Other reports and inquiries

Articles in this category

1. 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, Wednesday at 12:28

   • 0 comments
   • 115 views
   • 
   • Added by Mark Hughes
   • Wednesday at 12:28

2. 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

   • 0 comments
   • 1,035 views
   • 
   • Added by Patient Safety Learning
   • 26 November

3. 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

   • 0 comments
   • 87 views
   • 
   • Added by Patient Safety Learning
   • 16 November

4. 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

   • 0 comments
   • 58 views
   • 
   • Added by Patient Safety Learning
   • 2 November

5. "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

   • 1 comment
   • 813 views
   • 
   • Comment by Steve Turner
   • 26 October

6. 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

   • 0 comments
   • 220 views
   • 
   • Added by Patient Safety Learning
   • 21 October

7. 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

   • 0 comments
   • 196 views
   • 
   • Added by Mark Hughes
   • 10 September

8. 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

   • 0 comments
   • 165 views
   • 
   • Added by PatientSafetyLearning Team
   • 14 August

9. 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

   • 0 comments
   • 80 views
   • 
   • Added by Claire Cox
   • 4 August

10. 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

    • 0 comments
    • 1,380 views
    • 
    • Added by Patient Safety Learning
    • 9 July

11. 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

    • 0 comments
    • 284 views
    • 
    • Added by PatientSafetyLearning Team
    • 17 April

12. 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

    • 0 comments
    • 242 views
    • 
    • Added by Patient Safety Learning
    • 17 February

13. 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

    • 0 comments
    • 380 views
    • 
    • Added by Patient Safety Learning
    • 12 February

14. 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

    • 0 comments
    • 508 views
    • 
    • Added by Patient Safety Learning
    • 11 February

15. 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

    • 0 comments
    • 200 views
    • 
    • Added by Sam
    • 6 February

16. 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

    • 0 comments
    • 551 views
    • 
    • Added by Patient Safety Learning
    • 5 February

17. 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

    • 0 comments
    • 287 views
    • 
    • Added by PatientSafetyLearning Team
    • 1 January

18. 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
    • 307 views
    • 
    • Added by Patient Safety Learning
    • 19 November, 2019

19. 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
    • 296 views
    • 
    • Added by PatientSafetyLearning Team
    • 6 November, 2019

20. Independent audit to review the NMC’s handling of documentation relating to midwives at Furness General Hospital (September 2019)

    • Obstetrics and gynaecology/ Maternity
    • Patient death
    • (and 3 more)

      Tagged with:

      • Obstetrics and gynaecology/ Maternity
      • Patient death
      • Investigation
      • Baby
      • Patient / family involvement

    By Patient Safety Learning, 24 October, 2019

    • 0 comments
    • 219 views
    • 
    • Added by Patient Safety Learning
    • 24 October, 2019

21. The inquiry into hyponatraemia-related deaths (January 2018)

    • Investigation
    • Recommendations
    • (and 3 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Quality improvement
      • Patient safety strategy
      • Patient safety incident

    By Patient Safety Learning, 20 October, 2019

    • 0 comments
    • 198 views
    • 
    • Added by Patient Safety Learning
    • 20 October, 2019

22. Review relating to the care of patients on Tawel Fan ward prior to its closure (June 2018)

    • Patient harmed
    • Investigation
    • (and 2 more)

      Tagged with:

      • Patient harmed
      • Investigation
      • Older People (over 65)
      • Mental health - old age

    By PatientSafetyLearning Team, 6 October, 2019

    • 0 comments
    • 176 views
    • 
    • Added by PatientSafetyLearning Team
    • 6 October, 2019

23. ICO: Royal Free – Google DeepMind trial failed to comply with data protection law (July 2017)

    • Information processing
    • Legal issue

    By PatientSafetyLearning Team, 6 October, 2019

    • 0 comments
    • 171 views
    • 
    • Added by PatientSafetyLearning Team
    • 6 October, 2019

24. The Shipman Inquiry (2002-2005)

    • Patient death
    • Older People (over 65)
    • (and 3 more)

      Tagged with:

      • Patient death
      • Older People (over 65)
      • Legal issue
      • Investigation
      • Regulatory issue

    By PatientSafetyLearning Team, 6 October, 2019

    • 0 comments
    • 1,455 views
    • 
    • Added by PatientSafetyLearning Team
    • 6 October, 2019

25. A report for Norfolk and Suffolk NHS Foundation Trust: Independent review of unexpected deaths, April 2012 – December 2015

    • Patient death
    • Organisational learning
    • (and 5 more)

      Tagged with:

      • Patient death
      • Organisational learning
      • Organisational development
      • Safety culture
      • Safety process
      • Evaluation
      • Recommendations

    By Claire Cox, 6 October, 2019

    • 0 comments
    • 233 views
    • 
    • Added by Claire Cox
    • 6 October, 2019