Patient Safety Watch: Baby death targets missed and negligence bill hits £58bn

Good afternoon and welcome to this fortnight’s edition of the Patient Safety Watch newsletter, this time from me, Jeremy. Let’s dive in – starting with the not unfamiliar theme of maternity safety, rapidly becoming the touchstone for broader worries about patient safety.

Saving babies’ lives 2025: A wake-up call

The Sands and Tommy’s Joint Policy Unit has published a superb new report warning that baby deaths in the UK are not falling fast enough — and thousands of preventable losses have occurred since 2018. Well worth a read, with key findings including:

• Stillbirth and neonatal death rates are off track to meet 2025 targets
• Deep inequalities by ethnicity with entrenched deprivation
• Weak national oversight: just one in 10 safety action plans are rated “strong”.

Also worth reading is Rob Wilson’s powerful blog on why this report matters. It follows a recent publication from NHS Providers also calling for urgent action.

This is a big deal for me because I focused a lot on maternity safety as health secretary. After Morecambe Bay, I launched the national programme aimed at halving avoidable baby deaths in the England by 2025. Although that target will be missed, in 2023 perinatal mortality rates in England were 20 per cent lower than a decade earlier – meaning around 690 fewer baby deaths each year. In other words it was that rare thing: an NHS programme that actually worked! Which is why we were all so worried about the axing of ringfenced maternity funding by the government which I have written to health and social care secretary Wes Streeting about.

The APPG on Patient Safety, which I chair, is now thinking about what needs to happen next, with excellent advice from Donna Ockenden and Bill Kirkup.

NHS clinical negligence bill soars to £58.2bn

In related news, a damning new report from the public accounts committee has found that the government’s second largest financial liability – after nuclear decommissioning – is now clinical negligence claims, the vast majority of which sadly arise from harm in maternity services. The report warns that poor planning around NHS England’s reorganisation has left uncertainty over how these spiralling costs will be addressed.

But there is also good news…

ABC programme to prevent brain injuries at birth rolls out nationally

The NHS’s Avoiding Brain Injury in Childbirth (ABC) programme will launch across England this September. Following promising results in pilot sites, the programme will train maternity teams to recognise and respond more effectively to signs of fetal distress. Developed with frontline staff and major professional bodies, the programme aims to reduce avoidable brain injuries and address persistent inequalities in maternity outcomes.

In other patient safety news this edition…

‘Carrot and Stick’ for NHS execs raises safety questions

Mr Streeting has announced a new pay framework linking NHS managers’ salaries to performance on finances and waiting times. Executives who miss targets will lose pay rises; top performers could gain up to £30,000 in bonuses, with an extra £15,000 for leading struggling trusts.

But safety advocates warn that incentives focused on financial metrics risk sidelining what matters most – patient care. Leadership groups have voiced concern that this approach penalises those trying to fix the most broken parts of the system, deterring skilled staff from stepping up.

NHS Confederation chief Matthew Taylor warned that the new framework could unfairly penalise leaders for issues beyond their control.

Aortic stenosis: 600+ die while waiting for treatment

As reported by The Guardian, more than 600 people died last year waiting for treatment for aortic stenosis, a common and life-threatening heart valve condition. Many could have been saved with timely access to a TAVI procedure – but delays, workforce gaps, and health inequalities are blocking progress, with a particular impact on minority ethnic patients.

Yeovil maternity unit closes after safety fears

Care Quality Commission inspectors have closed the maternity unit at Yeovil District Hospital, citing unsafe staffing, leadership issues and failure to meet basic safety standards. Pregnant women now face longer travel times for care, raising further equity concerns.

Hepatitis C risk for pre-1996 transfusion patients

People who had blood transfusions before 1996 are now being offered hepatitis C tests when they register with a new GP. Many remain unaware they may have been exposed, decades on. This follows the damning findings of the Infected Blood Inquiry.

Tick-box mental health assessments under fire

The Health Services Safety Investigations Body (HSSIB) has released its fifth and final report on patient safety in mental health inpatient settings. The investigation highlights ongoing risks including the harmful impact of out-of-area placements, lack of therapeutic care due to staffing and resource issues, and poor transition support for young people moving into adult services. It also raises concerns about a blame culture that prevents meaningful learning from patient deaths and excludes bereaved families from the review process.

HSSIB calls for systemic improvements, including better integration between health, social care, and housing services, improved staff training and ward environments, and more transparent, compassionate approaches to incident investigation.

‘Corridor care’ linked to patient deaths in Cornwall

As reported by HSJ, CQC inspectors have warned that patients at Royal Cornwall Hospital are dying after being left in overcrowded “surge spaces” and corridors. These areas are increasingly used as a stopgap for overloaded wards – but carry serious risks.

And finally some good stuff…

Help us improve patient safety – tell us about your interventions

Patient Safety Watch is gathering insights from healthcare professionals, managers, and patient safety leads to understand which interventions are truly making a difference in NHS hospitals. Your experience could shape future campaigns for safer care.

We’re looking to hear from anyone who has been involved in designing or delivering patient safety improvements in hospital settings – whether as a clinician, manager, safety lead or project contributor.

Find out more about the project and take the part in our short survey here.

If you don’t think the survey is something you can complete, maybe you know someone who could? Please do help us spread the word and gather as much insight as possible.

Amplifying voices: NHSEs new framework for safer, fairer care

NHSE’s Patient Safety Healthcare Inequalities Reduction Framework is a fresh attempt to place patient voices at the heart of efforts to tackle unsafe care. From language barriers to culturally insensitive treatment, the framework identifies how systemic issues lead to harm – and how community-led design, better data, and targeted action can close the gap. Important and welcome work.

New NHSE launches ‘Being Fair’ tool

NHSE has also recently released its new Being Fair tool — a framework to support staff involved in patient safety incidents. Replacing the previous Just Culture guide, it helps leaders assess whether issues relate to individual conduct or wider system failings, aligning with the Patient Safety Incident Response Framework. The tool promotes a fair, open culture in NHS organisations, where staff feel safe to speak up, learn from mistakes, and improve care. A welcome new initiative, but as James Titcombe argues in this blog, embracing a just culture in healthcare must encompass wider system change too.

New edition of the Stories of Safety podcast now available

In this episode of Stories of Safety, Jane O’Hara sits down with Charles Vincent, one of the world’s leading experts in patient safety, to explore how the field has evolved and where it’s headed next. Drawing on decades of research and experience, Professor Vincent reflects on the fundamental challenges of measuring and improving safety in complex healthcare systems. Another must listen!

Enter the HSJ Patient Safety Improvement Competition 2025

Do you have a project that’s making patient care safer? Showcase your work at the HSJ Patient Safety Congress – Honest Conversations: Putting Safety at the Heart of Reform (15-16 September 2025, Manchester Central Convention Centre).

Ten category winners will be invited to present lightning talks in the Innovation Spotlight Theatre, with one overall winner announced at the event. The deadline is 5pm Friday 13 June.

Download the entry template and apply now!

Any questions: Please reach out to James.elliot@hsj.co.uk

That’s it for this edition, thanks for reading. Look out for the next update from James Titcombe in two weeks’ time.

Jeremy Hunt