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Martha's Rule represents one of the most significant patient safety initiatives introduced across English NHS trusts in recent years. Designed by NHS England to ensure that patients, families and staff can raise concerns about deterioration and receive an appropriate response, Martha’s Rule aims to strengthen communication, support earlier recognition of deterioration and amplify patient and family voices. The policy rule was first introduced in June 2024 across 143 pilot sites. As implementation continues across England, independent researchers undertaking national evaluation pause to consider: What have we learned from early implementation of Martha's Rule in real-world NHS settings? What challenges have emerged alongside the successes? How has the formative evaluation already influenced policy developments? What questions can only be answered through the forthcoming summative evaluation? About this webinar In this webinar, researchers from the NIHR Policy Research Unit Quality Safety Outcomes of Health and Social Care (NIHR QSO PRU) will share key interim findings from the formative evaluation of Martha’s Rule, drawing on in-depth ethnographic research, involving interviews, observations, and documentary analysis undertaken across three NHS pilot sites, as well as public survey data (collected in partnership with Picker and YouGov). The session will explore how organisations have implemented Martha's Rule within different local contexts, the opportunities it has created for improving communication and collaborative care, and the practical challenges encountered during implementation. The webinar will also look ahead to the newly commissioned national summative evaluation to be delivered by the NIHR SafetyNet - The Patient Safety Research Collaboration Network. Building on the learning from the formative work, this large-scale mixed-methods evaluation has been designed to assess the implementation, effectiveness, impact and value of Martha's Rule as it is adopted more widely across England. In other words, it will explore which aspects of Martha's Rule work well, for whom, under what circumstances and why, generating evidence to inform future national policy and practice. Attendees will gain insight into the realities of implementing complex safety interventions at scale, the importance of learning during implementation, and how robust evaluation can support evidence-informed policy, practice and continuous improvement. This is a joint webinar hosted by Patient Safety Learning in collaboration with NIHR SafetyNet – The Patient Safety Research Collaboration Network. Presenters Professor Rebecca Lawton Rebecca is Professor, Psychology of Healthcare at the University of Leeds, UK and an NIHR Senior Investigator. She is a behavioural scientist and patient safety researcher. Rebecca is Director of the NIHR Yorkshire and Humber Patient Safety Research Collaboration and leads the NIHR SafetyNet, which brings together all six of the PSRCs in England to co-ordinate shared learning, PPIE/EDI, safety equity research, impact and dissemination. She also leads on Safety within the national Policy Research Unit for Quality, Safety and Outcomes in England, the team that delivered the Martha’s Rule formative evaluation. As Director of the Yorkshire Quality and Safety Research Group of over 45 researchers and PhD students, Rebecca and her team focus on ‘delivering research that makes care safer’. Rebecca is a leading patient safety academic whose track record of patient safety solutions informed by theory and evidence has generated significant international impact. She has over 250 publications in leading journals, successful doctoral and post-doctoral supervision of 23 early career researchers and external funding as PI of over £25million. Dr Lavanya Thana Lavanya is a Senior Policy Research Fellow with the NIHR Policy Research Unit for Quality, Safety and Outcomes in Health and Social Care (NIHR QSO PRU) and the Yorkshire Quality and Safety Research group in the UK. As a qualitative research psychologist with over 15 years of experience, her projects span patient safety, implementation science, and the evaluation of complex interventions in acute, primary, community and mental health settings. Her current research focuses on understanding how healthcare policies and innovations are implemented in practice, with particular interests in patient and staff experience, person-centred care, addressing inequalities, and improving the quality and safety of care. Lavanya leads the delivery of the independent formative evaluation of Martha's Rule, working with a team of researchers and external partners to understand public awareness, how the policy is being implemented across NHS organisations, the factors influencing its delivery, and how early learning can support national rollout. She also contributes to the design and delivery of the qualitative workstream of the national summative evaluation, which will assess the impact and effectiveness of Martha's Rule across England. Register

I have spent almost three years as an NHS stop smoking advisor in Luton. A client called me five days after removing her nicotine patch due to a skin reaction. She had started smoking again. She was distressed and convinced she had failed. The answer to her question took me thirty seconds. She could have had it five days earlier if there had been anywhere to turn at the moment she needed it. That moment made me ask whether technology could do what the NHS structurally cannot. Provide trusted, clinically grounded support at any hour, in any language, in the moments when relapse is most likely to happen. So, I developed an AI-powered stop smoking support tool. This blog is about what building this innovative product taught me about patient safety. The gap that innovation has to fill Relapse in smoking cessation does not usually happen because someone stops wanting to quit. It happens in unguarded moments between appointments. At 11pm on a Saturday. After a stressful day at work. When something goes wrong with nicotine replacement therapy (NRT) and there is nobody to call. That structural gap is not a failure of the NHS. It is a limitation of what any appointment-based service can provide. Innovation exists to fill gaps that existing systems cannot reach. This was mine to fill. The innovation I built alongside my NHS role While continuing in my NHS role, I built an AI-powered stop smoking support platform delivered through WhatsApp. The choice of WhatsApp was deliberate. No app download is required. It works on any smartphone and is available in six languages. In Luton, where significant communities speak Urdu, Bengali, Arabic, Polish and Romanian as their first language, removing every possible barrier to access was a patient safety decision as much as a design one. The platform provides real-time nicotine craving support, NRT guidance, behavioural nudges, relapse prevention messaging and proactive check-ins. Every response is grounded in verified NHS clinical guidance using a technique called retrieval augmented generation, meaning the AI draws from a curated clinical knowledge base rather than generating health information from general training data. The innovation is not the technology itself. The technology exists. The innovation is applying it to a specific, underserved clinical gap with genuine patient safety discipline built in from the beginning. Why patient safety had to come before innovation Before I wrote a single line of code, I had to answer an uncomfortable question. What could go wrong if this AI got something wrong? In a stop smoking context the risks are real and specific. A pregnant client might ask about NRT safety. Someone in mental health crisis might reach out through the tool. A user might receive confident sounding information that is clinically incorrect. These were not hypothetical concerns. They were situations I had encountered as a human advisor. I completed a full clinical hazard log covering fifteen clinical and technical risks before the platform went live. I built human escalation logic as the first feature not the last. When the AI detects language suggesting crisis, risk or a clinical situation beyond its scope, it immediately directs the user to their advisor, a crisis line or emergency services. The innovation only works if the safety net is stronger than the gap it is trying to fill. The innovation lesson I learned from getting it wrong My first multilingual responses were translations of English text rather than naturally generated responses in each language. They were grammatically correct but culturally flat and in some cases confusing. For communities in Luton where English is not the first language this was a patient safety issue not just a usability one. A client who misunderstands health information because the language feels unnatural may make the wrong decision at a critical moment. I rebuilt the language handling so the AI generates responses directly in each language as a native speaker would write them rather than translating from English. Sometimes the most important innovations are not the ones you planned. They are the ones you discover by getting something wrong. What this innovation does not yet know I am currently preparing the AI-powered stop smoking support tool for a pilot with NHS stop smoking services in Luton in partnership with University of Bedfordshire and Luton Borough Council Public Health. The evaluation will compare quit rates against NICE benchmarks and traditional support methods. But I want to be honest about what this innovation does not yet know. Whether AI can fully replicate the human connection that makes stop smoking support effective. How clients with complex needs will interact with the tool in real-world conditions. What risks will emerge in practice that did not appear in design. Innovation in health is not finished when the technology works. It is finished when the evidence says it is safe, effective and reaching the people it was built for. We are not there yet. The pilot is where that work begins. Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.

In operating theatres and other high pressure clinical environments, clear identification shouldn’t be a nice ‘extra’, it is a patient safety need. When staff cannot quickly recognise names and roles, communication becomes harder, escalation can be delayed and patients are left unsure who is caring for them. Reviews of patient safety repeatedly show that poor teamwork and unclear roles can contribute to avoidable harm. Danielle Checketts, Managing Director of Eco Ninjas, discusses why being able to identify staff by their names and roles is so important not only for the staff themselves but also patients. She explains how a simple idea, reusable hats with detachable name badges that can be removed before laundering, can support safety and teamwork. In theatre, everyone can look the same. Masks, gowns, visors and lead aprons often cover name badges, while lanyards are easily hidden or turned around. Theatre teams include surgeons, anaesthetists, students, agency staff and industry representatives, yet patients and colleagues are still expected to know who is who. When names, roles and seniority are unclear, questions may go to the wrong person, and valuable seconds can be lost. Even when introductions are made during the WHO surgical safety checklist,[1] names and roles can quickly be forgotten once a procedure is underway. In an emergency, it must be immediately clear who is who. This lack of clarity can lead to: Miscommunication at critical moments. Delays in escalation. Reduced patient confidence and psychological safety. Errors due to misunderstood roles or instructions. This isn’t just theoretical. Liz Fitzhugh, net zero lead and former theatre manager at University Hospitals Coventry & Warwickshire (UHCW), put it simply: “If a patient arrests and someone asks for the crash trolley, either everyone goes or no one goes.” In critical moments, teams need to be immediately identifiable so they can act without hesitation. Liz’s team at UHCW were among the first to introduce name and role theatre caps in 2019. It feels fitting that she was also the person who once asked me to write my name on my disposable cap with a marker pen, quietly sparking the idea that grew into this work. For years, poor identification in theatre has become accepted and been treated as normal. But it shouldn’t be. Patients want to know who is caring for them, and staff work more safely when names and roles are clearly visible. That is why the ‘theatre cap challenge’ gained momentum internationally, highlighting a simple idea: if the hat remains visible when wearing sterile attire, it can help make names and roles visible too. Patient perspectives: what matters most Patients consistently say they want to know who is in the room, who is leading their care and who they can turn to for reassurance. Feedback from surgical and maternity care journeys, including caesarean births, shows that visible names and roles help people feel safer, calmer and better able to engage in what is happening around them. Patients describe feeling more reassured when: Staff introduce themselves clearly. Visible names and roles help patients and colleagues remember who is who after introductions, rather than relying on memory alone. There is consistency in communication throughout their care. When identification is unclear, patients can feel anxious and excluded at the point they are most vulnerable. Visible names and roles do more than support courtesy, they strengthen communication, teamwork and reassurance for patients and families. Infection prevention, hygiene and practical constraints Efforts to improve identification must also align with infection prevention standards. Theatre attire cannot simply be adapted without considering contamination risk, laundering processes and the wider pressure to reduce reliance on single use items. The challenge with current approaches The current embroidered theatre caps improve visibility of names and roles, but they are difficult to manage at scale and fail to support consistent identification for all staff. Students, visitors and temporary staff are often excluded, and new starters can wait months before receiving one. They also create ongoing operational challenges, including time-consuming bespoke ordering, poor fit, loss and replacement costs, outdated roles, and complications with laundering. As Alan Dickens, Theatre Manager at MMUH Birmingham, explains: “Bespoke embroidered caps are hard to manage over time. When staff leave or change roles, the hats issued to them often leave with them or need replacing. This creates ongoing cost for the trust and delays in maintaining accurate identification.” Emerging responses across the NHS Several NHS organisations are now testing a more practical approach: reusable hats with detachable name badges that can be removed before laundering. This keeps identification visible while fitting more easily into real hospital systems. In Somerset, a pilot at Musgrove Park showed how a simple change can support safety and teamwork. Mr Andy Stevenson, orthopaedic consultant at Somerset NHS Foundation Trust, said: “In theatre, there can be a really high turnover of colleagues at times, with new people coming and going all the time. This can make it really difficult to know who is who, let alone what jobs they have. Some days, it will be the first time working with half the people in the room. The badge hats have helped to positively transform communication and safety.” A similar message has come from maternity services. Kathryn Harrison, delivery suite manager at Great Western Hospital, said: “Despite staff introducing themselves in the morning, remembering everyone’s name and role throughout the day is challenging, especially when more than 12 people can be in the room at any one time. The badge hats reinforce this critical stage in safe surgery, improve teamwork and communication, and help break down hierarchical barriers. They can be worn by all staff, students, birthing partners and even the patients wear them on our unit”. Building the evidence base There is growing research interest in identification in healthcare.[2][3][4] We have started to work with medical schools on exploring the impact on training environments, role visibility and communication. This is helping to strengthen the evidence base for scalable, system-wide approaches. Students can be included simply using a badge with their name and role alongside a standard fitted hat. Towards integrated, system-based solutions The challenges across current approaches show the need for solutions that fit existing NHS processes, including laundering and distribution, while also identifying temporary staff, visitors and students. The most effective solutions will improve safety without creating new inefficiencies. A call to action Clear identification in healthcare is not optional. It is a practical safety intervention. When people can immediately see names and roles, communication improves, hierarchy softens, patients feel more reassured and teams are better able to act quickly when it matters most. If the NHS is serious about reducing avoidable harm, improving teamwork and strengthening patient experience, visible identification should be part of the solution. Wearing a detachable badge on a reusable theatre cap sounds very simple but this is a small change that can make a very big difference to the safety of patients. References World Health Organization. WHO Surgical Safety Checklist. Kouba LP, Fabi A, Bayer S, et al. Labeled surgical caps improve perioperative patient safety and interprofessional communication in the operating room: a scoping reviewe. Patient Saf Surg, 2026; 20:(9). Liverpool University Hospitals NHS Foundation Trust (LUHFT) and Warwick Med. Case study – Switching to Reusable Theatre Caps. NHS England. Douglas N, Demeduik S, Conlan K. Surgical caps displaying team members' names and roles improve effective communication in the operating room: a pilot study. Patient Saf Surg 2021;15:27. doi: 10.1186/s13037-021-00301-w.

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 18 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 How the reasonable adjustment digital flag can help identify and support people with a learning disability Sebastian Gonzalez, hub topic lead and learning disability lead nurse at Barts Health NHS Trust, reflects on the lack of progress made in reducing health inequalities for people with a learning disability despite a number of reports and recommendations over the last few years. He highlights the new reasonable adjustment digital flag that is being implemented across the NHS, which allows the sharing of detailed information across the healthcare system about the reasonable adjustments individuals require. 10 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. 11 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. 12 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. 13 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. 14 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. 15 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. 16 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. 17 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. 18 Learning Together - A review of the quality of care provided to adults with a learning disability who were admitted to hospital acutely unwell The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reviewed the care of adults with a diagnosed learning disability who attended/were admitted to hospital as an emergency between 1 July and 30 September 2024. The recommendations highlight areas that are suitable for regular local clinical audit and quality improvement initiatives by those providing care to this group of patients. 19 Voices for Safety podcast: Unequal cancer care for people with a learning disability in the UK This episode of Voices for Safety explores a critical patient safety issue: the inequalities people with a learning disability face when accessing cancer care. Host Dr Louise Gorman and Dr Oliver Kennedy explains how they are less likely to be referred for specialist tests, more likely to be diagnosed at a later stage, and around half as likely to receive treatment, resulting in much shorter survival times. They explore why these gaps exist – from communication challenges and diagnostic overshadowing to systemic barriers in screening and treatment – and discuss what needs to change across prevention, diagnosis, and care to create a more equitable system. 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].

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

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.

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].

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.

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.