HSJ hosts the Patient Safety Watch newsletter, written by Patient Safety Watch chief executive James Titcombe
Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter – this time from me, Jeremy, with lots to report.
All change
Since our last newsletter, the major political development has been Wes Streeting’s resignation as health secretary. I have mixed feelings about his tenure. He is one of the most gifted and able politicians in the Cabinet, which should have been good for the NHS, but I was hoping for much more substantive reform – it felt like a missed opportunity.
However, he did engage extensively with me and others on maternity safety, where he set up and agreed to chair the National Maternity and Neonatal Taskforce. Its terms of reference and full membership were published this week. I hope his successor, James Murray, sees this through. Mr Murray seems less of a communicator – not necessarily a bad thing if it means he is a doer instead.
And there is lots to do: this week saw a new Health Bill in the King’s Speech, which contains several major reforms impacting patient safety – including plans for a national single patient record and the controversial merger of the Healthcare Safety Investigation Branch (HSSIB) into the Care Quality Commission (CQC). The former is brilliant, and the latter would be a big mistake, as my Patient Safety all-party Parliamentary group warned in the British Medical Journal.
CQC warns against HSSIB transfer
As reported by HSJ, the CQC itself has warned that government plans to abolish HSSIB and transfer its functions into the regulator could undermine patient safety and create serious conflicts of interest.
I suspect the House of Commons Health and Social Care Committee may say the same after its evidence session this week, where I was a witness alongside interim HSSIB chief investigator Rosie Benneyworth and respected academic Carl Macrae.
I argued that the real issue was that too many recommendations get ignored – 1,400 recommendations in 30 reports over 30 years, according to the Dash Review. So instead of a flawed merger, the bill should require the National Quality Board to assess and, if it agrees, implement all recommendations from inquiries, select committees, and coroners within six months. Another key confusion the bill should resolve is over duty of candour: how is it that more than a decade after trusts were legally required to tell the truth to harmed patients and families, their lawyers still advise them not to?
New national maternity adviser announced
The government has appointed Labour MP Michelle Welsh as its first national maternity adviser. Her role will focus on working with families, ministers, the NHS, and maternity organisations to help drive improvements in maternity and neonatal safety.
Ms Welsh has been a powerful voice for maternity safety in Parliament following her own experiences as a harmed patient in Nottingham. Her first month in post will be busy, coinciding with the publication of Baroness Valerie Amos’s National Maternity and Neonatal Investigation and Donna Ockenden’s report on Nottingham.
Nursing shortages raise renewed patient safety concerns
As reported by The Guardian, a new survey from the Royal College of Nursing has highlighted mounting concerns about patient safety linked to nurse staffing shortages across the NHS. More than 13,000 nurses took part in the survey, with 64 per cent reporting that staffing levels on their last shift were below what was needed to deliver safe care. The RCN described the combination of workforce shortages and increasingly complex patient needs as a “deadly mix” for patient safety.
Yet the government continues to water down 2023’s NHS long-term workforce plan, which nearly doubled the number of nurse training places. The apparent justification is that AI means fewer nurses will be needed – even though most experts argue that professions like nursing are among the most resistant to AI. Labour rebelled with me against the government’s refusal to back a long-term workforce plan in 2022, then supported me when I introduced it as chancellor. I hope they know what they are doing.
Staff compensation claims follow nitrous oxide exposure concerns in maternity unit
As reported by HSJ, more than 140 compensation claims have been brought by staff working in the maternity unit at Basildon Hospital over alleged exposure to unsafe levels of nitrous oxide, commonly known as “gas and air”.
The claims relate to staff working at Mid and South Essex Foundation Trust between 2018 and 2023, including midwives and healthcare assistants.
NHS Resolution has received 141 claims linked to exposure to “excessive and foreseeably dangerous” levels of Entonox, with more than £89,000 already paid out in compensation.
CQC upgrades leadership rating at Sussex trust, despite ongoing cultural concerns
As reported by HSJ and the BBC, University Hospitals Sussex FT has had its leadership rating upgraded by the CQC from “inadequate” to “requires improvement”. Inspectors acknowledged progress since 2023 while highlighting continuing concerns around culture, inclusion, and governance.
The CQC said trust leaders demonstrated commitment to improvement and identified positive partnership working and stronger “freedom to speak up” arrangements. However, inspectors also reported concerns about workplace culture, describing issues relating to psychological safety, risk management, and inclusion.
Children harmed following delays in paediatric audiology care
As reported by HSJ, at least 40 children are believed to have suffered harm linked to delays and failings in paediatric audiology services at Bedfordshire Hospitals FT. An interim patient safety review, supported by NHS England, identified 109 children potentially at risk of harm relating to hearing aid management at Luton and Dunstable University Hospital. Of these, 14 cases were initially graded as involving “moderate physical harm” and a further nine as “severe physical harm”.
The findings form part of a wider national improvement programme for paediatric audiology services following 2025’s Kingdon Review, which concluded that warnings about audiology testing failures had been overlooked nationally for more than a decade.
Coroner finds missed care opportunities contributed to death of autistic man
As reported by the BBC, a coroner has concluded that failures in hospital care “materially contributed” to the death of Tom Parsons, a 32-year-old autistic man with epilepsy and learning disabilities.
An inquest heard that Mr Parsons died in July 2024 from complications caused by blood clots after being admitted to East Surrey Hospital with psychosis. During his admission, he did not receive prescribed blood-thinning injections for 14 days due to concerns about safely administering treatment while he was distressed.
The coroner found there had been a “lost opportunity” in his care and concluded that the failure to administer the medication contributed to his death. Surrey and Sussex Healthcare Trust said it would carefully consider the coroner’s findings and ensure lessons were learned to improve care for patients and families in future.
Sharing some good stuff…
Why the distinction between safety and quality matters
HSSIB chair Ted Baker has published an important new blog exploring why patient safety should be viewed not as one dimension of healthcare quality, but as its foundation. Reflecting on a paper produced by HSSIB colleagues, the blog argues that healthcare systems too often treat safety as something that can be “balanced” against competing pressures such as efficiency, performance, or patient flow.
Professor Baker argues that we need to move away from the traditional model where safety sits alongside other dimensions of quality, towards a “foundational” model in which safety is the non-negotiable basis upon which all other aspects of care depend.
This is a view that gets a strong endorsement from James and me here at Patient Safety Watch – essential reading for our new health secretary!
New GIRFT guidance on catheter safety
The guidance focuses on reducing catheter-associated infections, avoiding unnecessary catheter use, improving communication between services, and supporting better patient-centred care across primary, community and hospital settings.
I was pleased to establish the GIRFT programme while health secretary, and it continues to show the value of clinically led improvement programmes focused on reducing unwarranted variation, improving outcomes, and strengthening patient safety across the NHS.
New HSSIB briefing on bias in patient safety investigations
Fantastic work from the HSSIB and the NHS Race and Health Observatory this week, which have published a new briefing exploring bias and discrimination in NHS patient safety investigations.
The briefing highlights the need for stronger consideration of racism, inequalities, and family involvement within investigations, alongside improved accountability and use of data to identify inequities in care and outcomes. Important and timely work.
Clinical Human Factors Group launches new training courses
The Clinical Human Factors Group (CHFG) has launched two new training courses which are now available to book:
SEIPS in Health and Care Investigation and Design – CHFG – Clinical Human Factors Group
Reader of this newsletter will likely already be aware of CHFG and the fantastic work they do – these courses will undoubtedly be top quality and will sell out quickly, so please do book early.
HSJ Patient Safety Congress Returns
The HSJ Patient Safety Congress returns on 28-29 September with the theme “Beyond Honest Conversations: Delivering Safer Care”.
For 19 years, Congress has brought together healthcare leaders, clinicians, safety specialists and patient voices to tackle the biggest challenges in patient safety. Join 800+ peers this September to explore how the NHS can deliver safer care amid system reform, workforce pressures and the government’s 10-year plan.
Across two days, 12 content streams and 150 expert speakers, you will discover practical strategies to reduce avoidable harm, improve quality of care and embed modern safety approaches across the system.
Download the programme to discover the streams and topics that have been confirmed so far.
Early Bird tickets are now available, saving up to £70 per ticket. Book now.
For group bookings (three or more tickets) or further information, please contact James Elliott on +44 (0)20 7490 0049 or email James.Elliott@hsj.co.uk.
That’s all for this edition. Thanks for reading, and please look for the next edition of the Patient Safety Watch newsletter from James in a fortnight’s time.
Jeremy
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