Andrew Carson-Stevens

This article explores prison health, healthcare, and harm. The provision of healthcare in prisons is convoluted, as it combines practice and problems across a prison’s approach to care, custody, commissioning, purchasing, regime, and staffing, and requires an appreciation for the prisoner-patient group’s health and illness needs. At present, there are unmet physical and mental health needs in prisons, and concerning levels of healthcare-associated harm experienced by people residing in prison. People in prison are dying years before they should compared to their counterparts in the community as a result of these unmet needs. We describe the complexities of safely delivering healthcare in prison and the emergent harms when healthcare fails those in custody. This (ill)health and (in)justice landscape could be improved, and avoidable healthcare-associated harm should not occur. This article utilises our original qualitative prison data created with 55 prisoner-patients and prison staff interviewees to further understand avoidable healthcare-associated harm in prisons and to make recommendations for future prison healthcare. We evidence how the population experiences both acute and chronic healthcare needs which are not always recognised or supported; where acute care management takes precedence over long-term health conditions; and where security priorities take precedence over timely intervention for life-threatening issues. Hierarchies regarding care and neglect arise, and the principle that prison care should be equivalent to community care is rarely said to be achieved or even attempted. We find systemic failures across varied forms of healthcare, including a lack of emergency response, absent follow-up after hospital discharge, physical health being relatively neglected, unsupported mental illness, medication mismanagement, and issues at transition points (prison to prison, prison to community, and community to prison). Healthcare provision in prison is perceived to be negatively impacted by tensions amongst personnel and pervading security concerns, as well as by poor intra-prison communication. Healthcare responses could be typified as “too little, too late”; for example, appointment delays and cancellations causing avoidable harm. Staff report disillusionment, and prisoners describe disparaging responses from staff members; epistemic injustice is at play, whereby prisoners’ claims to pain or illness and medication need are enveloped in suspicion and risk concerns first and foremost. To align with this special issue, we end with suggestions for intra-prison healthcare improvement for the coming decade and beyond.

Background: Paediatric patient safety incidents remain a significant global concern, with parents often playing a crucial role in detecting and preventing harm. Despite international calls for family partnerships in healthcare, evidence on how to meaningfully engage parents as participants in improvement interventions or within their development is limited. Objective: To summarise and describe healthcare interventions that engage parents to improve key paediatric patient safety issues (relating to medication, communication, diagnosis and assessment, documentation, and administrative processes) and to explore the nature of parental engagement within the studies, including as research participants within the interventions themselves and/or the design and conduct of the study. Methods: In this scoping review five databases (Medline, EMBASE, CINAHL, Web of Science and Scopus) and grey literature were searched for studies published from 2000 to August 2025. Eligible studies (published in English) described interventions aimed at mitigating key patient safety issues and engaged parents within the intervention and/or the wider study design. Data were independently charted and synthesised narratively using the Patient and Family Engagement (PFE) framework and the International Association for Public Participation (IAP2) Spectrum. Results: 111 studies were included, predominantly from secondary care settings ( n = 89, 80%), conducting experimental study designs ( n = 43, 39%) or quality improvement projects ( n = 36, 32%). Communication and medication safety were the most frequently targeted areas ( n = 72, 65% and n = 55, 50%, respectively). Interventions were categorised into 17 groups, totalling 179 interventions, most commonly involving process standardisation ( n = 26/111, 23%) or parent‐targeted education ( n = 25/111, 23%). Outcome measures largely reported parent‐specific factors, such as their perception ( n = 38/111, 10%) or knowledge ( n = 21/111, 19%), with minimal evaluation of real‐world safety outcomes. Parental engagement within healthcare interventions was focused on Direct Care ( n = 108, 97.3%) and most commonly occurred through consultation‐based approaches ( n = 78, 70.3%). Parental engagement within research activities was primarily classified as Inform ( n = 66, 59.5%), suggesting limited involvement in research design, development, or delivery. Conclusion: Parental engagement is essential to improving paediatric patient safety, yet it remains limited, inconsistent, and often tokenistic. Greater partnership with parents is needed, both as contributors to research and as partners in the design and delivery of healthcare services and safety interventions. Embedding engagement within research and quality improvement, alongside standardised approaches to its evaluation and reporting, will be critical to achieving a more inclusive, human‐centred approach in which parental perspectives meaningfully shape safer paediatric care. Patient and public contribution: The parent patient and public involvement and engagement (PPPIE) contributor for this study met with the principal investigator on several occasions to review the findings and shape the interpretation of the results. They contributed to reviewing and editing the manuscript to improve clarity and accessibility.

Background: Patient safety learning systems operate primarily at the national level, yet the potential for international sharing of safety data and learning remains largely unrealised. Other safety-critical industries, including civil aviation, nuclear power, and rail, have developed international incident reporting and learning systems whose design principles may offer transferable insights for healthcare. Objective: To explore the views and experiences of safety-critical industry experts regarding the purpose, key functions and features, transferability, barriers, enablers, and incident priorities of a potential international patient safety learning system. Design: Qualitative phenomenological study using semi-structured key informant interviews analysed with the five-stage framework analysis method. Participants: Eleven international experts purposively sampled from safety-critical industries (healthcare, civil aviation, maritime, and railway) across six countries. Interviews were conducted by telephone or internet-based audio call between May and September 2019. Results: Seven themes were identified: (1) purpose of an international patient safety learning system; (2) key functions; (3) key features; (4) transferability of learning; (5) enablers; (6) barriers; and (7) patient safety incident types appropriate for international sharing. Rare and emerging event detection emerged as the most distinctive value of an international system, a capability that cannot be replicated at national level. Critical functions included robust feedback loops, multidisciplinary analytical capability, and actionable recommendations. Key barriers, including blame culture, inter-organisational mistrust, and cross-border privacy legislation, were each amplified at the international level relative to their national-level equivalents. Conclusions: This study provides the first cross-industry qualitative account of design requirements for an international healthcare patient safety learning system, highlighting transferable lessons from established industries alongside healthcare-specific challenges that require bespoke solutions.

Background: People in prison experience high rates of physical and mental health problems and although prison provides opportunities to improve health and wellbeing, they often experience worse health outcomes. This study aimed to explore the perspectives of staff and people in prison, considering their experiences of perceived avoidable healthcare-associated harm and the factors they felt influenced prevention of harm. Methods: Qualitative, semi-structured, interviews were conducted with 32 prison staff and commissioners and 23 people in prison across five prisons in England. Interviews were conducted between August 2022 and January 2024 and were analysed thematically. Results: Problems with access to timely and appropriate healthcare were commonly raised by participants in relation to issues around medication management and access to healthcare. Prison policies and practice were highlighted by participants as factors that influenced the prevention of harm; interviewees referred to the impact of staffing capacity and the skillsets of staff in terms of trauma and mental health, the impact this had on relationships between staff and people in prison, as well as challenges related to communication and coordination between teams within the prison. Conclusion: Experiences of perceived avoidable healthcare-associated harm in prisons centred on medication management issues and difficulties with accessing healthcare. Recruiting and retaining skilled staff and systems lacking communication and coordination were considered important factors influential to harm prevention. A systems-based approach is needed to improve patient safety considering how integration and communication can be improved but this is needed alongside improved health literacy and interventions to increase autonomy that are led by people in prison.

Background: Children are particularly vulnerable to healthcare-associated harm. Parents play a vital but under-recognised protective role in paediatric patient safety. Parent perceptions of and contributions to safety improvement efforts within hospital settings are well documented, but little is known about parent experiences and perspectives in primary care. Aim: To explore diverse parental perspectives on paediatric safety in primary care and identify target areas for improvement. Design and setting: This qualitative study in UK primary care was conducted through online ( n = 2) and in-person ( n = 2) workshops with parents, taking place between 24 June and 8 July 2024. Method: Workshops were structured around a descriptive analysis of paediatric patient safety incident reports in general practice. Parents discussed and reflected on their own experiences in relation to the findings. Transcripts and field notes were analysed thematically to identify key themes. Results: Parents ( n = 33) from varied backgrounds, including under-served communities, participated. Three major themes were identified: responsibility of care , highlighting perceived unclear roles between parents and healthcare teams; navigating the system , where parents described the need to ‘fight’ for care and the challenges of understanding healthcare processes; and communication and language , emphasising the difficulties of being heard, especially among ethnic minority parents and those lacking the confidence to speak up. Conclusion: Parent perspectives on paediatric safety in primary care have highlighted key areas for practices, researchers, and safety improvement teams to target system change and intervention development. Engaging parents as co-designers in these efforts could enhance trust, reduce risk, and improve safety outcomes for paediatric patients.

Background: Demand for community-based end-of-life care is rising globally, driven by ageing populations with increasingly complex needs. Community nurses have a central role in providing end-of-life care, yet the proportion of their time spent in supporting people in their final year of life remains unclear. Aims: To investigate how much of community nurses’ daily work involves caring for people in their last year of life, and the extent to which end-of-life care visits are cancelled, deferred or undertaken to unsatisfactory standards. Design: Anonymous online survey and multimethod analysis. Setting/participants: United Kingdom survey of community nurses, circulated via professional networks, social media and snowball sampling, between 28 April and 27 June 2025. Results: A total of 1,471 nurses responded. Most worked in community and district nursing services (78.6%, 1156/1471) or specialist palliative care services (11.8%, 174/1471). Community and district nurses spent 23.5% (median) of their last shift providing end-of-life care. Over one in ten respondents (11.6% (171/1471) reported deferring at least one end-of-life visit during their last shift. Specialist palliative nurses were twice as likely to defer visits compared to community and district nurses (OR=2.48, 95% CI: 1.63–3.72, p <0.001). Staff shortages, demand exceeding capacity, and other systematic barriers contributed to deferring visits. Conclusions: Community nurses play a vital role in end-of-life care, yet some of this important patient care is left undone or deferred. Investment in core and specialist nursing services, with efforts to enable and sustain this workforce, is urgently needed to meet globally growing demand for community-based end-of-life care. What is already known about the topic?: Demand for community end-of-life care is growing in many countries. Community nurses play a key role in end-of-life care, yet the volume and complexity of their daily work supporting people in the last year of life remains poorly understood. What this paper adds: Nurses working in community and district nursing services spent a median of 23.5% of their last clinical shift providing end-of-life care. Half (52%) of respondents who provided end-of-life care during their last shift reported delivering one or more aspects of this care below their professional satisfaction, due to workload and capacity issues. Over one in ten (11.6%) of nurses reported having deferred or cancelled end-of-life care visits on their last shift, significantly more specialist palliative care nurses (24%) than community and district nurses (10.4%). Implications for practice, theory or policy: Our findings reveal a notable proportion of deferred and cancelled end-of-life care visits and care not undertaken to nurses’ professional satisfaction. Sustained, intentional investment in core and specialist nursing services, together with improved system-wide integration, is needed to support this vital workforce. Further research is necessary to understand how community and district nurses and specialist palliative care nurses can most effectively prioritise end-of-life care within finite resources and competing demands.

Background: Despite widespread recognition that patient safety learning can transcend national boundaries, no international patient safety learning system (PSLS) currently exists. There is no expert consensus on the purpose, key requirements, or feasibility of such a system. Objective: To gain consensus from an international panel of healthcare experts regarding the key requirements and feasibility of a potential international PSLS, with or without an incident reporting function. Methods: A two-round modified online Delphi study was conducted with 21 international healthcare experts in patient safety and learning systems, representing all six continents. The study was informed by a prior systematic literature review and semi-structured key-informant interviews with safety-critical industry experts. Panellists rated statements on a 9-point Likert-like scale. Consensus was defined a priori as ≥70% agreement (ratings 7–9) with an interquartile range (IQR) ≤2.00. A post-hoc threshold of ≥80% was applied to identify the strongest areas of consensus. Results: Of 73 experts invited, 21 completed round one (29% response rate) and 15 completed round two (71% retention). Across two rounds, 103 statements were evaluated; consensus was achieved on 85 (83%) at the ≥80% threshold across all four domains: purposes (15/19 statements); key functions and features (17/22); patient safety incidents and criteria for international concern (19/24 combined); and enablers and challenges (34/38). The panel endorsed a proposed framework for an international PSLS and generated novel consensus-based lists of patient safety incidents and criteria for determining what should be shared internationally. Conclusions: International healthcare experts broadly agree on the purposes, key functions, and feasibility of an international PSLS. The consensus-derived framework provides a foundation for future feasibility research and potential pilot implementation. Validation with frontline end-users is an essential next step. KEY MESSAGES: What is already known on this topic: National patient safety learning systems vary considerably in design, governance, and the degree to which they generate actionable learning, and no international system currently exists to enable systematic cross-border sharing and learning from patient safety data. What this study adds: This is the first Delphi study to establish international expert consensus on the purposes, key functions and features, and feasibility of an international Patient Safety Learning System (PSLS), producing novel consensus-based lists of patient safety incidents relevant to international sharing and criteria for determining what constitutes a risk of international concern. How this study might affect research, practice or policy: The proposed framework and consensus-derived criteria provide a starting point for feasibility research and potential pilot implementation by organisations such as the World Health Organization (WHO), in alignment with the Global Patient Safety Action Plan 2021–2030. The findings also highlight the structural prerequisites — including a standardised international taxonomy, governance frameworks, and equitable participation mechanisms — that must be addressed before implementation can proceed.

Background: The inadequate design of work procedures is often cited as a contributory factor in patient safety incidents globally, indicating a potential learning need for healthcare teams. Further, the recent COVID-19 pandemic has necessarily witnessed a proliferation of new and re-designed work procedures introduced as staff adapted to altered working conditions, work environments and expanded job roles. In response, this study aimed to rapidly develop guidance on the human-centred design of work procedures by and for healthcare teams. Methods: A rapid, pragmatic consensus building study using a modified-Delphi involving international multi-professional ‘experts’ was undertaken during April 2020. 66 study participants comprising healthcare professionals (n=49) and Human Factors/Safety Science specialists (n=17), based across six countries, were identified from healthcare networks and contributed to the rapid guidance development, informed by Human Factors design principles. Results: Ten key guidance steps and descriptors were identified and agreed upon on how to better develop and implement work procedures based on Human Factors design principles. Examples include: ‘Ensure a procedure is needed’; ‘Involve the whole team’; ‘Identify the hazards’; ‘Capture work-as-done’; ‘Test it out’; ‘Train people’; ‘Put it into practice’ and ‘Keep it under review’. Conclusions: The developed guidance outlines a series of ‘good practice’ principles for care teams in this area. The guidance is freely accessible and will be of interest to healthcare teams at the ‘sharp end’ of clinical practice, risk, safety and improvement advisors, and educators at all levels internationally both in response to crises situations and in routine healthcare delivery.