Trust investigations

Articles in this category

1. Ockenden Report: Findings, conclusions and essential actions from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust (24 June 2026)

   • Maternity
   • Investigation
   • (and 6 more)

     Tagged with:

     • Maternity
     • Investigation
     • England
     • Patient death
     • Patient harmed
     • Baby
     • Clinical governance
     • Organisational culture

   By Mark Hughes, 24 June

   • 0 comments
   • 2,402 views
   • 
   • Added by Mark Hughes
   • 24 June

2. An independent investigation into potential missed opportunities for identification and avoidance of possible harm to paediatric orthopaedic patients at Cambridge University Hospitals NHS Foundation Trust (October 2025)

   • Patient harmed
   • Surgeon
   • (and 4 more)

     Tagged with:

     • Patient harmed
     • Surgeon
     • Investigation
     • Paediatrics
     • Surgery - Trauma and orthopaedic
     • Decision making

   By Patient Safety Learning, 29 October, 2025

   • 0 comments
   • 478 views
   • 
   • Added by Patient Safety Learning
   • 29 October, 2025

3. Walsall Healthcare NHS Trust: Final report on the Patient Notification Exercise (PNE) and patient recall regarding patients under the care of Mr Mian Munawar Shah (11 March 2025)

   • Investigation
   • Surgery - Trauma and orthopaedic
   • (and 3 more)

     Tagged with:

     • Investigation
     • Surgery - Trauma and orthopaedic
     • Patient harmed
     • Surgeon
     • Skills

   By Patient Safety Learning, 12 March, 2025

   • 0 comments
   • 611 views
   • 
   • Added by Patient Safety Learning
   • 12 March, 2025

4. Lessons learned: External review of the Royal Devon University Healthcare NHS Foundation Trust's response to the management of a consultant with a criminal conviction (May 2024)

   • Organisational culture
   • Just Culture
   • (and 5 more)

     Tagged with:

     • Organisational culture
     • Just Culture
     • Investigation
     • Speaking up
     • Criminal behaviour
     • Anaesthetist
     • Restorative Justice

   By Patient Safety Learning, 8 August, 2024

   • 0 comments
   • 485 views
   • 
   • Added by Patient Safety Learning
   • 8 August, 2024

5. Executive summary to the investigation report prepared on behalf of the Northern Care Alliance NHS Foundation Trust (5 March 2024)

   • Patient death
   • Investigation
   • (and 5 more)

     Tagged with:

     • Patient death
     • Investigation
     • Surgery - Trauma and orthopaedic
     • Organisational culture
     • Hierarchy
     • Accountability
     • Bullying

   By Patient-Safety-Learning, 21 March, 2024

   • 0 comments
   • 891 views
   • 
   • Added by Patient-Safety-Learning
   • 21 March, 2024

6. Investigation report on behalf of the Northern Care Alliance NHS Foundation Trust (5 March 2024)

   • Patient harmed
   • Surgeon
   • (and 1 more)

     Tagged with:

     • Patient harmed
     • Surgeon
     • Investigation

   By Patient Safety Learning, 11 March, 2024

   • 0 comments
   • 1,075 views
   • 
   • Added by Patient Safety Learning
   • 11 March, 2024

7. Royal College of Surgeons of England: Report on the general surgical service on behalf of University Hospitals Sussex NHS Foundation Trust (17 January 2024)

   • Investigation
   • Speaking up
   • (and 4 more)

     Tagged with:

     • Investigation
     • Speaking up
     • Whistleblowing
     • Organisational culture
     • Organisation / service factors
     • Surgery - General

   By Mark Hughes, 7 February, 2024

   • 0 comments
   • 1,482 views
   • 
   • Added by Mark Hughes
   • 7 February, 2024

8. Independent Organisational Culture Review: Report for University Hospitals Birmingham NHS Foundation Trust (27 September 2023)

   • Investigation
   • Organisational culture
   • (and 5 more)

     Tagged with:

     • Investigation
     • Organisational culture
     • Staff safety
     • Bullying
     • Culture of fear
     • Psychological safety
     • Recommendations

   By Patient Safety Learning, 28 September, 2023

   • 0 comments
   • 1,573 views
   • 
   • Added by Patient Safety Learning
   • 28 September, 2023

9. A report for the Northern Care Alliance NHS Foundation Trust Spinal Patient Safety Look Back Review (“SPSLBR”)

   • Investigation
   • Patient harmed
   • (and 2 more)

     Tagged with:

     • Investigation
     • Patient harmed
     • Surgeon
     • Consent

   By Patient_Safety_Learning, 31 July, 2023

   • 1 comment
   • 1,840 views
   • 
   • Comment by Anonymous
   • 1 August, 2023

10. Government response to ‘Reading the signals: maternity and neonatal services in East Kent - the report of the independent investigation’ (20 July 2023)

    • Investigation
    • Maternity
    • (and 13 more)

      Tagged with:

      • Investigation
      • Maternity
      • Recommendations
      • Patient harmed
      • Patient death
      • Baby
      • Leadership
      • Organisational learning
      • Reporting
      • Teamwork
      • Data
      • Standards
      • Restorative Justice
      • Training
      • Organisational culture

    By Patient Safety Learning, 20 July, 2023

    • 0 comments
    • 2,058 views
    • 
    • Added by Patient Safety Learning
    • 20 July, 2023

11. The Report of the Independent Review in to alleged failures of patient safety and governance at the North East Ambulance Service (3 July 2023)

    • Investigation
    • Patient / family involvement
    • (and 5 more)

      Tagged with:

      • Investigation
      • Patient / family involvement
      • Paramedic
      • Ambulance
      • Whistleblowing
      • Speaking up
      • Patient death

    By Patient Safety Learning, 12 July, 2023

    • 0 comments
    • 1,554 views
    • 
    • Added by Patient Safety Learning
    • 12 July, 2023

12. University Hospitals Birmingham NHS FT (UHB) oversight report of phase 1 , 2 and 3 reviews "Bewick 2" (IQ4U, 30 June 2023)

    • Investigation
    • Leadership
    • (and 6 more)

      Tagged with:

      • Investigation
      • Leadership
      • Organisational culture
      • Bullying
      • Staff factors
      • Clinical governance
      • Staff safety
      • Self harm/ suicide

    By Patient Safety Learning, 3 July, 2023

    • 0 comments
    • 1,620 views
    • 
    • Added by Patient Safety Learning
    • 3 July, 2023

13. University Hospitals Birmingham NHS FT (UHB): Phase 1 Review by IQ4U - Clinical safety (28 March 2023)

    • Investigation
    • Organisational culture
    • (and 7 more)

      Tagged with:

      • Investigation
      • Organisational culture
      • Bullying
      • Staff factors
      • Staff safety
      • Self harm/ suicide
      • Leadership
      • Clinical governance
      • Culture of fear

    By Patient Safety Learning, 29 March, 2023

    • 0 comments
    • 5,482 views
    • 
    • Added by Patient Safety Learning
    • 29 March, 2023

14. A system-wide independent investigation into concerns and issues raised relating to the safety and quality of CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust (21 March 2023)

    • Investigation
    • Mental health
    • (and 8 more)

      Tagged with:

      • Investigation
      • Mental health
      • Organisational culture
      • Organisation / service factors
      • Leadership
      • Patient harmed
      • Patient suffering
      • Self harm/ suicide
      • Restrictive practice
      • Mental health - CAMHS

    By Patient Safety Learning, 21 March, 2023

    • 0 comments
    • 2,006 views
    • 
    • Added by Patient Safety Learning
    • 21 March, 2023

15. Government’s initial response to the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust (7 March 2023)

    • Maternity
    • Investigation
    • (and 7 more)

      Tagged with:

      • Maternity
      • Investigation
      • Leadership
      • Patient / family involvement
      • Patient death
      • Recommendations
      • Implementation
      • Patient harmed
      • Baby

    By Patient Safety Learning, 7 March, 2023

    • 0 comments
    • 1,026 views
    • 
    • Added by Patient Safety Learning
    • 7 March, 2023

16. Stories of our times podcast: The scandal that shook the NHS (6 February 2023)

    • Investigation
    • Recommendations
    • (and 4 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Patient harmed
      • Legal issue
      • Organisation / service factors
      • Organisational culture

    By Patient Safety Learning, 6 February, 2023

    • 0 comments
    • 983 views
    • 
    • Added by Patient Safety Learning
    • 6 February, 2023

17. RQIA: Report on the Expert Review of Records of Deceased Patients (Neurology) (November 2022)

    • Investigation
    • Recommendations
    • (and 8 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Decision making
      • Communication problems
      • Diagnosis
      • Patient / family involvement
      • Patient harmed
      • Northern Ireland
      • Medicine - Neurology
      • Reports / results

    By Patient Safety Learning, 1 December, 2022

    • 0 comments
    • 1,100 views
    • 
    • Added by Patient Safety Learning
    • 1 December, 2022

18. Bill Kirkup speaks to HSIB staff about 'Reading the signals' (17 November 2022)

    • Investigation
    • Maternity
    • (and 5 more)

      Tagged with:

      • Investigation
      • Maternity
      • Recommendations
      • Organisational culture
      • Patient harmed
      • Patient death
      • Organisation / service factors

    By Patient Safety Learning, 18 November, 2022

    • 0 comments
    • 993 views
    • 
    • Added by Patient Safety Learning
    • 18 November, 2022

19. Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report

    • Investigation
    • Recommendations
    • (and 11 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Maternity
      • Organisational culture
      • Baby
      • Patient harmed
      • Patient death
      • Patient / family involvement
      • Just Culture
      • Standards
      • Regulatory issue
      • System safety
      • Organisational learning

    By Patient Safety Learning, 17 November, 2022

    • 3 comments
    • 4,130 views
    • 
    • Comment by rich squince
    • 21 July, 2023

20. House of Commons debate – Abuse and deaths in secure mental health units (3 November 2022)

    • Mental health
    • Self harm/ suicide
    • (and 4 more)

      Tagged with:

      • Mental health
      • Self harm/ suicide
      • Patient death
      • Investigation
      • Children and Young People
      • Mental health unit

    By Mark Hughes, 4 November, 2022

    • 0 comments
    • 899 views
    • 
    • Added by Mark Hughes
    • 4 November, 2022

21. Independent investigation reports into the care and treatment of Christie, Nadia and Emily at Tees, Esk and Wear Valley NHS Foundation Trust (November 2022)

    • Mental health
    • Self harm/ suicide
    • (and 4 more)

      Tagged with:

      • Mental health
      • Self harm/ suicide
      • Patient death
      • Investigation
      • England
      • Children and Young People

    By Patient-Safety-Learning, 3 November, 2022

    • 0 comments
    • 2,512 views
    • 
    • Added by Patient-Safety-Learning
    • 3 November, 2022

22. House of Commons Debate - East Kent Maternity Services: Independent Investigation (20 October 2022)

    • Maternity
    • Investigation
    • (and 3 more)

      Tagged with:

      • Maternity
      • Investigation
      • Patient harmed
      • Patient death
      • Baby

    By Mark Hughes, 24 October, 2022

    • 0 comments
    • 853 views
    • 
    • Added by Mark Hughes
    • 24 October, 2022

23. Ministerial Statement: Independent Investigation into East Kent Maternity Services (19 October 2022)

    • Maternity
    • Investigation
    • (and 3 more)

      Tagged with:

      • Maternity
      • Investigation
      • Patient harmed
      • Patient death
      • Baby

    By Mark Hughes, 20 October, 2022

    • 0 comments
    • 863 views
    • 
    • Added by Mark Hughes
    • 20 October, 2022

24. Patient Safety Learning: Initial response to the East Kent Maternity Inquiry Report (19 October 2022)

    • Recommendations
    • Maternity
    • (and 7 more)

      Tagged with:

      • Recommendations
      • Maternity
      • Investigation
      • Patient harmed
      • Patient death
      • Baby
      • Leadership
      • Organisation / service factors
      • Teamwork

    By Patient Safety Learning, 19 October, 2022

    • 1 comment
    • 2,251 views
    • 
    • Comment by Sam
    • 7 November, 2022

25. 'Reading the signals': Maternity and neonatal services in East Kent – the Report of the Independent Investigation (19 October 2022)

    • Investigation
    • Recommendations
    • (and 6 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Patient death
      • Patient harmed
      • Maternity
      • Organisational learning
      • Patient / family involvement
      • Leadership

    By Patient Safety Learning, 19 October, 2022

    • 0 comments
    • 4,188 views
    • 
    • Added by Patient Safety Learning
    • 19 October, 2022