Search the hub
Showing results for tags 'Investigation'.
Found 1,566 results
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
Content ArticleStatement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
-
Content ArticleThe NHS Patient Safety Incident Response Framework (PSIRF) was launched in 2022 and is intended for full implementation by Autumn 2023. PSIRF requires Integrated Care Board (ICB)’s to work collaboratively with providers to develop a Patient Safety Incident Response Plan (PSIRP) and Patient Safety Incident Response Policy. Within the PSIRP, each organisation must work with their ICB and other stakeholders to identify how it will respond proportionately to all incidents requiring investigation. Suffolk and North East Essex NHS Foundation Trust share their Standard Operating Procedure on PSIRF ICB sign off process.
-
Content ArticleIt's now a decade since the Francis Report, which outlined the causes of serious failures in care at Mid Staffordshire NHS Foundation Trust. The report and prior media coverage exposed a wide set of issues surrounding the culture and transparency of health care, and these topics remain of major concern today. In this article for the Nuffield Trust, Shaun Lintern has interviewed Sir Robert Francis KC about the weight of those patient stories and treatment of the NHS's staff, then and now.
-
Content ArticleThe UK Covid-19 Inquiry is the independent public inquiry set up to examine the UK’s response to the Covid-19 pandemic, assess the impact of the pandemic and learn lessons for the future. The Inquiry is Chaired by Baroness Heather Hallett, a former Court of Appeal judge. This is a recording of the UK Covid-19 Inquiry's preliminary hearing for its third investigation looking at the impact of the pandemic on healthcare. The agenda includes: introductory remarks from the Chair update from Counsel to the Inquiry including designation submissions from core participants. Read the transcript of the hearing.
-
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Laura and Suzy talk to us about the importance of embedding human factors in the design of healthcare systems and tools, the importance of equipping staff to think about system safety, and their work to establish a nationwide conversation about the impact of fatigue. -
Content ArticleThe Healthcare Safety Investigation Branch (HSIB) have published a third interim report for this investigation which focuses on staff wellbeing across the urgent and emergency care systems and the impact that this has on patient safety.
-
Content ArticleFatigue is increasingly considered as one of the most significant hazards to aviation safety and other safety-critical industries. Both the academic community and industry have focused on understanding the phenomenon of fatigue and the factors that contribute to it in order to prevent it, but also to mitigate its possible consequences. As a result, procedures and regulations have been developed for operators to comply with and there is now a requirement for operators to demonstrate that they are actively managing fatigue. The aim of this white paper by Clockwork Research is to provide safety practitioners with a better understanding of the process of investigating fatigue.
-
Content ArticleMany clinicians and managers struggle with the concept of waste in clinical processes. After hearing and reading about the transformation of healthcare at Virginia Mason Medical Center in Seattle, the Gordon Caldwell read Toyota Culture the Heart and Soul of the Toyota Way. This article discusses some of the concepts of waste in clinical processes, concentrating particularly on the waste and costs of over-investigation.
-
News Article
Three investigations launched into trust beset by bullying and safety scandals
Patient Safety Learning posted a news article in News
Three “major” reviews are being launched into a struggling teaching trust in response to growing concerns over bullying and poor workplace culture. Birmingham and Solihull integrated care board has begun a series of investigations into University Hospitals Birmingham, whose chief executive announced he was standing down last month. The first review will get under way immediately and will focus on specific allegations made recently on BBC Newsnight. These include patient safety concerns, the “bullying” of clinicians and the issues raised by a review of 12 patient deaths undertaken by former consultant Dr Manos Nikolousis in 2017. It will be led by an “experienced senior independent clinician” from outside the local health system who is expected to report by the end of January. The second and third investigations will review the trust’s leadership and broader cultural issues respectively. The probes will be carried out with UHB and NHS England. Both are expected to report in the first half of 2023. Read full story (paywalled) Source: HSJ, 9 December 2022 -
News Article
Parents of man left to die in prison say care failures will haunt them for ever
Patient Safety Learning posted a news article in News
The parents of a 25-year-old man left to die in a cell by a negligent prison nurse given responsibility for 800 inmates have told how the conditions in which their son died will haunt them for ever. The case – the 27th death in just five years at HMP Nottingham – was said to illustrate the desperate state of Britain’s understaffed and increasingly dangerous prison system. Alex Braund was being held on remand awaiting trial when he fell ill in his cell with the first signs of pneumonia on 6 March 2020. Four days later, on the morning of 10 March, after a series of ill-fated attempts by Braund’s cellmate to get prison staff to take the situation seriously, the young man collapsed. Prison staff responded to an emergency bell rung by Braund’s cellmate at 6.55am, but they initially only looked through the cell hatch, taking five minutes to enter the cell in order to give CPR. Braund was subsequently taken to Queen’s medical centre in Nottingham, where he was pronounced dead at 11.44am of cardiac arrest caused by pneumonia. The jury at an inquest at Nottinghamshire coroner’s court found there had been a “continuous failure to provide adequate healthcare”, with a prison officer told by a nurse a few hours before Braund’s death that there was “nothing to be done at this time of night”. Questioning during the hearing revealed that the nurse, who has since lost her job and been reported to the nursing and midwifery council, had amended her records on the morning of Braund’s death. Read full story Source: The Guardian, 6 December 2022 -
News Article
Prolific surgeon ‘harmed more than 100 patients’
Patient Safety Learning posted a news article in News
A consultant orthopaedic surgeon who carried out double the average number of knee and hip operations over a three year-period is facing a tribunal over alleged misconduct and more than 100 legal cases lodged by former patients, HSJ has been told. Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, is currently appearing before a misconduct hearing. The tribunal is investigating allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It has also been alleged that Mr Parker performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest. The trauma and orthopaedic surgeon is also facing allegations that he added pre-typed operation notes to approximately 14 patients’ records ahead of an invited review into his clinical practice by the Royal College of Surgeons, without indicating they had been made retrospectively. Read full story (paywalled) Source: HSJ, 5 December 2022 -
News Article
More than 10,000 patients given faulty knee replacements
Patient Safety Learning posted a news article in News
More than 10,000 patients have been given a faulty knee replacement which doubles the risk of joint failure, The Telegraph has disclosed. The implant, which has been in use since 2003, was withdrawn from the market by its manufacturer in October. The Telegraph has learnt that UK health regulator the Medicines and Healthcare products Regulatory Agency (MHRA) is now preparing to issue a field safety notice, prohibiting its use. Available across multiple NHS trusts, the implant, manufactured by Zimmer Biomet, a US firm, has been shown to fail in up to 7% of patients after ten years - twice the accepted failure rate of 3.5% set by the National Joint Registry. One study found the failure rate to be much higher at 17.6% - more than five times as high as the accepted level. This can have catastrophic consequences for patients, many of whom are elderly, as undergoing a second knee replacement operation poses a much greater risk. The knee replacement, called the Nexgen, is part of a family of Zimmer Biomet implant devices with 88 possible variants. In total, these have been given to over 183,000 people in England, Wales and Northern Ireland, and more than five million worldwide. Of these variants, three combinations have been proven to place patients at a dangerously high risk of joint failure. Read full story (paywalled) Source: The Telegraph, 5 December 2022 -
News Article
Dr Ted Baker announced as the new Chair of HSSIB
Patient Safety Learning posted a news article in News
Dr Ted Baker has been formally appointed as the new chair of the Health Services Safety Investigations Body (HSSIB). The Secretary of State for Health and Social Care, Rt Hon Steve Barclay MP, made the announcement today (1 December 2022). Dr Baker is a retired consultant paediatric cardiologist, and most recently was Chief Inspector of Hospitals at the Care Quality Commission (CQC) between 2017 and 2022. Dr Baker says: “I am delighted to be joining such a ground-breaking organisation. I have been impressed by the quality of the work coming from the HSIB and I am excited to be joining the organisation at such an important time in its history." Source: HSIB, 1 December 2022
