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Showing results for tags 'Investigation'.
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Content ArticleIn this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
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Content ArticleIncreasing adverse events, hospital-associated infections, and other harm to patients have compounded and now fuel the call for the formation of a national patient safety board in the USA. But, with so many established health entities already within the government, will adding one create more complexities than it will oversight? A bill introduced in the House in December 2022 proposes such a body loosely modelled off the National Transportation Safety Board. The group behind the efforts for the board's creation note in a document that it still would not be the "sole solution" needed to properly address patient safety issues nationally, but rather is designed to "augment" the work of other federal agencies and patient safety organisations. The bill proposes that it would not be necessary to identify providers in reports that the board would investigate, and some patient safety experts say this is not the right approach, noting that it would not provide the accountability necessary — particularly since the board would be nonpunitive to begin with. But others argue that this structure could help promote voluntary reporting for more data collection. Three patient safety professionals shared their takes in Becker's Hospital Review.
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Content ArticleSome of the same people that noted surgical masks were useless for airborne viruses also made decisions to limit the use of effective respirator masks: a decision that had devastating ramifications when the pandemic struck. In this article in the Byline Times, Josiah Mortimer delves deeper into a hub blog written by David Osborn: 'The pandemic – questions around Government governance' and questions the decisions made by the Government during the pandemic.
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Content ArticleThe Director of Investigations will be an established leader and confident working alongside system leaders to play a crucial part in supporting the long-term strategic transformation of patient safety. This is an exciting period of change, and HSSIB are looking for an established senior leader to drive the transformation of investigations and insight teams to improve patient outcomes. Pay scheme: VSM Closing date for applications is 19 September 2023 Please note: This role is not part of NHS England and will start once the Health Services Safety Investigations Body (HSSIB) is established as a stand-alone organisation in October 2023.
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Content ArticlePatient Safety Learning invited David Osborn, a chartered safety and health practitioner and member of the Covid Airborne Transmission Alliance (CATA) to give a talk to the Safer Healthcare and Biosafety Network (SHBN) explaining what CATA is, its aims and objectives and its involvement with the UK Covid-19 Public Inquiry. Here is a recording of David's talk and the presentation he delivered.
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Content ArticleThis report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2022/23. During this period HSIB completed 702 reports and made more than 1,380 safety recommendations.
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HSIB Annual Review 2022/23 (1 August 2023)
Mark Hughes posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) Annual Review 2022/23 looks back at its work over this period, during which HSIB published 16 investigation reports and issued 36 safety recommendations to 13 different organisation. -
Content ArticleWitness statement from Professor Kevin Bampton LLB FCMI FRSA FHEA, who is also: a member of the Covid-19 Airborne Transmission Alliance (CATA) Chief Executive Officer of the British Occupational Hygiene Society (the Chartered Society for Worker Health Protection) on the Board of the Council for Work and Health Chair of the British Standards Institute Health and Safety Management Committee Chair to the Occupational Health Multidisciplinary Forum a member of the International Standards Organisation Infectious Diseases Committee. In response to the COVID-19 Inquiry Rule 9 Request in relation to Module 1, Professor Kevin Bampton responds to the Inquiry's questions under four broad headings: i) overview of who CATA is, how it was formed and why ii) discussion of the basis in principle for claiming that the failure to recognise the airborne route of transmission was a fundamental barrier in pandemic resilience, preparedness and emergency planning iii) expressing CATA's position, advocacy and engagement around issues of pandemic resilience, preparedness and emergency planning iv) CATA's proposed lines of enquiry and interim recommendations for Module 1.
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Content ArticleThis investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic.
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Content ArticleWhen many people think about NHS services they often think about clinical staff, such as doctors or nurses, and how they deliver care and interact with patients and families. However, in the context of patient safety, there is often more to see ‘behind-the-scenes’ in non-patient facing services. These services may be less visible, but they play a vital part in ensuring patient safety. Understanding the importance of these services, and how they are crucial to the ability of the NHS to operate effectively, is often underestimated. In this blog for the Healthcare Safety Investigation Branch (HSIB), National Investigators Russ Evans and Craig Hadley highlight how 'behind-the-scenes' services are crucial to help the NHS operate effectively and safely.
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Content ArticleA useful glossary attached of PSIRF terms and acronyms created by the Tavistock and Portman NHS Foundation Trust. See also: HSIB: Safety investigation jargon buster
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Duty of Candour for Wales
Gethin posted an article in NHS Wales (Gig Cymru)
The Duty of Candour for Wales statutory guidance. -
Content ArticleWales' national policy on patient safety incident reporting and management.
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This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. -
Community PostI’ve just been listening to the 10 o’clock news tonight and it has been covering the report into Paterson, the breast surgeon who may have needlessly operated on thousands on women. One of the recommendations is that patient safety should be a ‘top priority’ across the NHS (again!!). Another interesting recommendation is that the NHS (and private healthcare providers) need to be better at sharing information about medical staff. Currently, medical staff seem to be able to be investigated in one hospital, and then move to another without any of their history following them. Maybe we need some sort of central system, like Doctify for employers? What do you think?
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Community Post
The Patient Safety Incident Response Framework
Jon Holt posted a topic in Investigations, risk management and legal issues
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Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?- Posted
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Investigation methodologies - please help colleagues in Australia
HelenH posted a topic in Investigations, risk management and legal issues
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Dear hub members We've a request to help from New South Wales. They and their RLDatix colleagues request: The public healthcare system in New South Wales (NSW), Australia is changing how we investigate health care incidents. We are aiming to add to our armoury of investigation methods for serious clinical incidents and would love to hear your suggestions. Like many health care settings worldwide, in NSW we have solely used Root Cause Analysis (RCA) for over 15 years. We are looking for alternate investigation methods to complement RCA. So we are putting the call out … Are there other serious incident investigation methods (other than RCAs) you would recommend? What’s been your experience with introducing and/or using these methods? Do you have learnings, data or resources that you could share? Do you have policy or procedure documents about specific methods? Any journal articles – health care or otherwise – that are must-reads? We've many resources on investigations on the hub and recent thinking in the UK and internationally that might be of value including: UK Parliamentary report - Investigating clinical incidents in the NHS and from that the creation of A Healthcare Safety Investigation Branch applying a wide range of methodologies in national learning investigations informed by ergonomics and human factors UK's NHS Improvement recent engagement on a new Serious Incident Framework (due to piloted in early 2020) Dr Helen Higham work with the AHSN team in Oxford to improve the quality of incident investigations Patient engagement in investigations Lessons to be learned from Inquiries into unsafe care and reflections on the quality of investigations Insights by leading investigators and resources written specifically for us by inclusion our Expert Topic Lead @MartinL Do check these out in this section of the hub https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/ Please add to this knowledge and give us your reflections. We'd be happy to start up specific discussions on topics of interest. Thank you all, Helen- Posted
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Who should investigate?
Patient Safety Learning posted a topic in Investigations and complaints
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Great blog in Learn from Martin on who should be in an investigation team - the expertise of the team, their roles and responsibilities. Do you agree?- Posted
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Unexpected deaths in patients known to Mental Health Services
Catherine Evans posted a topic in Investigations, risk management and legal issues
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Does anyone have examples of templates they use for reviewing unexpected deaths in the community of patients known to mental health services?- Posted
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Content ArticleThis webpage explains the approach of the Parliamentary and Health Service Ombudsman (PHSO) to financial remedy relating to complaints against organisations. Where someone believes they have experienced an injustice or hardship because an organisation has not acted properly, or has given a poor service and not put things right, PHSO makes recommendations on the amount of compensation based on its severity of injustice scale. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts the PHSO would usually recommend in those circumstances.
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Content ArticleIn this report, Professor Brian Edwards summarises contributions given to the UK Covid-19 Inquiry by various politicians and senior civil servants, relating to how prepared the UK and Scottish Governments were for the Covid-19 pandemic. It contains reflections on the contributions of: Nicola Sturgeon (First Minister of Scotland during the pandemic) Matt Hancock (Secretary of State for Health and Social Care during the pandemic) Jenny Harries (Chief Executive of the UK Health Security Agency) Emma Reed (civil servant, DHSC)
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UK Covid 19 Inquiry Hearings
Patient Safety Learning posted an article in Covid-19 Inquiry
All the public and preliminary hearings from the Covid 19 Inquiry can be found here. -
Content ArticleHealth and care services in England are not always able to provide individualised, equitable and coordinated palliative and end of life care (PEoLC) to meet the holistic needs of people and their families. To understand the impact of inconsistent palliative care, the Healthcare Safety Investigation Branch (HSIB) looked at the case of Dermot, a 77-year-old cancer patient. Dermot's case shows the gap between what is needed and what is available. HSIB make three safety recommendations to NHS England aimed at improving the delivery of palliative and end of life care.
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Content ArticleNHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues.
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Content ArticleGloucestershire Hospitals NHS Foundation Trust introduced a policy for reviewing deaths in 2017 based on the structured judgement review (SJR) methodology, which identified triggers for which deaths to review. To support implementation, the Datix system was modified to report deaths. The new tool required a culture change in how mortality was reviewed and raised concerns regarding responsibilities, workload and resource. This webpage and poster describe the quality improvement process and how these issues were overcome.
