Other reports and inquiries

Articles in this category

1. National Medical Examiner’s report 2020

   • Medical examiner
   • Patient death

   By PatientSafetyLearning Team, 29 April

   • 0 comments
   • 142 views
   • 
   • Added by PatientSafetyLearning Team
   • 29 April

2. House of Lords Debate - Independent Medicines and Medical Devices Safety Review: Sodium Valproate (2 March 2021)

   • Patient harmed
   • Investigation
   • (and 2 more)

     Tagged with:

     • Patient harmed
     • Investigation
     • Maternity
     • Patient safety incident

   By Mark Hughes, 3 March

   • 1 comment
   • 242 views
   • 
   • Comment by Steve Turner
   • 3 March

3. First Do No Harm APPG meeting: Answers from the Minister to questions raised

   • Investigation
   • Womens health
   • (and 5 more)

     Tagged with:

     • Investigation
     • Womens health
     • Patient harmed
     • Obstetrics and gynaecology/ Maternity
     • Medical device
     • Epilepsy
     • Pregnancy

   By Patient Safety Learning, 24 February

   • 0 comments
   • 157 views
   • 
   • Added by Patient Safety Learning
   • 24 February

4. Infected Blood Inquiry: The Haemophilia Society under pressure (21 February 2021)

   • Blood / blood products
   • Medicine - Haematology
   • (and 3 more)

     Tagged with:

     • Blood / blood products
     • Medicine - Haematology
     • Patient safety incident
     • Investigation
     • Communication problems

   By Patient Safety Learning, 22 February

   • 0 comments
   • 111 views
   • 
   • Added by Patient Safety Learning
   • 22 February

5. The Haemophilia Society: The Infected Blood Inquiry

   • Blood / blood products
   • Medicine - Haematology
   • (and 3 more)

     Tagged with:

     • Blood / blood products
     • Medicine - Haematology
     • Investigation
     • Patient safety incident
     • Communication problems

   By Patient Safety Learning, 22 January

   • 0 comments
   • 60 views
   • 
   • Added by Patient Safety Learning
   • 22 January

6. House of Commons Debate - Ockenden Review

   • Patient harmed
   • Investigation
   • (and 2 more)

     Tagged with:

     • Patient harmed
     • Investigation
     • Maternity
     • Patient safety incident

   By Mark Hughes, 11 December, 2020

   • 0 comments
   • 274 views
   • 
   • Added by Mark Hughes
   • 11 December, 2020

7. Senedd Cymru - Welsh Parliament: Ministerial response to a written question on the Cumberlege Review (26 November 2020)

   • Medical device
   • Medication
   • (and 5 more)

     Tagged with:

     • Medical device
     • Medication
     • Maternity
     • Recommendations
     • Pregnancy
     • Patient harmed
     • Womens health

   By Mark Hughes, 2 December, 2020

   • 0 comments
   • 359 views
   • 
   • Added by Mark Hughes
   • 2 December, 2020

8. The life and death of Elizabeth Dixon: a catalyst for change (26 November 2020)

   • Investigation
   • Special needs
   • (and 9 more)

     Tagged with:

     • Investigation
     • Special needs
     • Patient death
     • Recommendations
     • Baby
     • Care plan
     • Clinical process
     • Complaint
     • Clinical governance
     • Transparency
     • Organisational culture

   By Patient Safety Learning, 26 November, 2020

   • 0 comments
   • 1,633 views
   • 
   • Added by Patient Safety Learning
   • 26 November, 2020

9. Open letter to Boris Johnson on the Cumberlege report (21 October 2020)

   • Womens health
   • Patient harmed
   • (and 2 more)

     Tagged with:

     • Womens health
     • Patient harmed
     • Recommendations
     • Investigation

   By Patient Safety Learning, 16 November, 2020

   • 0 comments
   • 204 views
   • 
   • Added by Patient Safety Learning
   • 16 November, 2020

10. Cornwall and Isles of Scilly Safeguarding Adults Board: Safeguarding Adults Review, The Morleigh Group (November 2020)

    • Older People (over 65)
    • Care home
    • (and 6 more)

      Tagged with:

      • Older People (over 65)
      • Care home
      • Patient harmed
      • Patient suffering
      • Private sector
      • Investigation
      • Recommendations
      • Legal issue

    By Patient Safety Learning, 2 November, 2020

    • 0 comments
    • 217 views
    • 
    • Added by Patient Safety Learning
    • 2 November, 2020

11. "Autistic Bristol teenager Oliver McGowan's death was avoidable" – new independent review into Thomas Oliver McGowan’s LeDeR process

    • Monitoring
    • Treatment
    • (and 21 more)

      Tagged with:

      • Monitoring
      • Treatment
      • Adminstering medication
      • Observations
      • Learning disabilities
      • Patient death
      • Communication problems
      • Omissions
      • System safety
      • Accountability
      • Leadership
      • Organisational culture
      • Organisational Performance
      • Transparency
      • protocols and procedures
      • Risk assessment
      • Autism
      • Clinical governance
      • Complaint
      • Investigation
      • Legal issue
      • Root cause anaylsis
      • Coroner reports

    By Steve Turner, 21 October, 2020

    • 1 comment
    • 1,303 views
    • 
    • Comment by Steve Turner
    • 26 October, 2020

12. Independent review into Thomas Oliver McGowan’s LeDeR process. Phase two (20 October 2020)

    • Autism
    • Learning disabilities
    • (and 4 more)

      Tagged with:

      • Autism
      • Learning disabilities
      • Investigation
      • Coroner
      • Recommendations
      • Patient death

    By Patient Safety Learning, 21 October, 2020

    • 0 comments
    • 407 views
    • 
    • Added by Patient Safety Learning
    • 21 October, 2020

13. Scottish Parliament Debate - Baroness Cumberlege Report (8 September 2020)

    • Medical device
    • Medication
    • (and 5 more)

      Tagged with:

      • Medical device
      • Medication
      • Maternity
      • Recommendations
      • Pregnancy
      • Patient harmed
      • Womens health

    By Mark Hughes, 10 September, 2020

    • 0 comments
    • 374 views
    • 
    • Added by Mark Hughes
    • 10 September, 2020

14. Better than cure: Injury prevention policy (13 August 2020)

    • Patient harmed
    • Safety report
    • (and 1 more)

      Tagged with:

      • Patient harmed
      • Safety report
      • Patient safety strategy

    By PatientSafetyLearning Team, 14 August, 2020

    • 0 comments
    • 249 views
    • 
    • Added by PatientSafetyLearning Team
    • 14 August, 2020

15. Patient safety in private hospitals: The known and unknown risks (August 2014)

    • Private sector
    • Safety report
    • (and 2 more)

      Tagged with:

      • Private sector
      • Safety report
      • Safety process
      • Safety behaviour

    By Claire Cox, 4 August, 2020

    • 0 comments
    • 144 views
    • 
    • Added by Claire Cox
    • 4 August, 2020

16. First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review (8 July 2020)

    • Medical device
    • Medication
    • (and 8 more)

      Tagged with:

      • Medical device
      • Medication
      • Patient harmed
      • Investigation
      • Recommendations
      • Pregnancy
      • Epilepsy
      • Baby
      • Maternity
      • Womens health

    By Patient Safety Learning, 9 July, 2020

    • 0 comments
    • 2,148 views
    • 
    • Added by Patient Safety Learning
    • 9 July, 2020

17. Health and Social Care Committee: Management of the coronavirus outbreak (17 April 2020)

    • Infection control
    • Virus
    • (and 3 more)

      Tagged with:

      • Infection control
      • Virus
      • Social care staff
      • Care home
      • Staff safety

    By PatientSafetyLearning Team, 17 April, 2020

    • 0 comments
    • 395 views
    • 
    • Added by PatientSafetyLearning Team
    • 17 April, 2020

18. BMJ Analysis. Rogue breast surgeon Ian Paterson: what has the inquiry told us?

    • Private sector
    • Surgeon
    • (and 4 more)

      Tagged with:

      • Private sector
      • Surgeon
      • Patient harmed
      • Investigation
      • Recommendations
      • Cancer

    By Patient Safety Learning, 17 February, 2020

    • 0 comments
    • 359 views
    • 
    • Added by Patient Safety Learning
    • 17 February, 2020

19. Ian Kennedy: The Paterson case is not a one-off—it indicates systemic weaknesses in the NHS (7 February 2020)

    • Investigation
    • Patient safety incident
    • (and 5 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Leadership
      • Bullying
      • Culture of fear
      • Organisational culture
      • Regulatory issue

    By Patient Safety Learning, 12 February, 2020

    • 0 comments
    • 447 views
    • 
    • Added by Patient Safety Learning
    • 12 February, 2020

20. Patient Safety Learning’s response to the Paterson Inquiry (11 February 2020)

    • Surgeon
    • Patient harmed
    • (and 4 more)

      Tagged with:

      • Surgeon
      • Patient harmed
      • Recommendations
      • Investigation
      • Criminal behaviour
      • Patient safety strategy

    By Patient Safety Learning, 11 February, 2020

    • 0 comments
    • 825 views
    • 
    • Added by Patient Safety Learning
    • 11 February, 2020

21. Ministerial Statement on the Paterson Inquiry in the House of Commons (4 February 2020)

    • Surgeon
    • Surgery - General
    • (and 4 more)

      Tagged with:

      • Surgeon
      • Surgery - General
      • Patient harmed
      • Investigation
      • Patient safety incident
      • Medicine - Oncology

    By Sam, 6 February, 2020

    • 0 comments
    • 298 views
    • 
    • Added by Sam
    • 6 February, 2020

22. Report of the independent Inquiry into the issues raised by Paterson (4 February 2020)

    • Surgeon
    • Patient harmed
    • (and 4 more)

      Tagged with:

      • Surgeon
      • Patient harmed
      • Recommendations
      • Patient safety incident
      • Criminal behaviour
      • Flawed processes

    By Patient Safety Learning, 5 February, 2020

    • 0 comments
    • 904 views
    • 
    • Added by Patient Safety Learning
    • 5 February, 2020

23. PHSO – Labyrinth of Bureaucracy (March 2015)

    • Patient factors
    • Investigation
    • (and 2 more)

      Tagged with:

      • Patient factors
      • Investigation
      • Complaint
      • Organisational culture

    By PatientSafetyLearning Team, 1 January, 2020

    • 0 comments
    • 412 views
    • 
    • Added by PatientSafetyLearning Team
    • 1 January, 2020

24. A review of quality governance arrangements at Cwm Taf Morgannwg University (November 2019)

    • Obstetrics and gynaecology/ Maternity
    • Resources / Organisational management
    • (and 2 more)

      Tagged with:

      • Obstetrics and gynaecology/ Maternity
      • Resources / Organisational management
      • Organisation / service factors
      • Organisational culture

    By Patient Safety Learning, 19 November, 2019

    • 0 comments
    • 371 views
    • 
    • Added by Patient Safety Learning
    • 19 November, 2019

25. Gosport War Memorial Hospital: The Report of the Gosport Independent Panel (June 2018)

    • Culture of fear
    • Accountability
    • (and 3 more)

      Tagged with:

      • Culture of fear
      • Accountability
      • Patient death
      • Prescribing
      • Investigation

    By PatientSafetyLearning Team, 6 November, 2019

    • 0 comments
    • 434 views
    • 
    • Added by PatientSafetyLearning Team
    • 6 November, 2019