PHSO investigations

Articles in this category

1. 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
   • 394 views
   • 
   • Added by Heather PHSO
   • 4 March, 2020

2. 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
   • 359 views
   • 
   • Added by Claire Cox
   • 12 February, 2020

3. 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
   • 373 views
   • 
   • Added by PatientSafetyLearning Team
   • 1 January, 2020

4. 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
   • 247 views
   • 
   • Added by PatientSafetyLearning Team
   • 1 January, 2020

5. 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
   • 511 views
   • 
   • Added by Claire Cox
   • 19 December, 2019

6. 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
   • 319 views
   • 
   • Added by Patient Safety Learning
   • 26 October, 2019

7. 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
   • 248 views
   • 
   • Added by Claire Cox
   • 25 September, 2019

8. 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
   • 288 views
   • 
   • Added by Claire Cox
   • 20 September, 2019

9. 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
   • 529 views
   • 
   • Added by Heather PHSO
   • 10 September, 2019

10. 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
    • 293 views
    • 
    • Added by Claire Cox
    • 22 July, 2019

11. 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
    • 663 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019