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Showing results for tags 'Investigation'.
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Content ArticleThis article in the Manchester Evening News details the experience of Amy, whose daughter Harper was stillborn following failings in Amy's care. After being induced, Amy was left on her own in a room at the Royal Oldham Hospital's maternity unit overnight, without any monitoring. She had raised concerns about her baby's reduced movements but was denied additional checks. When Amy was finally checked in the morning, Harper had no heartbeat. An internal investigation conducted by The Royal Oldham Hospital found that if Amy had received appropriate monitoring, CTG abnormalities would have been noticed. This would have led to an escalation in her care, earlier delivery and Harper is likely to have been born alive.
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Content ArticleIn healthcare, there is a well-recognised gap between what we know should be done, and what is actually done. This article considers new models that look at the implementation of evidence-based practice in healthcare systems, particularly looking at the application of a conceptual model called 'sticky knowledge'.
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Content ArticleThese slides provide the outline of a tutorial about the Causal Analysis using System Theory (CAST) and System-Theoretic Accident Model and Processes (STAMP) approaches to accident analysis, delivered at the Second STAMP Conference in 2013. The presentation slides cover: Model and method: Why STAMP and CAST? Why do accident analysis? Goals for an accident analysis technique Overcoming hindsight bias CAST worked example of emergency plane landing
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EventThe NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This virtual conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements. The conference will also discuss the role of Medical Examiners which were introduced in April 2019, providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and to improve patient safety. Register hub members can receive a 20% discount. Email info@pslhub.org to receive the discount code.
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EventuntilThe Westminster Health Forum is a division of Westminster Forum Projects, an impartial and cross-party organisation which has no policy agenda of its own. Forums operated by Westminster Forum Projects enjoy considerable support from within Parliament and Government. The agenda: The impact of investigations in the NHS and the priorities of the Healthcare Safety Investigation Branch Progress of improving patient safety in the NHS Maintaining patient safety during COVID-19 - rapid learning to respond to the virus, continuity of care, and adapting care delivery practices Delivering safe care in the NHS - preventing errors, utilising data and technology, supporting the workforce, and promoting high quality leadership Learning from the voice of parents and families How to improve patient safety by reducing unwarranted variation and learning from clinical negligence claims The role of technology in reducing errors, enhancing care, and ensuring safety in remote healthcare and telemedicine Taking forward the National Patient Safety Syllabus and supporting the workforce to deliver care safely during the presence of COVID-19 Learning from harm, reducing the cost of litigation in the NHS, and the impact of COVID-19 Assessing findings from the Independent Medicines and Medical Devices Safety Review The role of the regulator in reducing avoidable harm and informing future practice Register
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EventuntilThe story of Alison Bell, and her family's uncovering of the truth about what happened to her in the care of an NHS Trust will be told by her brother Tom. He will describe the nature of the various investigations that were held into Alison's death and the role of the prevailing cultures within the public sector organisations they have dealt with; the NHS, Police, CPS and Regulatory Bodies. This true and ongoing story shines a light on the personal, emotional and financially costly impact that public sector service cultures can have on the lives of their service-users and their own bottom-line. Tom’s lived and current experience will help us to explore the implications for our own practice and the organisations we might seek to influence, manage and lead. Registration
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In Conversation Live with David Sellu
Patient Safety Learning posted an event in Community Calendar
David Sellu FRCS, distinguished Consultant Colorectal Surgeon, will be joining RSM President Professor Roger Kirby for an extraordinary discussion about his unfair trial, his imprisonment, and his subsequently quashed conviction for Gross Negligence Manslaughter. He will be talking about his highly acclaimed and candid book, Did He Save Lives? A Surgeon's Story, patient safety and the practice of defensive medicine, as well as what the future now looks like for him. In February 2010, David operated on a patient and despite his efforts, the patient died two days later. There followed a sequence of extraordinary events that led to David being convicted of Gross Negligence Manslaughter. He served 15 months in prison and eventually released on licence. His licence to practise medicine was suspended, his career cut short. It was later discovered that David's trial was unfair, and with Dr Jenny Vaughan leading the campaign along with friends, family and colleagues, David won the appeal against his conviction and is now a free man. The shock waves caused by David’s conviction has led more medical professionals to practise defensive medicine. This could have a huge impact on patient care in the future as our population ages and their health needs become more complex. Register -
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Root Cause Analysis: 1 Day Masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. hub members can receive a 10% discount with code hcuk10psl. Further information and registration -
Content ArticleParty leaders have written an open letter to Boris Johnson asking him to ensure recommendations made by Baroness Cumberlege are put in place. It's more than three months since her review found three treatments - mesh, primodos and sodium valproate - ruined thousands of lives.
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Content ArticleRobbie Powell, 10, from Ystradgynlais, Powys, died at Swansea's Morriston Hospital, of Addison's disease in 1990. Four months earlier Addison's disease had been suspected by paediatricians at this hospital, when an ACTH test was ordered but was not carried out. Although Robbie's GPs were informed of the suspicion of Addison's disease, the need for the ACTH test and that Robbie should be immediately admitted back to hospital, if he became unwell, this crucial and lifesaving information was not communicated to Robbie's parents. At the time of Robbie's death, the Swansea Coroner refused the Powells' request for an inquest claiming that the child had died of natural causes. However, the Powells secured a 'Fiat' [Court Order] from the Attorney General in 2000 and an inquest took place in 2004, fourteen years after Robbie died. The verdict was 'natural causes contributed by neglect' confirming that an inquest should have taken place in 1990. Since Robbie's death, his father Will Powell, has mounted a long campaign to get a public inquiry into Robbie's case.
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Content ArticleIdentifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk.
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Content ArticleRoot Cause Analysis (RCA) is a generic method used in quality improvement and patient safety projects. In patient safety, it should help teams to ‘get to the bottom’ of the circumstances that led or could lead to an incident and take appropriate and effective action to prevent the recurrence of the incident or minimise the probability of recurrence. Find out more about RCA in this Healthcare Quality Quest booklet.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation focused on: the management of VTE risk in inpatients following thrombolysis for an acute stroke detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke.
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Content ArticleThe Cornwall and Isles of Scilly Safeguarding Adults Review into The Morleigh Group has found elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated. The Morleigh Group operated seven homes in Cornwall and has since shut down. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
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Content ArticleDr Bill Kirkup, Chairman of the Morecambe Bay Investigation, presented at the Patient Safety Learning Conference on the common themes that have emerged, and the lessons we need to learn, from the numerous high-profile inquiries in which he has played a leading role.
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Content ArticleKeith Conradi, Chief Investigator at the Health Service Investigation Branch, presented at the Patient Safety Learning Conference on HSIB’s challenges and achievements in its first year.
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Content ArticleSacha Wells-Munro, Maternity Improvement Advisor at NHS Improvement and Professor Tim Draycott, consultant obstetrician and Health Foundation Improvement Science Fellow, present at the Patient Safety Learning Conference the lessons learned from the Morecambe Bay maternity scandal and changes needed to improve the safety of maternity services system wide.
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Content ArticleElderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
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Content ArticleThis Independent Report was commissioned by NHS Improvement to review the deaths set out above, after Southern Health NHS Foundation Trust had requested their assistance. This Report considers in the order of their deaths: 1. Robert Small, who died on September 17, 2012 2. David West, who died on October 21, 2013 3. Edward Hartley, who died on May 28, 2014 4. Marion Munns, who died on November 12, 2015
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts a four-month patient safety investigation that was launched following concern that patients were contracting COVID-19 after being admitted to hospital. The report references data presented to SAGE in mid-May that suggested around 20% of patients were reporting symptoms seven days after admission. The aim of the investigation was to understand the factors that could contribute to the risk of transmission, how the NHS operates to reduce that risk and where there may be opportunities to reduce that risk even further. The investigation represented the voices of those working across the health service, from strategic national planners to hospital porters. It also captured experiences of patients and families, providing further insight into the challenges of managing the transmission of COVID-19.
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Content ArticleThis statement has been developed and signed by several long COVID patient groups. It outlines a number of their concerns regarding approaches to treatment, in particular, the fear that psychological treatments will be favoured over clinical investigation.
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Content ArticleThe objective of this investigation was to explore the care of patients who have ureteric stents inserted following a diagnosis of a kidney or ureteric stone. A ureteric stent is a narrow tube that is inserted into the ureter (the tube that connects the kidney to the bladder) to help with urine drainage. The reference event investigated was a woman who suffered an episode of kidney stones which was treated successfully but required the insertion of a ureteric stent. The stent was left in situ (in position) for a longer period than intended and became encrusted – that is, minerals filtered from the bloodstream attached to and built up on the stent. This led to the patient needing a more extensive operation to remove the stent. The findings and conclusions aim to prevent the future occurrence of unplanned delayed removal of stents and improve care for patients across the NHS.
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Content ArticleA report by Fiona Ritchie OBE, Chair on behalf of Oliver’s Independent Panel for NHS England and NHS Improvement, has been published following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s Learning Disability Mortality Review (LeDeR) review into the death of Oliver McGowan.
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Content ArticleThis short blog from Jerome, a patient safety manager, gives a brief description of root cause analysis and asks why the NHS spends so much time generating root cause analysis reports rather than focussing on what changes should happen afterwards to current systems and processes.
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Content ArticleThis is a video recording of a formal meeting (oral evidence session) of the Health and Social Care Select Committee on Tuesday 29 September 2020, as part of their inquiry looking at the Safety of maternity services in England.
