Patient Safety Watch: Why HSSIB is too important to lose

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter. It’s been another busy period for patient safety news, so let’s get stuck in.

MPs raise concerns over plans to abolish HSSIB

During the second reading debate on the Health Bill on Monday, MPs from across the House raised serious concerns about the government’s proposal to abolish the Health Services Safety Investigations Body (HSSIB) and transfer its functions to the Care Quality Commission (CQC).

Sir Bernard Jenkin MP called the plans a “dreadful mistake”, arguing that HSSIB is the only healthcare body able to conduct investigations independent of regulation and enforcement.

My view? The proposal to abolish HSSIB is one of the most worrying aspects of the Health Bill. HSSIB was born from tragic failures and avoidable loss of life to help healthcare learn through independent, system-focused investigations. Its independence is not optional; it is fundamental to its effectiveness and to the confidence that patients, families, and healthcare staff place in its work.

While the government argues that transferring HSSIB’s functions to the CQC will strengthen the link between learning and action, regulation and safety investigation serve different purposes.

As Carl Macrae argues in this paper, healthcare is now at risk of losing its capacity for system-wide safety investigation at precisely the time it is needed most.

Independent investigation bodies are now recognised as a core part of safety infrastructure in other safety-critical sectors such as aviation and rail, and HSSIB has helped establish healthcare as part of that international movement. It would be a tragic setback for patient safety if that progress were allowed to be undone.

In other news this fortnight….

Oxford maternity services rated ‘good’ despite safety concerns

The CQC has rated Oxford University Hospitals’ maternity services as “good” overall, despite identifying several safety concerns at the John Radcliffe Hospital and rating the service “requires improvement” for safety.

As HSJ reported, inspectors found inadequate staffing levels, unsafe working hours, and reported instances of midwives working back-to-back shifts without sleep breaks. The inspection also identified breaches of several of the CQC’s fundamental standards.

Oxford is one of 12 trusts being examined as part of the National Maternity and Neonatal Investigation (NMNI), now expected to publish at the end of June.

The report has prompted campaigners to question how a service rated “requires improvement” for safety can still be rated “good” overall – in my view, a very valid point that the CQC should carefully consider.

Government rejects mass prostate cancer screening

The government has accepted the UK National Screening Committee’s advice not to introduce a national prostate cancer screening programme for most men. Instead, routine screening will be offered only to a small group of men with specific genetic mutations and a family history of cancer.

Health and social care secretary James Murray said the decision follows the evidence and aims to avoid causing harm through overdiagnosis and unnecessary treatment.

The decision has prompted criticism from some campaigners and several high-profile figures, including former prime minister David Cameron, who described the decision as a “missed opportunity”.

In response to concerns about inequalities, the government announced a £20m expansion of the Transform prostate cancer trial, which will invite thousands more Black men to participate in research aimed at improving early detection.

The Sunday Times provided a thoughtful analysis of the debate, publishing opposing viewpoints from NSC chair Professor Sir Mike Richards and prostate cancer survivor Nick Jones.

HSSIB highlights risks linked to e-prescribing 

HSSIB has published a report examining the safety of electronic prescribing and medicines administration (ePMA) systems, which are widely used across NHS hospitals.

While ePMA systems can help to reduce medication errors, HSSIB found significant variation in how systems are designed, procured, and assured, with no national framework setting out core patient safety requirements. The investigation identified concerns that trusts are often required to assess complex digital safety issues themselves, despite varying levels of expertise and resources, and that important safety learning is not consistently captured or shared across the NHS.

The report makes five recommendations to national bodies, including developing a national ePMA safety framework, stronger assurance processes, greater support for trusts, and clearer guidance on when ePMA software should be regulated as a medical device.

Important work from HSSIB, which continues to show its value in driving system-wide learning.

NMC faces fresh criticism after 12-year checking failure

As first reported by The Guardian, the Nursing and Midwifery Council (NMC) has admitted a “completely and utterly unacceptable” failure to properly assess health and character declarations from applicants over a 12-year period.

A review of more than 18,000 applications found more than 400 registrants require reassessment, with around 15 cases potentially leading to removal from the register. The Royal College of Nursing warned that the failure may have created patient safety risks.

For me, this strongly echoes the Professional Standards Authority’s review of the NMC’s handling of the Morecambe Bay maternity cases, which, during a similar time period, identified serious failures in how concerns were investigated and acted upon.

While the NMC says it is undertaking a major transformation programme under new leadership, the latest findings will raise further questions about its ability to consistently fulfil its core responsibility of protecting the public.

Lab error leads to unnecessary cancer investigations for more than 1,300 patients

As reported by HSJ, a processing error at South West London Pathology resulted in more than 4,200 incorrect bowel cancer screening test results being issued between December 2025 and March 2026.

The error affected faecal immunochemical tests (FITs), which are used to help identify patients who may require further investigation for bowel cancer. Results were reported as around five times higher than they should have been after a unit conversion process was not applied correctly.

As a result, up to 1,326 patients may have been unnecessarily referred to urgent suspected cancer pathways and undergone invasive investigations such as colonoscopy or CT colonography. No cancers are believed to have been missed because of the error.

A harm review involving 17 organisations is now underway, with findings expected later this year.

Research links empathy with safer care and better staff wellbeing

As reported by The Guardian, new research suggests NHS trusts with more empathetic organisational cultures achieve better outcomes for patients and staff.

Trusts with higher “empathy scores” were more likely to receive “good” or “outstanding” CQC ratings for patient safety and effectiveness. They also reported lower staff burnout and sickness absence, and spent less on agency staff and consultants.

Patients call for stronger oversight of AI scribes in the NHS

A new report based on discussions with members of the public found broad support for AI scribes’ usage in healthcare, recognising their potential to reduce administrative burden and give clinicians more time with patients.

However, participants stressed that patient safety must remain paramount. Key concerns included accuracy, data security, staff training, and accountability for errors.

A central finding was the need for national oversight, with participants calling for independent assurance that AI scribes are safe, accurate, and used appropriately.

Sharing some good stuff…

That’s nearly all for this edition, but before signing off, some upcoming events and useful publications that readers may find of interest.

SafetyNet webinar: Tackling inequalities in surgical safety

SafetyNet is hosting a webinar on 24 June (12:30–1:30pm) exploring how to reduce harm from surgery among people living in more deprived communities.

NHS England’s national clinical director for critical and perioperative care, Ramani Moonesinghe, will discuss the NIHR-funded HIPPOCRATES research programme, which is developing and testing interventions to reduce health inequalities and improve surgical outcomes.

New research on birth expectations and maternal wellbeing

A recently published study by Rebecca Matthews and colleagues explores the impact of unmet birth expectations on maternal wellbeing. Through interviews with first-time mothers, the researchers found that women whose births differed from their expectations often experienced feelings of failure, shame, and self-blame.

The authors argue that cultural narratives which present certain types of birth as the “gold standard” can contribute to psychological harm when birth does not go as planned.

An important and timely study with the NMNI report expected later this month.

How should healthcare organisations respond when patients are harmed?

A review published in the Journal of Patient Safety and Risk Management examined the evidence for Communication and Resolution Programmes (CRPs) – structured approaches that combine open communication with patients and families, incident investigation, learning and improvement, apology, and, where appropriate, compensation.

Reviewing nine studies, the authors found that robust CRPs were associated with fewer malpractice claims and lower legal defence costs, with no evidence that they increased litigation or overall organisational costs.

A final reflection to end on. When things go wrong in healthcare and patients and their families suffer harm, healthcare organisations have an important choice to make. They can respond in ways that invariably compound the harm already suffered, or in ways that aid healing, enable resolution and maximise learning. This paper shows the benefits of the latter approach. The Harmed Patient Pathway project offers some invaluable guidance to healthcare organisations wishing to put systems and processes in place that will help get this right – please have a look.

That’s all for now. Thanks for reading, and look out for the next edition of the Patient Safety Watch newsletter from Jeremy in a fortnight.

James