Other reports and inquiries

Articles in this category

1. Independent investigation into the death of Baby A at HMP Bronzefield on 27 September 2019: A report by the Prisons and Probation Obudsman

   • Prison
   • Maternity
   • (and 5 more)

     Tagged with:

     • Prison
     • Maternity
     • Investigation
     • Baby
     • Patient death
     • Pregnancy
     • Womens health

   By Patient Safety Learning, Wednesday at 13:43

   • 0 comments
   • 128 views
   • 
   • Added by Patient Safety Learning
   • Wednesday at 13:43

2. Nimrod XV230: 15 years on (2 September 2021)

   • Aviation
   • Investigation
   • (and 3 more)

     Tagged with:

     • Aviation
     • Investigation
     • Organisational learning
     • Human factors
     • Leadership

   By Patient Safety Learning, Tuesday at 16:24

   • 0 comments
   • 35 views
   • 
   • Added by Patient Safety Learning
   • Tuesday at 16:24

3. Lessons learnt from accidental and unintended exposure to ionising radiation events notified to HIQA in 2020 (15 September 2021)

   • Investigation
   • Radiologist
   • (and 6 more)

     Tagged with:

     • Investigation
     • Radiologist
     • Patient harmed
     • Recommendations
     • Diagnosis
     • Human error
     • Human factors
     • Ireland

   By Patient Safety Learning, 16 September

   • 0 comments
   • 74 views
   • 
   • Added by Patient Safety Learning
   • 16 September

4. A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021)

   • Medical device
   • Medication
   • (and 5 more)

     Tagged with:

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

   By PatientSafetyLearning Team, 26 July

   • 0 comments
   • 524 views
   • 
   • Added by PatientSafetyLearning Team
   • 26 July

5. Government response to the report of the Independent Medicines and Medical Devices Safety Review (21 July 2021)

   • Medical device
   • Medication
   • (and 6 more)

     Tagged with:

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

   By Mark Hughes, 22 July

   • 0 comments
   • 1,006 views
   • 
   • Added by Mark Hughes
   • 22 July

6. Independent Report of the Patient Reference Group – response to the report of the Independent Medicines and Medical Devices Safety Review (21 July 2021)

   • Medical device
   • Medication
   • (and 6 more)

     Tagged with:

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

   By Mark Hughes, 22 July

   • 0 comments
   • 465 views
   • 
   • Added by Mark Hughes
   • 22 July

7. House of Commons Debate - Independent Medicines and Medical Devices Safety Review (8 July 2021)

   • Medical device
   • Medication
   • (and 5 more)

     Tagged with:

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

   By Mark Hughes, 9 July

   • 0 comments
   • 261 views
   • 
   • Added by Mark Hughes
   • 9 July

8. West Midlands Ambulance Service: Patient delayed on the back of an ambulance resulted in significant deterioration and ultimately death of patient (May 2021)

   • Deterioration
   • Ambulance
   • (and 1 more)

     Tagged with:

     • Deterioration
     • Ambulance
     • Patient death

   By Patient Safety Learning, 28 May

   • 0 comments
   • 116 views
   • 
   • Added by Patient Safety Learning
   • 28 May

9. National Medical Examiner’s report 2020

   • Medical examiner
   • Patient death

   By PatientSafetyLearning Team, 29 April

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

10. 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
    • 395 views
    • 
    • Comment by Steve Turner
    • 3 March

11. 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
    • 240 views
    • 
    • Added by Patient Safety Learning
    • 24 February

12. 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
    • 177 views
    • 
    • Added by Patient Safety Learning
    • 22 February

13. 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
    • 120 views
    • 
    • Added by Patient Safety Learning
    • 22 January

14. 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
    • 371 views
    • 
    • Added by Mark Hughes
    • 11 December, 2020

15. 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
    • 472 views
    • 
    • Added by Mark Hughes
    • 2 December, 2020

16. 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
    • 1,971 views
    • 
    • Added by Patient Safety Learning
    • 26 November, 2020

17. 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
    • 281 views
    • 
    • Added by Patient Safety Learning
    • 16 November, 2020

18. 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
    • 307 views
    • 
    • Added by Patient Safety Learning
    • 2 November, 2020

19. "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
    • 1,639 views
    • 
    • Comment by Steve Turner
    • 26 October, 2020

20. 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
    • 516 views
    • 
    • Added by Patient Safety Learning
    • 21 October, 2020

21. HIQA: Annual report of accidental or unintended exposures to ionising radiation in 2019

    • Radiology
    • Patient safety incident
    • (and 6 more)

      Tagged with:

      • Radiology
      • Patient safety incident
      • Cancer
      • Diagnosis
      • Health and safety
      • Safety culture
      • Human error
      • System safety

    By Sam, 15 September, 2020

    • 0 comments
    • 361 views
    • 
    • Added by Sam
    • 15 September, 2020

22. 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
    • 507 views
    • 
    • Added by Mark Hughes
    • 10 September, 2020

23. 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
    • 320 views
    • 
    • Added by PatientSafetyLearning Team
    • 14 August, 2020

24. 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
    • 210 views
    • 
    • Added by Claire Cox
    • 4 August, 2020

25. 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
    • 2,706 views
    • 
    • Added by Patient Safety Learning
    • 9 July, 2020