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. It’s been another busy two weeks for patient safety, and once again, maternity safety has been centre stage.

Urgent review of home birth services ordered

As HSJ reported, NHS England has told trusts to urgently review home birth services after a series of deaths, serious incidents and repeated coroners’ warnings about fragile provision and weak oversight.

The move follows the 2024 deaths of Jennifer Cahill and her baby, Agnes, after a home birth. A coroner identified failures by inexperienced midwives and highlighted the lack of national guidance on staffing, training and experience for home birth teams.

In a letter to trust and integrated care board CEOs, chief midwifery officer Kate Brintworth asked providers to review 24/7 availability of midwifery care, staff competence, senior clinical support, transfer planning, and risk assessment, and to report concerns to boards and NHSE regions.

Further HSJ analysis has highlighted recurrent coroners’ concerns since 2022, including missed fetal distress, inconsistent practice, and poor training.

My view?

Coroners have been raising concerns about the safety of home birth services for years. The fact that these issues are still emerging after serious harm and deaths is deeply concerning. Ms Brintworth’s intervention is a necessary step, which once again underlines how fragile the maternity system is. 

Parents’ confidence in maternity care remains fragile

New research from the National Childbirth Trust (NCT) has highlighted widespread concerns and a lack of support for women and families using maternity services.

A survey found 38 per cent of new parents feared for their baby’s safety during labour and birth, and nearly a quarter did not feel safe themselves. Around one in five reported poor communication, lack of informed consent, or not feeling listened to.

Among those currently pregnant, 56 per cent were concerned their chosen place of birth would be safe.

The NCT is calling for safe staffing, genuine choice, informed consent and guaranteed postnatal follow-up to restore safety, equity and trust in maternity care.

Coroner flags safety concerns over unregulated doulas

Sticking with maternity services, a coroner has raised concerns about the lack of regulation and clear guidance on doulas.

Matilda Pomfret-Thomas died aged 15 days from hypoxic ischaemic encephalopathy. The coroner warned that, during her home birth, escalation and hospital transfer did not occur in a timely way following early warning signs of fetal compromise.

A prevention of future deaths report noted that a doula being present created difficulties for midwives in communicating risk and building rapport. The coroner highlighted wider concerns that doulas are unregulated, may work beyond defined boundaries, and can influence clinical decisions without formal accountability.

The report has been sent to the Department of Health and Social Care, National Institute for Health and Care Excellence, and the Nursing and Midwifery Council, calling for consideration of clearer national guidance or regulation. Responses are due by 6 March 2026.

In other patient safety news…

CEO forced out after raising concerns about chair wins £1.4m settlement

Countess of Chester Hospital Foundation Trust has agreed a £1.4m settlement with former chief executive Susan Gilby after an employment tribunal found she was unfairly dismissed and subjected to whistleblowing detriment.

Dr Gilby was suspended in December 2022 after raising concerns about the behaviour of then chair Ian Haythornthwaite. The tribunal concluded she was removed through a coordinated campaign (“Project Countess”),  and that her concerns were not properly investigated. It also criticised the trust for deleting or losing relevant records and for inappropriately contacting the General Medical Council about her.

Corridor care continues to erode safety and morale

The Royal College of Nursing (RCN) has warned that corridor care is becoming normalised across the NHS, leaving nursing staff at risk of “losing all hope”.

New testimony from RCN members describes unsafe, undignified care, including patients left in chairs for days, resuscitation attempts in corridors, missed deterioration, and staff improvising to protect privacy during intimate procedures.

The RCN says corridor care is now spreading beyond emergency departments into acute assessment units, surgical, respiratory and elderly care wards.

The warning follows a report from the Health Services Safety Investigation Body highlighting the widespread and entrenched nature of corridor care, and new YouGov polling showing 18 per cent of UK adults have witnessed care in non-clinical spaces in the past six months.

RCN general secretary Nicola Ranger said there can be “no safe, dignified care” in corridors and called on ministers to publish promised data and set out a clear, funded plan.

Going backwards on patient safety?

Writing for HSJ, Ted Baker – former Care Quality Commission chief inspector of hospitals and current HSSIB chair – warns that the NHS risks sliding back into blame-focused, compliance-driven approaches to patient safety, despite recent progress towards systems-based learning.

Professor Baker also cautioned against blurring the relationship between safety and quality, arguing that safety must remain paramount: “Safety is not simply one domain of quality alongside experience or outcomes. It is the foundation on which all other dimensions depend.”

This is an important and timely commentary. As NHS reform accelerates following the Dash review, Professor Baker’s warning is clear: we must not allow patient safety to be diluted, reframed, or downgraded in the drive for broader system change.

National Maternity and Neonatal Investigation – call for evidence

The National Maternity and Neonatal Investigation, chaired by Baroness Amos, is asking women and families across England to share their experiences of maternity and neonatal care through a public call for evidence. The responses will inform the National Maternity and Neonatal Investigation’s findings and recommendations.

Two call for evidence surveys are available:

  • One for women and people who have been pregnant to share their own experiences of maternity and neonatal services.
  • One for other people to share their experiences supporting someone through pregnancy, which could include fathers, non-birthing partners, family members, friends, or other support people.

More information and links to make submissions here.

Sharing good stuff…

Baby Lifeline launches the National Maternity Safety Conference 2026

Baby Lifeline’s National Maternity Safety Conference is back! This year’s event will take place at the Hilton Metropole in Birmingham on Wednesday 16 September. Building on the six previous events’ success and popularity, this year’s conference will bring together NHS professionals, families, researchers and stakeholders to discuss the theme “Next Steps for Safer Care: From Insight to Implementation”.

This is an important year for maternity services. Read CEO Judy Ledger’s recent blog outlining why this conference comes at a pivotal moment.

That just about brings this edition of the newsletter to an end.

Before signing off, a quick mention that next week will be an important one for the Patient Safety Watch team. Our new report – the Global State of Patient Safety 2025, produced in partnership with the Institute for Global Health Innovation at Imperial College, London – is published on 29 January. Please look out for more news next week.

The 29th also sees a major patient safety conference taking place in Westminster, hosted by the All Party Parliamentary Group (APPG) for Patient Safety. I hope to see some of you there!

In the meantime, thanks for reading and stay safe.

James

Topics