Up early for a day of delivering PSIRF engagement training in Lancaster with Morecambe Bay teams…

A evening ride out to #Coniston - haven’t seen it this full for a while!

Top marks form the girls for today’s effort :-) #sundayroast

Operation Anzu has seen hundreds of families sent letters by the NHS asking them to contact Staffordshire police, after a trawl of thousands of records for patients seen by this doctor:

Agree, this is really significant and hugely welcome step forward.

One of the best things in the Hillsborough Law Bill is not the duty of candour on public officials, as welcome as that is, but news that bereaved families will have publicly funded legal representation at inquests. Finally an equality of arms that's been lacking for so long

A lovely time at the Lantern Festival in Ulverston with my daughter this evening - and the rain didn’t spoil the fireworks at all 😊

A wet and grey day in Cumbria - daughter is back from Uni for the weekend so cooking a roast and lighting a fire :-)

Enjoyed speaking with Liz and Darren from RLDatix at the HSJ Patient Safety Congress this week about maternity safety and the newly announced Amos investigation ⬇️⬇️⬇️⬇️ youtu.be/R_dW1uJ1aYQ

Good to see East Kent (and Yeovil!) among others on this list of Trusts to be reviewed by Baroness Amos & her team. I'll be discussing maternity care with @dockendenltd.bsky.social, @shaunlintern.bsky.social & @jamestitcombe.bsky.social at the @hsj.co.uk Congress tmw. www.bbc.co.uk/news/article...

A fun day with my daughter yesterday :-)

Around Joshua’s birthday is always a difficult time of year for me - so this year I’m doing something a bit different to raise money for @babylifeline.bsky.social Hugely grateful for the support & kindness already shown 🙏 #RememberingJoshua www.nwemail.co.uk/news/2545829...

This October, I’m riding solo by motorbike from Ho Chi Minh City to Hanoi - nearly 2,000km - in memory of Joshua & to raise funds for the brilliant charity @babylifeline who do amazing work to support safer maternity care. www.gofundme.com/f/vietnam-so...

Sir Keir Starmer’s plan to overhaul the NHS has been thrown into chaos after no money has been set aside to cover the costs of making thousands of redundancies at ICBs www.thetimes.com/article/14b7...

#kefalonia day 6

#Asos #Kefalonia

Enjoying a lovely week away in Kefalonia with my youngest daughter :-)

Overdue and urgently needed. The overriding message must be clear: If you make a mistake, be open & learn from it - but if you choose to cover up, suppress concerns or knowingly put safety at risk - look for a job outside the NHS.

It's served :-)

Some thoughts on the recent maternity announcements from @rthonwesstreeting.bsky.social patientsafetyfirst.wordpress.com/2025/07/11/a...

She will roll back many changes made since the Mid Staffs scandal, returning power to managers & DHSC Challenged she was giving back control to bodies numerous inquiries had shown had failed, she said: “No, I'm giving back the accountability to them". Right? Or dangerously naive?

It’s been a tough morning - the coffee machine ran out of beans….. but I got through and all is well again now.

A week to go before @hugh-willmott.bsky.social's third season of excavations at #cerneabbey! Here's an @timeteam.bsky.social reminder of what a gloriously evocative site it is. www.youtube.com/watch?v=ctpR...

Talk of Just Culture Without System Change Is a False Promise patientsafetyfirst.wordpress.com/2025/05/16/w...

Take part today 👉 bit.ly/4knzexP

“Nobody designed today’s NHS landscape; it evolved over many years of successive governments with new initiatives, often in response to past inquiries and scandals. While often well intentioned, this patchwork has created unnecessary complexity…” www.hsj.co.uk/patient-safe...

🩺 Helped improve inpatient care in the NHS? We want to hear from you! Share your experiences with @patientsafetywatch.bsky.social via a short survey to help build a shared library of what works. 🗣️ @jamestitcombe.bsky.social 📅 Closes 3 Aug 📄 CPD certificate available Take part using the link 👇

Lovely afternoon mountain biking :-)

A raining afternoon - drinking coffee and reading a book I probably should have read along time ago....

11 children died from whopping cough last year and there were more measles cases than any year back to 2012.

A little self-promotion: it’s nearly 10 years since Joshua’s Story was published. I wish it had become outdated—but sadly, the cultural issues it exposes are still relevant to healthcare today. If you haven’t read it, please consider. It’s available on Amazon and other retailers.

Lovely light on my evening bike ride - looking out over Pennington reservoir towards the Isle of Man

“There’s a dangerous contradiction in current policy. We claim to prioritise maternity safety, yet fail to provide the resources to make real progress.” inews.co.uk/news/health/...

UK maternity services face serious challenges in addressing the persistent health inequalities that directly undermine quality of care. Our report calls for urgent action and support to achieve equitable, safe maternity care. Read our report 👉 nhsproviders.org/resources/bo...

“The cost of harm in maternity services is now around £4 billion a year — that’s £126 every second. Just a fraction of that, invested upfront in safer care, could deliver transformational improvements”

Talk of Just Culture Without System Change is a False Promise patientsafetyfirst.wordpress.com/2025/05/16/w...

NHS England launched a new ‘Being Fair’ tool last week, replacing the previous ‘Just Culture’ guidance. Some thoughts from me as to why efforts to foster a just culture in healthcare organisations will fall short without tackling the wider system. patientsafetyfirst.wordpress.com/2025/05/16/w...

"The fact that government has set aside tens of billions of pounds for clinical negligence payments, its second most costly liability after some of the world’s most complex nuclear decommissioning projects, should give our entire society pause..." t.co/u3SyXjoaRN

A glorious evening for another mountain bike ride :-)

A lovely late evening bike ride with my daughter :-)

NHS chief Sir Jim Mackey delivers candid message at MJA annual lecture Read our story and key extracts from the night: mjauk.org/2025/05/09/n...

Swinging a ‘wrecking ball’ through safety work Our latest #patientsafety newsletter from @jamestitcombe.bsky.social is now available via @HSJnews here:- www.hsj.co.uk/patient-safe...

It’s gonna be a sunny one today…. Happy Friday folks 😊 ☀️

Some positive news (for once) with today's MBBRACE report showing that UK perinatal mortality rates fell in 2023. So much more to do, but the progress since 2013 shows that national efforts to prevent tragedies like Joshua's death - haven't been in vain. 🙏 timms.le.ac.uk/mbrrace-uk-p...

We’ve got a varied line-up of speakers at our webinar next week, where we’ll discuss our series of patient safety investigations looking at mental health inpatient care. Register now for the last remaining places: events.teams.microsoft.com/event/805b88... #HSSIBWebinar #MentalHealth #NHS

#patientsafety folks, if you know of any good work (papers, blogs, events, podcasts etc...) that I can help share in Friday's HSJ/Patient Safefy Watch newsletter - please send my way - [email protected] 🙏

Back in Cumbria after a good couple of days working in Brighton and visiting my daughter in Oxford. 🙂

Find out more about the work we presented at the Ergonomics and Human Factors 2025 conference: www.hssib.org.uk/news-events-... #EHF2025

Some of the incidents reported to NHSE by A&E doctors after patients turned up following private cataract surgery: