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Mental Health Awareness Week is an annual event which aims to raise awareness and promote open conversations about mental health. In this Top picks, we’ve pulled together resources, blogs and reports from the hub that focus on improving patient safety across different aspects of mental health services and also supporting staff with their own mental health and wellbeing. 1 World mental health today: latest data (WHO, 2025) This World Health Organization (WHO) document draws on the latest information available to outline the state of mental health and mental health systems in the world. It shows that mental health conditions remain highly prevalent, with more than a billion people worldwide living with a mental disorder. This report provides essential data to guide national and global dialogue. It highlights where progress is being made – and where critical gaps persist. This report should serve as a vital tool for policy-makers, implementers and advocates alike. 2 Jay’s Personalised Safety Planning Toolkit: A guide to support meaningful safety planning for self-harm and suicide This toolkit is a co‑designed set of materials created with researchers, people with personal experience of suicide and self-harm, and healthcare professionals. Inspired by the family of Jaymie Mart, known as Jay, who died by suicide in 2012 at the age of 32, the toolkit—which was funded by the National Institute for Health and Care Research (NIHR)—offers clear, practical guidance to help adults create and review personalised safety plans. 3 Harry’s story: Acute Behavioural Disturbance In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology. Harry’s death was found to be avoidable as carers were not fully aware of this condition associated with acute psychosis. In this blog, Harry’s mother Julie describes the barriers they faced in getting the right support and care for Harry before he died and highlights the need for healthcare staff to have a greater awareness of ABD and the associated risks of a medical emergency. You can also read a second blog by Julie, where she explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately. 4 Life Beyond the Cubicle: eLearning to support working well with families during mental health crises A set of eLearning modules designed to educate and update clinicians on the importance of involving families wherever possible during mental health crises to improve patient care, avoid harm and reduce deaths. They were developed as a partnership between Oxford Health NHS Foundation Trust and Making Families Count, with funding from NHS England South East Region (HEE legacy funds). The resources have been co-produced by people with lived experience as patients, family carers and clinicians, supported by an Advisory Group drawn from a wide range of expertise, tested in eleven NHS Trusts and independently evaluated. 5 Mental health crises: how to improve care In May 2024, National Institute for Health and Care Research (NIHR) Evidence held a webinar on care for adults in mental health crisis. The webinar shared research findings on what works in community crisis care, how acute day units compare to crisis resolution teams and whether peer-supported self-management can reduce acute readmissions. This Collection summarises the 3 research projects presented at the webinar. It includes video clips from the speakers and incorporates quotes from the day. The information will be useful for anyone involved in commissioning or delivering mental health crisis services. 6 Self-harm: assessment, management and preventing recurrence This new guideline from the National Institute for Health and Care Excellence (NICE) covers assessment, management and preventing recurrence for children, young people and adults who have self-harmed. It includes those with a mental health problem, neurodevelopmental disorder or learning disability and applies to all sectors that work with people who have self-harmed. The guideline sets out some important principles for care and treatment. For example, it states that self-harming patients treated in primary care must receive regular follow-up appointments, regular reviews of self-harm behaviour and a regular medicines review. 7 Hope Virgo: What needs to happen to stop people with eating disorders being failed by the healthcare system? In this blog, Hope Virgo, author and Secretariat for the All Party Parliamentary Group (APPG) on Eating Disorders, examines the crisis that continues in eating disorder services in the UK and the devastating impact this is having on patients and their families. She highlights how failures in services lead to avoidable deaths. Hope shares the key recommendations from a new report by the APPG and calls for adequate funding and attention to ensure people with eating disorders receive the help they need to recover. 8 Designing paediatric wards to support mental health Blog from the Health Services Safety Investigations Board (HSSIB) authored by Saskia Fursland, Senior Safety Investigator. She talks about her visit to a newly opened paediatric ward where its design has carefully considered children and young people with mental health needs. Saskia reflects on the learning which could support other paediatric wards to improve their environments. 9 Zero Suicide Alliance training The Zero Suicide Alliance is a collaboration of NHS trusts, charities, businesses and individuals who are committed to suicide prevention in the UK and beyond. Their website offers free online training courses to teach people the skills and confidence to have potentially life-saving conversations with someone they’re worried about. They offer short online modules covering general suicide awareness, social isolation and suicide in veterans and university students. 10 How can our team move past a traumatic event? After an extreme traumatic event there are things that you can do to help yourself, and your colleagues, to move on. Fiona Day, medical and public health leadership coach and chartered coaching psychologist, Stacey Killick, consultant paediatrician at Glan Clwyd Hospital, and Lucy Easthope, professor in practice at Durham University’s Institute of Hazard, Risk, and Resilience and adviser on disaster recovery give their tips in this BMJ article. 11 Trusted information collection: severe mental illness (Patient Information Forum) The Patient Information Forum (PIF) have launched a series of new collections to help people find trusted resources. Each collection only features resources that have the PIF TICK. That means they are easy-to-read, evidence-based and easy to understand. Topics include: schizophrenia, bipolar disorder and psychosis. 12 Vicarious trauma: The invisible epidemic In healthcare, an insidious epidemic lurks beneath the surface, affecting the very individuals tasked with providing care: vicarious trauma by empathy. Despite its profound impact, this phenomenon remains largely unrecognised and under-discussed within the sector. As leaders, it is imperative that we shed light on this invisible trauma and acknowledge it as one of the greatest challenges facing our industry, as Margarida Pacheco explains in this blog. 13 Beyond stereotypes: A lived experience guide to navigating support for disordered eating Disordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating. 14 “The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them” Frontline19 was established at the start of the Covid pandemic as an urgent response to support frontline workers who were under extreme pressure and experiencing significant mental health challenges. Psychotherapist Claire Goodwin-Fee is the founder and CEO of Frontline19. In this blog, Claire explains how systemic pressures and stigma around mental health are continuing to leave healthcare staff extremely vulnerable. 15 Blog: Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging This blog explores why men are reluctant to seek support when they are struggling with their mental health and why the suicide rate is so high. It looks at initiatives that exist to encourage men to seek help and highlights what more could be done to support mens’ mental health. 16 Time for a rebalance: psychological and emotional well-being in the healthcare workforce as the foundation for patient safety In this editorial for BMJ Quality and Safety, Kate Kirk explains why staff well-being is the foundation to improving patient safety. 17 Top tips and key actions for successful collaborative partnership working across mental health services These top tips and key actions have been co-developed to support effective collaborative partnership working in the planning and delivery of community mental health services. They recognise that every heath and care system will experience challenges in relation to partnership working given the statutory and cultural differences of organisations working across the mental health pathways and that there will be different arrangements to frame local partnership working, including for example a Section 75 agreement. 18 Balancing care: The psychological impact of ensuring patient safety In this blog, Leah Bowden, a patient safety specialist, reflects on the impact her job has on her mental health and family life. She discusses why there needs to be specialised clinical supervision for staff involved in reviewing patient safety incidents and how organisations need to come together to identify ways we can support our patient safety teams. 19 NHS England: Staying safe from suicide: Best practice guidance for safety assessment, formulation and management This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. 20 The Motherhood Group: Black maternal mental health report UK The Motherhood Group has launched a landmark report on Black maternal mental health in the United Kingdom, shining a light on the urgent need for safe spaces, culturally competent peer support, digital access, and community-driven, anti-racist solutions. This report centres the lived experiences of Black mothers and highlights systemic barriers to quality, affordable mental healthcare. By leading this research, The Motherhood Group places Black mothers’ voices at the forefront of national conversations, providing policy-makers, health services, and communities with the insights needed to drive meaningful change. 21 Mental Maintenance at NEAS: a proactive approach to staff mental health The North East Ambulance Service NHS Foundation Trust (NEAS) provides emergency medical and patient transport services to a population of 2.7 million people in the North East region, employing over 3,400 staff members. Exposure to traumatic events, the demands of shift working and an uncertainty of what’s in store each day, can impact ambulance staff mental health. Read how North East Ambulance Service NHS Foundation Trust created a campaign to provide proactive staff mental health support. 22 Mind: The big mental health report 2025 Mind’s 2025 Big Mental Health Report explores the state of mental health, and mental health services and support across England and Wales. It builds on the insights from their 2024 report and gives a comprehensive picture of mental health to date, serving as a crucial guide that anyone can use. It explores the latest evidence on the nation’s mental health including how well services are supporting mental health in England and Wales. 23 Making sense after a suicide: living with blame, uncertainty, and the need for answers. You are not alone Each year, more than 700,000 people die by suicide worldwide. In the UK, it is around 7,000 – making it the biggest cause of death for people aged 20–34 and for men under 50. Making Families Count have created this resource to offer some comfort, recognition, and companionship in the aftermath of bereavement by suicide, whether it seems the person intended to take their own life, or their intention was unclear. The resource consists of a booklet and three short films of people’s stories of their bereavement by suicide. Written by Dr Rachel Gibbons, with contributions from a group of bereaved families, Dr Karen Lascelles, and comments and suggestions from other affected people and those who work with them. 24 National Audit of Eating Disorders Service Mapping Report 2025 The National Audit of Eating Disorders (NAED) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England as part of the National Clinical Audit and Patient Outcomes Programme. In 2025 the NAED team conducted a comprehensive mapping of eating disorder service provision across England. This report provides an in-depth overview of NHS-funded and independent sector services for children, young people, and adults. 25 Mental health crisis care: legislative challenges in emergency departments (HSSIB) The Health Services Safety Investigations Body (HSSIB) published two reports intended for healthcare organisations, policymakers and the public to help improve patient safety in relation to safety issues identified for people experiencing a mental health crisis who come into contact with urgent and emergency care services. This first report focuses on the significant legal, policy and safety gap in the care of people in emergency departments (EDs) in mental health crisis. During consultation on this report, concerns were shared with HSSIB about the current challenges in relation to the resourcing and configuration of mental health services that exacerbate challenges faced in the ED. 26 Mental health: attempted suicide while under the care of community services (HSSIB) The second HSSIB investigation used the patient safety incident investigation (PSII) report template and Patient Safety Incident Review Framework (PSIRF) tools to investigate an attempted suicide in the community mental health setting. Findings and areas for improvement are listed for the organisations that were involved in this incident. However, the learning may be relevant to other organisations. Have your say Do you have any stories, insights or resources related to mental health? We would love to hear from you! Comment below (register for free here first) Get in touch with us directly to share your insights.- Posted
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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. To support. WHO's World Immunisation Week, we have picked 14 resources full of practical advice about vaccination in a range of settings. 1 WHO: Vaccines explained "Vaccines Explained" is a series of illustrated articles from the World Health Organization that describe how vaccines work, how they’re developed and distributed and how their safety is carefully monitored. 2 EDUCATE KS3 lesson pack: HPV vaccination Co-produced by young people and researchers from the University of Bristol and London School of Hygiene and Tropical Medicine, ‘EDUCATE’ helps teach students about the human papillomavirus (HPV) vaccine and provide reassurance about receiving the vaccine, which is usually offered to teenagers at school as part of the national vaccination programme. 3 The Green Book: Immunisation against infectious diseases The Green Book is published by the UK Health Security Agency and contains the latest information on vaccination procedures for vaccine-preventable infectious diseases in the UK. It offers guidance on general safety considerations and clinical procedures relating to immunisation, as well as specific information on a wide range of diseases and vaccinations. 4 Vaccination awareness toolkit for children and young people The School And Public Health Nurses Association (SAPHNA) has coproduced this vaccination toolkit with children and young people. It aims to increase young people's awareness of what vaccines are, why they are important and what to expect from different types of vaccines. 5 Improving communication about the human papillomavirus (HPV) vaccination programme among families In England, young people aged 12 to 13 years are offered immunisation against HPV as part of the NHS vaccination programme. However, research by the National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol has identified sustained inequalities in uptake by area and minority ethnic groups. They have produced a number of information videos to address information needs about HPV among young people. They were coproduced with young people from disadvantaged backgrounds and diverse ethnic groups. 6 A visual guide to vaccines for the UK routine vaccination programme This guide by the UK Health Security Agency is designed to help ensure healthcare workers administer the right vaccines at the right time. It provides photos of all vaccines used in the UK routine immunisation programme, as well as information on when each vaccine should be given and its different trade names and abbreviations. 7 Pain management in infant immunisation: A cross-sectional survey of UK primary care nurses Childhood immunisation is a critically important public health initiative. However, since most vaccines are administered by injection, it is associated with considerable pain and distress. Despite evidence demonstrating the efficacy of various pain management strategies, the frequency with which these are used during routine infant vaccinations in UK practice is unknown. This study aimed to explore primary care practice nurses’ use of evidence-based pain management strategies during infant immunisation, as well as barriers to evidence-based practice. 8 Shingles Vaccination Programme: GP toolkit for improving uptake About 1 in 5 people who have had chickenpox develop shingles, predominantly those who are over 70. However, uptake rates of the shingles vaccine are falling in London and across England. The purpose of this toolkit is to help GPs better protect their patients by suggesting ways to improve uptake of the shingles vaccine. These suggestions are based on best practice and evidence and have been shown to work with little or no cost to practices. 9 Interview with Charlet Crichton, founder of UKCVFamily UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video for the hub, founder of UKCVFamily Charlet Crichton talks about why she established the group and describes the support it offers to patients. 10 Measles and rubella vaccine microneedle patch: new hope to reach the unreached children This Lancet article looks at how microneedle patches (MNPs) could potentially improve coverage of childhood vaccinations by providing a more thermostable, individual-dose, injection-free vaccine delivery device suitable for administration by local, non-medical personnel. MNPs could also reduce wasted vaccine doses, needle-stick injuries and breaks in the cold chain, as well as making waste management easier. 11 Whooping cough resurgence as vaccination rates slump Official data on whooping cough show that reports of suspected cases are at a 15-year high in the first three months of 2024. This article in the Pharmaceutical Journal looks at why cases are increasing, including falling rates of children receiving the childhood 6-in-1 vaccine and maternal vaccination. It outlines the symptoms of whooping cough, describes how it can be treated and includes a map identifying infection 'hot spots' in England and Wales. 12 Enhancing vaccine confidence across ethnic minority communities The Collaboration for Change is a group of two UK universities, nine community organisations and two small and medium size enterprises, who have conducted research on how to improve vaccine uptake among ethnic minority groups. The report highlights the factors influencing vaccine uptake. 13 Vaccination in the UK: Access, uptake and equity Over the last decade, the uptake of vaccines in the UK has stalled and is in many cases falling. Declining rates of routine childhood vaccination in a country with a well-established universal healthcare system are extremely concerning and pose a significant public health risk, with outbreaks of preventable diseases such as measles and whooping cough already being seen. The Royal College of Paediatrics and Child Health (RCPCH)'s Commission on Immunisation policy report assesses how and why vaccine uptake has stalled or declined. It outlines the evidence and our recommendations to increase uptake of routine childhood vaccinations across three broad themes: access to services, improved data systems and strengthening public information, education and communication. 14 UK Covid-19 Inquiry: Module 4 -Vaccines and therapeutics The UK Covid-19 Inquiry has published its fourth report and recommendations following its investigation into ‘Vaccines and therapeutics of the United Kingdom’. It considers and makes recommendations on a range of issues relating to the development of Covid-19 vaccines and the implementation of the vaccine rollout programme in England, Wales, Scotland and Northern Ireland. Issues relating to the treatment of Covid-19 through both existing and new medications were examined in parallel. Do you have a resource or story to share about immunisation safety? We’d love to hear about it - leave a comment below or join the hub to share your own post.- Posted
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Rollout of Covid vaccines extraordinary feat - inquiry report
Patient Safety Learning posted a news article in News
The rollout of Covid vaccines – the largest immunisation programme in UK history - was an "extraordinary feat", the Covid inquiry said. The fourth report from the inquiry praised the speed in which jabs were developed and deployed – 132 million were given in 2021 - alongside how the UK discovered which treatments worked best against the virus. The positive headlines contrast with the first three reports that were highly critical of the government's pandemic planning, decision-making and management of the NHS. But the report said more needed to be done to address vaccine hesitancy and those harmed by the Covid jabs should have easier access to bigger payouts. Inquiry chair Baroness Hallett praised the vaccine programme, pointing to research which suggested it saved more than 475,000 lives after more than 90% of people aged over 12 came forward for a jab. But she said while most people took up the offer of vaccination, there was lower uptake within communities in areas of higher deprivation and in some ethnic minority communities. "Governments and health services must work with communities to rebuild trust and promote a better understanding of, and confidence in, vaccines," she said. Spread of false information online and lack of trust in authority, combined with how quickly the vaccines had been developed, were contributory factors, said the report. Read full story Source: BBC News, 16 April 2026- Posted
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The UK Covid-19 Inquiry has published its fourth report and recommendations following its investigation into ‘Vaccines and therapeutics of the United Kingdom’. It considers and makes recommendations on a range of issues relating to the development of Covid-19 vaccines and the implementation of the vaccine rollout programme in England, Wales, Scotland and Northern Ireland. Issues relating to the treatment of Covid-19 through both existing and new medications were examined in parallel.- Posted
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How the UK intends to rebuild readiness for future pandemics through a whole-of-government approach that prioritises the needs of the most vulnerable. The UK’s readiness for future pandemics is being overhauled through the publication of a new Pandemic Preparedness Strategy, backed by around £1 billion of investment in health protection measures including enhancing our access to essential vaccines and therapeutics, improving our pandemic surveillance systems and expanding our ability to roll out testing to the whole population. Published by the Department for Health and Social Care today, the strategy outlines concrete action already taken across government to embed lessons from Covid-19: PPE stockpiles will continue to be replenished with a variety of products and sizes. Departmental pandemic response plans will be reviewed to ensure government services and critical national infrastructure can be maintained effectively in a pandemic. An ‘All Pandemic Hazards Bill’ will be drafted to ensure the government has legislative options ready to review and introduce as necessary in response to a range of pathogens. This will sit alongside a suite of prepared options for community protection measures to support swift decision-making and prioritisation to keep people safe. UKHSA will build a new set of services to manage large scale testing, contact tracing and other scaled public health response measures’. Chemicals and equipment stockpiles needed for testing will be built up further to protect against supply risks that could develop in the early stages of a pandemic. Data requirements to support decision-making will be reviewed to ensure information needed in a pandemic response is available, transparent, and can be shared quickly between organisations and with the public.- Posted
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The Covid-19 Inquiry published its second report and recommendations following its investigation into the ‘Core decision-making and political governance’ on Thursday 20 November 2025. It looked into core political and administrative governance and decision-making. It includes initial response, central government decision making, political and civil service performance as well as the effectiveness of relationships with governments in the devolved administrations and local and voluntary sectors. Recommendations include: Broadening participation in SAGE (the Scientific Advisory Group for Emergencies), through open recruitment of experts and representation of devolved administrations. Reforming and clarifying the structures for decision-making during emergencies within each nation. Improving consideration of the impact that decisions might have on those most at risk in an emergency: changes should aim to identify any risks to vulnerable groups, in both the planning for and response to emergencies. Ensuring that decisions and their implications are clearly communicated to the public. Laws and guidance should be easily understood and available in accessible formats. Enabling greater parliamentary scrutiny of the use of emergency powers through safeguards such as time limits and regular reporting on how powers have been used. Establishing structures to improve the communication between the four nations during an emergency to ensure better alignment of policies where desirable and to provide a clear rationale for differences in approach where necessary. See also: UK Covid-19 Inquiry Module 1: The resilience and preparedness of the United Kingdom Covid-19 Inquiry: Module 3 Report – The impact of the Covid-19 pandemic on the healthcare systems of the United Kingdom Questions around Government governance- Posted
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The Covid-19 Inquiry published its third report and recommendations following its investigation into ‘the impact of the Covid-19 pandemic on the healthcare systems of the United Kingdom’ on Thursday 19 March 2026. It examines the governmental and societal response to Covid-19 as well as dissecting the impact that the pandemic had on healthcare systems, patients and healthcare workers. Recommendations There are many lessons to be learned from the experiences of the UK’s healthcare systems during the Covid-19 pandemic and many areas for improvement. The Inquiry has made 10 recommendations and considers them all to be necessary to prevent healthcare systems being overwhelmed in the next pandemic: Recommendation 1: Ensure that decision-making on infection prevention and control is underpinned by clear structures and a cautious approach to transmission risk The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready to be convened at the outset of any future pandemic, to consider and draft infection prevention and control guidance for healthcare settings. This body must: have clear lines of responsibility and a clear, pre-defined role and remit during a pandemic have multidisciplinary membership, including experts in the science of viral transmission as well as those with clinical expertise ensure that its guidance accounts for the risk of all plausible routes of transmission until sufficient evidence emerges to rule out specific routes ensure that guidance clearly explains the underlying rationale for the precautions recommended. Separately, the Department of Health and Social Care, NHS National Services Scotland, Public Health Wales and the Public Health Agency (Northern Ireland) should review the national infection prevention and control manuals and any future guidance to ensure that the approach to identifying risk of transmission is not confined solely to specific procedures. Emphasis should be placed on a combination of risk factors, such as rates of transmissibility, environment, setting and procedure. Recommendation 2: Guidance for visiting restrictions The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should publish guidance for the implementation of visiting restrictions in hospitals in the event of a future pandemic. The guidance should identify the circumstances in which visiting restrictions should be introduced, escalated, decreased and removed alongside the measures and exemptions at each level. The guidance should be led by the following core principles: Measures applied should be the least restrictive possible, both in terms of severity and the length of time for which they apply. Restrictions should be decided upon and applied at the most local level possible. Unless restrictions are applied at a specified level, trusts and health boards should take decisions on the severity of restrictions based on local risk assessments. Communications with the public must clearly explain the measures in place and the reasons why restrictions apply. The guidance should be reviewed every three years in line with the Inquiry’s Module 1 Report (Recommendation 4) Recommendation 3: Better preparation for fit-testing The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review the availability of qualified fit testers and take steps to increase the number of fit testers accordingly. Availability should be reviewed every three years in line with the Inquiry’s Module 1 Report (Recommendation 4). The Health and Safety Executive and the Health and Safety Executive for Northern Ireland should update their guidance to employers to emphasise the need to ensure that sufficient fit-testing capacity is available. Recommendation 4: Improve data systems to identify individuals at high risk during a pandemic The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in a future pandemic. This should include action to improve health data systems and patient record-keeping by: improving patient data by enabling more granular diagnostic coding ensuring that care records are compatible across primary and secondary care enabling secure data-sharing and linkage across multiple health datasets and systems for identifying individuals at high risk. Recommendation 5: Prepare to scale up urgent and emergency care capacity The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for surge capacity in urgent and emergency care during a pandemic. Plans must ensure that there is sufficient workforce capacity and the ability to surge, including the number and type of staff required, recruitment and training provision. This should be completed as part of the whole-system civil emergency strategy recommended in the Inquiry’s Module 1 Report (Recommendation 4). Plans should be published and subject to review every three years. Recommendation 6: Prepare for and test the ability to scale up hospital capacity The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with trusts and health boards to ensure that pandemic plans include practical steps to rapidly scale up hospital capacity to treat acutely unwell patients. This should include critical care services that can deliver multiple levels and types of organ support. It should also cover necessary equipment, supplies, space and staff, including redeployment and training. All trusts and health boards must keep an easily accessible, up-to-date record of the information needed to implement these plans in the hospital sites they operate. This should include technical aspects of critical care expansion such as power, ventilation, oxygen and waste management systems. Plans for expanding capacity should be published, subject to review every three years and tested as part of the pandemic response exercises recommended in the Inquiry’s Module 1 Report (Recommendation 6). Recommendation 7: A framework to guide the allocation of intensive care resources in the extreme event of saturation The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of adult intensive care resources in the extreme event that they are saturated during a pandemic. That framework must: be informed by comprehensive engagement with the public and developed in conjunction with professionals across healthcare, law and ethics, as well as with regulators of healthcare professionals set out clearly established triggers for its use, based at least in part on a UK-wide system that measures critical care capacity strain and facilitates mutual aid (such as the CRITCON tool used in England) establish clinicians’ legal and professional duties in applying the framework, which should be clearly explained to clinicians through guidance be regularly reviewed with reference to contemporary patient data during a pandemic, and any future use of it must be evaluated and reported on publicly. A plan and timeline for completing this work should be published within six months of this Report. Application of the framework should be tested as part of the pandemic response exercises recommended in the Inquiry’s Module 1 Report (Recommendation 6). Recommendation 8: Systematically recording and publishing healthcare worker deaths The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers to develop nation-specific mechanisms to collect, analyse and publish data systematically on the deaths of healthcare workers in the event of a pandemic outbreak. The UK Statistics Authority should work with data providers to ensure that the data are comparable across the four nations of the UK. Recommendation 9: A standardised process for advance care planning across the UK The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for clinicians to ascertain and record their patients’ wishes and preferences for future care and treatment in order to inform individualised decision-making, including Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) notices. Recommendation 10: Psychological and emotional support for healthcare workers The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place plans to deliver effective support for healthcare workers at scale from the outset of a pandemic. Plans should cover the nature and level of support that will be provided during and after a pandemic. All four governments should develop a programme of peer support visits that can, from the outset of a pandemic, be targeted towards areas of acute hospitals under considerable strain. The purpose of the visits should be to support front-line staff, collect insights on the pressures that healthcare workers are facing and understand what further support they might need. See also: UK Covid-19 Inquiry Module 1: The resilience and preparedness of the United Kingdom Covid-19 Inquiry: Module 2, 2A, 2B, 2C Report – Core decision-making and political governance- Posted
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With the UK Covid-19 Inquiry due to publish its report into the impact of the pandemic on healthcare systems this week, CATA (the Covid Airborne Transmission Alliance) has submitted its own reports to the Inquiry. These cover investigations that CATA carried out independently, based on Freedom of Information requests and other sources of information (see CATA's press release that explains the background to this initiative). David Osborn, a member of CATA's Executive Team, gave a brief overview of these reports in a presentation to the SHBN (the Safer Healthcare Biosafety Network). David Osborn SHBN Meeting 130326.mp4 David's presentation can also be downloaded from the PDF attachment below: 2026-03-13 SHBN Meeting.pdf CATA has released copies of their reports into the public domain although, due to Inquiry confidentiality rules, some material has had to be redacted. Links to CATA’s two reports: Changes in the Management of COVID-19 (March 2020) Independent Investigation into the conduct of the IPC Cell- Posted
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'I'm still haunted that he died alone': The last voices of the Covid inquiry
Patient Safety Learning posted a news article in News
Rivka Gottlieb said she still felt "haunted" by the fact that her father, Michael, died alone. He was a fit and active 73-year-old, she said, working part-time in a golf shop and teaching children at his local synagogue. Her story was one of the last to be told at the Covid inquiry, which heard its final evidence this week. In March 2020, Michael and Rivka's mother, Mili, were admitted to different wards of the Royal Free hospital, in north London, with Covid symptoms - just as the first lockdown was announced. "We were just expecting him to be given a bit of oxygen and then he'd be sent home," Rivka said. Michael deteriorated in hospital. His cough became so severe he had to send a WhatsApp message to tell her he was being put on a ventilator. Two weeks later, the family was told he would never recover and that doctors were going to reduce his life support. "It was a dark and terrifying time and difficult to get updates from the hospital. I feared the worst every time the phone rang," recalled Rivka. In the last week, the inquiry has heard more than eight hours of emotional testimony from bereaved relatives. The inquiry heard how families were "torn apart" by social distancing rules, which prevented them from being with their loved ones at the end of their lives. Others spoke about huge difficulties accessing information from care homes and hospitals. Families said they were often unable to ask questions about their relatives or felt the true situation was not properly explained to them. Read full story Source: BBC News, 6 March 2026- Posted
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The final module in the long-running Covid-19 inquiry has concluded, marking the end of public hearings that began almost three years ago. While other sections of the inquiry have focused on specific areas of the pandemic, such as the care sector, economy, vaccines and political decision-making, module 10 had a broader remit, looking at the overall impact on society and the legacy left behind. “This module is about making a permanent record of the impact of Covid-19, lest people forget, and about recommending improvements for the future,” said Heather Hallett, the inquiry chair, at its outset. This Guardian article highlights some of the key things we learned: Related reading on the hub: "Why should a vulnerable person be expected to tolerate lack of protections against Covid?" Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn- Posted
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Six years ago, the Director-General of the World Health Organization sounded the highest global alarm available under international law at the time, declaring the outbreak of a new coronavirus disease (later known as COVID-19) a Public Health Emergency of International Concern (PHEIC). While the PHEIC was declared over in May 2023, the impact of COVID-19 remains etched in our collective memory – and continues to be felt worldwide. As we cross this six-year mark, WHO asks countries and partners, just as we ask ourselves: Is the world better prepared for the next pandemic? -
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David is a health and safety consultant and member of the Covid Airborne Transmission Alliance (CATA). The Safer Healthcare Biosafety Network (SHBN) is an independent forum focused on improving healthcare worker and patient safety. It is made up of clinicians, professional associations, trades unions and employers, patient organisations, industry, and government agencies with the shared objective to prevent occupational and patient safety incidents and improve occupational health and safety and patient safety in healthcare. It includes representatives from the UK-Health Security Agency, NHS, Health and Safety Executive (HSE), Care Quality Commission (CQC), Public Health, Royal College of Nursing (RCN), British Medical Association (BMA) and many others. You can watch the recording of David’s presentation to the Network below. This took place the day after Baroness Hallett published her report for module 2 of the UK COVID-19 Inquiry. David was speaking on behalf of CATA, the COVID Airborne Transmission Alliance, a core participant in module 3 (impact on healthcare). Summary of presentation David reminded the Network that Baroness Hallett, in her module 1 report (July 2024), had already confirmed that the primary routes of transmission for coronaviruses (including SARS-CoV-2) are “airborne and respiratory”. This was based on expert evidence presented to the Inquiry. David felt it was discourteous to Baroness Hallett for anybody to claim that COVID-19 is not an airborne disease, yet that is exactly what ministers (Andrew Gwynne and his successor Ashley Dalton) have been repeatedly saying in their correspondence with CATA. In her module 2 report, Baroness Hallett mentioned that “policy makers paid insufficient attention to … airborne transmission”. She went on to commend Professor Cath Noakes for the evidence she provided, praising her for raising her concerns and highlighted a comment that there could have been “significant public concern” (i.e. panic) if the disease was declared to be airborne. David shared evidence of this in the form of a WhatsApp message from Matt Hancock sharing concerns that if mainstream media published stories about the advisability of wearing masks, there would be a “loo roll type rush” on them. The Inquiry report had included comments that Professor Sir Jonathan Van Tam had made to the Inquiry during his oral evidence that “If we knew then what we know now, there may have been less emphasis on contact transmission and more emphasis on airborne transmission and ventilation”. David rejected this statement outright, maintaining that, right from the start of the pandemic, it was known to be airborne. He presented proof of this via a statement by the the Health and Safety Executive (HSE) to its inspectors in April 2020 confirming that the risk of aerosol transmission was at its greatest within a metre of the infectious person—exactly the setting where most care is given to patients. CATA UK Covid-19 Public Inquiry and related issues_21 Nov2025_small.mp4 -
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Face masks ‘inadequate’ and should be swapped for respirators, WHO is advised
Mark Hughes posted a news article in News
Surgical face masks provide inadequate protection against flu-like illnesses including Covid, and should be replaced by respirator-level masks – worn every time doctors and nurses are face to face with a patient, according to a group of experts urging changes to World Health Organization guidelines. There is “no rational justification remaining for prioritising or using” the surgical masks that are ubiquitous in hospitals and clinics globally, given their “inadequate protection against airborne pathogens”, they said in a letter to WHO chief Dr Tedros Adhanom Ghebreyesus. “There is even less justification for allowing healthcare workers to wear no face covering at all,” they said. At the height of the Covid pandemic an estimated 129bn disposable face masks were being used around the world every month, by the public and healthcare workers, with surgical masks the most widely available and recommended by most health authorities. Respirators designed to filter tiny particles – such as masks meeting FFP2/3 standards in the UK or N95 in the US – should instead be standard practice for medical interactions, they said. Read full article. Source: The Guardian, 9 January 2026 Related reading Open Letter to WHO: A Call for the Universal use of Respirators in Healthcare (7 January 2025)- Posted
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On 28 November 2025, the Covid-19 Airborne Transmission Alliance (CATA) sent an open letter to Baroness Heather Hallett, Chair of Covid-19 Public Inquiry. The letter outlines a number of concerns regarding the response of State bodies to the findings and recommendations contained in the Module 1 Report. You can read the letter here: 2025-11-29 Open Letter - CATA to Baroness Hallett (3).pdf Find out more about CATA and the Covid-19 Inquiry in the following blogs and presentations on the hub: Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn Healthcare workers with Long Covid: Group litigation – a blog from David Osborn Covid-19 : A risk assessment too far? A blog by David Osborn CATA and the UK Covid-19 Public Inquiry: Presentation from David Osborn -
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Poor ventilation leaves hospitals ‘not ready’ for another covid
Patient Safety Learning posted a news article in News
Just four years after the peak of the pandemic, four in five NHS acute trusts are concerned their ventilation systems may be inadequate, according to an investigation by HSJ. Maintaining a flow of fresh air into a room is considered an important measure to reduce the spread of airborne infections, such as coronavirus and flu. However, an analysis of trust risk registers reveals that many are operating with ageing ventilation systems which pose a risk to patient safety. HSJ asked all 118 acute trusts whether a lack of adequate ventilation was on their risk register. Just under 80% of the 91 who replied said yes. This does not mean the risk has necessarily materialised, but is significant enough – either in likelihood, potential impact, or both – to require regular review by managers. HSJ also asked for trusts to estimate the cost of reaching full compliance with the latest ventilation standards. Twenty-six trusts responded with data which suggested the average cost per trust was around £13m. One trust estates director contacted by HSJ said: “Based on this research, it is clear the NHS is not ready for another respiratory outbreak.” They added that ventilation was “one of the biggest risks” in managing healthcare estates and a “huge chunk” of their trust’s repair backlog. “One of the reasons these risks exist is because it is so expensive to replace.” Read full story (paywalled) Source: HSJ, 29 October 2025- Posted
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The knowledge gained during the Covid-19 pandemic and other health emergencies could prove invaluable for planning responses to future health crises. In this blog, Dr Landry Ndriko Mayigane and Dr Stella Chungong from the Health Security Preparedness Department of the World Health Organization’s Health Emergency Programme describe how they devised the open-source ‘Nuggets’ of Knowledge (NoK) platform to facilitate effective knowledge management and continuity during health emergencies. The NoK platform collates vital knowledge collected by first responders during past and present health crises to inform the planning of interventions and actions during future emergencies.- Posted
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The Covid-19 pandemic, which rapidly escalated into a global crisis that impacted millions of lives and disrupted economies around the world, was a wake-up call for the management of infectious disease outbreaks. Dr Stella Chungong and Dr Landry Ndriko Mayigane work for the Health Security Preparedness Department in the World Health Organization’s Health Emergencies Programme. In this article, they encourage countries to implement early action reviews (EARs) of disease outbreaks. EARs help countries assess their vigilance, planning and responsiveness, and could help countries be better prepared during outbreaks. The guidelines detail three time-based metrics, named 7-1-7, which offer a simple, structured approach to outbreak management: 7 Days to Detect, which measures how quickly the country can detect a suspected disease outbreak, with the aim being detection within 7 days. 1 Day to Notify, which measures the time taken to notify relevant public health authorities and stakeholders, with the aim being notification within 1 day. This goal is not new; it is consistent with the International Health Regulations (2005) that require countries to notify the relevant authorities within 24 hours of detecting a disease outbreak. 7 Days to Respond measures how quickly the country can establish a response to the outbreak, the aim being the instigation of effective response actions within 7 days.- Posted
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An update attached on the COVID-19 Airborne Transmission Alliance (CATA) involvement in the UK Covid-19 Public Inquiry and their plans for the future. -
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This opinion paper addresses the role of nurses and the relevance of models and theories, both nursing and infection prevention and control (IPC), to visitor restrictions that were widely enforced in many countries during the COVID-19 pandemic, with a focus on person-centredness.- Posted
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This cross-sectional analysis aimed to find out how state restrictions affected the number of excess Covid-19 pandemic deaths across 50 US states plus the District of Columbia. It found that if all states had imposed Covid-19 restrictions similar to those used in the 10 most (least) restrictive states, excess deaths would have been an estimated 10% to 21% lower (13%-17% higher) than the 1.18 million that actually occurred during the two-year period analysed. Behaviour changes were associated with 49% to 79% of this overall difference.- Posted
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In this interview, David Osborn, chartered occupational safety and health practitioner and member of the Covid-19 Airborne Transmission Alliance (CATA), speaks to Lotty Tizzard, Digital Content Manager at Patient Safety Learning, about how CATA was established during the pandemic to advocate for adequate respiratory protection for NHS employees. David explains how CATA advocated for the government and heath service to recognise that Covid-19 is passed on by aerosol transmission (through microscopic particles in the air). He also outlines why surgical masks do not adequately protect people against catching airborne viruses and describes how inadequate respiratory protective equipment (RPE) contributed to thousands of NHS staff catching Covid-19 at work. As a result, many healthcare workers died and a large number still live with the ongoing symptoms of Long Covid. David describes CATA's involvement as a Core Participant in the Covid-19 Inquiry and outlines what he hopes will be done to ensure the UK is better prepared for future pandemics. Patient Safety Learning is also a member of CATA. Clarification David wishes to clarify a point raised in the interview: "When talking about the “IPC Cell” I said that they 'didn’t produce minutes'. In fact, notes or minutes were taken at all IPC Cell meetings. The point I was making is that they were not published ('produced' in the sense of being released into the public domain), when the minutes of most other groups such as SAGE and NERVTAG were published. The few IPC Cell minutes that have trickled into the public domain have mostly been as a result of Freedom of Information requests by a colleague and a few that I have managed to obtain myself. In some cases, public authorities have taken around 18 months to disclose documents, and it has required the intervention of the Information Commissioner's Office. I anticipate that more minutes will be disclosed for public scrutiny as time goes on." You can read more about CATA and the Covid-19 Inquiry in David's blogs and presentations on the hub: Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn Healthcare workers with Long Covid: Group litigation – a blog from David Osborn Covid-19 : A risk assessment too far? A blog by David Osborn CATA and the UK Covid-19 Public Inquiry: Presentation from David Osborn Join the conversation Were you working in health and social care during the pandemic? We'd like to hear about your experience of health and safety at work. Were you provided with adequate PPE to carry out your job safely? Did you catch Covid-19 while at work? You can join the conversation by commenting below (you'll need to sign up first) or get in touch with us directly by emailing [email protected]- Posted
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The CovidD-19 pandemic challenged primary care to rapidly innovate. In response, the Western Victorian Primary Health Network (WVPHN) developed a Covid-19 online Community of Practice comprising general practitioners (GPs), practice nurses, pharmacists, aged care and disability workers, health administrators, public health experts, medical specialists, and consumers. This Experience Report describes the progress towards a durable organisational learning health system (LHS) model through the Covid-19 pandemic crisis and beyond. In March 2020, WVPHN commenced weekly Community of Practice sessions, adopting the Project ECHO (Extension of Community Health Outcomes) model for a virtual information-sharing network that aims to bring clinicians together to develop collective knowledge. The work was underpinned by the LHS framework proposed by Menear et al. and aligned with Kotter's eight-step change model. There were four key phases in the development of our LHS: build a Community of Practice; facilitate iterative change; develop supportive organisational infrastructure; and establish a sustainable, ongoing LHS. In total, the Community of Practice supported 83 unique Covid-19 ECHO sessions involving 3192 h of clinician participation and over 10 000 h of organisational commitment. Six larger sessions were run between March 2020 and September 2022 with 3192 attendances. New models of care and care pathways were codeveloped in sessions and network leaders contributed to the development of guidelines and policy advice. These innovations enabled WVPHN to lead the Australian state of Victoria on rates of COVID vaccine uptake and GP antiviral prescribing. The Covid-19 pandemic created a sense of urgency that helped stimulate a regional primary care-based Community of Practice and LHS. A robust theoretical framework and established change management theory supported the purposeful implementation of the LHS. Reflection on challenges and successes may provide insights to support the implementation of LHS models in other primary care settings. -
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The Covid and non-Covid example models below have been locally developed, and have been through local provider governance sign off. These examples demonstrate what can be done, and are not a prescription for what should be done – providers will need to consider the way their services work, their own population, and take their own SOPs through governance sign off to assure quality and safety as per any service development change. Walsall Healthcare NHS Trust safe at home SOP Leicestershire Partnership NHS Trust and University Hospitals of Leicester NHS Trust Covid-19 oxygen weaning virtual community ward service SOP Leicestershire Partnership NHS Trust and University Hospitals of Leicester NHS Trust Covid-19 virtual community ward service SOP -
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Project proposal to improve equality and reduce health inequalities. This NHS guidance is to assist organisations to develop a Standard Operating Process (SOP) for managing Covid-19 risk assessments.- Posted
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A new report from the American Hospital Association (AHA) using data analysed by Vizient finds that hospital performance on key patient safety and quality measures is better in the first quarter of 2024 than it was before the Covid-19 pandemic, and that hospitals made these improvements while caring for patients with more significant health care needs. In the years prior to the Covid-19 pandemic, hospitals across the country achieved success in improving key markers that measure patient safety, including reducing infections, expediting the diagnosis and provision of life saving treatments for heart attack and stroke, and preventing unnecessary readmissions. Unsurprisingly, the Covid-19 pandemic disrupted that progress. However, new data analyses show not only a rebound but an improvement on pre-pandemic performance in patient safety. Key takeaways Despite being sicker and more complex, hospitalised patients in the first quarter of 2024 were on average over 20% more likely to survive than expected given the severity of their illnesses compared to the fourth quarter of 2019. Based on Vizient’s analysis, the AHA using national hospitalisation data projects that while caring for sicker patients, hospitals’ efforts to improve safety led to 200,000 Americans hospitalised between April 2023 and March 2024 surviving episodes of care they wouldn’t have in 2019. Hospitals cared for more patients overall in the first quarter of 2024 than in the last quarter of 2019, including providing care to a sicker, more complex patient population. Hospitals’ central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) in the first quarter of 2024 were at rates lower than those recorded in the fourth quarter of 2019. Not only did multiple key preventive health screenings rapidly rebound to pre-pandemic levels, but ongoing improvement has led to a 60%-to-80% increase in breast, colon and cervical cancer screenings in the first quarter of 2024 compared to the fourth quarter 2019.- Posted
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