Patient Safety Watch: Recognising risk, listening to patients and acting early

Good morning and welcome to the latest edition of the Patient Safety Watch newsletter, this time from me, Jeremy. We start, as we so often do, with maternity news.

Home birth review highlights safety concerns

A new report on home births from Maternity and Newborn Safety Investigations (MNSI), the body I set up in 2017 to independently investigate serious maternity issues, has identified recurring safety concerns around risk assessment, fetal monitoring, escalation, transfer, and access to senior clinical support.

The investigation found that midwives sometimes lacked the experience needed to recognise emerging risks and manage emergencies. It also found cases where warning signs were normalised, fetal heart abnormalities or bleeding were not acted on promptly, monitoring was incomplete, and transfer to hospital was delayed.

Most worryingly, midwives said that there was sometimes a focus on supporting a “desire for a physiological birth and avoiding interventions” – exactly the pressure for so-called “normal births” that should be avoided above all for home births. Let’s hope Yvette Cooper notices.

East Kent stillbirth review finds further failures

East Kent Hospitals has published an independent review of 11 stillbirths between June 2025 and March 2026. Unfortunately, issues remain at the troubled trust – deficiencies in care likely affected the outcome in four cases and may have contributed to another four. The review identified concerns around the management of high-risk pregnancies, fetal surveillance, triage, and escalation.

In its published statement, the trust said: “It is clear that, sadly, we have failed families. We are truly sorry.” It said it is implementing the recommendations, including improvements to continuity of care, training, and access to interpreters.

Leeds investigation terms of reference published

The Department of Health and Social Care has published the terms of reference for the Leeds maternity and neonatal review, led by Donna Ockenden. The investigation will examine severe harm and deaths linked to care between January 2011 and March 2028. Clinical case reviews are due to begin in November, with the final report expected by 31 March 2029.

The terms of reference require the review to consider failures to escalate or refer concerns, including issues relating – once again – to the “prioritisation of normal birth”. As previously reported by The Sunday Times, Leeds Teaching Hospitals’ 2015 maternity strategy called for services to “actively promote normal birth, with minimal medical interventions” and that “all birth environments should share this philosophy”.

Fiona Winser-Ramm, whose daughter Aliona died in 2020 following serious neglect, told the newspaper that she and her partner were “convinced a normal birth ideology played a part in their daughter’s death”, adding: “The steer to continue with a vaginal birth at every opportunity was evident throughout my labour.”

Poppy’s Promise follows preventable baby death

The BBC reports⁠ how Katie and Neil Russell are working to improve care following their daughter Poppy’s preventable death at Princess Royal Hospital, Telford – another trust with a history of issues – in April 2021.

During pregnancy, Katie told midwives she had tokophobia and requested a caesarean, but says she was repeatedly told she “couldn’t just ask for a C-section”. Following induction, failures in monitoring meant signs of Poppy’s distress were missed. She was eventually delivered by emergency caesarean, but died from a hypoxic brain injury just 12 hours after birth. An inquest found she would have survived had she been delivered earlier.

Poppy’s Promise, now being rolled out to 8,000 staff, is based on four care principles:

• Compassion - showing kindness
• Acknowledgement - recognising a patient’s feelings
• Respect - valuing their opinion
• Empowerment - involving patients in their care

It’s a valuable initiative, but why should it be necessary to do this? Once again, I worry that structural flaws such as a target culture are undermining the compassion and patient-centred care everybody aspires to.

In other patient safety news…

New priorities for medicines and AI safety

Patient safety commissioner Henrietta Hughes has published her strategy for 2026–28, setting out three priorities: strengthening the safety and regulation of medicines and medical devices; helping patients make informed decisions; and advancing equity, justice and patient safety leadership.

The programme includes tougher safeguards around remote prescribing, better medicines information, stronger monitoring of medical devices, and ensuring AI is introduced safely and transparently. It also commits to improving consent and patient information, increasing transparency around payments and conflicts of interest, addressing inequalities in access to safe care, and continuing to press for redress for people harmed by historic healthcare failures.

Ms Hughes said: “Patients want healthcare that is safe, transparent and designed around their needs,” adding that “lives can be saved and harm prevented when working in partnership with patients.”

10 mental health trusts referred to regulator over monitoring consent

Ten mental health trusts have been referred to the Care Quality Commission following concerns about consent procedures for camera-based patient monitoring.

As reported by the BBC, NHS England told the Lampard Inquiry it had passed on findings from a review of digital monitoring systems.

Coroner warns of further deaths after patient killed on mental health ward

A coroner has warned East London Foundation Trust that further deaths could occur unless serious failings are addressed, following the killing of 34-year-old Hugo Flint Cahan by another patient at Newham Mental Health Centre in January 2023.

The BBC reports that staff were asleep or using their phones for prolonged periods, with failures to observe patients, falsified records, and delays in starting CPR. The inquest concluded that neglect contributed to Hugo’s death. The trust described the failings as wholly unacceptable and said it had undertaken a substantial improvement programme.

Trusts review unusually high rates of repeat breast cancer surgery

At least five trusts are reviewing their rates of repeat breast cancer surgery after a national audit identified levels significantly above the expected range, HSJ reports. Airedale, Buckinghamshire, Royal Berkshire, Blackpool, and Torbay and South Devon recorded rates more than five percentage points above their upper statistical limits, which account for differences in patient case mix.

Repeat surgery can be clinically appropriate, and the findings do not establish avoidable harm at these trusts. However, unusually high rates are an important safety signal for further review.

And onto some more positive items (there are some!)…

How can public inquiries restore dignity and trust?

A new study in Health Expectations examines a restorative approach to surgical mesh harm in New Zealand. It highlights how inquiry processes can compound harm when they overlook people’s experiences, emotions, and understanding of responsibility.

The research identifies three approaches that helped restore dignity, wellbeing, and trust: collaborative and adaptable design; opportunities for people to tell their stories in ways that uphold their dignity; and sensitivity to trauma. Developed with patients, families and community representatives, it offers valuable lessons for making public inquiries more humane and responsive to those affected.

‘Be careful’ is not a safety system

This powerful Substack piece by Peter Hambly is a highly recommended read. Peter recounts the tragic death of 12-year-old Richie William after vincristine was mistakenly injected into his spine.

Peter’s central argument deserves attention: safety measures should account for predictable human mistakes and, wherever possible, physically prevent them. For me, this raises a broader question about what we mean by “learning lessons”. Publishing an alert or reminding staff to take care is easy. Changing equipment, procurement, and working practices requires sustained action. In patient safety, the response can only truly be judged on how well it protects the next patient.

Have an idea to share on patient safety?

The Journal of Patient Safety and Risk Management welcomes ideas for papers, case studies, and articles that can help improve patient safety. Whether you have research findings, practical lessons, or a perspective to share, please get in touch with American Veterinary Medical Association associate editors Peter Walsh or James Titcombe to discuss a potential contribution.

That’s it, but worth mentioning that today is the first day of Baby Loss Awareness Week. All our thoughts are with all parents and families affected by the loss of a baby, including my co-writer James. I will be speaking in the Baby Loss Awareness Week debate on Monday in Parliament.

Thanks for reading. Next newsletter from James in a fortnight.

Jeremy