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Showing results for tags 'Investigation'.
Found 1,559 results
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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.
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Content ArticleCoroner regulations: Regulation 28 - Report on action to prevent other deaths. Regulation 29 - Response to a report on action to prevent other deaths.
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Content ArticleRule 43 reports were replaced on implementation of the Coroners and Justice Act 2009 with Reports on Action to Prevent Future Deaths (‘reports’) .For short they can be referred to as PFDs or PFD reports or Regulation 28 reports. These reports are important. Coroners have a duty not just to decide how somebody came by their death but also, where appropriate, to report about that death with a view to preventing future deaths. A bereaved family wants to be able to say: ‘His death was tragic and terrible, but at least it shouldn’t happen to somebody else.’ Broadly speaking reports should be intended to improve public health, welfare and safety. They should not be unduly general in their content; sweeping generalisations should be avoided. They should be clear, brief, focused
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Content ArticlePresentation from Patricia Harding, Senior Coroner, Mid Kent & Medway, North East Kent, Central & South East Kent on the role of the coroner. Includes reportable deaths, the Cor0navirus Act 2020, how to complete a MCCD, inquests, preparation of reports and giving evidence.
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Content ArticlePodcast from the NHS England and NHS Improvement National Patient Safety Team, where Tracey Herlihey, head of patient safety incident response policy, and Lauren Mosley, head of patient safety implementation, talk about the Patient Safety Incident Response Framework (PSIRF) which will be launched in Spring 2022. The framework is a key component of the NHS Patient Safety Strategy, and will outline how NHS providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. Once implementation is completed it will replace the current Serious Incident Framework. The podcast gives an overview of PSIRF and its key features, talks about findings from work with early adopters over the past two years to pilot an introductory version of the framework, and explains what providers can do now to prepare for its launch in the Spring.
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Content ArticleThe West Suffolk Review, commissioned by NHS England on behalf of the Department for Health and Social Care, was published last month. NHSE/I asked the West Suffolk Board to produce an action plan for the 28 January meeting of the Board of Directors. This paper summarises the current position in relation to the learning, reflection and response thus far, including the organisational development actions that have already been taken and require further embedding. It also highlights the engagement undertaken to date, and what more needs to happen, to ensure our plans are based on the priorities for staff, governors, patients and teams and can carry the confidence of stakeholders. The report, 'West Suffolk Review – organisational development plan (p. 217)', sets out nine broad themes of work, linked to the trust’s core functions, “that capture the priority areas for organisational and cultural development at WSFT in light of the learnings from the report”. The document sets out how the trust’s governance, freedom to speak up, HR, staff voice, patient safety and other parts of its corporate infrastructure failed and contributed to a scandal.
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Content ArticleThe COVID-19 pandemic placed unprecedented pressure on councils and care providers. A new report from the Local Government and Social Care Ombudsman analyses just how those organisations coped.
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Content ArticleA letter to the Chair of the Commons Health and Social Care Select Committee expressing concern that written evidence provided to the Committee's “Coronavirus: Lessons Learned to Date" inquiry was not properly considered and opportunities to protect healthcare workers from disease were missed.
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Content ArticleEvidence submitted outlining the issues relating to the protection of health and care workers. It explains how surgical masks are not 'protective' against airborne disease and represent a breach of COSHH Regulations.
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Content ArticleWith allegations into racial discrimination at the workplace rarely upheld by employers or courts, Roger Kline, Naledi Kline and Joy Warmington give a set of questions for investigators to ensure more robust investigations.
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HSIB Maternity newsletter (May 2021)
Patient Safety Learning posted an article in HSSIB investigations
HSIB is pleased to present the first quarterly newsletter sharing learning from trusts across the whole of England. The purpose of this newsletter is to allow clinical teams and trusts to share the changes that have been made as a result of the findings and recommendations from maternity investigations undertaken by the Healthcare Safety Investigation Branch (HSIB). These initiatives were developed by the trusts and their maternity teams, we would like to thank them for sharing their work with others. This approach to collaborative learning supports trusts to share resources and improvement ideas that relate to similar concerns each trust experiences, as they strive to continually improve the care and safety of mothers and their babies. These examples of learning reflect what is being implemented in trusts with varying requirements to support their maternity services. This allows what is learnt in Newcastle to be known about in Penzance. -
Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
