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Showing results for tags 'Investigation'.
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Content ArticleThis Care Quality Commission (CQC) briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS. It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review. The briefing provides a summary of the findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.
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Content ArticleThis powerful blog by Sarah Seddon discusses her experience during a 'fitness to practice' hearing. Sarah is a clinical pharmacist, however , has now found herself as a witness following the tragic death of her son Thomas. This blog explains what it is like for the witness during the process and how it made her feel.
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Content ArticleThis is part three of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’. It concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types was introduced. That facts are best collected by a minimum of two investigators. Pictures being our friend, and the cognitive interview concept was introduced. This part focuses on ‘Who’ should investigate and deals with the experience and expertise of the team, their roles and responsibilities in the light of the facts they will collect. This blog is aimed at individual trusts and organisations rather than regulators/national bodies, etc.
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Content ArticleAn extensive governance review of the events leading to the closure of Tawel Fan ward in December 2013 and a review of the current governance arrangements in older people’s mental health in Betsi Cadwaldr University Health Board.
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The Shipman Inquiry (2002-2005)
PatientSafetyLearning Team posted an article in Other reports and inquiries
Harold Fredrick Shipman was convicted at Preston Crown Court on 31 January 2000 of the murder of 15 of his patients while he was a General Practitioner at Market Street, Hyde, near Manchester and of one count of forging a will. He was sentenced to life imprisonment. On 1 February 2000, the Secretary of State for Health announced that an independent private inquiry would take place to establish what changes to current systems should be made in order to safeguard patients in the future. The Inquiry's First Report was published on 19 July 2002 and its Final Report on 27 January 2005. -
Content ArticleThis investigation was prompted by evidence given to the Bristol Royal Infirmary Inquiry which spoke of the benefits of retaining hearts for the purpose of study and teaching and identified Alder Hey as holding the largest collection. Previously, the Director of the Association of Community Health Councils had expressed concerns about contraventions of the Human Tissue Act 1961 to the then Secretary of State for Health.
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Content ArticleNHS England published an independent report into the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust and highlighted a system-wide response. The report was commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust. Both Southern Health NHS Foundation Trust and the clinical commissioning groups (CCGs) that commission services from them have accepted the recommendations.
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Content ArticleThe Gosport Independent Panel was set up to address concerns raised by families over a number of years about the initial care of their relatives in Gosport War Memorial Hospital and the subsequent investigations into their deaths. The Report is an in-depth analysis of the Gosport Independent Panel’s findings. It explains how the information reviewed by the Panel informed those findings and illustrates how the disclosed documents add to public understanding of events at the hospital and their aftermath.
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Content ArticleAn independent review into the widespread failings by Liverpool Community Health Trust. The review conducted by Dr Bill Kirkup CBE, commissioned by NHS Improvement, looks into the issues at the Trust from November 2010 to December 2014. It also looks at the oversight of the Trust by the NHS Trust Development Authority, NHS England and commissioners.
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Content ArticleChaired by Robert Francis QC, this Inquiry was set up to examine the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Inquiry looked at why the serious problems at the Trust were not identified and acted on sooner, to identify important lessons to be learnt for the future of patient care.
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Content ArticleThe Inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary.
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Content ArticleThe preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died. This is a review of all deaths of people in receipt of care from Mental Health and Learning Disability services in the Trust between April 2011 and March 2015. It is not a clinical case review of each service user and we have therefore not tried to identify clinically unavoidable deaths. It does seek to establish the extent of unexpected deaths in Mental Health and Learning Disability services provided by the Trust and to identify any themes, patterns or issues that may need further investigation based on a scope provided by NHS England. We were asked to benchmark this Trust with other similar organisations where this was possible. In the report, we focus on the responsibilities as they impact on the Trust to report deaths and then to secure the right level of review, enquiry or investigation. However, the responsibility for investigating deaths lies with a number of organisations across the area and we refer to these responsibilities where appropriate.
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Content ArticlePresentation from Dr Helen Highham at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticleThe Healthcare and Safety Investigation Branch (HSIB) identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in a patient inadvertently receiving two anticoagulant medications at the same time, possibly causing an episode of gastrointestinal (digestive tract) bleeding. Increasingly, healthcare facilities in primary and secondary care are introducing digital solutions (electronic prescribing and medicines administration (ePMA) systems) to improve medicines safety. However, analysis of the reference event identified how ePMA systems can create their own risks – risks that will need to be addressed as these systems become more widespread. Other risk factors relating to prescribing and the discharge of the patient, including medicines reconciliation, availability of pharmacy services and weekend working, were identified during the investigation.
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Content ArticleConcern was raised about a number of deaths at Furness General Hospital leading to the establishment of the Morecambe Bay Investigation in September 2013, led by Dr Bill Kirkup. In May 2018 the Professional Standards Agency published a ‘Lessons Learned Review’ into the handling of concerns relating to the fitness to practise of nurses in Furness General Hospital (now part of the University Hospitals of Morecambe Bay NHS Foundation Trust) by the Nursing and Midwifery Council (NMC). Amongst other issues, the report identified problems with the handling of a document produced by the father of one of the babies who died at Furness General Hospital. In August 2018, the NMC commissioned Verita to carry out an independent audit to review the way the NMC handled the chronology. The audit was asked to focus on the NMC’s systems and processes in order to establish what happened to the chronology and to identify learning for the NMC from the case. Verita is a consultancy specialising in the management and conduct of investigations, reviews and inquiries. Peter Killwick and Kieran Seale carried out the investigation which was supported by Bethany Simpson.
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Content ArticleA protocol for liaison and effective communications between the NHS, Association of Chief Police Officers (replaced in 2015 by a new body, the National Police Chiefs' Council) and Health and Safety Executive (HSE). Although now archived in The National Archives, much of the protocol is still relevant today. The protocol took effect in circumstances of unexpected death or serious untoward harm requiring investigation by the police, or the police and the HSE jointly. The protocol sets out the general principles for the NHS, police and HSE to observe when liaising with one another. It focused on investigations in NHS Trusts, although the principles and practices it promotes should apply to other locations where healthcare is provided and the NHS is required to investigate under its performance management and other duties.
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Bottle of Lies by Katherine Eban
Patient Safety Learning posted an article in Recommended books and literature
The troubles of Indian pharma companies abroad raise questions about the domestic drug regulator. Although Bottle of Lies, a book about the quality problems plaguing generic drugs, focuses on medicines intended for American consumers, the real and continuing victims of the failings described in the book are consumers in developing countries, including Indians. In May 2013, soon after the erstwhile Ranbaxy Laboratories admitted in an American court to selling adulterated drugs, journalist Katherine Eban published a gripping 10,000-word account of the saga in Fortune magazine. But the story left Eban wondering if Ranbaxy was an isolated case. Could there be more rotten eggs, she asked, given the United States Food & Drugs Administration’s (FDA) lax policing of overseas manufacturers? Bottle of Lies is the result of the multi-year investigation that followed. -
Content ArticleThe phrase “lessons learned” is such a common one, yet people struggle with developing effective lessons learned approaches. The Lessons Learned Handbook is written for the project manager, quality manager or senior manager trying to put in place a system for learning from experience, or looking to improve the system they have. Based on experience of successful and unsuccessful systems, the author recognises the need to convert learning into action. For this to happen, there needs to be a series of key steps, which the book guides the reader through. The book provides practical guidance to learning from experience, illustrated with case histories from the author, and from contributors from industry and the public sector.
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Content ArticleAction Against Medical Accidents (AvMa) is a UK charity for patient safety and justice. AvMA supports people affected by avoidable harm in healthcare; to help them achieve justice; and to promote better patient safety for all.
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Content ArticleThe Citizens Advice provides advice on how to take legal action to get compensation for clinical negligence.
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Content ArticleFollowing the inquest into the death of former patient Amy Allan and the subsequent Preventing Future Deaths report given to Great Ormond Street Hospital for Children, Chief Executive Matthew Shaw would like to outline how the hospital is learning from this and what action has been taken to address the concerns that have been raised.
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Content ArticleThe All Party Parliamentary Group (APPG) for Whistleblowing was launched in July 2018 to look at the case for an Independent Office for the Whistleblower. The APPG have set an ambitious workplan aiming to take back the UK’s lead on this legislation, proposing to deliver world class, gold standard draft legislation – a global solution to a global problem. The objectives of the APPG for Whistleblowing are: Influencing policies and decisions that affect whistleblowers globally. Drafting legislation to ensure effective protection for whistleblowers. Commissioning and publishing research, based on our work with whistleblowers and relevant groups and stakeholders across all sectors. Engaging our supporters in campaigns to influence decisions affecting whistleblowers. Giving whistleblowers safe platforms to speak out on issues affecting them. Promoting positive social attitudes towards whistleblowing. Encouraging MPs to promote positive recognition for whistleblowers. Supporting and upskilling MPs and their staff to identify and manage constituent whistleblower cases.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) latest report highlights that mislabelling of blood samples could pose a deadly risk to patients. The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating. There’s the potential for serious injuries and even death.
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Content ArticleThis is part two of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’ and concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types rather than by (deep breath) public speakers, non-technical skills (NTS) professionals, those who create team talks, medics who have been on a course about being nice and polite to other medics, and those that have married a human therefore they must be qualified to talk about humans – was also discussed. This and the next blog will introduce the concept of where facts or data comes from. Later blogs will deal with the who, how, when etc. The ‘who’ investigates (next blog) really is determined by where the facts come from. Later – if the cake lasts – we can chat about what to do with the data, and how to report it and save lives.
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Why investigate? The patient's perspective
Joanne Hughes posted an article in Investigations and complaints
A brief, heartfelt piece presented purely from the harmed patient's perspective and urging those involved in making decisions about whether or not to investigate to consider the impact of a good investigation on the ability of the harmed patient and their family to heal... Well received on twitter and described by a number of patients as 'you've said what I feel'. A reminder that a crucial purpose of the investigation is to give a harmed patient and their family a full explanation to help them understand, process and share for learning their experience. All necessary to their recovery. All necessary to their own 'safety' following an incident (we know poor responses cause additional suffering to those already harmed). The author also highlighted (via twitter) how much of this blog relates to the needs of staff involved in incidents too...- Posted
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