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Content ArticleThis policy explains how the Structured Judgement Review (SJR) process is implemented within Maidstone and Tunbridge Wells NHS Trust. The policy advises staff on how to undertake a mortality case record review, which documentation to use, in which circumstances an SJR is required and how the new process relates to previous systems and processes. The policy also explains how the process links to revised mortality reporting, escalation of concerns and dissemination of learning. It covers all inpatients and Emergency Department patients who die whilst in the Trust’s care, and patients who die within 30 days of discharge.
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Content ArticleSince retiring from his role in public health, Dr Bill Kirkup has focused on independent investigations into public service failures, including maternity services at Morecambe Bay and East Kent. In this podcast, Bill talks to Parliamentary and Health Service Ombudsman Rob Behrens about his career, what he's learnt during his investigations and how we can make more progress in improving patient safety.
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In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report.- Posted
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Content ArticleA number of serious concerns were 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. A follow up report into concerns raised about University Hospitals Birmingham NHS Foundation Trust has now been published showing the progress made against the recommendations made in the clinical safety (phase 1) report. It also collates the evidence from phase 2 and 3 of the review and assesses how the lessons learned can at this point be incorporated into the recovery and development plan that the Trust is already progressing. It also takes account of any other concerns that have arisen or been communicated to the review team.
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Content ArticleProfessor Brian Edwards summarises this week's evidence in the Covid-UK inquiry.
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Content ArticleThere have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
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Content ArticleThis report examines the reporting of patient deaths at the Norfolk and Suffolk Foundation NHS Trust (NSFT) between April 2019 and October 2022. It was undertaken by Grant Thornton on behalf of the NHS Suffolk and North East Essex and NHS Norfolk and Waveney integrated care boards at NSFT’s request.
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Content ArticleThis report highlights the failure to learn from preventable state related deaths in the UK. It focuses on concerns around the implementation of recommendations following inquests, public inquiries, investigations and official reviews, calling for the creation of a new independent public body, a National Oversight Mechanism, to address this. The report was launched as part of the ‘No more deaths’ campaign by Inquest, an independent charity combining specialist support for bereaved people following a state related death with campaigning for justice and change.
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Content ArticleCommunity public access defibrillators (CPADs) contain an automated electronic device (AED) that, in the event of a sudden out of hospital cardiac arrest, can provide lifesaving treatment by delivering an electric shock to the heart. CPADs can be found in public areas such as disused telephone boxes or community centres, and often the defibrillators are locked and a special code is needed to open the unit. In this blog, Sharon Perkins, HSIB Maternity Investigator, looks at the issues surrounding the accessibility of CPADs. During the course of a maternity investigation, the HSIB team became aware of instances where access to CPADs had been restricted by their location and lack of registration.
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Content ArticlePaul Brand investigates why 6,000 people have been given "notices to quit" by care homes across England, and why so many people are being kicked out of them.
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Content ArticleSickle cell disease is the name for a group of inherited red blood cell disorders that affect haemoglobin, which is a protein in red blood cells that carries oxygen through a person’s body. It mainly affects people from African or Caribbean backgrounds, though it can affect anyone. It affects approximately 15,000 people in the UK. In November 2021, the All-Party Parliamentary Group for Sickle Cell and Thalassaemia published a report detailing the issues that people with sickle cell disease experience in relation to their care. The report made 31 recommendations to organisations across the healthcare system to help address these issues. HSIB launched two investigations (see also: Management of sickle cell crisis) to find out what additional learning or knowledge could be added in this area and to provide further insights into the practical challenges that patients with sickle cell disease may face when receiving NHS care. This investigation set out to review the care of patients with sickle cell disease who need to have an invasive procedure. Invasive procedures involve accessing the inside of a patient’s body, either through an incision (cut) or one of the body’s orifices. Specifically, the investigation focused on: how haematology teams – the specialists who treat people with blood disorders – are involved and informed when a patient with sickle cell disease is treated in another area of healthcare how patients with sickle cell disease are prepared for invasive procedures how and where clinical information relevant to the patient is shared.
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Content ArticleSickle cell disease is the name for a group of inherited red blood cell disorders that affect haemoglobin, which is a protein in red blood cells that carries oxygen through a person’s body. It mainly affects people from African or Caribbean backgrounds, though it can affect anyone. It affects approximately 15,000 people in the UK. In November 2021, the All-Party Parliamentary Group for Sickle Cell and Thalassaemia published a report detailing the issues that people with sickle cell disease experience in relation to their care. The report made 31 recommendations to organisations across the healthcare system to help address these issues. The Healthcare Safety Investigation Branch (HSIB) launched two investigations (see also: Invasive procedures for people with sickle cell disease) to find out what additional learning or knowledge could be added in this area and to provide further insights into the practical challenges patients with sickle cell disease may face when receiving NHS care. HSIB used a real patient safety incident, referred to as ‘the reference event’, to explore how sickle cell crises are managed within hospital settings. In particular, the investigation considered: the knowledge nursing staff may have about the care of patients in sickle cell crisis how patient-controlled analgesia (PCA) – where a patient can use a device to give themself doses of pain relief medication – is considered holistically, such as monitoring the patient and staff workload.
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Content ArticleThese templates were developed by Liverpool Heart and Chest Hospital for use in After Action Review, SWARM and Rapid Review toolkit responses.
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Content ArticleThis study aimed to operationalise and use the World Health Organization's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths.
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Content ArticleOn the 9 October 2021 an investigation was carried out into the death of Ms Sandra Diane Finch, a 44 year old woman who had a history of Type 1 diabetes mellitus. The investigation concluded at the end of the inquest on 3 May 2023. The conclusion of the inquest was a narrative conclusion of ketoacidosis due to insulin depravation contributed to by neglect. The cause of death was: 1a) Ketoacidosis 1b) Uncontrolled Type 1 Diabetes Mellitus 1c) Insulin depravation.
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Content ArticleIn this blog, specialist medical negligence solicitor Maria Panteli discusses the upcoming investigation and possible inquests into deaths relating to jailed breast surgeon Ian Paterson. She looks at what families of those affected by his treatment can expect and covers topics including:What happens at a Pre-Inquest Review?Who takes part in an inquest?How can the medical negligence solicitors help?
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Content ArticleBackground to the independent review by Lewisham and Greenwich into Dr Chris Day's whistleblowing case.
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Content ArticleIn the first in a series of blogs looking at the range of investigation methods used by HSIB, Nichola Crust reflects on how Appreciative Inquiry can be used to examine patient safety and identify opportunities for learning.
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The National Institute for Health and Care Research (NIHR) Evidence Collections draw together evidence from important NIHR-funded and wider research. They aim to help people in policy and practice understand recent important research in a topic area. The most recent Collection is Maternity services: evidence for improvement. In this blog, one of the Collection's authors, Candace Imison, describes how it was framed by the findings from a recent investigation into failings in East Kent Hospitals’ maternity services. She focuses on some key messages from evidence on how to identify poor performance and provide effective board governance and oversight. -
Content ArticlePaediatric wards in acute hospitals are increasingly caring for children and young people (CYP) who have mental health needs. Paediatric wards are primarily designed to accommodate children with physical health needs and are not specifically designed to help keep children and young people with mental health needs safe. This national investigation looks at the risk factors associated with the design of paediatric wards in acute hospitals for children and young people with mental health needs.
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Content ArticleSignificant Event Audit (SEA) ensures that primary care teams learn from patient safety incidents and ‘near misses’ by highlighting both strengths and weaknesses in the care provided. This guidance from the Royal College of General Practitioners (RCGP) aims to enable primary care teams to conduct an effective SEA with the aim of improving care for all patients.
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Content ArticleEnsuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult.
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Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist -
Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
