical consequences of missed or misunderstood recalls and shared responsibility for improving recall communication. Further reading on the hub: Diabetes technology is life-changing, but we need to be prepared when it fails - A blog by Andrew Stroud How safe are closed loop artificial pancreas systems? Blog - When diabetes devices fail
  19. Content Article
    Patient safety has become a central component of quality of care. One of the best known and most widely used security tools in all work settings is the checklists. The checklist is a tool that helps to not forget any step during the performance of a procedure, to do tasks with an established order, to control the fulfilment of a series of requirements or to collect data in a systematic way for its subsequent analysis. It is an aid to improve the efficiency of teamwork, promote communication, decrease variability, standardise care and improve patient safety. This article discusses the barriers in establishing checklists and the practical applications in paediatrics.
  20. Content Article
    By setting out 6 core standards, this guidance describes what NHS providers should have in place for the safe, effective and reliable implementation of Martha’s Rule. Standard 1: Reliable implementation and equitable access to all components of Martha’s Rule Intent To ensure that all 3 components of Martha’s Rule – patient wellness question, access to escalation and rapid clinical review – are implemented in line with guidance. All 3 components are operational and consistently accessible to patients, families, carers and staff in both adult and children’s inpatient settings in England. The patient wellness question is asked in line with adult, children and young people implementation guidance to ensure it is always asked in the same way (including response options) and the patient or family member’s direct response is recorded and actioned appropriately. Rapid reviews are carried out in line with guidance: reviewers are independent, appropriately skilled and can undertake or facilitate the review. Patients, families, carers and staff can reliably activate escalation and access rapid review. Self-assessment question Would patients, families, carers and staff be confident that all 3 components of Martha’s Rule are reliably available and implemented as intended? Standard 2: Rapid review conducted by independent, appropriately skilled clinicians Intent To ensure that when Martha’s Rule is activated, a rapid review is conducted or facilitated by an independent clinician with the appropriate skills. Rapid reviews are triggered promptly and involve a clinician not directly responsible for the patient’s ongoing care. The reviewing clinician has the appropriate skills to assess deterioration and either undertakes the review or facilitates timely access to the right clinician. The review focuses on the concerns raised and considers the patient’s condition in the round. All concerns raised by patients, families, carers and staff are listened to and acted on appropriately. Outcomes and any actions are communicated clearly to those who raised the concern, including patients and families. Self-assessment question If Martha’s Rule were activated today, would there be confidence that an independent clinician could review the patient and provide clear feedback to those involved? Standard 3: Meaningful involvement of patients, families, carers and staff in the patient wellness question and rapid review Intent To ensure that patients, families, carers and staff are meaningfully involved in the patient wellness question and the rapid review process, so concerns are accurately captured and acted on. Patients and families are made aware of the patient wellness question and understand its purpose and how their responses are used, whether within or outside an early warning system. Patients are always involved in the patient wellness question, other than in exceptional circumstances, for example when sedated. Older children who can engage are supported to answer the patient wellness question for themselves. Families or carers support patients with a learning disability or dementia or who are a very young child to answer the patient wellness question or provide relevant information. A staff member can advocate for such a patient who has no support. Where patients cannot engage directly, supportive tools such as soft signs of deterioration, observations or communication aids are used. During rapid review, patients, families, carers or staff who raised the concern are actively listened to, and their perspectives and responses are recorded and used to inform decisions about the patient’s care. Feedback from both the patient wellness question and rapid review is provided in a way that patients, families, carers and staff can understand and use. Staff understand their role in monitoring and escalating deterioration and how the patient wellness question will support their understanding of a patient’s condition over time. Self-assessment question Would patients, families, carers and staff report that their perspectives are actively sought, captured and used in both the patient wellness question and rapid review? Standard 4: Equitable access, awareness and understanding of Martha’s Rule Intent To ensure that patients, families, carers and staff are aware of Martha’s Rule and can access it fairly and consistently. All relevant groups are aware of Martha’s Rule and understand its purpose and how to access it. Martha’s Rule is promoted to all patients, families and carers, to ensure access is equitable across different needs, circumstances and clinical settings. Communication aids are readily available to support those whose first language is not English, who have low health literacy or who have a disability that limits access. Staff support patients and families to access Martha’s Rule. No patient, family member, carer or staff member is disadvantaged by language, disability, role, background, confidence or access to digital devices. Self-assessment question Would all relevant groups have equal opportunity to know about and access Martha’s Rule? Standard 5: Staff education, knowledge and understanding of Martha’s Rule Intent To ensure that all staff understand Martha’s Rule and their role in supporting it, have the confidence to recognise deterioration, involve patients, families and carers, and are able to activate and respond to the review process as appropriate. All staff understand the purpose and intent of all 3 components, including locum, agency and transient staff. Staff have the knowledge and the confidence to recognise changes in wellness and support patient, family and carer involvement. Staff know how to facilitate or activate escalation and rapid review. Staff understand how to involve patients who cannot self-report directly and older children appropriately. Staff feel empowered, supported and able to act when they have a concern or when concerns are raised with them. Self-assessment question Would staff feel confident that they understand Martha’s Rule, their role in the patient wellness question and escalation, and how to involve patients, families and carers appropriately? Standard 6: Embedding Martha’s Rule in governance and quality management systems Intent To ensure that Martha’s Rule is integrated into the organisation’s broader approach to patient safety, deteriorating patient management and quality improvement. Martha’s Rule is reflected in governance structures, quality management systems and strategies for patient deterioration. Martha’s Rule continues to be aligned with other patient safety initiatives around deterioration such as NEWS, NPEWS, NEWTT2 and MEWS. Responsibilities for oversight and review are clear. Martha’s Rule is embedded as a routine part of patient care, not a separate process. Data is submitted nationally and used locally to generate insight and continually improve patient outcomes, experiences and care. Feedback and learning from activations of Martha’s Rule is used to inform governance, quality management and staff training. Self-assessment question Would organisational leadership and governance structures be able to describe how Martha’s Rule contributes to patient safety and insight generation, and how improvements are identified and acted on?
  21. Content Article
    The Essentials of Safe Care is a practical package of evidence-based guidance and support that enables Scotland’s health and social care system to deliver safe care. It forms the building blocks for each Scottish Patient Safety Programme (SPSP) programme of work. Working in partnership with health and social care teams and several representative bodies across Scotland, the following essentials have been identified as being central to supporting the safe delivery of care across health and care. A people-led approach to the planning and delivery of safe care Effective and inclusive communication Leadership at all levels to support a culture of safety Safe clinical and care processes
  22. News Article
    A hospital trust has seen "widespread improvements" in its maternity and emergency care after being told to improve by inspectors. The Care Quality Commission (CQC) carried out unannounced visits to check on improvements it told the University Hospitals of Morecambe Bay NHS Foundation Trust to make previously. Inspectors visited maternity services at Furness General Hospital, Westmorland General Hospital and Royal Lancaster Infirmary, and urgent and emergency services at Furness General Hospital and Lancaster Royal Infirmary. All maternity services were rated "good" with staff providing "exemplary care", going "above and beyond to ensure women and their babies were well cared for", they said. In maternity services, inspectors said women were given the opportunity to speak to staff at Royal Lancaster Infirmary about their birthing experience, especially if the experience was not what they had wanted or expected. Maternity staff at Westmorland General Hospital actively listened to information about women who were most likely to experience inequality in care outcomes and supported their treatment, the CQC said. People attending A&E at Furness General Hospital scored above average in the national patient survey for how staff communicated with people and how they were treated with dignity and respect. Chris Storton, CQC deputy director of operations in the north-west of England, said: "We were encouraged to see widespread improvements across maternity care. "We saw staff providing exemplary care who went above and beyond to ensure women and their babies were well cared for. "Leaders and staff should feel proud of the changes they've made and the positive impact these changes have had on people using services." Read full story Source: BBC News, 30 January 2026
  23. Content Article
    In her first newsletter of 2026, Judy Walker discusses how After Action Review Conductors need to strike a balance between standardisation and authenticity through practicing self-awareness, setting adaptable ground rules and closing effectively
  24. News Article
    A charity has called for systematic changes to stop patients from discovering their disease diagnoses through the NHS App without proper support. Kidney Care UK says that thousands of patients are learning that they have chronic kidney disease (CKD) through the app, despite NHS guidelines stating that serious diagnoses should not be received through digital channels “without adequate support or context”. In the report ‘Falling through the G-App’, the charity says that around 10% of calls to its support line are from people who have recently discovered they have CKD without any explanation from their doctor, either through medical notes, the NHS App or other healthcare professionals. Read full article. Source: Digital Health, 10 December 2025
  25. News Article
    A father of seven was not told he was terminally ill by doctors, who instead said he would be okay, an investigation has found. William Chapman, known as Syd, only found out he had deadly pulmonary fibrosis when his GP, who thought he already knew the prognosis, mentioned it during a phone call. He died eight months later. An investigation by the Parliamentary and Health Service Ombudsman (PHSO) has found doctors at the Countess of Chester Hospital showed a "worrying lack of accountability" and failed to keep proper records, engage fully with Mr Chapman's family or learn from mistakes. Read full article. Source: Sky News, 4 December 2025.
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