PHSO investigations

Articles in this category

1. 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
   • 1,107 views
   • 
   • Added by PatientSafetyLearning Team
   • 1 January, 2020

2. 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
   • 1,697 views
   • 
   • Added by Claire Cox
   • 19 December, 2019

3. 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
   • 1,192 views
   • 
   • Added by Patient Safety Learning
   • 26 October, 2019

4. 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
   • 1,090 views
   • 
   • Added by Claire Cox
   • 25 September, 2019

5. 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
   • 1,236 views
   • 
   • Added by Claire Cox
   • 20 September, 2019

6. 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
   • 1,648 views
   • 
   • Added by Heather PHSO
   • 10 September, 2019

7. 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
   • 1,051 views
   • 
   • Added by Claire Cox
   • 22 July, 2019

8. 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
   • 1,921 views
   • 
   • Added by Patient Safety Learning
   • 26 June, 2019