Patient Safety Watch: Fears mount over corridor care, HSSIB reform and ‘never events’

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter, this time from me, Jeremy.

HSSIB’s future under scrutiny

It’s been a big week for the Health Services Safety Investigations Body (HSSIB) debate. The patient safety world continues to strongly oppose the government’s proposal to transfer its functions to the Care Quality Commission.

I gave evidence to the Health Bill Committee earlier this week, and before me, HSSIB interim chief executive Rosie Benneyworth patiently explained the fundamental difference between safety investigations and safety regulation, pointing out that weeding out regulatory failures would be difficult if you are part of a regulator. NHS England chair Penny Dash, of course, argued the opposite.

Perhaps the best summary of the arguments is this letter to The Times  from the All-Party Parliamentary Group on Patient Safety. The reform isn’t going to save any money, so why on earth is it necessary?

What should prime minister Andy Burnham do?

If newly elected Makerfield MP Andy Burnham – or indeed Wes Streeting – becomes prime minister, he will be the first to have been health secretary in the NHS’s history. What reforms could transform the NHS in a world of stretched public finances? I consider this in a Substack article next week. I don’t charge for my Substacks, so do sign up here if you would like to get it.

Corridor care cases more than 90,000 in May

At the top of the list of any new administration should be sorting out corridor care – sadly, the daily reality in the NHS. New data shows more than 90,000 patients received care in corridors or other inappropriate clinical areas for longer than 45 minutes in May. That’s nearly 3,000 patients every day.

Less reported on – although The Guardian  has – is the Royal College of Emergency Medicine’s analysis suggesting that thousands of patients may be dying yearly because of prolonged emergency department waits.

Emergency care has deteriorated in other ways – one in four emergency department patients now waits more than four hours, and the average category 2 ambulance response (which cover conditions including strokes and heart attacks) is now 29 minutes compared with an 18-minute standard – while the elective waiting list also rose. The APPG for Patient Safety has raised these concerns with health secretary James Murray

More than 400 ‘never events’ recorded

As reported by Sky News, the English NHS recorded 403 “never events” between April 2025 and March 2026. Never events are serious, largely preventable patient safety incidents that should not occur if appropriate safeguards are in place.

The incidents included 166 wrong-site surgeries, such as procedures performed on the wrong patient or the wrong body part, and 121 foreign objects – such as surgical instruments, swabs, guidewires and, in two cases, surgical gloves – left inside patients after procedures.

I used to have these written on a whiteboard in my office. I believe, overall, the NHS has got safer, but it is immensely depressing that the number of never events has barely budged over a decade.

Comments ahead of major maternity reports spark concern

This month is a big one for maternity care with two major reports due out – the Nottingham maternity investigation, chaired by Donna Ockenden, and the National Maternity and Neonatal Investigation, chaired by Baroness Amos.

However, comments made by Royal College of Midwives former president, Caroline Flint, have generated controversy. Speaking to LBC, Professor Flint argued that maternity safety problems were linked to maternity care’s “overmedicalisation”, suggesting that doctors had increasingly taken over services and “don’t do it very well”.

The Royal College of Obstetricians and Gynaecologists (RCOG) has said it is “extremely disappointed” with the comments, and I’m afraid I agree. The natural birth ideology has, in practice, done far more damage. Surely, rather than pitting one profession against another, we should be encouraging trust and teamwork so that interventions happen without delay when they are needed.

HSSIB highlights challenges of delivering safe care across organisational boundaries

An HSSIB report examining a regional care pathway spanning multiple organisations has highlighted the patient safety risks that can arise when services are redesigned and centralised without sufficient ongoing oversight, shared governance and evaluation.

The investigation found that while the redesigned pathway aimed to improve outcomes and reduce inequalities, there were significant gaps between how the pathway was intended to operate and how it worked in practice.

The report calls on integrated care boards to proactively assess commissioning decisions’ safety implications and ensure robust evaluation of new care pathways. It also provides practical learning prompts for healthcare organisations covering implementation, governance, data sharing, interoperability, and cross-organisational collaboration. Essential reading for ICBs!

Trust fined over preventable infection death

As reported by HSJ, Gloucestershire Hospitals Foundation Trust has been fined £324,143 after chemotherapy patient Chris Elliot contracted a fatal pseudomonas infection linked to a contaminated shower in an en-suite hospital bathroom. The bacteria had been identified during routine testing before Dr Elliot’s infection, but no action was taken, and the bathroom remained in use. 

Inquiry finds gender care safety failures at GP practice

As reported by the BBC, an independent NHS investigation found that 78 children and young people were potentially harmed after a Brighton GP practice prescribed puberty blockers and cross-sex hormones without appropriate safeguards.

The inquiry concluded that clinicians prescribed medications when they were not appropriately qualified to do so, and there were failures in assessment, monitoring, and clinical oversight. This should not be happening – I hope every GP practice takes careful note.

Some more positive items…

The ingredients of successful surgical hubs

A study by The Healthcare Improvement Studies (THIS) Institute has identified high-performing elective surgical hubs’ key features. Researchers found that the most successful hubs protect elective activity from emergency pressures, make strong use of data, follow evidence-based best practice and foster a continuous improvement culture. The findings provide practical lessons for NHS organisations seeking to improve productivity, reduce waiting times and deliver safer elective care.

New briefing highlights importance of learning from complaints

A Parliamentary and Health Service Ombudsman briefing has highlighted the role complaints can play in improving patient safety and care quality. Drawing on discussions with trust leaders, it found organisations that learn most effectively from complaints have visible leadership, strong governance, and actively use patient feedback alongside safety and quality data.

Voices for Safety: Unequal cancer care for people with a learning disability

To mark Learning Disability Week 2026, the latest Voices for Safety podcast features Oliver Kennedy discussing research involving more than 180,000 people with learning disabilities, which found significant inequalities in cancer diagnosis, treatment, and outcomes. The episode explores the barriers people face in accessing cancer care and highlights the changes needed to create a more equitable and safer healthcare system. It is well worth a listen.

You can help make maternity care safer!

Baby Lifeline has two fantastic opportunities to share the best work happening across UK maternity and neonatal units:

National Maternity Safety Conference 2026: Poster Competition

Submit your poster abstract by 28 June. The team is keen to highlight quality improvement projects with measurable outcomes, especially those relevant to this year’s theme: “Next Steps for Safer Care: From Insight to Implementation.”

UK Maternity Unit Marvels (MUM) Awards 2026

Nominations are open until 20 July. The Workforce Awards will celebrate teams or individuals who have introduced changes to make maternity or neonatal services better for families and staff. Families are also encouraged to nominate those who went above and beyond in their care for a Family Award.

Finally, I wanted to recognise two people who received King’s Birthday honours this week. The amazing Merope Mills was awarded a CBE in recognition of her incredible work campaigning for Martha’s Rule, and Maureen Treadwell, founder of the Birth Trauma Association, has been awarded an MBE for her work over many decades working to improve maternity services. Hugely well-deserved recognition.

That’s all for now. The next edition of the Patient Safety Watch newsletter comes from James in a fortnight.

Jeremy