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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation focuses on the systems used by healthcare providers to book patient appointments for clinical investigations, such as diagnostic tests and scans. ‘Clinical investigation booking systems’ are used throughout the NHS to support the delivery of patient care. Healthcare services use paper-based or fully electronic systems, or a combination of the two (hybrid systems), to communicate to patients the time, date and location of their appointment. These systems also produce information for patients about actions they need to take to prepare for their appointment. Written patient communication is a key output of clinical investigation booking systems. This investigation examines the safety implications of patient communications, produced by booking systems, that do not account for the needs of the patient. In addition, it looks at why patients are ‘lost to follow-up’ after an appointment is cancelled, rescheduled or not attended. Lost to follow-up is the term used to describe a patient who does not return for planned appointments (whether for continued care or evaluations) or is no longer being tracked in the healthcare system when they should be.
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Content ArticleA research paper was published in October 2021 highlighting results of Freedom of Information (FOI) Requests sent to NHS Trusts in England. The FOI Requests asked for the number of incidents of sexual assault reported by hospitals where the victim was aged over 60, and the alleged perpetrator was a member of staff. The resulting findings were that there were at least 75 reports of sexual assault on patients over 60 by hospital staff in the past five years. The findings also show that whilst the majority of victims were female, 30% were male and that a disappointing number were reported to police – only 16. Of these, 14 were closed as “No Further Action” by the police. In this viewpoint paper published in the Journal of Adult Protection, Amanda Warburton-Wynn highlights the findings of this research.
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Content ArticleHindsight bias (colloquially known as ‘the retrospectoscope’) is the tendency to perceive past events as more predictable than they actually were. It has been shown to play a significant role in the evaluation of an past event, and has been demonstrated in both medical and judicial settings. This study in Clinical Medicine aimed to determine whether hindsight bias impacts on retrospective case note review, through an internet survey completed by doctors of different grades. The authors found that in some cases, doctors are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. They also suggest that hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.
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Content ArticleOn 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.
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In this blog, Olivia Lounsbury, Committee Lead for Patients for Patient Safety US's National Patient Safety Oversight committee, looks at a new Bill calling for the creation of a US National Patient Safety Board (NPSB). She outlines why the NPSB is needed and demonstrates the importance of engaging patients and families in its design and processes. Olivia also look at existing healthcare safety organisations in other countries, highlighting the opportunity that the NSPB has to benefit from their approaches. -
Content ArticleSamuel Howes was 17 when he died by suicide in September 2020. Samuel had ongoing mental health issues including anxiety and depression. This led to his use of drugs and dependency on alcohol, which in turn further worsened his mental health. This blog by his mother Suzanne details her experience of the final day of the inquest into her son's death, which found multiple failings on the part of Child and Adolescent Mental Health Services (CAMHS), social services and the police.
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Content ArticleClinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
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Content ArticleNine care home workers are facing trial for neglecting, verbally abusing and deliberately antagonising extremely vulnerable patients at Whorlton Hall. The six men and three women, aged 25-54, are being prosecuted after a reporter went undercover and filmed the behaviour for a BBC Panorama documentary. George Julian repots on the case at Teesside crown court in Middlesbrough.
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Content ArticleSometimes after an incident, a system-wide change is implemented that makes work more difficult and creates new problems. This story from aviation is one such example, which contains useful lessons for responding to rare events. Steven Shorrock recounts the tale.
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In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.- Posted
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) will transition into new arms-length body The Healthcare Services Safety Investigation Body (HSSIB) in October 2023. In this article, HSSIB's Chair Designate, Ted Baker, reflects on: how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS. the role of HSIB over the last five years in identifying systemic causes of patient harm. what the future holds for HSSIB.
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Content ArticleThis blog by Dr Georgia Richards looks at the system of learning from preventable deaths in the UK. She highlights that following the publication of a Prevention of Future Deaths report (PFD), there is no system in place to ensure responses are received and actions are taken. She then describes how the Preventable Deaths Tracker collects information from PFDs to screen and analyse preventable deaths, so that lessons can be learnt
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Content ArticleNHS Wales has published a new report detailing the good progress being made to investigate and learn from hospital-acquired COVID-19 in Wales. Established in April 2022, the National Nosocomial COVID-19 Programme is supporting NHS Wales organisations to carry out a review of nosocomial (hospital acquired) COVID-19 patient safety incidents that occurred between March 2020 and April 2022. The programme has prioritised the investigation of the most complex cases, with an aim to provide as many answers as possible for service users, families, carers and staff impacted by nosocomial COVID-19. The programme also aims to maximise learning opportunities across NHS Wales, to drive quality and safety improvements.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply. Specifically, it looks into the use of tunnelled haemodialysis central venous catheters, which are a type of central line. The reference event involved Joan, who had a cardiac arrest caused by an air embolus after her haemodialysis catheter was uncapped, unclamped, and left open to air. This took place during a procedure to take blood culture samples to test for a possible line infection (where bacteria or viruses enter the bloodstream). This investigation’s findings, safety recommendations and safety observations aim to prevent the future occurrence of an air embolus following uncapped and unclamped haemodialysis catheters, and to improve care for patients across the NHS.
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Content ArticleOn 24 August 2022, the Employment Tribunal found that Mr Shyam Kumar, a consultant orthopaedic surgeon employed at University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB), had been disengaged from his role as a Specialist Advisor within the Care Quality Commission (CQC) on account of having made “protected disclosures” to the CQC. This means he had raised concerns with CQC about the health of patients and other important issues and had done so in the public interest. The Employment Tribunal found that the fact that he had raised these various concerns with CQC had materially influenced its decision to disengage him. It awarded him £23,000 in damages for injury to feelings, on account of what it described as “the inevitable impact” of CQC’s actions upon Mr Kumar’s reputation among his peers and the shock, confusion and concern it caused to him. The CQC has accepted these findings and apologised to Mr Kumar. CQC’s Chief Executive, Ian Trenholm, issued a public statement on 6 September 2022 about what occurred, including a recognition of the importance of the concerns Mr Kumar raised, the importance of the information raised by staff and the public generally, and the “vital role” played by Specialist Advisors in CQC’s inspections. Following this, Zoe Leventhal KC was appointed by CQC’s Executive Board to carry out an independent review into whether CQC took appropriate action as a regulator in response to the protected disclosures that Mr Kumar made, and whether it dealt appropriately with a sample of other instances where concerns have been raised with CQC.
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Content ArticleWomen should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs. That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk. This Parliamentary and Health Service Ombudsman (PHSO) report looks at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help families complain and help NHS organisations understand the issues.
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Content ArticleA number of serious concerns have been raised about the University Hospitals Birmingham NHS Foundation Trust, relating to patient safety, governance processes and organisational culture. The Trust has been under review by the Birmingham and Solihull Integrated Care Board (ICB), following a junior doctor at the trust, Dr Vaishnavi Kumar, taking her own life in June 2022. In response to these concerns, a series of rapid independently-led reviews have been commissioned at the Trust. This report outlines the outcomes of the first of these reviews, which is focused on clinical safety. It identified a number of issues which require attention, setting out 17 recommendations for further action.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the work of community mental health teams (CMHTs). Specifically, the investigation looked at the following four areas: assessing a patient’s risk of self-harm or suicide considering menopause as a risk factor for mental health conditions engaging with families caring for people with a first episode of psychosis. Reference event Ms A was 56 years old when she came into contact with mental health services for the first time in September 2019, following a suicide attempt. Ms A spent a month in hospital, and was then discharged home under the care of a community mental health team (CMHT) with a diagnosis of psychotic depression. At the end of May 2020, Ms A was again admitted to hospital following a second suicide attempt. She again stayed in the hospital for about four weeks before being discharged home under the care of a CMHT. Ms A was seen by CMHT workers regularly throughout July, and had a telephone review with a consultant psychiatrist. At the end of July, Ms A’s family became increasingly concerned about her mental state and were unable to make contact with her. On 2 August, Ms A was found deceased at home having died by suicide.
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Content ArticleThis video offers an introduction to the Systems Engineering Initiative for Patient Safety (SEIPS) framework, an approach that looks at work systems and processes from a systems-based perspective. SEIPS is the main model used within the Patient Safety Incident Response Framework (PSIRF) adopted by the NHS. This video includes an explanation of the model and a dramatisation of the process of making a round of tea in a staff room, illustrating the error traps and design issues present in the environment.
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Content ArticleThe Operating Room Black Box, a system of sensors and software, is being used in operating rooms in 24 hospitals in the US, Canada and Western Europe. The device captures video, audio, patient vital signs and data from surgical devices in an effort to improve patient safety. This article in the Wall Street Journal looks at how Black Box technology at Duke University Hospital has identified several areas for improvement, including that the hospital needed a better system for sending and tracking specimens. The article also highlights some concerns raised by healthcare professionals about the use of Black Boxes, including fear that data collected might be used to punish staff, or that it may be used as evidence in medicolegal cases outside of hospitals' control.
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Content ArticleThis editorial commentary, published in the Journal of the Royal College of Physicians of Edinburgh, looks at the College's response to the Mid Staffordshire inquiry.
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Content ArticleNiche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019. WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services. This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review.
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Content ArticleWithin the last two decades, it has been commonly agreed that patient safety and error management in healthcare organizations can best be attained by adopting a systems approach via re-engineering efforts and the introduction of industrial safety technologies and methodologies. This strategy has not delivered the expected result. Based on John Dewey’s pragmatism, in this study Kirstine Z. Pedersen and Jessica Mesman propose another vocabulary for understanding, inquiring into and learning from safety situations in healthcare. Drawing especially on Dewey’s understanding of transaction as the inseparability between human and environment, they develop an analytical approach to patient safety understood as a transactional accomplishment thoroughly dependent on the quality of situated and shared habits and collaborative practices in healthcare. They further illustrate methodologically how a transactional attitude can be situationally practised through video-reflexive ethnography, a method that allows for inquiry into mundane safety practices by letting interprofessional teams see, reflect upon and possibly modify their shared practices and safety habits.
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Content ArticleIn this blog, Sonia Barnfield, Clinical Adviser for Maternity Investigations at the Healthcare Safety Investigation Branch (HSIB), looks at risk assessments during the maternity care pathway, following HSIB's recent national learning report on the same subject. Sonia outlines the need for change in the way that risk during pregnancy is assessed and managed, highlighting that there is currently no single national guidance and that HSIB identified repeated examples of insufficiently robust, continuous risk assessment in the maternity pathway. She lays out six key themes highlighted in HSIB's report and looks at how risk assessments should change to improve safety for pregnant women and their babies.
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Content ArticleIn this blog, Laura Pickup, Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB) talks about NHS staff fatigue in the run up to World Sleep Day and HSIB's fatigue event on 17 March 2023. She looks at the scientific basis of fatigue and the impact it can have on safety in healthcare settings. She also examines how the rail industry has made changes to deal with staff fatigue and improve safety, highlighting the unique challenges faced by healthcare due to workforce shortages. Laura highlights the conversation that HSIB has initiated about fatigue in healthcare and how to tackle the challenges it poses to safety.
