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This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. Through its core work to review recorded patient safety events, the National Patient Safety Team identified a report of feeding tube blockage following administration of hydrocortisone granules. The incident report described administration of soluble hydrocortisone granules, via a patient’s jejunal tube causing blockage; the tube had to be removed and reinserted. Alkindi® is a brand of hydrocortisone, presented as ‘granules in capsules for opening’. It is used in children when the body is not making enough cortisol due to the adrenal gland not working. The manufacturer’s information outlines that the granules are not suitable for giving through a nasogastric feeding tube as they may block the tube. NHS England communicated with the British National Formulary who revised information in the BNF and BNFC to specify that non-soluble granules of hydrocortisone should not be given via any feeding tube, as this may cause blockage. We also liaised with the British Society for Paediatric Endocrinology and Diabetes who agreed to highlight these concerns to its members who care for children with adrenal insufficiency.

This update highlights the significant achievements across the strategy’s national patient safety programmes. Early identification of deterioration (including Martha’s Rule) Implementation of Martha’s Rule began in May 2024 to give patients, families and staff a way to request a rapid review if they are worried their concerns about deterioration are not being addressed. It is now being implemented in all acute trusts in England for adult and children’s inpatient services, with pilots to roll-out to maternity and neonatal units, emergency departments, mental health and community settings under way. In its first year Martha’s Rule supported earlier intervention for more than 1,000 patients, including around 400 transfers to higher levels of care. A new early warning system for staff treating children launched November 2023. New tools have also been rolled out to manage early identification of deterioration in maternity and neonatal care including NEWTT2 which is now being used in over 90 Trusts, and MEWS used in over 65 Trusts. 1,621 care homes have been supported to identify deterioration, reducing 999 calls, emergency admissions and length of hospital stays. Modelling suggests if this work is scaled up across England, there is the potential for around 45,000 fewer emergency admissions and 485,000 fewer bed days in a 21-month period. Maternity and neonatal care Over 1,900 neonatal lives saved through safer care bundle interventions, including improvements in optimal cord management and the administration of antenatal steroids. 600 fewer premature babies with cerebral palsy from the administration of magnesium sulphate during pre-term labour; the estimated saving in lifetime care costs is £600 million. Medicines safety 1,900 deaths prevented through medicines safety initiatives £9 million has been saved in admission costs and further care costs avoided, due to harm reduction in relation to gastric bleeds, methotrexate overdose, opioid dependency, and drug induced Acute Kidney Injury (AKI). Since a dedicated improvement programme to reduce long term opioid use began in 2021, there are now 160,000 fewer people prescribed long term opioids than would have been if the trends from before the initiative continued. This equates to 16,000 harms avoided and 2,597 lives saved over the course of the programme. The reduced rates of opioid prescribing have been maintained since the programme concluded. The Valproate improvement programme has delivered major patient safety gains since 2018. Pregnancies exposed to valproate have fallen from 67 to just 2 in the equivalent six-month period (April to September 2018 versus April to September 2025), according to the Medicines in Pregnancy Registry. New prescribing for women aged 16–44 years has fallen by 77%, overall prescribing by 56%, and more than 8,500 women can now have a family without risks from valproate. Sodium valproate, while an effective treatment for epilepsy and bipolar disorder, carries a high teratogenic risk, with around 1 in 9 exposed pregnancies resulting in congenital malformations and up to 2 in 5 in neurodevelopmental disorders. Transforming how we learn and respond to patient safety events. Patient Safety Incident Response Framework (PSIRF) Patient Safety Incident Response Framework (PSIRF), a new national approach to incident response and investigation was launched in 2022, embedding systems thinking and improved engagement with patients, families and staff, and promoting a patient safety culture. The framework centres on maximising learning and patient safety improvement. It has been implemented in every NHS secondary care provider since 2024 and is now being piloted in 200+ GP practices with wider primary care scoping planned in 2027. Learn from Patient Safety Events (LFPSE) service Learn from Patient Safety Events (LFPSE) service is the national NHS platform for recording and learning from patient safety events. In use across all NHS trusts in England since November 2024, it captures more than 3 million events each year. Next steps include using AI to improve data quality and insight, and publishing a Recorded Data Dashboard to support transparency, learning and targeted safety improvement. National medical examiner system National medical examiner system became statutory in September 2024, meaning all deaths in England and Wales not subject to coroner inquiries now receive an independent review and bereaved families are offered a chance to speak to a medical examiner office. The National Medical Examiner’s Annual Report for 2025 highlights the system’s growing contribution to patient safety, providing real-time, independent identification of safety issues across care pathways. Identifying and responding to patient safety risks The National Patient Safety Team’s statutory function to identify and act on emerging safety risks, includes issuing National Patient Safety Alerts and working in collaboration with partners on system wide action. It is estimated that annually this: - saves 160 lives - prevents 480 severe harm incidents - saves £13.5 million in treatment costs. Building capability and capacity to address safety challenges Patient safety leadership A Network of over 800 patient safety specialists has been created, providing expert patient safety leadership, guidance and support at NHS organisations across England. All patient safety specialists are offered in-depth training in patient safety. Patient safety training and education The first National patient safety syllabus launched in 2022. Over 1.65 million completions of the essentials for patient safety’ training. Over 950,000 completions of the level 2 access to practice training for staff who want to understand more about patient safety or go on to access higher levels of training. Over 80,000 completions of bespoke level 1 training for NHS board members and senior leaders. Over 500 Patient Safety Specialists and other safety specialist roles such as Medicines Safety Officers and Medical Device Safety Officers trained in Level 3 and 4 of the Patient Safety Syllabus, delivered by Loughborough University. A second cohort for 2026/27 is in progress with a further 300 learners. 3,000+ digital clinical safety training completions. Involving patients and the public in patient safety Framework for involving patients in patient safety published in 2021. Patient safety partner (PSP) role introduced to enhance the involvement of patients in patient safety work at a national and local level. Since 2025/26 it has been a contractual requirement for NHS organisations to have PSPs on their safety governance committees. Patient Safety Partner Matters bulletin launched in 2024 to support PSPs in their role. The bulletin is nearing 1,000 subscribers. Simple steps to keep you safe during your hospital stay video and leaflet has been developed for patients. Strengthening national patient safety systems Primary care patient safety strategy was published in September 2024 and added to the GP contract in April 2025. Implementation monitoring of Learn from Patient Safety Events (LFPSE) service is demonstrated in an increase of registered GP accounts to 64% by March 2026. Promoting openness, just culture and continuous improvement has included publication of the Being Fair tool in 2025, and Improving patient safety culture – a practical guide in 2023 – setting out approaches for NHS organisations to improve their patient safety culture. The Patient safety healthcare inequalities reduction framework published in 2025, sets out key principles to reduce patient safety healthcare inequalities across the NHS. Digital clinical safety A Digital clinical safety strategy was published in September 2021. Continuation of Scan4Safety, an initiative supporting the introduction of barcode scanning technology to drive patient safety improvements. Ongoing national review of digital clinical risk management standards (DCB 0129 and DCB 0160) including a public consultation, to help ensure healthcare IT systems are safe for patient use.

Samuel Cross, Karl Claxton, and Andrew Hill argue that diversion of billions of NHS funding to pay more for new drugs under the UK-US trade deal will harm public health and result in thousands of excess deaths.

This BMJ article argues that repeated failures in NHS maternity services—highlighted by the Nottingham review, which found hundreds of cases of potentially avoidable harm and deaths—cannot be explained solely by staffing, leadership or system pressures, but instead stem from a deeper cultural issue: an entrenched ideology that prioritises “normal childbirth” over safety. This mindset has led to patterns such as delaying interventions, discouraging women from seeking care early and failing to escalate risks, even when warning signs are present. The author suggests that clinicians often act according to what seems reasonable within their belief system (“local rationality”), meaning harmful decisions are shaped by training and culture rather than intent.

The Patient Safety Commissioner, Prof Henrietta Hughes, has written to No.10 to request further information in relation to the Hughes Report exercising her statutory powers under the Medicines and Medical Devices Act for the second time since her appointment. The deadline for a response to her request is 16 July.   Prof Hughes has asked for information on: Internal and cross-government discussions held in relation to the Hughes Report, including ministerial and official-level meetings, engagement and correspondence. Actions taken beyond DHSC in response to her recommendations, over and above the information previously provided including policy decisions and considerations of feasibility and cost. Future plans and – crucially – clarity on outstanding actions in order for Ministers to make a decision on redress and the timetable for a full response to her recommendations, as well as details of relevant planned work. The Commissioner said: “Nearly two and a half years ago, the Hughes Report set out clear and urgent recommendations shaped by the experience of patients harmed by valproate and pelvic mesh and the systemic failures that followed. It provided compelling evidence of enduring gaps in recognition of harm, access to redress, and the adequacy of support available to affected patients. These are not new concerns, but as the Hughes Report highlighted, they continue to have significant consequences for those who have been harmed and indeed continue to do so. “The recommendations in the Hughes Report are direct and actionable. They address fundamental issues in how the system responds to harm, including the need for timely acknowledgment, fair and accessible routes to compensation, and a more coordinated, compassionate response from Government and public bodies. The continued absence of visible and timely progress against these recommendations risks perpetuating the very harms and inequities the Hughes Report identifies.  “Given the seriousness of these findings, and the continued impact on patients and their families, it is disappointing that the Government still hasn’t provided a substantive response to the Hughes Report. There is a clear need for transparency and accountability regarding the Government’s response. Understanding what action has been taken, and where progress has been made, is essential to driving improvement and restoring confidence with patients and the public. “

The Independent review of maternity services at Nottingham University Hospitals NHS Trust was commissioned in June 2022 and looks at the provision of maternity and neonatal care at the Trust between 2012 and 2025. More than 2,500 families and over 800 staff have contributed to this review. It concluded that there were potentially avoidable outcomes relating to 444 maternity cases examined up to May 2025, alongside 76 neonatal cases. Key issues identified in this report include insufficient staffing and funding across perinatal care settings; the inability of staff to undertake even basic (often, mandatory) training; a persistent failure to listen to and believe mothers and fathers; and a corresponding failure to investigate, and therefore learn from, mistakes. The Review identifies 18 immediate and essential actions to improve care and safety in maternity services across England, which are summarised below: 1. Strengthening women-centred communication and informed choice All women must be provided with clear, consistent and accessible information throughout pregnancy to support informed decision-making. This should include information about labour and birth, pain relief options in labour, anaesthetic care for operative delivery, and the potential benefits and risks of different interventions. 2. Support a nationally agreed perinatal workforce planning methodology as a critical enabler of perinatal improvement at pace and scale Investment should be made in the development and implementation of a robust, evidence-based workforce planning tool across perinatal services. The tool should move beyond birth rates alone to reflect population complexity, including factors such as maternal age, co-morbidities, deprivation, acuity and service configuration. 3. National immediate and essential actions labour ward coordinator (LWC) role Implement a nationally recognised LWC programme for all Band 7 LWC midwives undertaking the LWC role. Provide structured opportunities and support to achieve the competencies and standards outlined across the six domains of the national LWC Framework. Introduce 360-degree feedback for all LWCs to support reflection, performance development and understanding of the impact of behaviour on the multidisciplinary team. 4. All trusts must support training for midwives in the use of speculum examination All Trusts must ensure that midwives are supported to achieve local training competencies to perform speculum examinations for women at any gestation of pregnancy, with clear escalation pathways for women in pre-term labour or those requiring immediate ongoing care. 5. Enhanced maternal care All staff caring for pregnant women must receive regular, structured multidisciplinary training to ensure timely recognition and effective management of the deteriorating woman. Training must equip midwives, obstetricians, anaesthetists, critical care teams and outreach services with the skills, knowledge and confidence to deliver safe, high-quality enhanced maternal care. National education programmes must cover key areas of maternal care and include the recognition and management of lesser-known but clinically important conditions, such as maternal ketosis, to ensure consistent, safe and excellent care across all maternity services. 6. Delivering safe, personalised and equitable maternity care through early risk recognition, coordinated care and responsive services All Trusts must ensure women receive the appropriate ‘safety-netting’ within their care, enabling them to access services and treatments, including the consideration of reducing barriers to enable to the provision of safe maternity care. 7. National standard for standardisation and recording of fetal growth risk assessment There must be standardisation of fetal growth risk assessment, management and audit across RCOG, SBLCB and NICE guidance, with clear concise recommendations on the choice of pathways and charts to ensure consistency of the approach to the reduction in stillbirth. All practitioners performing ultrasound growth scans should have training to undertake and report examinations to meet the standardised methods used in the recommended charts. 8. There must be a national standard and documentation for maternity triage and record keeping in maternity care provision Trusts must develop a robust method of training for midwives providing triage care. This must include minimum competency standards for telephone risk assessment, agreed pathways for mandatory attendance for review and a holistic review of physical, mental and social wellbeing assessment. Suppliers of Electronic Patient Record (EPR) systems must ensure there is a standardised national maternity handover tool that addresses interoperability gaps between Trust systems. All Trusts must implement the standardised national Maternity Early Warning System (MEWS) with clearly defined escalation pathways wherever they are being cared for. 9. Support the development and implementation of a structured assessment framework for the latent phase of labour, ensuring clarity when the ‘latent phase of labour’ becomes abnormal requiring escalation Develop and implement a structured assessment framework for the latent phase of labour, incorporating maternal and fetal wellbeing, the woman’s preferences and narrative, social circumstances, potential barriers to accessing care (e.g. language or socioeconomic factors), time of day, and distance from the unit when determining the appropriateness of admission. 10. All Trusts must define criteria for the safe use of telephone postnatal follow-up, indicating when telephone follow-up is acceptable or when face-to-face follow-up is mandatory The first risk assessment for this should be documented in the woman’s notes in the antenatal period (by 34 weeks gestation), and the risk assessment reviewed before postnatal discharge from the hospital, and after every postnatal community visit. 11. National standard for obstetric anaesthetic record-keeping All Trusts must introduce and use standardised approaches to key areas of maternity anaesthetic care to reduce variation and improve outcomes. An agreed minimum standard for obstetric anaesthetic documentation must be implemented. This should include routine recording of intra-operative pain scores and accompanying narrative log, particularly during unexpected or critical events. 12. Safe, accessible and comprehensive maternity anaesthetic documentation All Trusts must strengthen maternal anaesthetic and critical care documentation, ensuring it is clear, contemporaneous and readily accessible, ideally within a single unified electronic patient record. Documentation must capture all relevant multidisciplinary discussions and care plans, and be woman centred, reflecting the woman’s needs, preferences, and involvement in decisions. 13. Department of Health and Social Care/NHS England (DHSC/NHSE) should introduce and support access to coordinated multidisciplinary debrief and psychological support. DHSC/NHSE must support Trusts to ensure that maternity services provide timely, accessible psychological support for women and families following traumatic events. This must include clear referral pathways, adequately resourced specialist provision, and processes that proactively identify and respond to unmet emotional and psychological needs 14. Funding for implementation of maternity Patient Safety Incident Reporting Framework (PSIRF) DHSC/NHSE must provide adequate funding to address the systemic resource gap that prevents Trusts from operationalising new national policy, enabling women and families to experience safer, more consistent care, with improvement demonstrated through full implementation, audit compliance, and sustained delivery of required standards. DHSC/NHSE should develop clear maternity-specific definitions and guidance on patient-safety incidents to resolve national inconsistency in interpretation, ensuring women and families receive transparent and accurate reporting of harm, with improvement evidenced by nationally standardised grading and reliable national data. 15. Strengthened multidisciplinary governance and learning All Trusts must ensure protected time for multidisciplinary governance, review and learning. This must include learning from both adverse events and examples of good practice to support continuous improvement in the quality and safety of care provided to women. Learning from neonatal PSIRF investigations should be considered alongside maternity investigations, recognising the opportunities for shared learning across perinatal services. 16. Foster a compassionate, psychologically safe, and learning culture All Trusts must actively foster a culture of safety, compassion and respect across all maternity services. Staff must feel supported to speak up and raise concerns without fear of reprisal. Women must feel listened to, respected, and fully involved in decisions about their care. Trusts must promote compassionate leadership, a civil and kind workplace, and the use of positive feedback as a tool to reinforce good practice and drive continuous improvement. A psychologically safe and learning culture is essential to improving clinical outcomes, supporting staff wellbeing and enhancing the experiences of women and their families. 17. DHSC/NHSE should recommend and support recruitment processes and implement a consistent onboarding package for new starters Trusts must streamline recruitment processes and implement a consistent onboarding package for all staff involved in the delivery of perinatal care with named supervision and support during initial shifts. 18. All Trusts to ensure compliance, audited annually, with the NHS Records Management Code of Practice post-death care The report also notes that in post-death care, Trusts should cease the practice of conducting post mortem examinations anywhere except the mortuary. They should ensure all investigations or reviews into after-death care include an independent post-death care specialist. Nationally there should be statutory regulation of Anatomical Pathology Technologists introduced.

The long-awaited report into maternity failures at Nottingham University Hospitals NHS trust, the largest investigation of its kind in the UK, involving about 2,500 families, will be published shortly. Led by the senior midwife Donna Ockenden, the inquiry investigated stillbirths, neonatal deaths, maternal deaths and babies or mothers who suffered brain damage and other injuries between 2012 and 2025. In this article some of the families affected share their stories about what happened to them in Nottingham, and explain why this is such a landmark moment.

Following revelations in 2017 of the abuse of patients by staff at Muckamore Abbey Hospital, the Minister for Health in Northern Ireland ordered a public inquiry be held into that abuse and related matters. The Inquiry, chaired by Tom Kark KC, and heard from 235 witnesses, including a number of service users, and over 90 relatives of service users. It found that patients had been abused and systematically bullied by staff members at Muckamore Abbey Hospital whose job it was to look after them. The report includes 106 recommendations. The Inquiry heard extensive evidence concerning injuries sustained by patients, particularly bruises, unexplained marks and signs consistent with physical abuse. Some patients were verbal and were able to express that they had been assaulted by staff, but such direct evidence was very limited. Relatives reported being informed by staff that injuries were caused by self-harm, behavioural incidents or peer-on-peer violence. They were told their relative was clumsy or may have fallen in the night. Over time, many families lost confidence in these explanations, especially where injuries were located on areas of the body difficult to self-inflict or appeared repeatedly in similar patterns. Sometimes injuries were unexplained even when a patient was supposed to be under supervision. The Inquiry also heard evidence of physical abuse captured on CCTV, including forceful handling, dragging, pushing and inappropriate restraint. These incidents provided confirmation that unexplained injuries reported by families over many years could not be attributed solely to patient behaviour or peer-on-peer violence. The presence of injuries alongside incidents captured on CCTV demonstrated that earlier concerns had been justified and should have prompted urgent intervention. The Inquiry notes that families’ concerns were exacerbated by the lack of communication from staff at the hospital about when patients had been injured, and many complained of significant delays in injuries being reported to them. The Panel concluded that injuries such as bruises and marks were not isolated or incidental; they were visible indicators of systemic failure. Dealing with each incident individually resulted in the inability of the organisation to recognise patterns, escalate concerns and protect patients, and allowed physical abuse and neglect to continue unchecked, causing lasting harm to patients and profound distress to their families. Key themes Key patient safety issues highlighted in this report include: Information sharing and co-production Families described not being informed of their rights when relatives were detained under the Mental Health (NI) Order 1986. Many believed decisions were made without consultation, leaving them feeling excluded from their loved one’s care. The Inquiry repeatedly heard that families were informed of decisions rather than involved in making them. Families reported not being able to visit during early stages of admission, removing opportunities to share crucial information. Many families struggled to identify a consistent point of contact or key worker. Restrictive practices The Panel identified serious and persistent concerns regarding the frequency, rationale, recording and governance of restrictive practices over a prolonged period. Seclusion was a particular area of concern. Although policies on seclusion became increasingly prescriptive over time, including requirements for monitoring, the Inquiry heard evidence that implementation was inconsistent, sometimes inadequate and not effectively audited. The use of PRN medication as a form of restrictive practice was also problematic. Although guidance emphasised that PRN medication should only be used with a clear therapeutic rationale and as a last resort, families frequently described experiencing their relatives as sedated, disengaged or ‘zombified’. The Panel accepted that this was not necessarily an indication of overmedication by use of regularly prescribed drugs but may have reflected the use of PRN medication to control behaviour when other non-medical approaches had either not been available or not been attempted. Governance and oversight of restrictive practices were inadequate. Although data on restraint, seclusion and incidents was collected and reported internally, the Inquiry found limited evidence of effective senior management challenge, trend analysis or sustained action to reduce use. Complaints and concerns Evidence revealed widespread confusion, fear and mistrust among families, alongside systemic weaknesses in complaint handling, oversight and organisational learning. Many family members found the complaints system opaque and difficult to navigate, with little clarity about how complaints were investigated, how decisions were reached or what outcomes, if any, resulted. Many families reported finding out about injuries, assaults or significant incidents only during visits, or after long delays. Others described communications they perceived as defensive, dismissive or designed to protect the institution rather than investigate the facts. Some believed that staff were effectively ‘investigating themselves’, creating perceptions of bias and eroding confidence in outcomes. Even when complaints were upheld in part, families often felt responses lacked empathy, apology or accountability. Fear was a major barrier to complaint-raising. Witnesses described explicit or implicit warnings suggesting that complaining could affect their relative’s care or future admissions. Patients themselves were sometimes frightened to speak up. Governance and oversight arrangements were also found wanting. Although complaints data was presented in dashboards and discussed at Muckamore Abbey Hospital management meetings, there was limited evidence of robust analysis, challenge or sustained organisational learning. Previous concerns, previous investigations and warning signs The Panel concluded that Muckamore Abbey Hospital exhibited multiple, persistent and well-documented warning signs long before 2017: sustained understaffing; inadequate specialist supports; unsafe environments; escalating violence and restraint; frequent safeguarding referrals; family complaints; and a geographically and culturally closed institution. While individual allegations were often investigated, the system failed to connect the dots. No single mechanism brought together incident reporting, safeguarding intelligence, complaints and workforce pressures in a way that would have revealed the scale of risk Safeguarding The Panel found that safeguarding systems were fragmented and insufficiently integrated with the Trust’s wider clinical governance and risk management arrangements. Safeguarding investigations were structurally separated to preserve independence, but this separation limited organisational learning. Staff and ward management The Panel concluded that staffing challenges at Muckamore Abbey Hospital were long-standing, well-documented and increasingly severe, yet were never adequately resolved. These systemic workforce failures significantly increased patient vulnerability and contributed to the conditions in which abuse was able to occur and persist. Staffing shortages were persistent from at least 2009 onwards and worsened significantly after 2012, when recruitment freezes and temporary contracts became common due to the anticipated closure of Muckamore Abbey Hospital. The ratio of registered nurses to healthcare assistants was frequently below safe levels, and in some wards fewer than half of staff were registered nurses. Healthcare assistants, who provide the majority of direct patient care, had no specialist training requirements and relied heavily on informal learning. Supervision of healthcare assistants inconsistent, and clinical supervision arrangements fell far below what would be expected in a high-risk inpatient setting. This created a task-focused culture where staff prioritised basic physical care over personal and therapeutic engagement. Throughout this period, senior leadership and the Trust Board repeatedly reassured themselves and external bodies that staffing was safe, even as the regulator and whistleblowers raised escalating concerns. Leadership While extensive governance structures existed, they consistently failed to work to bring relevant information to the Board of Belfast Health and Social Care Trust, and to translate information into understanding of risks or into an active response. There was a resulting lack of insight by the Board into the difficulties faced at Muckamore Abbey Hospital. A central failure identified by the Inquiry was the Trust’s focus on governance processes rather than outcomes. Reports to the Board emphasised the existence of policies, action plans and committees but rarely demonstrated whether these arrangements were effective in protecting patients or improving care. Incident reporting, safeguarding referrals, complaints and staff intelligence were routinely aggregated at Trust level, masking significant variation at hospital level and thus obscuring sustained patterns of harm at Muckamore Abbey Hospital. Risks from Muckamore Abbey Hospital were often downgraded or removed as they ascended the risk register hierarchy, even when underlying conditions persisted or deteriorated. Risks affecting specific services were smoothed out through aggregation and failed to reach the Board as Principal Risks. Even after external regulators raised serious concerns, including the issuing by the Regulation and Quality Improvement Authority (RQIA) of Improvement Notices in 2019, the Board continued to accept assurances that care was safe, often disputing regulators’ findings without providing robust supporting data. Senior leaders failed to reconcile contradictory evidence from inspections, incidents, safeguarding reviews and staffing data. Crucially, the Board did not adequately address structural risk factors such as chronic staffing shortages, excessive use of untrained agency staff and inappropriate ward mixes. Reassurances provided by executive directors were not properly scrutinised for any underlying supporting data. External agencies inspection and oversight The Inquiry concluded that, although multiple agencies were involved with Muckamore Abbey Hospital over many years, none succeeded in identifying, preventing or stopping abuse before it was revealed, exposing significant limitations in the external oversight framework. Between 2009 and 2019, RQIA conducted over 100 inspections of Muckamore Abbey Hospital, initially at ward level and later using a whole-hospital approach. These inspections frequently identified problems such as staffing shortages, safeguarding weaknesses, excessive restrictive practices and governance failings. However, the inspection methodology relied heavily on documentation review and there was limited involvement with staff, patients and families, providing only a snapshot of practice. Inspectors acknowledged that staff behaviour changed when inspectors arrived on the wards and that therefore they were unlikely to observe ‘normal’ ward culture. Despite having statutory powers to do so, RQIA did not review CCTV footage at Muckamore Abbey Hospital, even after CCTV was viewed by the Trust and by Police Service of Northern Ireland and serious concerns were raised. Evidence to the Inquiry suggested that families repeatedly raised concerns through various routes but felt unheard, contributing to a loss of confidence in advocacy and oversight mechanisms. Overall, the Panel concluded that external inspection and oversight failed to operate as an effective safety net. Warning signs, including staffing instability, increased violence, high use of restrictive practices and repeated complaints, were visible and known but not interpreted as indicators of potential abuse. Oversight was reactive rather than preventive. The central lesson is that external regulation and investigation must extend beyond procedural compliance and episodic inspection. For services caring for highly vulnerable people, effective oversight requires proactive, risk-based approaches that: examine culture; triangulate multiple data sources, including where appropriate the use of CCTV; engage directly with families and, where possible, patients; and act decisively when conditions associated with abuse are present. Planning and funding of learning disability services Overall, the Inquiry found there was a failure to align policy, funding, workforce planning and accountability that prevented meaningful transformation of learning disability services. The absence of a coherent, long-term, system-wide approach contributed directly to sustained institutionalisation of individuals at Muckamore Abbey Hospital and to risks in care quality and safety. Redress There is no doubt that patients did suffer as a result of abuse within Muckamore Abbey Hospital but to try to assess the extent of such abuse in relation to individual patients or the nature of the harm caused was deemed as beyond the Inquiry’s capacity. In relation to direct redress, including the consideration of financial compensation, however, our recommendation would be that the Department of Health should set up a small working party to consult with patients, service user groups and individuals connected to those who have suffered abuse at Muckamore Abbey Hospital in relation to what form redress might properly take.

Medical device makers have been rushing to add AI to their products. While proponents say the new technology will revolutionize medicine, regulators are receiving a rising number of claims of patient injuries. This Reuters Special Report investigates some of the hazards associated with AI-enabled medical devices, including errors in a navigation system integrated into a medical device used in ENT surgery, AI software used for prenatal ultrasound scans that misidentified fetal body parts and AI assisted heart monitors that failed to recognise abnormal rhythms.  Issues with the capacity of the U.S. Food and Drug Administration (FDA) to review the flood of new AI-enabled medical devices are also raised, as well as concerns that the FDA's traditional approach to regulating medical devices may no longer be fit for purpose.