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Showing results for tags 'Investigation'.
Found 1,563 results
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Content ArticleThe Parliamentary and Health Service Ombudsman (PHSO) was set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. This report look at how a man died after excessive wait for cancer treatment.
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Content ArticleThis note provides guidance to those who may be approached to give evidence as a witness if you were involved in providing care and treatment to a claimant on behalf of a Trust.
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Content ArticleThe Parliamentary and Health Service Ombudsman (PHSO) has published a report following investigations into the deaths of two vulnerable young men. They found a series of significant failings in their mental health care and treatment. The PHSO are publishing the report and recommendations to alert parliament to systemic problems in care and treatment of patients with acute mental health problems at former North Essex Partnership University NHS Foundation Trust. NHS Improvement has agreed to establish a review in line with our recommendations and will share any learning it identifies across the NHS as needed. The North Essex Partnership University NHS Foundation Trust (now merged into the Essex Partnership University NHS Foundation Trust) has accepted the recommendations and are committed to continuing to work the PHSO to put things right. It is important the NHS understands why this happened and what lessons can be learned to prevent it happening again.
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Content ArticleConnor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. Following publication of this report in February 2014, Oxfordshire Safeguarding Adults Board and NHS England (South) commissioned a second report in June 2014 to find out whether there were wider commissioning, leadership or management issues that could have contributed to the inadequate care that Connor received.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) became operational on 1 April 2017. Their purpose is to improve safety through effective and independent investigations that don't apportion blame or liability. Although funded by the Department of Health & Social Care and hosted by NHS England and NHS Improvement, HSIB operates independently. It is also independent from regulatory bodies like the Care Quality Commission (CQC). By offering a new perspective and developing meaningful and influential recommendations, they aim to drive positive change at a wider level.
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Content ArticleA new medical examiner system is being rolled-out across England and Wales to provide greater scrutiny of deaths. The system will also offer a point of contact for bereaved families to raise concerns about the care provided prior to the death of a loved one. Acute trusts in England and local health boards in Wales have been asked to begin setting up medical examiner offices to initially focus on the certification of all deaths that occur in their own organisation. The purpose of the medical examiner system is to: provide greater safeguards for the public by ensuring proper scrutiny of all non-coronial deaths ensure the appropriate direction of deaths to the coroner provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased improve the quality of death certification improve the quality of mortality data.
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After completing nearly 600 investigations and research projects in human factors, it might be worth sharing some observations of why we do incident (forensic) investigations. This will be a series of short blogs that will cover the investigation process, answer questions about humans and shine a light on the method of forensic investigations. This will be undertaken alternating with the topic of human factors – the most misunderstood bit of science the healthcare sector deals with. In these posts I’ll cover what human is, the limits of human performance – covering the senses, fatigue – and why pilots and CRM is very dangerous to healthcare. Above all I want to get the idea that human factors is a science and it’s about understanding how human limits restrict how we deal with the built environment and complex systems.- Posted
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The Last Time We Spoke – A Carer’s Story
Claire Cox posted an article in Patient stories
Based on the testimony of eight families, this drama-documentary was commissioned in response to a series of investigations where poor carer experience was a particular feature. -
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Patient Stories: Beth's story (27 December 2013)
Claire Cox posted an article in Patient stories
A moving and challenging short film about the Bowen family following the tragic death of five year old Bethany during ‘routine’ surgery and subsequent sudden death of father Richard aged 31, following the trauma of his daughter’s death and the ‘torture’ of the inquest. -
Content ArticleThe Canadian Incident Analysis Framework is a resource to support those responsible for, or involved in, managing, analysing and/or learning from patient safety incidents in any healthcare setting. The aim is to increase the effectiveness of analysis in enhancing the safety and quality of patient care.
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Content ArticleThis document sets out the policy statement and procedure for reporting, reviewing and investigating deaths of people who have been in receipt of services from the Southern Health NHS Foundation Trust. The policy demonstrates how Southern Health NHS Foundation Trust will quality monitor the process and provide the Board with assurance that deaths are being reviewed and learning/improvement is taking place to benefit future patients.
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Content ArticleSerious Incidents in healthcare are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. This procedure describes the circumstances in which such a response may be required and the process and procedures for achieving it This policy provides managers with the process and procedures into the management and investigation of a Serious Incident, including guidance, templates and information.
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Content ArticleLewis Blackman, a healthy 15-year-old boy, died in 2000 after an elective surgery. In this video, Lewis' mother Helen Haskell, President of Mothers Against Medical Error and member of the Institute for Healthcare Improvement (IHI) Board of Directors, explains why communication isn’t always the norm after adverse events and why this dynamic is changing.
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Content ArticleProfessor Don Berwick, an international expert in patient safety, was asked by the UK Prime Minister to carry out a review following the publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals.
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How to investigate and manage a medication incident
Claire Cox posted an article in Medication
Of the nearly 237 million medication errors occurring in England each year, 28% have the potential to cause harm. This article published in The Pharmaceutical Journal outlines the immediate steps to be taken following identification of a medicines safety incident. -
Content ArticleSir Stephen Moss, Patient Safety Learning Trustee, is the former Chairman of Mid Staffordshire Hospitals NHS Trust, following their damming Healthcare Commission report of 2009. In this interview with Patient Safety Learning, Sir Stephen tells us about lessons learnt and what more needs to be achieved to make the NHS one of the safest healthcare systems in the world. View video (15 minutes)
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Content ArticleBetween 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area. During this period this hospital was managed by a Board which succeeded in leading its Trust (the Mid Staffordshire General Hospital NHS Trust) to foundation trust (FT) status. The Board was one which had largely replaced its predecessor because of concerns about the then NHS Trust’s performance. In preparation for its application for FT status, the Trust had been scrutinised by the local Strategic Health Authority (SHA) and the Department of Health (DH). Local scrutiny committees and public involvement groups detected no systemic failings. In the end, the truth was uncovered in part by attention being paid to the true implications of its mortality rates, but mainly because of the persistent complaints made by a very determined group of patients and those close to them. This group wanted to know why they and their loved ones had been failed so badly. The report was laid before Parliament in response to a legislative requirement.
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Content ArticleThis paper by Kumaralingam Amirthalingam, published in the Singapore Medical Journal, argues that most medical disputes are better resolved through alternative dispute resolution mechanisms and that these mechanisms can contribute to improve patient safety.
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Content ArticleThe Tavistock and Portman NHS Foundation Trust has produced this policy to aid patient safety and risk managers to investigate serious incidents with in their Trust.
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Content ArticleThis review by the Care Quality Commission included a sample of 74 investigation reports from 24 NHS acute hospital trusts, representing 15% of the 159 acute trusts in England.
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Content ArticleThis report by the Parliamentary and Health Service Ombudsman is about an investigation into the Care Quality Commission’s (CQC) regulation of the Fit and Proper Persons Requirement (FPPR), which requires NHS providers to ensure that their directors are ‘fit and proper’ to carry out their duties.
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Content ArticleThe lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed this Healthcare Safety Investigation Branch (HSIB) investigation. In this event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.
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Content ArticleDr Sara Ryan is a senior researcher and autism specialist at Oxford University's Nuffield department of primary health sciences. Her son, Connor Sparrowhawk, died in a residential unit, aged 18.
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Content ArticleThe findings of an independent investigation established to review the management, delivery and outcomes of care provided by the maternity and neonatal services of the University Hospitals of Morecambe Bay NHS Foundation Trust between January 2004 and June 2013.
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Content ArticleThe following is an example of a case investigator’s report based on the Dr Purple case used in training, produced by the NHS National Clinical Assessment Service.
