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Showing results for tags 'Investigation'.
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Content ArticleThe findings in this report followed a 14-year inquiry into hyponatraemia-related deaths in five children in Northern Ireland. The inquiry was set up in 2004 to investigate the deaths of Adam Strain, Claire Roberts, Raychel Ferguson, Lucy Crawford and Conor Mitchell. The chairman said that the deaths of Adam Strain, Claire Roberts and Raychel Ferguson were the result of "negligent care".
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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 ArticleJo Wailling is a registered nurse and research associate with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington. Jo presented on restorative practice at the Commission’s mental health and addiction (MHA) quality improvement programme workshop held in Wellington on 26 June for mental health and addiction leaders. This blog is a continuation of that presentation.
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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 ArticleWhen a serious incident occurs, it is vital that the investigation process is thorough and can withstand scrutiny. Getting to the heart of what went wrong and putting solutions in place to reduce the chances of a repeat incident requires an acute focus on the whole investigation process. Experienced investigator, Chris Brougham, who previously worked at the National Patient Safety Agency, shares her thoughts on what a high quality investigation actually looks like and how you can go about achieving that.
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Content ArticleEighteen years after the advent of the National Patient Safety Agency (NPSA) why is investigating in such a parlous state? Ed Marsden, Managing Director of independent investigative consultants Verita, discusses why making improvements to patient safety comes second place to sorting out problems with the investigative process.
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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 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 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 ArticleHealth and social care providers internationally are heavily scrutinised by external regulators as part of accreditation, inspection and external review processes. The aims are generally to identify poor performance and/or to improve performance and in particular to ensure the delivery of good quality services. This can result in a complex, costly and overlapping network of oversight arrangements. In his editorial, published by the Journal of Health Services Research & Policy, Sheldon discusses this topic further.
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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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Community Post
Unexpected deaths in patients known to Mental Health Services
Catherine Evans posted a topic in Investigations, risk management and legal issues
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Does anyone have examples of templates they use for reviewing unexpected deaths in the community of patients known to mental health services?- Posted
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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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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 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 ArticleRob Hackett, Patient Safe Network, in the video below discusses the danger of Indistinct chlorhexidine which can easily be mistaken for other colourless solutions. He highlights the story of Grace Wang, who in 2010 had antiseptic solution injected into her epidural. She nearly died and was left paralysed. Indistinct chlorhexidine was mistaken for saline. The investigation recommended all skin antiseptic solutions to be coloured in a way that distinguished them. Sadly this recommendation isn't followed. Accidental chlorhexidine injections continue to occur and there are many more examples. This same error continues to play out again and again throughout the world. There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost.
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Content ArticleThe Learning Disabilities Mortality Review (LeDeR) programme was established in May 2015 to support local areas across England to review the deaths of people with a learning disability, to learn from those deaths and to put that learning into practice.
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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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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.
