Patient Safety Watch: The good, the moving-the-deck-chairs, and the positively bad

Good afternoon, and welcome to the first Patient Safety Watch newsletter after the summer break – this time from me, Jeremy. Lots going on in both Parliament and across the NHS, so let’s get started.

The Health Bill: a missed opportunity

On Tuesday, the Health Bill completed its Commons stages, and I think there is a sense of disappointment that so little was ultimately changed to improve patient safety. It contains some good stuff, including the single patient record; some moving-the-deck-chairs stuff, notably abolishing NHS England; and some positively bad stuff, particularly moving the Health Services Safety Investigations Body to the Care Quality Commission.

I tabled or supported several amendments, including proposals to: set up a system for tracking patient safety recommendations so that findings from inquiries, investigations, and reviews are not lost; prevent lawyers acting for hospitals from wrongly advising trusts not to observe the duty of candour; and restore continuity of care by bringing back the GP list system. I got a chance to speak on continuity of care, which got widespread support.

But the biggest blow was the government’s refusal to drop the clause moving HSSIB to the CQC. Many of us are struggling to understand why this is happening. It won’t save money, but it will create a conflict of interest both for the CQC and NHS staff.

As a regulator, the CQC is legally obliged to act on information when trusts are failing in their statutory duties. But will NHS staff want to speak out if the consequences could lead to enforcement action or even the closure of their unit? The bill still has to go through the Lords, so we haven’t given up hope. But what a shame to do this to an organisation finally beginning to show its worth.

National clinical audits being neutered

Shaun Lintern is respected as the national journalist who probably understands patient safety better than any other. So his report in the Sunday Times about NHSE restrictions on national clinical audits was a real concern. In particular, recommendations are now being limited and authors restricted from speaking to the press. Marian Knight, who leads the MBRRACE work on maternal and baby deaths, said the restrictions meant her team’s recommendations on improving midwifery education and training had been watered down. Surely the lesson of Mid Staffs is that we need more openness and transparency, not less?

Prime minister acknowledges ‘structural difficulties’ in maternity services

This week, the prime minister referred to “structural difficulties” in NHS maternity services. This followed North Devon District Hospital suspending births because of staffing shortages. As HSJ reported, some women locally have faced journeys of up to two hours while in labour to reach alternative maternity services.

But with the number of midwives per birth up nearly 40 per cent, isn’t it time to recognise that maternity care’s problems extend beyond staffing? One example is the normal birth ideology’s insidious persistence despite all the evidence of its dangers. This reached a critical point in July, when the highly respected Bill Kirkup resigned from the Amos review after comments on the issue were watered down, despite clear evidence that it remains a problem. I wrote to James Murray, then health secretary, about it. I hope to get a response from his successor and will certainly be raising it in the House of Commons.

Maternal mortality 20 per cent higher than in 2009–11

And the latest MBRRACE-UK report highlights why further progress is urgently needed.

Between 2022 and 2024, 252 women died during pregnancy or within six weeks of its end – a maternal mortality rate of 12.8 per 100,000, 20 per cent higher than it was in 2009-11.

Profound inequalities persist, and only 16 per cent of the women whose care was examined in depth were judged to have received good care. In 61 per cent of cases, reviewers concluded that improvements might have altered the outcome.

The report identifies recurring failures, including confirmation bias, dismissal of red-flag symptoms, incomplete observations, missed deterioration, delayed escalation and failures to listen to women. Workforce pressures, insufficient theatre capacity and fragmented multidisciplinary care also affected outcomes.

In other patient safety news…

Safety watchdog urges pause in NHS ‘advice and guidance’ expansion

A recent HSSIB report underlined independent patient safety investigations’ value.

As HSJ reported, HSSIB has urged NHSE and the Department of Health and Social Care to assess the safety of the expanding “advice and guidance” system before any further rollout. The policy encourages GPs to seek specialist advice before – and sometimes instead of – referring patients to hospital to bring down waiting lists.

HSSIB found examples of the system working well, but also evidence that poorly designed or monitored schemes can lead to delayed or missed diagnoses, including cancer. NHSE and DHSC won’t have liked what HSSIB said – but isn’t that precisely why it matters that our investigations body is independent?

Northern Care Alliance receives further CQC warning on patient safety

Northern Care Alliance Foundation Trust has received a further section 29A warning notice from the CQC, after inspectors identified “significant concerns” about leadership, risk management, patient safety, complaints, speaking-up processes, and staff wellbeing. As reported in The Independent, the notice follows earlier action from both CQC and NHSE.

The warning comes amid continuing concerns from whistleblowers across the trust, including allegations of unsafe theatre staffing and reports of inexperienced nurses working without adequate support. One staff member told The Independent  they “wouldn’t want a family member operated on” at the trust. The trust is also facing an independent external review of gynaecology surgery.

AI scribes introducing errors into medical records

Healthwatch England has warned about the rapid rollout of AI “scribes”, which automatically transcribe and summarise patient consultations. As reported in The Guardian, Healthwatch research found patients spotted mistakes in AI transcriptions that clinicians missed, including incorrect diagnoses and confusion between similarly named medicines. In one case, a patient was wrongly recorded as having demyelination – a possible indicator of multiple sclerosis – when her MRI showed no such evidence.

I have slightly mixed feelings on this because I am a huge fan of AI innovation and the £3.4bn I allocated to NHS technology in my last budget may even be funding AI scribes. But trust in new IT systems can evaporate quickly, so this problem needs to be sorted rapidly.

On to a few positives…

New course: Implementing Martha’s Rule in maternity services

Baby Lifeline has launched a new course on implementing Martha’s Rule in maternity services.

Maternity investigations have repeatedly shown the devastating consequences when women and families are not listened to, deterioration is missed, or concerns are not escalated. Martha’s Rule has the potential to help change this, but successful implementation will require more than simply introducing a new escalation process.

The course examines the practical foundations needed to make Martha’s Rule work in maternity settings, drawing on learning from early-adopter organisations and using realistic maternity scenarios to explore how the rule can operate in practice.

The first open course takes place online on 17 November 2026.

Find out more and book here⁠

World Patient Safety Day – 17 September

That’s just about all for this edition, but before signing off, a quick reminder that World Patient Safety Day takes place next week, on 17 September. One of my proudest achievements – as foreign secretary, not health secretary, as it happens – was to organise a vote at the World Health Assembly to get it established.

This year’s theme is “safe care for noncommunicable diseases”, with the slogan: “Safe care for life!” It highlights the particular safety challenges faced by people living with long-term conditions, who often receive care from multiple professionals and organisations over many years.

The World Health Organisation is calling for stronger primary care systems, safer diagnosis and medication practices, and greater involvement of people with lived experience in designing and delivering care. 

That’s all for now. Please look out for the next edition of the Patient Safety Watch newsletter from James in a fortnight.

Jeremy