Patient Safety Watch: Some progress but blame culture still persists

Good afternoon and welcome to the latest edition of the Patient Safety Watch newsletter, brought to you this time by Jeremy.

Baby Loss Awareness Week

This week is Baby Loss Awareness Week – a time to remember every family who has faced the unimaginable heartbreak of losing a baby. It is also, for me, a moment to reflect honestly on what we have achieved – and what we have not – in the long fight to make maternity care safer.

There has been progress. In the last decade, baby deaths in England have fallen by 20 per cent, meaning two fewer babies die every single day. However, despite the greater transparency we now have about NHS failings, a blame culture still persists.

According to the 2024 NHS Staff Survey, only 62 per cent of employees reported feeling safe to raise concerns. Other countries have shown us a better way: if our outcomes matched Japan’s, we would save almost two more babies every day.

To get there, we must confront the structural barriers that hold us back, starting with a litigation system that is both adversarial and counterproductive, costing £4bn annually, roughly the same as running every NHS maternity unit in England. Reform is essential if we are serious about learning and prevention. I’ve shared more of my thoughts in this article.

On Monday, I’ll be speaking in this Parliamentary debate on baby loss, in what will no doubt be a very powerful and emotional occasion. For anyone affected, some helpful resources and support links are available here.

In other patient safety news…

A new Royal College of GPs poll shows nearly three-quarters of GPs believe current workload levels are threatening patient safety, with many saying they no longer have the time needed to properly assess patients or build the relationships that are essential to safe care. When clinicians feel they are rushing, patients feel it too, and corners inevitably get cut, even by the most dedicated professionals.

The college’s survey also found significant concern among GPs over the new neighbourhood health services proposed in the 10-Year Health Plan, with 68 per cent of respondents reporting worries over the lack of GPs to effectively deliver them, and the impact introducing neighbourhood health services would have on GP workload.

Hospital missed woman’s cancer after scanning wrong patient

As reported by the BBC, a coroner has criticised an NHS trust after a woman’s cancer went undiagnosed when radiology staff scanned the wrong patient and filed the result under an incorrect record. The error led to a significant delay in diagnosis and, according to the coroner, exposed systemic failings in identity checks, record keeping and follow-up of scan results.

The case highlights ongoing risks around wrong-patient errors in diagnostics and reinforces the need for strict verification and safety barriers in imaging departments. But for me, this case poses a different question: does anyone actually listen to what coroners say, including countless Prevention of Future Deaths notices? We urgently need a system that logs recommendations made, decides whether they need to be implemented across the NHS and makes sure someone is accountable if they are. Step forward Wes Streeting’s reinvigorated National Quality Board…

BMA warns of safety risks in new GP access plans

The British Medical Association has warned that government plans to allow patients unlimited online GP appointment requests could lead to safety risks. GP leaders said the move could overwhelm practices and undermine triage systems that help prioritise urgent care.

The BMA asked Mr Streeting to pause the rollout, saying the current model risks missed diagnoses and patient harm through unmanageable demand. But is pausing the digital transition we all want the right approach? Wouldn’t we be better off allowing the new system to bed down and then adapting it as necessary, as happens with all innovation?

CQC finds safety concerns at new A&E

Fascinating evidence that new buildings do not automatically lead to safer care, as countless private finance initiative projects across the NHS also show. This time, the Care Quality Commission has warned the newly opened emergency department at Queen Alexandra Hospital, in Portsmouth, requires improvements to meet safety standards. The BBC reports that inspectors raised concerns about staffing levels, patient flow, and timely response to deteriorating patients.

Procurement pilot puts patient safety at its core

Thirteen trusts are trialling a new procurement process that prioritises patient safety and long-term value over the lowest price. As reported by HSJ, the pilot aims to ensure that purchasing decisions reflect clinical outcomes, product reliability, and overall impact on patient care.

If successful, the approach could mark a major shift in how the NHS embeds safety into procurement, encouraging suppliers to demonstrate measurable safety benefits alongside cost savings. Sounds pretty smart.

Sharing some good stuff…

The Clinical Human Factors Group (CHFG) is running a series of sessions to enhance understanding of human factors. Each session includes an expert presentation, group discussion, Q&A, and an optional workplace assignment to apply your learning. You can book your place on any of the courses below here.

• What is Good HF? – Friday 14 November, 11.30am–1.00pm

  Charles Vincent, professor of psychology, Oxford University

• HF and Usability – Friday 21 November, 11.30am–1.00pm

  Lauren Morgan, director, Morgan Human Systems

• Patients in HF – Friday 28 November, 11.30am–1.00pm

  Tom Reader, associate professor of organisational psychology, London School of Economics

Must-read: After Martha by Paul Laity

Well worth a read is this powerful and heartbreaking piece. Paul Laity tells the story of Martha Mills, his 13-year-old daughter, who tragically died of septic shock following a series of missed warning signs and systemic failures at King’s College Hospital. Martha and her parents’ efforts have led to the introduction of Martha’s Rule, which is already saving lives in the NHS.

Reflections and learning from the National Maternity Safety Conference

If you missed the National Maternity Safety Conference, run by the brilliant charity Baby Lifeline, last month, this is a great summary of the day, including some of the key messages and learning.

I was there, and a real highlight for me was seeing the fabulous examples of safety and quality improvement projects on display in the poster competition. If you work in maternity services and are looking for inspiration from some great work being done elsewhere, please do take a look at the shortlisted projects here. A special mention to Ngawai Moss, Madeleine Benton and colleagues for the winning poster – A Co-Designed Health Literacy Programme for Pregnant Women Whose First Language is not English: A Pilot Study – which is really inspirational work addressing a hugely important issue for maternity safety.

That’s just about all for this edition. Our next edition will be a little later than usual, on 7 November, because James is biking from the south to the north of Vietnam for his forthcoming charitable trip! He is raising money for the wonderful Baby Lifeline, and there is still time to sponsor, so please do!

Jeremy Hunt