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Showing results for tags 'Investigation'.
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Content ArticleThis annual publication presents statistics of deaths reported to Coroners in England and Wales in 2021. Information is provided on the number of deaths reported to coroners, post-mortem examinations and inquests held, and conclusions recorded at inquests.
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Content ArticleIn the first in a two-part series looking at the work of the coroner, James Sira talks to Derek Winter about the role of the coroner, medical examiner, and the coroner’s inquest. Derek is HM Senior Coroner for the City of Sunderland and was appointed as one of the two Deputy Chief Coroners of England and Wales in 2019. He has conducted a wide range of cases in the 15 years he has spent as a coroner and has modernised the Sunderland coroner service. Most intensive care doctors will at some point in their career be required to provide a statement for or give evidence at a coroner’s inquest, and this can be a daunting experience.
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Content ArticlePretty soon there won’t be a trust without an associate director or even board level director fully dedicated to all things equality, diversity and inclusion; relatively new senior roles that must have a purpose, job description and performance indicators. They will spend energy on yet more strategies, start from the top and hope something trickles down. Or they could start where the work is done, and build the tools to make equality, diversity and inclusion (EDI) everyone’s responsibility. Trusts are full of people passionate about EDI. So many roles, so many champions. They meet, share stories, and champion the importance of EDI. All this busyness typically outside a governed frame without the necessary reporting, investigating, actions, outcomes, learning, and measurable improvement. To normalise EDI and make it everyone’s responsibility will involve enabling reporting of EDI incidents, investigating it, taking action, and learning from it, writes Dr Nadeem Moghal in an article for HSJ.
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Content ArticleIn a 2021 survey conducted by the Federal Aviation Administration (FAA), 35% of engineers working for the aviation company Boeing said they couldn’t raise safety concerns without interference. As a result, US aviation regulators are opening a new review of Boeing. This article in the Irish Times outlines the issues faced by Boeing staff and the reasons for the FAA's concerns.
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Content ArticlePharmacists and pharmacy technicians across different settings work hard to provide person-centred, safe and effective care to patients. But, in reality sometimes things go wrong. The way that professionals respond to these situations is key to supporting the people affected and improving patient safety for the future. This guidance from the General Pharmaceutical Council aims to provide you with guidance on how to implement the Duty of Candour.
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Extravasation: a patient safety priority
Patient Safety Learning posted an article in Extravasation
Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. This leaflet describes the risks posed by extravasation to patients, the extent of the problem in the NHS and what is currently being done to reduce the risk of avoidable harm. The leaflet sets out the action to prevent, recognise, treat and report extravasation which is urgently needed. It emphasises the importance of all suspected extravasation injuries being reported and investigated, with reviews undertaken to learn and take action to prevent harm to future patients. -
Content ArticleDerek Richford shares Harry's Story from last year's HSJ Patient Safety Congress. Derek is grandfather of Harry Richford who died seven days after an emergency delivery at East Kent Hospitals Trust. Derek is joined by Donna Ockenden, Chair of the Independent review of maternity services at Shrewsbury & Telford Hospital, and Sarah-Jane Marsh, Chair of NHS England's Maternity transformation programme, in the 'Actioning recommendations from the Ockenden report' session at the Congress.
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Content ArticleThe Belfast Health Trust failed to intervene quickly enough in the practice of a doctor which led to Northern Ireland's largest ever patient recall, the Independent Neurology Inquiry has found. More than 5,000 former patients of neurologist Michael Watt were invited to have their cases examined for possible misdiagnoses. Among the conditions being treated were stroke, Parkinson's disease and multiple sclerosis (MS). The inquiry found "numerous failures". The Independent Neurology Inquiry concluded that the combined effect of the failures ensured that patterns in the consultant's work were missed for a decade.
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Content ArticleInvestigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.
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Content ArticleThe Royal Society's science and the law programme brings together scientists and members of the judiciary to discuss and debate key areas of common interest and to ensure the best scientific guidance is available to the courts. The judicial primers project is a unique collaboration between members of the judiciary, the Royal Society and the Royal Society of Edinburgh. Designed to assist the judiciary when handling scientific evidence in the courtroom, the primers have been written by leading scientists, peer reviewed by practitioners, and approved by the Councils of the Royal Society and the Royal Society of Edinburgh. Each primer presents an easily understood and accurate position on the scientific topic in question, as well as considering the limitations of the science, challenges associated with its application and an explanation of how the scientific area is used within the judicial system. The primers are created under the direction of a Steering Group chaired by Dame Anne Rafferty and distributed to courts in conjunction with the Judicial College, the Judicial Institute, and the Judicial Studies Board for Northern Ireland.
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Scottish Covid-19 Inquiry
Patient Safety Learning posted an article in Other reports and inquiries
The Inquiry is investigating the Covid-19 pandemic in Scotland. The Inquiry will establish the facts about the devolved response to the Covid-19 pandemic, in order to identify what lessons there are for the future. The aim is to learn from the handling of the Covid-19 pandemic. People in Scotland have suffered as a result of Covid-19. The Inquiry will examine what was done to face the challenge of the pandemic. The Inquiry will report on what worked well, areas where things could have been done better, and make recommendations. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment. HSIB has published an interim report outlining early investigation findings, and recommends a national response to tackle this urgent issue. Findings so far emphasise that an effective response should consider the interactions of the whole system: an end-to-end approach that does not just focus on one area of healthcare and prioritises patient safety. For its reference case, the investigation looks at the case of a patient who was found unconscious at home and taken to hospital by ambulance. The patient was then held in the ambulance at the emergency department for 3 hours and 20 minutes, and during this wait their condition did not improve. They were taken directly to the intensive care unit where they remained for nine days before being transferred to a specialist centre for further treatment.
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Content ArticleThis second comprehensive edition of these Principles is to help public authorities, industry and communities worldwide anticipate accidents involving hazardous substances resulting from technological and natural disasters, as well as sabotage. It addresses the following issues: preventing the occurrence of chemical accidents and near-misses; preparing for accidents through emergency planning, public communication, etc.; responding to accidents and minimising their adverse effects; and following-up to accidents, regarding clean-up, reporting and investigation.
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Content ArticleThis ITV documentary tells the story of how surgeon Ian Paterson duped his patients into believing they had cancer and performed unnecessary surgeries on them, before he was caught and jailed for 20 years in 2017. It features personal accounts of patients who were harmed by Paterson while he worked in NHS and private practice. Further reading: Report of the independent Inquiry into the issues raised by Paterson (4 February 2020) Patient Safety Learning’s response to the Paterson Inquiry (11 February 2020) Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson (16 December 2021)
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Content ArticleThis study by Sir Robert Francis QC looks at options for a framework for compensation for the victims of the infected blood tragedy. Sir Robert will give evidence about his work to the Infected Blood Inquiry in July. Before then, it is important that the Inquiry, and recognised legal representatives of its infected and affected core participants, have an opportunity to consider his work.
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Content ArticleLucie Musset, Senior Product Manager, and Hugh Archibald, Product Manager, at NHS England and NHS Improvement present on the new Learn from patient safety events (LFPSE) service (formerly known as PSIMS).
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Content ArticleIn this Editorial for the journal Midwifery, maternity experts come together to respond to the Ockenden review and discuss what went wrong and what needs to happen now.
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Content ArticleSir David Sloman, Chief Operating Officer NHS England and NHS Improvement, has sent a letter to the families involved in the Nottingham Maternity Inquiry announcing that Donna Ockenden will taking over the Inquiry. A copy of the letter is below and attached.
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Content ArticlePresentation slides from NHS England and NHS Improvement's Tracey Herlihey, Head of Patient Safety Incident Response Policy, Lauren Mosley, Head of Patient Safety Implementation and Matthew Fogarty, Associate Director of Patient Safety (Policy and Strategy) on the Patient Safety Incident Response Framework (PSIRF).
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Content ArticleAlexander James Davidson was aged 17 years and 6 months when he died at the Queens Medical Centre on 26 February 2018. Alex was previously fit and well before suddenly taking ill with abdominal pain on 17 January 2018. Between that date and his admission to the Queens Medical Centre on 8 February 2018, Alex made contact with his GP on three occasions, had four telephone triage assessments undertaken by the NHS 111 service and two admissions to his local Accident & Emergency Department at the Kingsmill Hospital. Alex’s symptoms of sudden onset acute abdominal pain, tachycardia, and vomiting and diarrhoea were attributed either to stress or to a bout of gastroenteritis. At no stage prior to 8 February 2018 was gallstones or pancreatitis considered as a differential diagnosis. When Alex was eventually admitted to the Queens Medical Centre Emergency Department on 8 February 2018, he was found to be septic as a result of an infected and necrotic pancreatic pseudocyst, which had evolved as a complication of gallstone pancreatitis, a rare condition in someone of Alex’s age. Despite medical intervention, Alex did not survive. The inquest explored the medical treatment and intervention that Alex received in the six weeks prior to his death. The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition
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Content Article
Prevention of Future Deaths: Sebastian Hibberd (23 August 2019)
Sam posted an article in Coroner reports
Sebastian Hibberd, 6 years old, became ill on Saturday 10 October having developed intussusception of the bowel. He deteriorated over the weekend. His father sought medical advice on the Monday from NHS 111 and from his GP's surgery. Sebastian's condition went unrecognised as being life threatening. There were several missed opportunities for him to receive life saving treatment. Sebastian suffered a cardiac arrest and transferred to Derriford Hospital where he sadly died in the Emergency Department shortly after his arrival on the 12 October. -
Content ArticleMyla Deviren had congenital intestinal malrotation and developed a volvulus on 26 August 2015. Her mother checked the NHS Symptom finder on line and the advice was to take her to A&E but she called 111 for advice. The Health Assistant who took the call did not appreciate the significance of key symptoms due to multiplicity of symptoms described at the outset. He passed the caller on a “ warm” transfer to the Clinical Adviser whose initial reaction on hearing that the symptoms included blue lips and breathlessness was to call an ambulance, ignored her instincts and took mum through a series of digital pathways re lesser symptoms. When directly asking about the breathlessness Myla's mum put the phone close to her daughter enabling the Clinical Adviser to hear the rapid breathing herself however they did not appreciate the significance of it and did not call an ambulance. She did however pass the call to the Out Of Hours Nurse who decided that this was a case of gastroenteritis early in the call and did not appreciate the description of a child with worsening signs. Whilst the precise point at which Myla stopped breathing is not known it was sometime between when she was last seen alive approximately 06.00 and then found unresponsive at 08.00 on the 27 August 2015. She was then taken by ambulance to Peterborough City Hospital where, despite attempts at resuscitation, she did not recover a heartbeat and she died. Post mortem revealed small bowel infarction from untreated small intestinal volvulus. It is probable that with earlier transfer to hospital by ambulance and with appropriate treatment Myla would have survived.
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Content ArticleTeri Price has been on a pretty steep learning curve since her husband Greg’s death. She (like many people) made a lot of assumptions about the healthcare system. She assumed that every possible action to make care safe would be undertaken and that healthcare providers worked in a supportive, collaborative environment where they could focus on their patients. Over the last couple of months, leading up to today, Teri has been reflecting on what has happened in the last ten years and what we have learned.
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Content Article
Falling through the cracks: Greg’s story
Patient Safety Learning posted an article in Patient stories
Falling Through the Cracks: Greg’s Story is a short film on Greg Price’s journey through the healthcare system. The film gives a glimpse of who Greg was and focuses on the events of his healthcare journey that ended in his unexpected and tragic death. In spite of the sadness of Greg’s Story, the message of the film is intended to inspire positive change and improvement in the healthcare system. Greg's family believe the film will resonate with the audience and create a platform for further dialogue. They hope people will feel empowered and challenge the status quo of the current healthcare system so we all end up with better care and outcomes. -
Content ArticleSystemic racism in maternity care is an urgent human rights issue. For too long, evidence and narratives about why racial inequities in maternal outcomes persist have focussed on Black and Brown bodies being the problem – ‘defective’, ‘other’, a risk to be managed. Birthrights’ year-long inquiry into racial injustice has heard testimony from women, birthing people, healthcare professionals and lawyers outlining how systemic racism within maternity care – from individual interactions and workforce culture through to curriculums and policies – can have a deep and devastating impact on basic rights in childbirth. This jeopardises Black and Brown women and birthing people’s safety, dignity, choice, autonomy, and equality. The inquiry’s report, Systemic Racism, Not Broken Bodies, uncovers the stories behind the statistics and demonstrates that it is racism, not broken bodies, that is at the root of many inequities in maternity outcomes and experiences.
