PHSO investigations

Articles in this category

1. PHSO - Our strategy 2022 to 2025 (5 April 2022)

   • Investigation
   • Complaint
   • (and 1 more)

     Tagged with:

     • Investigation
     • Complaint
     • UK

   By Patient-Safety-Learning, 30 August, 2022

   • 0 comments
   • 227 views
   • 
   • Added by Patient-Safety-Learning
   • 30 August, 2022

2. PHSO investigation - Man died after doctors missed opportunities to identify abnormalities on his X-ray (20 July 2022)

   • Imaging
   • Diagnostic error
   • (and 2 more)

     Tagged with:

     • Imaging
     • Diagnostic error
     • Investigation
     • Patient death

   By Patient-Safety-Learning, 4 August, 2022

   • 0 comments
   • 284 views
   • 
   • Added by Patient-Safety-Learning
   • 4 August, 2022

3. PHSO: Failure to act on sepsis led to man’s death, Ombudsman finds (3 March 2022)

   • Sepsis
   • Deterioration
   • (and 4 more)

     Tagged with:

     • Sepsis
     • Deterioration
     • Monitoring
     • Negligence claim
     • Patient death
     • Communication

   By Patient-Safety-Learning, 3 March, 2022

   • 0 comments
   • 628 views
   • 
   • Added by Patient-Safety-Learning
   • 3 March, 2022

4. Northern Ireland Public Services Ombudsman: Investigation of a complaint against the Belfast Health and Social Care Trust (July 2020)

   • Investigation
   • Patient death
   • (and 8 more)

     Tagged with:

     • Investigation
     • Patient death
     • Northern Ireland
     • Observations
     • Learning disabilities
     • Commissioner
     • Prescribing
     • Complaint
     • Patient / family involvement
     • Nutrition

   By Patient Safety Learning, 17 June, 2020

   • 0 comments
   • 268 views
   • 
   • Added by Patient Safety Learning
   • 17 June, 2020

5. PHSO: Ignoring the alarms – How NHS eating disorder services are failing patients (December 2017)

   • Mental health unit
   • Mental health - CAMHS
   • (and 5 more)

     Tagged with:

     • Mental health unit
     • Mental health - CAMHS
     • Resources / Organisational management
     • Internal major
     • Patient death
     • Adolescent
     • Young Adult

   By Heather PHSO, 4 March, 2020

   • 0 comments
   • 1,058 views
   • 
   • Added by Heather PHSO
   • 4 March, 2020

6. Parliamentary and Health Service Ombudsman - 'How can we help you?'

   • Patient
   • Complaint
   • (and 3 more)

     Tagged with:

     • Patient
     • Complaint
     • Investigation
     • Policies / Protocols / Procedures
     • Standards

   By Claire Cox, 12 February, 2020

   • 0 comments
   • 773 views
   • 
   • Added by Claire Cox
   • 12 February, 2020

7. An investigation report into how the NHS failed to properly investigate the death of a three-year old child (July 2016)

   • Investigation
   • Children and Young People
   • (and 4 more)

     Tagged with:

     • Investigation
     • Children and Young People
     • Patient death
     • Safety culture
     • Organisational culture
     • Organisational learning

   By PatientSafetyLearning Team, 1 January, 2020

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

8. Clinical Advice Review Commissioned by the PHSO: Report of the Independent Adviser to the Review (December 2018)

   • Recommendations
   • Safety report
   • (and 3 more)

     Tagged with:

     • Recommendations
     • Safety report
     • Systematic review
     • Organisational culture
     • Investigation

   By PatientSafetyLearning Team, 1 January, 2020

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

9. Baby’s death from heart defect was avoidable (August 2019)

   • Baby
   • Patient death
   • (and 4 more)

     Tagged with:

     • Baby
     • Patient death
     • Omissions
     • Human error
     • Complaint
     • Investigation

   By Claire Cox, 19 December, 2019

   • 0 comments
   • 1,039 views
   • 
   • Added by Claire Cox
   • 19 December, 2019

10. Second PHSO investigation into the Care Quality Commission’s regulation of the Fit and Proper Persons Requirement (July 2019)

    • Investigation
    • Recommendations
    • (and 1 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Complaint

    By Patient Safety Learning, 26 October, 2019

    • 0 comments
    • 654 views
    • 
    • Added by Patient Safety Learning
    • 26 October, 2019

11. PHSO Investigation: Man died after excessive wait for cancer treatment (2019)

    • Pre-op period
    • Medicine - Oncology
    • (and 3 more)

      Tagged with:

      • Pre-op period
      • Medicine - Oncology
      • Patient death
      • Complaint
      • Investigation

    By Claire Cox, 25 September, 2019

    • 0 comments
    • 572 views
    • 
    • Added by Claire Cox
    • 25 September, 2019

12. Missed opportunities: What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust (June 2019)

    • Mental health unit
    • Mental health
    • (and 4 more)

      Tagged with:

      • Mental health unit
      • Mental health
      • Patient death
      • Staff factors
      • Investigation
      • Young Adult

    By Claire Cox, 20 September, 2019

    • 0 comments
    • 612 views
    • 
    • Added by Claire Cox
    • 20 September, 2019

13. PHSO: Maintaining momentum – driving improvements in mental health care (March 2018)

    • Mental health unit
    • Organisational learning
    • (and 1 more)

      Tagged with:

      • Mental health unit
      • Organisational learning
      • Mental health

    By Heather PHSO, 10 September, 2019

    • 0 comments
    • 1,016 views
    • 
    • Added by Heather PHSO
    • 10 September, 2019

14. Blowing the whistle: An investigation into the Care Quality Commission’s regulation of the Fit and Proper Persons Requirement (13 December 2018)

    • Investigation
    • Organisational culture
    • (and 2 more)

      Tagged with:

      • Investigation
      • Organisational culture
      • Leadership
      • Complaint

    By Claire Cox, 22 July, 2019

    • 0 comments
    • 562 views
    • 
    • Added by Claire Cox
    • 22 July, 2019

15. PHSO submission: PACAC’s follow-up to PHSO report ‘Ignoring the Alarms’ Inquiry (April 2018)

    • Recommendations
    • Investigation
    • (and 4 more)

      Tagged with:

      • Recommendations
      • Investigation
      • Mental health
      • Transfer of care
      • Patient death
      • Training

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 1,181 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019