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Showing results for tags 'Investigation'.
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Content Article
In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).- Posted
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Content ArticleTwo professionals who treated Jack Adcock before his death were convicted of gross negligence manslaughter, receiving 24-month suspended sentences. His nurse, Isabel Amaro, was erased from the nursing register; but after reviews in the High Court and Court of Appeal, his doctor, Hadiza Bawa-Garba, was merely suspended. Nathan Hodson explores the proposition that nurses are at greater risk of erasure than doctors after gross negligence manslaughter through a close reading of the guidance for medical and nursing tribunals informed by analysis from the High Court and Court of Appeal in the Bawa-Garba cases.
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Content ArticleThe Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
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Content ArticleIn this article in the journal Health Expectations, the authors explore how current investigative responses can increase the harm for all those affected by failing to acknowledge and respond to the human impacts. They argue that when investigations respond to the need for healing alongside learning, it can reduce the level of harm for everyone involved, including including patients, families, health professionals and organisations.
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Content ArticleAt the moment, we’ve got maternity scandals day in, day out, which are pure evidence of the fact that our maternity units are just not up to scratch. They’re unsafe for mothers, unsafe for babies, and that is not acceptable. Suzanne White, a former radiographer and a clinical negligence lawyer for the past 25 years, looks at the maternity safety scandals across the NHS and considers if any lessons have been learnt.
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Preventable deaths tracker
Patient-Safety-Learning posted an article in Coroner reports
The Preventable Deaths Tracker was set up to explore concerns raised by coroners to prevent future deaths. The tracker aims to collate data, information and analysis arising from coroners reports and other investigations and make it accessible for all. It hopes to warn against repeat hazards and highlight important lessons, to improve public safety, reduce avoidable harms and prevent premature deaths. The tracker was originally developed with funding from the National Institute for Health Research (NIHR) School for Primary Care Research. -
Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. Pulmonary embolisms can form when clots from the deep veins of the body, usually originating in the legs, travel through the venous system and become lodged in the lungs. A person suffering from a pulmonary embolism requires urgent treatment to reduce the chance of significant harm or death.
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Content ArticleThis Joint Committee on Human Rights inquiry will look at human rights concerns in care settings in England, highlighting areas in which the human rights of patients, older people and others living with long-term disabilities, including learning disabilities and autism, are currently undermined or at risk.
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Content ArticleThis chapter from the book 'Learning from High Reliability Organisations' focuses on a systems-based technique for accident analysis referred to as the AcciMap approach. The technique involves the construction of a multi-layered diagram, in which the various causes of an accident are arranged according to their causal remoteness from the outcome. It is particularly useful for establishing how factors in all parts of a sociotechnical system contributed to an organisational accident and for arranging the causes into a coherent diagram that reveals how they interacted to produce that outcome. By identifying these causal factors and the interrelationships between them in this way, it is possible to identify problem areas that should be addressed to improve the safety of the system and prevent similar occurrences in the future.
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Content ArticleThroughout Jens Rasmussen’s career there has been a continued emphasis on the development of methods, techniques and tools for accident analysis and investigation. In this paper, Waterson et al. focus on the evolution and development of one specific example, namely Accimaps and their use for accident analysis.
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Content ArticlePatient safety, staff moral and system performance are at the heart of healthcare delivery. Investigation of adverse outcomes is one strategy that enables organisations to learn and improve. Healthcare is now understood as a complex, possibly the most complex, socio-technological system. Despite this the use of a 20th century linear investigation model is still recommended for the investigation of adverse outcomes. In this review, Isherwood and Waterson use data gathered from the investigation of a real life healthcare near incident and apply three different methodologies to the analysis of this data. They compare both the methodologies themselves and the outputs generated. This illustrates how different methodologies generate different system level recommendations. The authors conclude that system based models generate the strongest barriers to improve future performance. Healthcare providers and their regulatory bodies need to embrace system based methodologies if they are to effectively learn from, and reduce future, adverse outcomes.
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Content ArticleAll health and care professionals have an ethical responsibility to be open and honest with service users and their employers when things go wrong with a person’s care. This is otherwise known as the professional duty of candour. Learn more about the Duty of Candour on the Health and Care Professions Council website.
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Content ArticleSharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this blog, Sharon reflects on events that have unfolded since the publication of the Independent Medicines and Medical Devices Safety Review 'First Do No Harm' report and the Government's response to it. She examines ongoing failures in the government's response and fulfilment of their policy recommendations. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Primodos: The next steps towards justice (November 2020) Mesh: Denial, half-truths and the harms (March 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy
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UK Covid-19 Public Inquiry (10 March 2022)
Patient Safety Learning posted an article in Covid-19 Inquiry
This is the independent public inquiry to examine the UK’s preparedness and response to the Covid-19 pandemic, and to learn lessons for the future. The Inquiry has been established under the Inquiries Act 2005. This means that the Chair will have the power to compel the production of documents and call witnesses to give evidence on oath. The Chair has been appointed and will set out her vision for the Inquiry’s work in the coming months. The Inquiry has received the draft Terms of Reference from the Cabinet Office, and will open a public consultation tomorrow, Friday 11 March. The consultation will remain open for four weeks, and will be available online. See the UK COVID-19 Inquiry: draft terms of reference. -
Content ArticleMr M was convicted of the murder of a man in October 2017 whilst under the care of the Thomas project in Salford. The Thomas project provides a range of recovery focused services through detox and residential rehabilitation into community-based provision. This is the report of the independent investigation into the care and treatment of mental health service user Mr M.
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Content ArticleMr A experienced mental health issues over a number of years. He was arrested and charged with the murder of Philip Owen in October 2017 and was later found guilty of manslaughter. He was sentenced to an indefinite hospital order to treat his mental illness and has been detained in a secure hospital. This is the report of the independent investigation into his care and treatment under Greater Manchester Mental Health NHS Foundation Trust.
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Content ArticleThis is the executive summary of the independent investigation report into the care and treatment of 16 year-old David, who committed suicide in October 2016. At the time of his death David was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust.
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Content ArticleThis is the report of an independent assurance review of North West Boroughs’ internal investigation which considered the care and treatment of mental health service user A. User A was found guilty of manslaughter in May 2018 and was ordered by the court to be detained under Section 37/41 of the Mental Health Act (1983) in a medium secure hospital. At the time of the homicide, mental health service user A was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust.
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Content ArticleThis is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user David at North West Boroughs Healthcare NHS Foundation Trust, published in June 2020.
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Content ArticleThis is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user Mr A in Greater Manchester, which was published in 2020.
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This is the third in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Deinniol tells us about how his role at the Healthcare Safety Investigation Branch (HSIB) helps make healthcare services in the UK safer for both patients and staff. He explains the importance of understanding the complexity of healthcare systems and the pressures that staff within the NHS face. He highlights the need build trust with patients, staff and other stakeholders to find ways forward in improving patient safety. -
Content ArticleNHS England commissioned this external review of all Independent Investigations following Mental Health Homicides (IIMHH) and related national governance arrangements. The review considered investigations undertaken between 2013 and 2017. NHS England has accepted the report findings and has developed an action plan which is being implemented and monitored via regional and national governance mechanisms.
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Content ArticleThis Annual Report provides an overview of independent investigations commissioned by regional independent investigation teams, primarily relating to homicides committed by patients in receipt of mental health services. Focusing on financial years 2019/20 and 2020/21, it details the key findings from investigations and the performance of the commissioning arrangements.
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Content ArticleThe rapid review was commissioned by NHS England and NHS Improvement, following concerns raised by staff at The Christie Hospital in relation to the Research & Innovation department. The review makes a number of recommendations and the Trust will be developing and action plan to address these.
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Content ArticleIn this episode of the Institute of Economic Affairs (IEA) Podcast, IEA Head of Political Economy Dr Kristian Niemietz discusses the findings of the Independent Medicines and Medical Devices Safety Review, and how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices. Kristian speaks with Simon Whale, panel member and communications lead for the Independent Medicines and Medical Devices Safety Review and Dr Sonia Macleod, lead researcher, Independent Medicines and Medical Devices Safety Review. They discuss how the NHS, and other health bodies, could improve their services to address poor care and prevent harm.
