HSJ hosts the Patient Safety Watch newsletter, written by Patient Safety Watch chief executive James Titcombe
Good afternoon and welcome to the latest edition of the Patient Safety Watch newsletter. This is our first edition after a short summer pause. There is a lot to cover, so let us get straight to it.
Baroness Valerie Amos to lead national maternity and neonatal rapid inquiry
Earlier this month, it was confirmed that Baroness Valerie Amos will lead the rapid national maternity and neonatal safety investigation, announced by health secretary Wes Streeting in June.
The inquiry will examine up to 10 services and review the wider maternity and neonatal system. It will also bring together the findings of past reviews into a single, coherent set of national actions. Work will begin this summer, with an initial set of recommendations expected by December 2025.
Alongside the inquiry, the government is establishing a National Maternity and Neonatal Taskforce, chaired by the secretary of state, with input from experts and bereaved families.
These announcements follow years of campaigning by families who have suffered tragic loss and harm. They also reflect growing concern that, despite multiple inquiries and improvement efforts, too many families continue to experience the same devastating failings.
Baroness Amos is currently consulting on the terms of reference and appointing a team of expert advisers, with further announcements expected soon. Having tracked both progress and setbacks in maternity safety over many years, I believe Baroness Amos’ leadership has the potential to mark a genuine turning point, though the challenges should not be underestimated.
Some bereaved families have already voiced scepticism, with concerns that the investigation may be “doomed before it has started”. Media reports also point to difficult early engagement with other families. At the same time, campaigns continue for separate inquiries into services, including at Leeds and Oxford.
This backdrop of divided views, deep trauma, and long-standing unmet needs underlines how vital it is that the rapid investigation is carried out with compassion, sensitivity, and thoroughness. Baroness Amos brings strong capability and credibility to the role, and to succeed, she will need the right support, resources, and time to deliver a plan for lasting change.
Meanwhile, the Health Services Safety Investigations Body (HSSIB) has published an exploratory review of maternity and neonatal services. Drawing on stakeholder feedback and past reports, the review is intended to inform the national investigation. It provides a comprehensive summary of the issues, highlighting fragmented systems, repeated recommendations that are not acted on, gaps in risk awareness and learning, persistent inequalities, and concerns around the focus on “normal births” in undergraduate midwifery education. I shared my thoughts on Channel 4 News.
In other news this edition…
HSSIB investigates temporary care environments
HSSIB has launched an inquiry into the growing use of temporary spaces, such as corridors, waiting rooms and storage areas, for patient care. The investigation will examine the risks to safety, dignity, and staff wellbeing, with findings due in December 2025.
Royal College of Nursing general secretary and chief executive Nicola Ranger said in response: “No patient should languish in a corridor, a chair, or be forced to endure intimate examinations in public areas. This investigation must shed more light on the scale and impact of these shocking conditions and mark the beginning of the end for this unacceptable practice.”
Violence against A&E nurses nearly doubles
The Guardian has reported that violence against accident and emergency nurses in England has soared, jumping 91 per cent, from 2,122 incidents in 2019 to 4,054 in 2024. In Bristol, assaults nearly doubled from 83 to 152; Maidstone and Manchester saw similar rises.
England’s chief nursing officer, Duncan Burton, said: “It is totally unacceptable that NHS staff are facing acts of physical violence from patients and the public while at work. NHS staff do an incredible job every day to care for others, and they have the right to come to work without fear of being harmed.
“We encourage staff to report all incidents to their employer and for employers to inform the police where appropriate so that perpetrators can be brought to justice.”
RCN warns ICB cuts threaten patient safety
The RCN has warned that planned cuts to integrated care boards could undermine patient safety and the government’s 10-Year Health Plan, and is calling for every ICB to retain a chief nursing officer to provide essential clinical leadership.
It is concerned that the requirement for ICBs to halve running costs means senior nursing roles are at risk, leaving local services without the expertise needed to plan, commission, and safeguard care. Staff report rising anxiety and frustration over unclear futures, while the RCN stressed that rapid reforms leave little opportunity to assess risks to safety, quality, or equality.
BMA’s warning that NHS strike guidance risked patient safety
As reported by HSJ, the British Medical Association (BMA) warned that NHS England’s instruction not to cancel planned care during the most recent resident doctors’ strike risked endangering patients.
The BMA argued that instructing hospitals to run non-urgent planned care “stretches safe staffing far too thinly and risks not only patient safety in urgent and emergency situations, but in planned care too”.
The BMA also accused several trusts of poor planning, forcing it to approve multiple derogations to allow staff to work during industrial action and cover services including obstetrics, A&E, acute medicine, and radiology.
An NHSE spokesman said derogation requests are made by the most senior clinical teams, and delays or refusals from the BMA “questions their integrity and risks patient safety”.
Failing to learn?
One of the UK’s most respected patient safety academics, Carl Macrae, has raised the alarm over plans to subsume HSSIB as an arm of the Care Quality Commission, as recommended in the Dash review. In a sharply critical article published in the Journal of the Royal Society of Medicine, he described the proposed merger as “dramatic and sweeping” and warned that it “risks setting back progress in the systematic improvement of quality and safety by a decade”.
Professor Macrae noted this change would remove the health system’s capacity for independent system-wide safety investigation and end “England’s globally leading role in pioneering a model that is emulated internationally”.
While the Dash review offers potential for many positive reforms, I share the concern that moving HSSIB under the CQC risks undermining its independence. This aligns with a detailed analysis from patient safety expert Suzette Woodward. It is vital that any implementation preserves HSSIB’s role and autonomy.
Sharing some good stuff…
Last chance to book your place at Baby Lifeline’s National Maternity Safety Conference
Baby Lifeline is hosting its sixth annual National Maternity Safety Conference on 25 September 2025 in Birmingham. The annual event has grown into a must-attend conference that brings the maternity community together, not just to discuss challenges, but to share solutions and foster collaboration. Speakers include Sir Jeremy Hunt, Jennifer O’Donnell, Richard Duggins, Ranee Thakar, Sandra Igwe, Gill Walton, Bill Kirkup and Donna Ockenden. Booking is open until 9 September. I look forward to attending and hope to see colleagues there.
What makes a competent healthcare safety investigator?
A team led by Rosemary Lim has published a preprint outlining a competency framework for healthcare safety investigators. The framework includes 38 competencies and 82 descriptors across four domains:
- Personal qualities
- Investigation knowledge and skill application
- Effective and compassionate engagement
- Managing the investigation lifecycle
It’s a great paper – well worth a read – and we look forward to seeing what comes next.
That’s all for this edition. Thanks for reading and please look out for our next edition from Jeremy in two weeks’ time.
James
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