Investigations, risk management and legal issues

Articles in this category

1. The Hazard and Operability Study (HAZOP) in clinical settings

   • Action plan
   • Methodology
   • (and 6 more)

     Tagged with:

     • Action plan
     • Methodology
     • Investigation
     • More staff training
     • Risk management
     • protocols and procedures
     • Quality improvement
     • Root cause anaylsis

   By Stefan, 28 May

   • 0 comments
   • 466 views
   • 
   • Added by Stefan
   • 28 May

2. Accountability, and what it means to bereaved families and harmed patients (by Corinne Cope)

   • Investigation
   • Accountability

   By Patient_Safety_Learning, 11 May

   • 0 comments
   • 812 views
   • 
   • Added by Patient_Safety_Learning
   • 11 May

3. The Deteriorating Patient - Clinical scenario to support SEIPS training (13 June 2024)

   • PSIRF
   • Investigation
   • (and 3 more)

     Tagged with:

     • PSIRF
     • Investigation
     • System safety
     • Human factors
     • Deterioration

   By Mark Hughes, 29 August, 2025

   • 0 comments
   • 773 views
   • 
   • Added by Mark Hughes
   • 29 August, 2025

4. The Misplaced Nasogastric Tube - Clinical scenario to support SEIPS training (13 June 2024)

   • PSIRF
   • Investigation
   • (and 3 more)

     Tagged with:

     • PSIRF
     • Investigation
     • System safety
     • Human factors
     • Medical device

   By Mark Hughes, 29 August, 2025

   • 0 comments
   • 725 views
   • 
   • Added by Mark Hughes
   • 29 August, 2025

5. Failing to learn? The NHS is losing its capacity for system-wide safety investigation (11 August 2025)

   • Leadership
   • Regulatory issue
   • (and 3 more)

     Tagged with:

     • Leadership
     • Regulatory issue
     • Safety management
     • Investigation
     • England

   By Mark Hughes, 22 August, 2025

   • 0 comments
   • 1,050 views
   • 
   • Added by Mark Hughes
   • 22 August, 2025

6. Why patient safety demands a Hillsborough Law with a legal duty of candour for all health and care professionals

   • Clinical process
   • Behaviour
   • (and 14 more)

     Tagged with:

     • Clinical process
     • Behaviour
     • Patient death
     • Patient harmed
     • Competence
     • Criminal behaviour
     • Non-compliance
     • Organisation / service factors
     • Accountability
     • Code of conduct
     • Legal issue
     • Patient / family involvement
     • Patient safety incident
     • Policies / Protocols / Procedures
     • Recommendations
     • Duty of Candour

   By Steve Turner, 12 August, 2025

   • 4 comments
   • 2,511 views
   • 
   • Comment by Alice2May3
   • 20 September, 2025

7. US Government sues pharmacy chains CVS and Walgreens for their alleged role in the opioid epidemic (7 March 2025)

   • Legal issue
   • Medication
   • (and 2 more)

     Tagged with:

     • Legal issue
     • Medication
     • Pharmacist
     • USA

   By Patient-Safety-Learning, 16 March, 2025

   • 0 comments
   • 1,831 views
   • 
   • Added by Patient-Safety-Learning
   • 16 March, 2025

8. DHSC: Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm (17 December 2024)

   • Investigation
   • Legal issue
   • (and 3 more)

     Tagged with:

     • Investigation
     • Legal issue
     • Criminal behaviour
     • Patient harmed
     • Patient death

   By Patient Safety Learning, 4 February, 2025

   • 0 comments
   • 1,015 views
   • 
   • Added by Patient Safety Learning
   • 4 February, 2025

9. NHS England: National Patient Recall Framework (1 June 2022)

   • Patient engagement
   • Collaboration
   • (and 3 more)

     Tagged with:

     • Patient engagement
     • Collaboration
     • Standards
     • Person-centred care
     • Policies / Protocols / Procedures

   By Patient Safety Learning, 3 October, 2024

   • 0 comments
   • 1,531 views
   • 
   • Added by Patient Safety Learning
   • 3 October, 2024

10. National medical examiner annual report 2023

    • Medical examiner
    • Investigation
    • (and 2 more)

      Tagged with:

      • Medical examiner
      • Investigation
      • Coroner
      • Patient death

    By Patient Safety Learning, 9 September, 2024

    • 0 comments
    • 1,201 views
    • 
    • Added by Patient Safety Learning
    • 9 September, 2024

11. What is the point of inquiries? (BMJ, 27 August 2024)

    • Investigation
    • Recommendations
    • (and 3 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Patient harmed
      • Patient safety strategy
      • Leadership

    By Patient Safety Learning, 30 August, 2024

    • 0 comments
    • 1,275 views
    • 
    • Added by Patient Safety Learning
    • 30 August, 2024

12. 10 key principles for investigation (HSSIB, July 2024)

    • Investigation

    By Patient_Safety_Learning, 23 July, 2024

    • 0 comments
    • 1,429 views
    • 
    • Added by Patient_Safety_Learning
    • 23 July, 2024

13. Effects of a systems approach in occurrence investigations (2024)

    • Investigation
    • Systems modelling

    By Patient_Safety_Learning, 31 May, 2024

    • 0 comments
    • 1,387 views
    • 
    • Added by Patient_Safety_Learning
    • 31 May, 2024

14. “Accountability is important, but that can only come when you get to the truth.” An interview with Will Powell, father of Robbie

    • Patient death
    • Patient / family support
    • (and 5 more)

      Tagged with:

      • Patient death
      • Patient / family support
      • Speaking up
      • Legal issue
      • Regulatory issue
      • Investigation
      • Organisational culture

    By Patient-Safety-Learning, 29 May, 2024

    • 0 comments
    • 4,072 views
    • 
    • Added by Patient-Safety-Learning
    • 29 May, 2024

15. Inside the opaque world of IVF, where errors are rarely made public (28 April 2024)

    • Sexual and reproductive health
    • Legal issue
    • (and 3 more)

      Tagged with:

      • Sexual and reproductive health
      • Legal issue
      • Investigation
      • Transparency
      • Accountability

    By Patient-Safety-Learning, 30 April, 2024

    • 0 comments
    • 1,619 views
    • 
    • Added by Patient-Safety-Learning
    • 30 April, 2024

16. Why it made sense at the time: Local rationality questions for healthcare investigations (24 January 2024)

    • Investigation
    • Staff safety
    • (and 2 more)

      Tagged with:

      • Investigation
      • Staff safety
      • Communication
      • Safety culture

    By Patient-Safety-Learning, 6 February, 2024

    • 0 comments
    • 1,992 views
    • 
    • Added by Patient-Safety-Learning
    • 6 February, 2024

17. Medical examiners in England: draft regulations (14 December 2023)

    • Medical examiner
    • Coroner
    • (and 2 more)

      Tagged with:

      • Medical examiner
      • Coroner
      • Investigation
      • Patient death

    By Patient-Safety-Learning, 18 January, 2024

    • 0 comments
    • 1,538 views
    • 
    • Added by Patient-Safety-Learning
    • 18 January, 2024

18. Mistakes and 'mafia-like' culture at NHS Trust (BBC Newsnight, 29 November 2023)

    • Investigation
    • Patient harmed
    • (and 7 more)

      Tagged with:

      • Investigation
      • Patient harmed
      • Patient death
      • Speaking up
      • Whistleblowing
      • Organisational culture
      • Patient / family involvement
      • Organisation / service factors
      • Police

    By Patient Safety Learning, 30 November, 2023

    • 0 comments
    • 3,311 views
    • 
    • Added by Patient Safety Learning
    • 30 November, 2023

19. Learning from deaths: Using the structured judgement review (SJR) methodology (GHNHSFT, 2018)

    • Patient death
    • Investigation
    • (and 3 more)

      Tagged with:

      • Patient death
      • Investigation
      • Organisational learning
      • Quality improvement
      • Implementation

    By Patient-Safety-Learning, 10 July, 2023

    • 0 comments
    • 2,209 views
    • 
    • Added by Patient-Safety-Learning
    • 10 July, 2023

20. Podcast: Dr Bill Kirkup on patient safety and investigating avoidable harms (27 June 2023)

    • Investigation
    • Patient harmed
    • (and 2 more)

      Tagged with:

      • Investigation
      • Patient harmed
      • Personal reflection
      • Maternity

    By Patient-Safety-Learning, 4 July, 2023

    • 0 comments
    • 2,527 views
    • 
    • Added by Patient-Safety-Learning
    • 4 July, 2023

21. Department of Health factsheet: Health Service Safety Investigations Body

    • Investigation
    • Organisational development
    • (and 1 more)

      Tagged with:

      • Investigation
      • Organisational development
      • Patient safety incident

    By Patient Safety Learning, 28 April, 2023

    • 0 comments
    • 1,806 views
    • 
    • Added by Patient Safety Learning
    • 28 April, 2023

22. A changing view on patient safety: how the Healthcare Safety Investigation Branch has brought system-focused investigations to the fore (Ted Baker, 31 March 2023)

    • Investigation
    • Recommendations
    • (and 4 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Safety culture
      • England
      • System safety
      • Human factors

    By Patient-Safety-Learning, 6 April, 2023

    • 0 comments
    • 2,264 views
    • 
    • Added by Patient-Safety-Learning
    • 6 April, 2023

23. Just a cup of tea – An introduction to the SEIPS framework (21 March 2023)

    • PSIRF
    • Investigation
    • (and 3 more)

      Tagged with:

      • PSIRF
      • Investigation
      • System safety
      • Human factors
      • Process redesign

    By Patient-Safety-Learning, 24 March, 2023

    • 1 comment
    • 4,463 views
    • 
    • Comment by Mark Hughes
    • 25 September, 2024

24. Newsnight: NHS Doctors vs managers (13 January 2023)

    • Regulatory issue
    • Doctor
    • (and 2 more)

      Tagged with:

      • Regulatory issue
      • Doctor
      • Investigation
      • Organisational culture

    By Patient Safety Learning, 19 February, 2023

    • 0 comments
    • 1,989 views
    • 
    • Added by Patient Safety Learning
    • 19 February, 2023

25. HSIB blog: New opportunities for risk management (10 January 2023)

    • Risk management
    • Clinical governance
    • (and 3 more)

      Tagged with:

      • Risk management
      • Clinical governance
      • Resources / Organisational management
      • Integrated Care System (ICS)
      • System safety

    By Patient-Safety-Learning, 12 January, 2023

    • 0 comments
    • 1,941 views
    • 
    • Added by Patient-Safety-Learning
    • 12 January, 2023