Jump to content

Search the hub

Showing results for tags 'Investigation'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Standards
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End

Group

First name

Last name

Country

Join a private group (if appropriate)

About me

Organisation

Role

Found 1,559 results
  1. Content Article
    Statement 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.
  2. Content Article
    The 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.
  3. Content Article
    It'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.
  4. Content Article
    The 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.
  5. 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.
  6. Content Article
    The 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.
  7. Content Article
    Fatigue 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.
  8. Content Article
    Many 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.
  9. News Article
    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
  10. News Article
    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
  11. News Article
    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
  12. News Article
    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
  13. News Article
    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
  14. News Article
    Whistleblowers at one of England's worst performing hospital trusts have said a climate of fear among staff is putting patients at risk. Former and current clinicians at University Hospitals Birmingham (UHB) NHS Trust allege they were punished by management for raising safety concerns, a BBC Newsnight investigation found. One insider said the trust was "a bit like the mafia". The trust said it took "patient safety very seriously". It said it had a "high reporting culture of incidents" to ensure accountability and learning. Staff concerns included a dangerous shortage of nurses and a lack of communication leading to some haematology patients dying without receiving treatment. The deaths of 20 patients in the haematology department of the Queen Elizabeth Hospital, which is run by the trust, led to a review in 2017 by consultant Emmanouil Nikolousis. Mr Nikolousis, who left the trust in 2020, told the BBC he was shocked by the failings he found and believes patients' lives could have been saved. A report by Mr Nikolousis criticised a lack of "ownership" of patients and a lack of communication among senior clinicians. In some cases this led to patients dying without having received treatment, he said. "Certainly there should have been different actions done," he said. "They could be saved. Certainly, when you don't have an action done, then you don't really know the outcome." Mr Nikolousis said he felt he had no option but to quit after his findings were ignored and his position was made "untenable". He left the NHS after 18 years. "They were trying, as they did with other colleagues, to completely sort of ruin your career," he said. Read full story Source: BBC News, 1 December 2022
  15. News Article
    Public health leaders were slow to act on repeated warnings over Christmas 2020 that contact tracing and isolation should be triggered immediately after a positive lateral flow test result, leaked evidence to the Covid inquiry shows. A scathing “lessons learned” document written by Dr Achim Wolf, a senior test and trace official, and submitted to the inquiry, gives his account of a trail of missed opportunities to improve the NHS test-and-trace regime in the first winter and spring of the pandemic – before vaccines were available. It suggests that people will have unnecessarily spread the virus to friends and relatives in the first Christmas of the pandemic and subsequent January lockdown period because they were not legally required to isolate and have their contacts traced as soon as they got a positive lateral flow test. Instead, for around two months, those eligible for rapid testing were told to get a confirmatory PCR test after a positive lateral flow. About a third of those who subsequently got a negative PCR result were likely to have had Covid anyway. In the “lessons learned” document seen by the Guardian, Wolf says: “Over the winter months, the prevalence in individuals who had 1) a positive lateral flow; followed by 2) a negative PCR; may have been upwards of 30%. These individuals were then allowed to return to their high-risk workplaces.” The former head of policy at NHS test and trace highlights how it took too long to get clear advice from Public Health England about policy on contact tracing and isolation rules in the face of changing scientific evidence on the accuracy of lateral flows. Read full story Source: The Guardian, 30 November 2022
  16. News Article
    The NHS could be facing its largest maternity scandal to date as the review into services in Nottingham is now expected to exceed 1,500 cases, The Independent has learned. The probe began in 2021 after this newspaper revealed dozens of babies had died or been left with serious injuries or brain damage as a result of care at NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC). But the scope of the investigation has more than doubled, with Nottingham University Hospitals NHS Trust sending more than 1,000 letters to families to contact the independent inquiry, after 700 families previously came forward with their concerns. Of these, the number of families expected to be covered by the probe is more than 1,500 – surpassing the 1,486 examined during the UK’s current largest maternity scandal in Shrewsbury. Read full story Source: The Independent, 30 November 2022
  17. News Article
    Five-year-old Yusuf Nazir died from pneumonia on Monday. It is reported an infection had spread to his lungs and caused multiple organ failure, resulting in several cardiac arrests. His family said they struggled to get the poorly child admitted to hospital in the run-up to his death, as they were told there were not enough beds or doctors available. His uncle, Zaheer Ahmed, said he had “begged” Rotherham General Hospital to take his nephew in. He told ITV’s Good Morning Britain a GP said Yusuf had “severe tonsilitis” and needed intravenous antibiotics - but the doctor had been told not to refer anyone to the ward and they needed to go to A&E instead. Mr Ahmed said he rang the hospital himself. “I begged them. I begged them. I’ve never begged for anything in my life and I begged them to help him,” the tearful uncle said. He said he told them Yusuf needed treatment but was told there were no beds. He claimed he was told: “What do you want me to do? Just get a bed out of the air? We’ve got kids waiting.” They say they drove him to the emergency department of Rotherham General Hospital the next day when his condition did not improve. The family waited for hours before Yusuf was seen but he was sent home even though the doctor treating him had said “it was the worst case of tonsillitis he had ever seen”, according to Mr Ahmed. Yusuf’s condition worsened while he was at home and his parents called an ambulance and insisted he was taken to Sheffield Children’s Hospital, where he later died. Rotherham NHS Foundation Trust has launched an investigation into Yusuf’s care. Read full story Source: The Independent. 29 November 2022
  18. News Article
    Patients who underwent brain operations at a West Midlands NHS trust suffered unnecessarily because of poor surgical outcomes, a report has found. More than 150 deep brain stimulation surgery cases at University Hospitals Birmingham (UHB) trust are now being investigated and surgery is suspended. There were unacceptable delays responding to patient concerns, the independent review also said. The investigation recommended indefinitely suspending the service at the NHS trust until it is safer. Deep brain stimulation (DBS) for movement disorders is used on patients with conditions including Parkinson's disease and dystonia, where medication is becoming less effective. The independent review, carried out by medics from King's College Hospital, was ordered by UHB after a serious incident investigation of a patient who underwent DBS for Parkinson's disease. One of those 21 people, Keith Bastable, 74, from Brierley Hill, had DBS in May 2019 for his Parkinson's disease and the review found his probes were placed too far away to be acceptable. Due to the misplacement, one was never switched on and the other probe had to be switched off as he suffered slurred speech and other side effects. They were removed and new ones recently reinserted in Oxford after he was referred to a hospital trust there. Mr Bastable said he had felt abandoned in the time it had taken to get resolved. Read full story Source: BBC News, 29 November 2022
  19. News Article
    A review of the clinical records of 44 patients who died under the care of former neurologist Michael Watt has found "significant failures in their treatment" and "poor communication with families". While this review looked at a sample of cases in which people died, potentially thousands more could be affected. The review arises from a 2018 recall of 2,500 outpatients who were in Dr Watt's care at the Belfast Health Trust. About one in five patients had to have their diagnoses changed. This separate review into 44 deaths was conducted by the Royal College of Physicians at the request of the regulator, the Regulation and Quality Improvement Authority (RQIA). It highlighted concerns over clinical decision-making, prescribing and diagnostics. It reveals a misdiagnosis rate of 45% among this group of patients, twice that for living patients. Speaking to BBC News NI, the RQIA's chair, Christine Collins, said the outcome of the review was "shocking and gut-wrenching as so many had experienced unpleasant deaths which they ought not to have done". Read full story Source: BBC News, 29 November 2022
  20. News Article
    Bosses at Nottingham's crisis-hit maternity units are set to miss a deadline for clearing a backlog of incomplete "serious incident" investigations. Nottingham University Hospitals Trust (NUH) has 53 outstanding maternity incidents yet to be investigated. The trust had said it aimed to complete investigations by December 23. But director of midwifery Sharon Wallis says they have not progressed as quickly as she had hoped. The Local Democracy Reporting Service said the trust has managed to clear a number of those incidents - but it declared another nine in September and October. An independent review team, led by senior midwife Donna Ockenden, is examining dozens of baby deaths at the trust. Read full story Source: BBC News, 25 November 2022
  21. News Article
    Hospital doctors failed to share with child protection services a list of "significant" injuries a five-year-old boy suffered 11 months before he was murdered, a case review has found. Logan Mwangi had a broken arm and multiple bruises across his body when he was taken to A&E in August 2020. But a paediatric consultant said these injuries were accidental and did not make a child protection referral. Logan, from Bridgend, was murdered by his mother, stepfather and a teenager. A Child Practice Review (CPR) has looked at how different agencies were involved with Logan's family in the 17 months before his death. Cwm Taf Morgannwg health board said it welcomed the commissioning of an independent review into how it identifies and investigates non-accidental injuries. The report said that if the injuries had been shared with social services, appropriate action could have been taken to safeguard Logan. Jan Pickles, the independent chair of the review panel, said it was a "a significant missed opportunity". She added: "Had further information from health been shared it most likely, though we cannot say for sure because of hindsight bias, would have triggered a child protection assessment in line with the joint agreed guidelines, as the nature of those injuries clearly met the threshold." Read full story Source: BBC News, 24 November 2022
  22. News Article
    A report by the Scottish Public Services Ombudsman (SPSO) said the health board's own investigation into the patient's complaint was of "poor quality" and "failed to acknowledge the significant and unreasonable delays" suffered. The delays led 'Patient C' to develop a severe hernia which left them unable to work, reliant on welfare benefits, and requiring riskier and more complex surgery than originally planned. The watchdog criticised NHS bosses for blaming Covid for the delays when the patient had been ready for surgery since December 2018, and said there had been "no sense of urgency" despite "the gravity of C's situation". The report said: "It is of significant concern that the Board has failed to fully acknowledge the consequences of the delays and the adverse effects upon C's physical and mental health as a result. "The consequences for C of these delays cannot and should not be underestimated." Read full story Source: The Herald, 24 November 2022
  23. News Article
    Ministers are considering the use of body cameras within mental health units as part of the government’s response to NHS abuse scandals, The Independent has learned. Senior sources with knowledge of the conversation between the Department for Health and Social Care and the NHS have raised concerns about the plans. There are fears that using the technology in mental health units could have implications for human rights and patient confidentiality. One senior figure criticised the proposals and said: “The DHSC are all talking about body-worn cameras, closed circuit TV, etc... The whole thing is fraught with huge difficulties regarding human rights, about confidentiality. They are thinking about it [cameras] and it is ridiculous.” The DHSC’s mental health minister Maria Caulfield said in parliament earlier this month that she and health secretary Steve Barclay were due to meet with NHS officials to discuss what response was needed to recent exposes of abuse within mental health services. It comes after a string of reports from The Independent, BBC Panorama and Dispatches revealing abuse of inpatients. The Panorama and Dispatches reports included video evidence of abuse captured by hidden cameras. Following a scathing independent review into the deaths of three young women, Tees, Esk and Wear Valleys NHS Trust said it is piloting the use of body-worn cameras across 10 inpatient wards “to support post incident reviews for staff and patients.” Read full story Source: The Independent, 23 November 2022
  24. News Article
    Greater Manchester’s mental health trust has been placed into the ‘equivalent of special measures’, the Manchester Evening News can reveal. The crisis measures enforced by the NHS come after allegations that patients were abused at a mental health unit run by the beleaguered trust. The Edenfield Centre is a mental health care facility in the grounds of the former Prestwich Hospital and was the subject of a BBC Panorama programme that claims patients were abused. Since the episode aired, 30 staff are facing disciplinary action and a dozen have already been sacked, the Manchester Evening News understands. The chair of the trust, Rupert Nichols, resigned last week after 'inexcusable behaviour and examples of unacceptable care' were 'exposed' at a mental health unit, he said. Now, NHS England is placing the Recovery Support Programme, the 'equivalent to the former special measures', multiple senior NHS sources say. Greater Manchester Mental Health NHS Foundation Trust (GMMH) is now under the highest level of NHS England intervention, the M.E.N. can confirm. Every trust is part of the NHS' Oversight Framework, those placed into its highest level are identified as experiencing the most significant and complex challenges in achieving financial sustainability and/or high-quality care receive intensive mandatory support. Read full story Source: 23 November 2022, Manchester Evening News
  25. News Article
    A maternity unit criticised for the preventable stillbirth of a baby is under investigation after the unexpected death of a second baby. The newborn baby died in December last year after her birth at the standalone midwifery-led unit (MLU) at Lagan Valley Hospital in Lisburn. Despite this, the unit continued to operate as normal for another three months when the South Eastern Trust temporarily paused births at the MLU. The second tragedy came four years after Jaxon McVey was stillborn when his delivery at the unit went catastrophically wrong. A post-mortem found he died as a result of shoulder dystocia – an obstetric emergency where the head is born but the shoulder becomes trapped behind the pubic bone. Jaxon’s mum, Christine McCleery, has hit out at the South Eastern Trust and raised concerns over the measures put in place following his stillbirth on Mother’s Day 2017. “I feel like they didn’t learn from Jaxon,” she said. “I don’t know if any other babies died before Jaxon, but I know one died afterwards. Read full story (paywalled) Source: The Independent, 23 November 2022
×
×
  • Create New...