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News Article
Defensive medicine: The method some GPs are using to avoid complaints
Patient Safety Learning posted a news article in News
Nearly eight out of ten general practitioners are admitting to altering their medical practices and deviating from standard care to avoid patient complaints or regulatory referrals, a new survey reveals. Family doctors reported a greater inclination to prescribe certain medications, refer patients, or dedicate more time to writing notes, all to prevent potential backlash. This approach, termed "defensive medicine," carries risks, potentially leading to overdiagnosis and leaving patients feeling needlessly anxious. A Pulse survey of 836 GPs found that 78% agreed the threat of complaints had led them to practise more defensively than they felt was truly best for their patients. One family doctors told Pulse: “I have found myself practising more defensive medicine at times, perhaps investigating or referring where previously I might have watched and waited. “Despite time constraints, I find myself writing essays in patient notes to make sure I’ve covered my own back, safety-netted clearly. “This, combined with patient attitudes, has made working in the NHS almost untenable in the current climate.” Figures from NHS Resolution show it is dealing with around 3,000 cases a year involving GPs. Read full story Source: The Independent, 10 June 2026 -
News Article
Record number of people waiting for NHS diagnostic tests in England
Patient Safety Learning posted a news article in News
A record number of people are waiting for a diagnostic test on the NHS, triggering fears that delays in accessing CT and MRI scans could endanger patients’ health. A total of 1.92 million patients in England are waiting to have a test to diagnose their illness such as by an ultrasound scan, assessment of their hearing, bone scan or various tests for cancer. Demand for tests is outstripping the NHS’s ability to meet it and one in five of those on the waiting list – more than 400,000 people – are having to wait longer than the supposed six-week maximum, an analysis of diagnostic services in England has found. The rise in the waiting list for diagnostic tests contrasts sharply with the NHS’s recent success in cutting the backlog for planned hospital care to 7.1 million, which was 500,000 fewer than in July 2025. The Patients Association voiced deep unease at the situation and warned that patients’ health can deteriorate while they are waiting to have the diagnostic test needed to kickstart their treatment. “A diagnostic test is not the end of a patient’s journey – it is the beginning. Without it, treatment cannot start, conditions deteriorate, and what might have been caught early becomes something far harder to treat,” said Rachel Power, its chief executive. “When more than one in five patients is waiting beyond the NHS’s own six-week maximum, and median waiting times have risen by more than half since before the pandemic, that is deeply concerning for patients’ health. “Every week of delay is a week a condition can worsen, a patient’s ability to live day-to-day can diminish, and their anxiety about what is wrong can grow,” she added. Read full story Source: The Guardian, 7 June 2026 -
Content ArticleNudges are subtle changes to the way options are presented to guide choice. These have been employed in healthcare systems to improve clinical decisions. This systematic review analyses six randomised controlled trials investigating overuse of opiods, antibiotics, high-risk medicines for older patients and imaging during palliative radiotherapy, in order to examine the effect of clinician-directed default nudges on overuse of tests or treatments. It was found that clinician-directed default nudges had inconsistent effects on overuse of healthcare, suggesting that high quality trials are required to determine whether default nudges reduce overuse or improve patient outcomes.
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Content ArticleNearly one million people in the UK have dementia. By 2040, that number will rise to 1.4 million. Yet the systems designed to diagnose and support people 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. Individuals and our health and care systems are paying for the price of inaction. Alzheimer's Society’s two new 'Unlocking the door' reports lay out a stark reality – and a clear programme of reform for England, Wales and Northern Ireland. Key recommendations Together, the two reports set out a coherent programme of reform across diagnosis and treatment. These reforms are designed to: ensure diagnosis is early and accurate support consistent access to effective dementia drugs and non-drug interventions reduce inequalities and unwanted regional variation strengthen systems’ readiness for future innovation in diagnosis and treatments deliver better outcomes for people living with dementia and their families. To do this, we need: clear targets to set a national ambition and local accountability strengthen clinical guidance and standardise pathways invest in and support the dementia workforce strengthen dementia data and monitoring build systems ready for innovation. Further reading on the hub: Top picks: Key patient safety resources for people with dementia
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News Article
Supermarket lung cancer checks find 10,000 cases in England
Patient Safety Learning posted a news article in News
Mobile NHS scanning units, strategically placed in supermarket car parks, sports stadiums, and high streets across England, have detected lung cancer in over 10,000 individuals, new figures reveal. Crucially, more than three-quarters of these cases were identified at early stages one and two, significantly boosting treatment success rates, NHS England confirmed. This vital initiative forms part of the NHS Lung Cancer Screening Programme, which began in 2019, specifically targeting areas most affected by the disease. Early detection is paramount, with officials stating that patients diagnosed in the initial stages are 13 times more likely to survive for five years compared to those whose cancer is found later. Mobile NHS scanning units, strategically placed in supermarket car parks, sports stadiums, and high streets across England, have detected lung cancer in over 10,000 individuals, new figures reveal. Crucially, more than three-quarters of these cases were identified at early stages one and two, significantly boosting treatment success rates, NHS England confirmed. This vital initiative forms part of the NHS Lung Cancer Screening Programme, which began in 2019, specifically targeting areas most affected by the disease. Early detection is paramount, with officials stating that patients diagnosed in the initial stages are 13 times more likely to survive for five years compared to those whose cancer is found later. Professor Peter Johnson, NHS England’s national clinical director for cancer, said: "Lung cancer checks and scans save lives, so it’s fantastic the NHS has now diagnosed over 10,000 people – the majority at an early stage, when treatment is most effective. The Lung Cancer Screening Programme has been designed around where people already are, bringing scanners into their local communities to make it easier for people to get checked." Read full story Source: The Independent, 25 May 2026 -
News Article
NHS spends record £241m outsourcing scan analysis to private firms
Patient Safety Learning posted a news article in News
The NHS is paying private firms record sums to analyse diagnostic scans because hospitals are too busy and understaffed to do the work themselves, research has revealed. The amount being spent on outsourced the interpretation of CT and MRI scans is “spiralling out of control” and reflects a short-sighted failure to train enough doctors, ministers are being told. Scans are vital for diagnosing diseases such as cancer and for monitoring patients’ responses to treatment, so they need to be done quickly. Many hospitals, however, rely on non-NHS health companies reading some scans to ensure they get the results promptly. NHS trusts and health boards across the UK gave £241m to private firms to undertake such work last year. As demand increases, spending has doubled in five years from £120min 2021 and tripled from the £81m spent in 2018. The Royal College of Radiologists (RCR), which collated the figures in its annual workforce census, said health service spending on private scan reading was “ballooning”. The NHS-wide shortage of radiologists has left hospitals with too little capacity to read all scans, meaning the service is “haemorrhaging” cash to independent firms, it said. The RCR also raised concerns that the analysis done by private firms was sometimes so poor that NHS radiologists had to read scans again, raising questions about the benefit of outsourcing. Read full story Source: The Guardian, 25 May 2026 -
News ArticleCancer patients are among dozens of people found to have been “harmed” after their diagnosis and treatment were delayed due to administrative failures at an NHS trust, The Independent can reveal. A review of hundreds of gynaecology patients under the care of consultant Dr Jim Wolfe at Salford Royal Hospital, in Greater Manchester, in 2024, was prompted by concerns that the necessary follow-ups were not carried out. The months-long audit revealed that some women had not been sent letters about their treatment, or their results had not been acted on for conditions including cancer, and concluded many had been “harmed” as a result. Northern Care Alliance Trust (NCA) NHS Trust, which manages the hospital, has apologised for the “distress we’ve caused” and said those affected had been offered support and ongoing treatment plans. Sources confirmed that Dr Wolfe is still working at the trust, but NCA said it would not comment on the status of its employees. But the revelation comes amid wider staff unrest over the trust’s gynaecology services with concerns about patient safety, workforce pressures and unsafe workloads. Read full story Source: The Independent, 17 May 2026
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News ArticleAfter more than a decade of global consultation, polycystic ovary syndrome (PCOS) – a condition that affects one in eight women – has been renamed. The hormonal disorder, estimated to affect 170 million women worldwide, will now be known as polyendocrine metabolic ovarian syndrome (PMOS). The name change was published in the Lancet and announced at the European Congress of Endocrinology in Prague on Tuesday, after 14 years of collaboration between international societies and patient groups across six continents. The renaming was spearheaded by the endocrinologist Prof Helena Teede, the director of Melbourne’s Monash Centre for Health Research and Implementation. For too long, experts including Teede say, the misleading nature of the term “polycystic” in PCOS contributed to delayed diagnosis and inadequate medical care. Announcing the new name at the European Congress of Endocrinology in Prague on Tuesday, Teede said the term PCOS didn’t capture the “multi-system burden that people with this condition have suffered”, and that it “directs attention to only one organ”. PMOS is hoped to better reflect the condition’s complex nature – which affects not only the reproductive system in people assigned female at birth but also the metabolism and the risk of diabetes and cardiovascular disease. Read full story Source: The Guardian, 12 May 2026
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Content ArticleDespite advances in treatment, many patients with heart failure still experience delays in diagnosis, variation in care and avoidable hospital admissions. To support systems in addressing these challenges, the Health Innovation Network has developed a suite of practical guides designed to improve the heart failure pathway from early identification through to long-term management and end-of-life care. This resource set brings together two complementary guides: Heart Failure Blueprint for Healthcare Professionals A comprehensive overview of the optimal heart failure pathway, structured across seven stages from case finding and diagnosis to ongoing management and palliative care. It includes data, best practice examples, and innovations from across health systems to support pathway redesign. Improving the Heart Failure Pathway Through Quality Improvement: A How-To Guide A practical, step-by-step guide to help teams identify gaps, design solutions, and implement sustainable improvements using a structured quality improvement approach. These guides are designed to: Support earlier diagnosis and intervention. Improve coordination across primary, community and secondary care. Enable adoption of evidence-based treatments and innovations. Reduce avoidable admissions and improve patient outcomes. Provide a practical ‘playbook’ for local transformation. These resources are intended for multidisciplinary teams working across the pathway, including: Cardiologists, GPs and clinical leads. Nurses, pharmacists and allied health professionals. Service managers and commissioners. Quality improvement and transformation leads. The guides can be used flexibly: As a complete programme to redesign your pathway end-to-end. To target specific challenges such as diagnosis or optimisation. As a facilitation tool for workshops and system-wide collaboration. Used together, they provide both the what (the blueprint) and the how (the improvement approach) to support meaningful and sustainable change.
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News Article
Rare pregnancy complication has put UK women into ‘emergency surgery’
Patient Safety Learning posted a news article in News
Women have had to undergo major emergency surgery, including a hysterectomy, when medical staff failed to detect they had a rare but potentially fatal complication of pregnancy. Scores of women have come forward to tell their stories of how they were affected by placenta accreta spectrum (PAS) since the launch in February of a campaign to raise awareness among NHS staff and mothers-to-be of the dangers it poses. One of them lost so much blood while giving birth that she has had to give up working as an NHS operating theatre nurse and suffers from PTSD. Another lost six litres of blood and blames her daughter’s cerebral palsy on the stroke the child had while hospital personnel were battling to save her life after an emergency caesarean section. Others have suffered permanent damage to their bladder or bowels. PAS is associated with a history of C-section birth while assisted fertility using in vitro fertilisation also increases the risk. It occurs when the placenta, which gives the foetus nutrients and oxygen, grows too deeply into the wall of the woman’s uterus and blocks some or all of the cervix. This makes the usual separation of the placenta from the uterus during birth difficult. One hundred women who are concerned about how medical teams dealt with their PAS have contacted Amisha and Nik Adhia, who set up the Action for Accreta campaign. The couple have collated the women’s experiences into a dossier of stories that vividly illustrate how often the condition goes undetected and the appalling physical consequences for those involved. The 100 cases reveal “a dangerous gap in maternity care” and “systemic failures” that should prompt UK hospitals to do much more to train staff how to spot and treat PAS once it is diagnosed, say campaigners. Politicians from all the main parties at Westminster are supporting their call for a major overhaul in how the NHS manages the condition. Read full story Source: The Guardian, 6 May 2026 -
News Article
Leaked review warns CDCs a ‘burden’ on trusts
Patient Safety Learning posted a news article in News
Community diagnostic centres could become a financial “burden” on providers without extra funding and changes to how tests are paid for, the programme’s architect has warned in an internal review obtained by HSJ. The NHS England review, led by Sir Mike Richards, follows ministers making community diagnostic centres a central plank of their elective recovery plan and mission to shift care into the community. The review concluded prices for some imaging tests are making significant amounts of CDC work loss-making – and says additional central funding over “multiple years” is required. It also called for CDCs to be rebranded and a major publicity campaign to address “low level[s] of awareness and understanding” among clinicians and the public about what they do. It also highlighted substantial digital challenges. The report declared the programme has “successfully” established 170 operational CDCs “delivering more than 20 million tests, primarily in new community settings”. But it also warned more funding and national directives are needed to “fully utilise” the centres. Read full story (paywalled) Source: HSJ, 5 May 2026 -
News Article
AI outperforms doctors in Harvard trial of emergency triage diagnoses
Patient Safety Learning posted a news article in News
A groundbreaking Harvard study has found that AI systems outperformed human doctors in high-pressure emergency medicine triage, diagnosing more accurately in the potentially life and death moments when people are first rushed to hospital. The results were described by independent experts as showing “a genuine step forward” in the clinical reasoning of AIs and came as part of trials that tested the responses of hundreds of doctors against an AI. The authors said the results, published in the journal Science, showed large language models (LLMs) “have eclipsed most benchmarks of clinical reasoning”. One experiment focused on 76 patients who arrived at the emergency room of a Boston hospital. An AI and a pair of human doctors were each given the same standard electronic health record to read – typically including vital sign data, demographic information and a few sentences from a nurse about why the patient was there. The AI identified the exact or very close diagnosis in 67% of cases, beating the human doctors, who were right only 50%-55% of the time. It showed the AIs’ advantage was particularly pronounced in triage circumstances requiring rapid decisions with minimal information. The diagnosis accuracy of the AI – OpenAI’s o1 reasoning model – rose to 82% when more detail was available, compared with the 70-79% accuracy achieved by the expert humans, though this difference was not statistically significant. But it is not curtains for emergency doctors yet, the researchers said. The study only tested humans against AIs looking at patient data that can be communicated via text. The AI’s reading of signals, such as the patient’s level of distress and their visual appearance, were not tested. That means the AI was performing more like a clinician producing a second opinion based on paperwork. “I don’t think our findings mean that AI replaces doctors,” said Arjun Manrai, one of the lead authors of the study who heads an AI lab at Harvard Medical School. “I think it does mean that we’re witnessing a really profound change in technology that will reshape medicine.” Read full story Source: The Guardian, 30 April 2026 -
News Article
Trial of non-invasive endometriosis scan boosts hopes for quicker diagnosis
Patient Safety Learning posted a news article in News
A non-invasive scan for endometriosis has shown promising results in a trial, boosting hopes for far quicker diagnosis. The trial, which included 19 women with the condition, suggests that an experimental radiotracer, called maraciclatide, can “light up” endometriosis on a scan. The current need for a surgical investigation is seen as a major obstacle to timely diagnosis, with women in England typically waiting nearly a decade. Prof Krina Zondervan, head of department at the Nuffield Department of Women’s and Reproductive Health (NDWRH) at the University of Oxford, and co-lead on the study, said: “The most prevalent subtype of endometriosis currently evades reliable detection, leaving women no choice for diagnosis other than invasive surgery. If these results are confirmed in larger phase 3 studies, imaging with maraciclatide could transform clinical research and practice and potentially empower the development of treatments for women across the globe.” Research by the charity Endometriosis UK suggests women in England currently wait an average of 9 years 4 months – rising to 11 years for women from ethnic minority communities. Wes Streeting, the health secretary, highlighted the problem in the government’s renewed Women’s Health Strategy, earlier this month. Endometriosis can progress, leading to more severe physical symptoms and restricting the ability to make informed choices around fertility. Read full story Source: The Guardian, 29 April 2026 -
News Article
One person diagnosed with cancer every 80 seconds in UK, report reveals
Patient Safety Learning posted a news article in News
The number of people in the UK being diagnosed with cancer has reached a record high, with one person diagnosed every 80 seconds, a report reveals. Cancer Research UK found that more than 403,000 people were being diagnosed with the disease each year. The rise is largely due to a growing and ageing population, as people are more likely to develop cancer as they get older. The NHS is struggling to cope with rising demand for care. Cancer waiting times across the UK are among the worst on record, according to the report. Incidences have risen to 620 per 100,000 people, from 610 a decade ago, partly driven by rising obesity levels. The proportion of cases diagnosed early has barely changed, inching up from 54% to 55%. There have been some major successes. Death rates have fallen, and the proportion of people surviving for a decade or more has risen. But Cancer Research UK said this progress was now at risk of stalling, in part due to pressure on cancer services. It said the government’s recent national cancer plan for England was a crucial step towards improving care but there needed to be “funding and resources to translate ambition into impact”. Read full story Source: The Guardian, 23 April 2026 -
News Article
NHSE reveals NHS App self-test specialties
Patient Safety Learning posted a news article in News
NHS England plans to centralise at-home diagnostics for seven specialties through the NHS App, commercial documents reveal. Market engagement documents released last week said NHS England wants to replace the fragmented and inconsistent infrastructure with “a single, trusted national home-testing capability”. The new service plans to fill “a recognised gap” in home-testing infrastructure, of “fragmented commissioning arrangements, inconsistent user journeys, and lack of interoperability between local providers and national digital platforms”. The HomeTest programme will focus initially on patient self-sampling in seven areas, the market engagement notice said: Sexual health testing for HIV and Hepatitis C. Gastroenterology tests for faecal calprotectin, coeliac, ferritin, and urea and electrolytes. Total prostate specific antigen testing. Several gynaecology tests, including follicle-stimulating hormone and human papillomavirus. MRSA, specifically in relation to orthopaedic services. Several rheumatology tests, including full blood counts and liver function tests. Primary care tests, including cholesterol levels. The HomeTest service wants to enable people to order, complete and receive results from diagnostic tests from home through the NHS App. NHSE “has an aspiration” for a basic version of the programme to be available from April 2027, though it added, “this timescale is indicative and is subject to change”. Read full story (paywalled) Source: HSJ, 21 April 2026 -
News Article
Timely cancer diagnosis ‘shouldn’t be a question of luck’ says Streeting
Patient Safety Learning posted a news article in News
The Health Secretary has asserted that securing a timely cancer diagnosis "shouldn't be a question of luck," as he announced a substantial funding injection to facilitate patient checks closer to home. The government is investing £237 million into new and improved community diagnostic centres (CDCs) across England. Wes Streeting described the new CDCs as "part of the biggest expansion in NHS diagnostics in a generation." “The NHS delivered a record number of tests and scans last year but there’s still a long way to go before we’re catching disease on time,” Mr Streeting said. “The NHS should be there for all of us when we need it, catching illness earlier so we can treat it faster.” The investment will lead to four new CDCs in Gorton, Luton, Boston and Bideford, which will open in 2026/27. Some 17 CDCs will be expanded and 15 will receive enhancements to boost diagnostic capacity, the Department of Health and Social Care said. Mr Streeting went on: “These new CDCs are part of the biggest expansion in NHS diagnostics in a generation – continuing the progress we’re making and helping save lives. Read full story Source: The Independent, 14 April 2026 -
News Article
Dr TikTok: patients diagnose chronic illnesses with anonymous commenters’ help
Patient Safety Learning posted a news article in News
Malina Lee, a 31-year-old wedding baker based in San Antonio, Texas, joined TikTok during the Covid pandemic lockdowns in 2020. Like many people at the time, she was bored and began using the platform to pass the time and advertise her business. She didn’t expect a cancer diagnosis. Four years after Lee joined the app, a commenter with the username “PickleFart” told her that her neck looked asymmetrical in a way that could suggest she had a goiter – an enlarged thyroid gland – and that she should get it checked out. The anonymous amateur clinician turned out to be right – Lee had thyroid cancer, received treatment quickly, and, less than a year later, was cancer free. TikTok users are increasingly reporting that the app’s hyper-specific algorithm has steered them towards detecting medical problems before they were aware of them themselves. In many instances, users reported that symptoms described by other TikTokers matched their own inscrutable set of ailments, which led to diagnoses. In instances like Lee’s, human commenters were responsible for diagnoses that doctors had missed or not yet identified. Lee is not the only user that PickleFart, whose real name is Billie Jean Tuomi, has accurately diagnosed in a comment section. By her estimate, Tuomi has commented on dozens of videos alerting content creators of potential thyroid problems – and correctly spotted serious problems in at least four cases that she knows of, including Lee’s. Tuomi’s career as the “thyroid avenger”, as some have started to call her, is personal in its origins: she herself was diagnosed with thyroid cancer in 2012, and after two years of treatment was declared cancer-free. But obtaining a diagnosis and undergoing the subsequent treatment were difficult processes. She now finds herself trying to spare strangers on the internet what she went through. “It’s something that you don’t ever stop struggling with – it’s constantly on my mind,” she said. “The earlier you get diagnosed, the easier it is to treat, so I feel like it’s important to say something if you see something.” Craig Mittleman, director of the department of emergency services at Lawrence + Memorial hospital in Connecticut, said in the last five years of his 36-year career practicing medicine, he has seen a sharp increase in patients coming in with internet-influenced diagnoses – for better and for worse. “In some ways, it’s allowed patients to feel empowered to ask certain questions and be more informed,” he said. “But I also find that we are often, as emergency physicians, spending a lot of time debunking information that patients present, which they’ve procured through social media.” Read full story Source: The Guardian, 12 April 2026 -
News Article
ChatGPT 'uncovered woman's rare condition' after years of misdiagnosis
Patient Safety Learning posted a news article in News
ChatGPT has helped to uncover a woman's rare condition after years of being misdiagnosed by doctors. Phoebe Tesoriere, 23, claims she was told she was anxious, depressed, had epilepsy and warned she'd be treated as a mental health patient if she kept returning to A&E. Following three days in a coma after a seizure, Phoebe, from Cardiff, put her symptoms into the AI chatbot. She said it suggested a number of conditions, including hereditary spastic paraplegia, external, which Phoebe presented to her GP. Genetic testing confirmed the diagnosis. Dr Rebeccah Tomlinson is a GP serving Cardiff and Vale of Glamorgan, and said: "It's difficult for GPs to know everything. "With the pressure on the NHS, we have to know even more. "Patients coming with information helps me understand what they are thinking and guide the discussion more clearly. "It's good as a starting talking point [AI tools] which should be followed by going to a medical professional to discuss concerns further. "It's helpful for patients to come armed with information but the GP has to be open and receptive to the patient. "General practice has to be a two-way conversation." A recent University of Oxford study found that people using AI for healthcare advice were given a mix of good and bad responses, making it hard to identify what advice they should trust. Phoebe understands the challenges the hospital faced diagnosing her, but said she turned to AI after finding the experience "really lonely". "I had to fight to be listened to," she added. Read full story Source: BBC News, 9 April 2026 -
Content Article
Stefan Peil summarises a pilot study he has done to see whether a structured systems model can support the preparation of a morbidity and mortality (M&M) conference discussion. The example used is a coronary angiography risk scenario to explore whether a model-based representation of patient safety knowledge could serve as a reliable basis for an artificial intelligence (AI)-assisted decision template. The work was produced to address a practical problem in patient safety: relevant information for M&M preparation is often spread across diagrams, reports and team knowledge, which can slow and make shared understanding less consistent. The pilot study, therefore, examined whether systems modelling could help organise, make transparent and reuse safety relevant information in a more structured way. The full study is attached at the end of this page. The challenge The identified challenge was the lack of a structured, reusable approach to preparing patient safety discussions for M&M conferences. The aim was not to automate clinical judgement, but to test whether a model-based risk analysis derived from team knowledge could serve as a structured input for drafting an M&M decision template. M&M preparation often relies on fragmented information and informal interpretation. In complex clinical environments, such as coronary angiography, risks do not arise from a single isolated factor. They emerge from the interaction between tasks, people, technology, information flow and organisational conditions. In this specific pilot example, the safety concern was a risk scenario in coronary angiography in which cognitive overload during real-time decision-making and escalation could contribute to complications not being detected in time. This formed the basis for testing whether a structured model could provide a clearer and more traceable starting point for discussion. Method and measures To explore this, a systems model based on Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 was created in Systems Modeling Language (SysML) using SPARX Enterprise Architect. The objective was to represent the work system, the contributory task factor, the resulting risk and the proposed measures in a traceable form. The model focused on one coronary angiography scenario. The critical task factor was described as cognitive density in real-time decision-making and potential escalation. In the model, this contributed to the risk that complications would not be detected in time. The text states an impact on quality of care, an occurrence rating described as relevant and an overall risk class of moderate. The proposed measures were: pre-procedure briefing risk-adapted staffing standardised laboratory layout regular simulation drills. The intended achievement was a more structured, transparent and reusable basis for M&M preparation and discussion. Outcomes and lessons learned The pilot showed that a structured model can be a useful way to organise safety-relevant knowledge. Because the model linked work system elements, risks and measures in a traceable way, it provided a clearer starting point for discussion than unstructured text alone. The practical process tested in this pilot was: defining a relevant patient safety scenario in coronary angiography modelling the work system and the contributory task factor linking this to a patient safety risk documenting possible mitigating measures using the model as the basis for an AI-assisted one-page decision template. One important observation was that the AI-generated output reflected the underlying model's content. This suggests that a structured model can support more consistent synthesis than relying only on memory or informal interpretation. The text does not describe multiple alternative technical approaches in detail, so it cannot be stated from the source whether other options were formally compared or ruled out. It also does not state direct patient involvement. Staff involvement is referenced indirectly by using team knowledge as an input to the model. The text does not report formal measurement tools, outcome metrics, time savings, patient safety indicators or model costs. Therefore, no validated impact measurement can be claimed from the source. A key lesson learnt was that AI can assist with drafting and synthesis, but cannot replace clinical judgement, governance or safety review. Any output generated from the model still needs to be checked against the source material and reviewed by responsible clinical and patient safety leads. Impact This work is only a prototype, not as a formal effectiveness study. As a result, the impact that can be claimed is limited. The main result was that the structured model appeared to support: clearer organisation of safety-relevant knowledge better traceability between work system factors, risks and proposed measures a more consistent starting point for multidisciplinary discussion reuse of modelled information for drafting a one-page M&M decision template. At the same time, the the study is explicit about what was not demonstrated. The pilot did not test whether the approach: improved patient outcomes reduced harm shortened preparation time in routine practice improved care delivery in a measurable way. A further limitation was that only a single, limited example was used, and some information was withheld for data protection reasons. This means the results were narrower than would be needed for broader implementation decisions. What worked was the structured linkage between the work system, contributory factors, risks and measures. What remains uncertain is whether this translates into measurable operational benefit in routine clinical governance. A likely barrier to improvement is the need for continued expert review, because AI-generated output cannot be used without clinical validation and governance oversight. If repeated, the next stage would need a clearer evaluation design, including defined measures of clarity, consistency, usability and possibly preparation time. Next steps The next step is a practical pilot in real clinical governance settings. A suitable next-stage comparison would be conventional M&M preparation versus model-supported preparation in a small, clearly defined pilot. The proposed questions for the next phase are: Does the approach improve clarity and shared understanding? Does it help teams identify contributory factors more systematically? Does it support consistency and traceability of measures related to patient safety? The study does not provide evidence of long-term organisational change, staff reaction, patient impact statistics or system-wide implementation results. Therefore, those elements cannot yet be stated as outcomes. However, based on insights from the pilot study, the anticipated longer-term value would be to make patient safety knowledge: more structured more reusable easier to discuss across professional groups more clearly linked to the wider work system rather than to isolated errors. A sensible next step would, therefore, be a controlled local test with defined governance, clinical review and evaluation criteria before any broader adoption. -
News Article
Deaths linked to ‘overwhelmed’ department
Mark Hughes posted a news article in News
At least eight cancer patients were harmed – and in some cases potentially died – because of operational and admin failures in an “overwhelmed” hospital department, HSJ has learned. A thematic review of 15 cases from the urology department at East Kent Hospitals University Foundation Trust said several of the patients had died, in some cases having developed metastatic cancer, following missed or late diagnoses. Others had suffered psychological harm as a result of delays. Read full article (paywalled). Source: Health Service Journal, 2 April 2026 -
News Article
US under-45s struggle for insurance approval as colon cancer rates rise
Patient Safety Learning posted a news article in News
As colon cancer rates are rising among people in their 20s and 30s, some adults in the US who are under 45 and experiencing worrying symptoms are struggling to get insurance coverage for colonoscopies, which can detect colon cancer. The Affordable Care Act (ACA) requires insurance companies to cover colonoscopies for people over 45 “because it’s been recommended by the US Preventive Services Task Force”, says Caitlin Murphy, a cancer epidemiologist and professor at the University of Chicago. The ACA requires preventive screenings, including pap smears, for example, to be completely covered. But, Murphy noted, for people “under 45, if you have symptoms like rectal bleeding, a colonoscopy would be considered a diagnostic test, and so it’s not going to be covered in the same way as a screening test would be”. She added that the cost of a diagnostic colonoscopy a given insurance plan will cover varies widely. Dominick, a 35-year-old software engineer living in Florida, learned about the distinction between preventative and diagnostic colonoscopy the hard way. His doctor recommended a colonoscopy after he experienced bowel movement changes, stomach pain and weight loss. At first, his insurance company said it would be covered. Then, three hours before the procedure was scheduled, he got a call saying the colonoscopy wouldn’t be covered because it was considered diagnostic. The out-of-pocket cost for Dominick’s colonoscopy was roughly $2,000, which he paid for with a credit card because he didn’t have the cash readily available. The procedure later revealed a precancerous polyp, which he had removed – he said it’s scary to think about what could have happened if he hadn’t been able to find a way to pay. Read full story Source: The Guardian, 23 March 2026 -
News Article
'I waited 30 years for my endometriosis diagnosis'
Patient Safety Learning posted a news article in News
"It's barbaric. That's how bad the pain is, It's absolutely barbaric." A woman who waited 30 years to be diagnosed with endometriosis describes how she struggles in pain. Nichola Howells from Manchester started experiencing extremely heavy periods at the age of 14 but spent decades being "dismissed" by doctors and even gynecologists. The 47-year-old said it meant that by the time she was diagnosed she was "literally riddled" with the disease. Nichola is not alone, with many other women reporting they were not taken seriously by health professionals. The Department of Health and Social Care said it was trying to change things by investing in training and women's health hubs, adding that "waiting decades for an endometriosis diagnosis is unacceptable". In the UK, one in 10 women have endometriosis, according to the World Health Organisation. The average waiting time for a diagnosis has now reached nine years and four months, according to a new report by the charity Endometriosis UK. Nichola, who grew up in London, started taking contraception to try and manage the bleeding but as time went on her symptoms got worse. She said she was ignored or dismissed by health professionals, with one doctor telling her to "rid herself of her crippled mentality". By the time she was diagnosed, she had reached stage 4, with deep infiltrating endometriosis spread across her ligaments, intestine, pelvis, ovaries and uterus. She said: "Three decades is absolutely insane, to the point where I am literally riddled with endometriosis." Read full story Source: BBC News, 23 March 2026 -
Content ArticleA new report, jointly produced by charities Cysters and Endometriosis UK, sheds light on the biases and inequalities faced by endometriosis patients from ethnically diverse communities. The report reveals that patients from these communities are waiting more than 16% (1 year and 8 months) longer than the UK average waiting time for an endometriosis diagnosis time. The report draws on findings from more than 500 people from ethnically diverse communities living with endometriosis, as well as ten supplementary interviews. Findings: People from ethnically diverse communities wait, on average, 11 years for an endometriosis diagnosis in the UK. This is compared to the UK-wide average diagnosis time of 9 years and 4 months. Patients from ethnically diverse backgrounds wait more than twice as long (4 years) between seeing a gynaecologist and being diagnosed with endometriosis as the UK-wide average (1 year and 10 months). This is despite going to their GP sooner after first noticing symptoms, and waiting less time to see a gynaecologist. More than two thirds (68%) believed their ethnicity either played a role in their diagnosis, proved a barrier to diagnosis, or was the subject of assumptions made by healthcare practitioners. Just 11% believed healthcare providers are culturally sensitive.
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News Article
Man died after GP's calls to hospital were missed
Patient Safety Learning posted a news article in News
A coroner said there was a "risk future deaths could occur" unless action was taken after a man with sepsis died after a GP's calls to a hospital went unanswered. Terrence Frost died of natural causes on 17 July 2024 at Ipswich Hospital, in Suffolk, after he collapsed and suffered a cardiac arrest. The 84-year-old had gone in with a serious infection or inflammation following advice from his GP, who tried to contact the hospital ahead of his arrival to no avail. Nigel Parsley, senior coroner for Suffolk, said the doctor's "inability to promptly communicate" with its medical assessment unit or A&E department was a concern. In a Prevention of Future Deaths report, he said: "[That] could lead to future deaths where suspected sepsis or other life-threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence's had at the time of his arrival. "I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the medical assessment unit extremely difficult, with internal hospital telephone calls frequently going unanswered." Read full story Source: BBC News, 16 March 2026 -
Content ArticleTerrence Frost’s death was verified at 00:26 on 18 July 2024, at the Ipswich Hospital, in Ipswich, Suffolk, although Terrence’s death had occurred earlier at approximately 22:20 on 17th July 2024. On the 11 July 2024 Terrence was admitted to the Ipswich Hospital for an elective surgery (angioplasty) to improve the blood flow to his left leg and foot. Terrence was discharged on the following day 12 July 2024. On the 14 July 2024 Terrence was admitted again to the Ipswich Hospital with abdominal pain and rectal bleeding. No diagnosis was made, and as this settled spontaneously, Terrence was discharged again on the 15 July 2024. On the 16 July 2024, due to concerns raised by his family, a GP’s Paramedic conducted a home visit, and following subsequent concerning blood test results Terrence was told to go back to Ipswich Hospital as a failed discharge. After a prolonged period in the Accident and Emergency department Terrence was readmitted to the Ipswich Hospital. Despite testing, no definitive diagnosis was made during Terrence’s final admission, and Terrence appeared reasonably stable until he suffered a sudden collapse and cardiac arrest at 21:22 on the 17th July 2024. A subsequent postmortem examination identified that Terrence suffered from significant cardiac disease (cardiomegaly and coronary artery disease) and significant vascular disease (systemic atherosclerosis). The pathologist identified that his clinical markers identified that sepsis played a factor in Terrence’s death, although evidence of any infection could not be found. MATTERS OF CONCERN Evidence was heard that prior to his attendance in the Accident and Emergency department on the 16 July 2024, Terrence had been seen at home by a paramedic from his surgery, who was concerned by Terrence’s presentation and wanted to admit him to hospital. However, Terrence was reluctant so it was agreed that urgent blood tests would be taken in the first instance. The results of these tests were seen by a GP, and due to the findings (which indicated a possible serious infection or inflammation) the GP called Terrence and told him to go straight to hospital, and whilst enroute she would speak to the Medical Assessment Unit. In evidence the GP said she then spent 30 minutes on the telephone trying to contact the Medical Assessment Unit as is the required procedure, to discuss Terrence’s admission. After being unable to contact the Medical Assessment Unit, the GP contacted Terrence, via a family member, and told him that as she could not contact the Medical Assessment Unit he should head to the Accident and Emergency department instead. The GP told Terrence she would pre- alert the Accident and Emergency department to his arrival. The GP then spent a further period of time telephoning the Accident and Emergency department but again could not get through. As such upon arrival, a patient who was considered by their GP to be significantly unwell enough to warrant either admission to the Medical Assessment Unit, or that Accident and Emergency should be pre-alerted to their arrival, was unable to speak to either unit prior to the patient’s arrival. Terrence endured a 5 hour wait in Accident and Emergency before being seen. Although observations taken at the time of his subsequent admission suggest he had not developed sepsis at this stage, I am concerned that the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department may lead to future deaths in cases where suspected sepsis or other life threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence’s had at the time of his arrival. I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the Medical Assessment Unit extremely difficult, with internal hospital telephone calls frequently going unanswered.
