Patient Safety Watch: Maternity safety reflections surface familiar concerns

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter – the first of 2026. It’s been a whole month since our last newsletter, so with plenty to cover, let’s get stuck in.

Maternity safety: interim reflections, familiar concerns

Maternity news has not been in short supply since our last newsletter. Just before Christmas, Baroness Valerie Amos published her Reflections and Initial Impressions from the Independent Investigation into Maternity and Neonatal Services in England.

For those following patient safety, little in the interim report will come as a surprise. Families continue to describe poor communication, failures to listen, lack of compassion following harm or loss, and persistent inequalities in care. Most troubling is that these issues remain deeply entrenched, despite hundreds of recommendations made over the past decade.

Baroness Amos said she was unprepared for the scale of the problems – none of us were, it has to be said – but her reflections reinforce that the challenges facing maternity services are systemic, not isolated to poor practice in a handful of troubled units. The question is, what structural changes can actually turn things around?

For my money, universal continuity of care would make a huge difference: one clinician responsible for every mother from the moment she knows she is pregnant. The all-party parliamentary group for patient safety (APPG), which I chair, will be submitting evidence to the Amos Review and is hosting a roundtable meeting next week with system leaders, experts and families to help shape that submission, which we plan to publish later this month.

Maternity services to report daily pressures to NHSE

Sticking with maternity safety, as reported by HSJ, NHS England has instructed maternity services to submit daily reports on operational pressures, including staffing gaps, bed capacity, acuity and escalation of concerns. This reflects the level of concern about maternity services’ fragility. But is more micro-management the answer?

In other news this edition…

Rogue surgeon at Great Ormond Street

The Sunday Times has reported that between 85 and 100 children suffered harm after being treated by Great Ormond Street Hospital for Children Foundation Trust surgeon Yaser Jabbar. One child underwent leg amputation, while others have been left with lifelong deformities and chronic pain. It’s just horrific.

The trust is expected to present its independent review’s full findings to its board on 29 January, more than two years after the surgeon was first suspended. Chelsea and Westminster Hospital FT, where Mr Jabbar worked before GOSH, has carried out its own review.

Patient safety risks from temporary care environments 

A new Health Services Safety Investigation Body report warns that “corridor care” poses significant risks to patients and is causing moral injury to staff. The investigation highlights temporary care environments’ widespread and routine use across the NHS, making clear it is no longer the result of seasonal pressure but a persistent feature of care delivery driven by capacity and patient flow challenges.

The report sets out key safety concerns associated with these environments, including reduced patient monitoring, delayed escalation of care and challenges maintaining dignity and infection control, and emphasises the need for longer-term system solutions to eliminate temporary care environment use altogether. The report also highlights practical steps some trusts are taking to reduce risks in the meantime, including clearer governance, risk assessments and improved oversight when such spaces are used.

Epidural drug shortage may continue until March

BBC News has reported that a national shortage of epidural medications is expected to last until at least March, affecting access to pain relief during labour. Clinicians are being asked to prioritise use for those with the greatest clinical need, while women are warned they may not be able to access epidurals when requested.

This is a totally unacceptable situation. We must rapidly reduce the medicines supply chain’s fragility and ensure this cannot happen again.

GPs to receive new tools to support domestic abuse victims

As reported by Pulse Today, the government is rolling out a domestic abuse referral service across GP practices, giving clinicians improved tools and pathways to identify and support people experiencing abuse. The really welcome initiative aims to strengthen early intervention, improve safeguarding, and reduce reliance on patients disclosing harm unaided. 

Chickenpox (varicella) vaccine introduced on the NHS

The NHS has begun rolling out the routine chickenpox vaccination for children, a major shift in UK immunisation policy. The move is expected to significantly reduce infections, complications, hospital admissions and transmission to vulnerable groups, including newborns and immunocompromised patients – an important preventative patient safety intervention with long-term population health benefits.

And some more positive news for the New Year….

NHSE has published a new Maternal Care Bundle, setting out national standards to reduce avoidable maternal deaths and serious harm. The bundle focuses on five high-risk areas where variation in care has been linked to poor outcomes:

• venous thromboembolism;
• pre-hospital and acute care for unwell pregnant women;
• epilepsy in pregnancy;
• maternal mental health; and
• obstetric haemorrhage.

It emphasises early risk identification, timely escalation, multidisciplinary working and tackling inequalities in outcomes. All maternity providers are expected to implement the bundle in full by March 2027, supported by national tools and measures.

A huge amount of work will have gone into producing this bundle, which I am sure will help save lives. Sincere thanks to everyone involved.

Free webinar series

The patient safety training organisation Medled is offering a free webinar series through 2026. These monthly one-hour sessions will cover various topics central to patient safety, such as human factors, the Patient Safety Incident Response Framework, and clinical leadership. They will be led by experienced trainers, and designed to support reflection, discussion and shared learning.

Booking is live now for the first three webinars, with further dates to be published soon. 

Tim Draycott’s legacy

We were all totally shocked and saddened to learn of Tim Draycott’s sudden and unexpected passing. The last newsletter from James paid tribute to Tim, but I wanted to add my own. He really was a giant in maternity safety, combining intellectual rigour with unbridled enthusiasm. His PROMPT training package must have saved thousands of lives.

In Tim’s memory, colleagues at THIS Institute, at Cambridge University, have established the Tim Draycott Scholarship Fund, with the support of Tim’s family. The fund will support future researchers to continue the work Tim championed: generating evidence that leads directly to safer, fairer, higher-quality care, particularly in maternity and women’s health. You can read more about the fund and donate here.

And finally, at the end of January, in partnership with Imperial College London, Patient Safety Watch will publish our fourth major patient safety research report. This year’s report focuses on the global state of patient safety, how the UK compares internationally, and what lessons can be learned from progress made in other countries – a comprehensive update to our 2023 report.

The Patient Safety APPG also hits the ground running this year. On 29 January, we are hosting a major Patient Safety Symposium in Westminster, bringing together Parliamentarians, patient safety experts, system leaders, clinical staff, patients and families to focus on key patient safety issues and solutions. The event is invitation-only, but a very small number of places remain available. If you are interested in attending, please contact the APPG secretariat at patientsafetyAPPG@avma.org.uk.

Thanks for reading, and wishing everyone all the best for the New Year!

Jeremy