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Showing results for tags 'Investigation'.
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Content ArticleThis report is the Healthcare Safety Investigation Branch (HSIB) first complete investigation which relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery — a surgical never event. A never event is a serious incident that is entirely preventable.
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James Titcombe: The complexity of failure (2 October 2018)
PatientSafetyLearning Team posted an article in Culture
When James Titcombe is hit by the biggest tragedy imaginable to any parent, he and his wife need to confront a tragedy on a bigger scale still: the structural learning disabilities of the organisation that robbed them of their child. The ‘complexity of failure’ video documents the struggle to get the largest employer of the land to account for what was lost. Behind the bureaucracy and posturing, the lies and denials, it discovers a humanity and a richly facetted suffering by many others. It drives a determined James Titcombe to change how we learn from failure forever. -
Content ArticleIn this BMJ Opinion article, David Rowland from the Centre for Health and the Public Interest discusses why he thinks the Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model. David believes that although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. Yet these concerns about how the private hospital system works and the associated patient risks it produces had been established in a number of previous inquiries. He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies.
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NHS Resolution videos: How to prepare for an inquest
PatientSafetyLearning Team posted an article in Legal matters
The purpose of these three films is to share insights about inquests and support all staff working in the NHS who are called to give evidence, so that they can prepare well following the death of a patient in their care. They are intended to be used as a stand-alone product by those called to be a witness as well as integrated as a part of full inquest training package. -
Content ArticleThis is the response form the Parliamentary Under-Secretary of State for Health and Social Care, Nadine Dorries MP, to an urgent question from Sir Roger Gale MP on maternity care failings at the East Kent Hospitals University NHS Foundation Trust. It was followed by questions from MPs in the chamber and Ms Dorries’ responses.
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Content ArticleThe independent inquiry into how the rogue breast surgeon Ian Paterson was able to inflict harm on patients over more than decade described the UK healthcare system as “dysfunctional at almost every level.” In this BMJ analysis, Gareth Iacobucci summarises the findings of the inquiry.
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Silent witness – My experience when filing an incident report
Anonymous posted an article in Florence in the Machine
A newly qualified nurse describes what happened when she reported her first Datix for a serious incident.- Posted
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Content ArticleResponding to the Paterson Inquiry, Ian Kennedy, Emeritus Professor of Health Law and Policy at University College London, discusses the systemic weaknesses in the NHS.
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Content ArticleOrganisations should make sure people know the Parliamentary and Health Service Ombudsman (PHSO) is the final stage for complaints that haven’t been resolved through the organisation’s own complaints process. This applies to small NHS organisations like GP and dental practices as well as larger ones like hospitals or government departments. It’s important that people complain to the provider organisation first and give them a chance to respond to their concerns, before they come to the PHSO. But if someone isn’t happy with how the provider organisation has answered their complaint, they need to know they have a right to come to the PHSO with it. Here are some tips to help providers make sure people know when and how to use the PHSO service.
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Content ArticleSarah O'Neill, Family Liaison Manager, Solent NHS Trust, presented at the recent Bevan Brittan seminar on the role of family liaison. The presentation slides are attached.
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Content ArticlePresentation from Joanna Lloyd, Bevan Brittan, on incident investigations.
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Content ArticleThe Independent Inquiry into the Issues raised by Paterson, published on Tuesday 4 February 2020, was prompted by the case of Ian Paterson, a breast surgeon who was convicted of wounding with intent some of the 11,000 patients he treated and jailed for 20 years in 2017. More than 200 patients and family members gave evidence as part of the Inquiry and it is estimated that he could have harmed more than 1000 patients.[1] The Inquiry gave those involved an opportunity to be heard and to learn how this happened, in both the NHS and the independent sector. It found that this “is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again”.[2] At Patient Safety Learning we have reflected on some of the key patient safety themes that have emerged from this Inquiry and the actions required these issues. You can read Patient Safety Learning's full response here.
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Content ArticleIn this podcast, Peter Duffy, Consultant Urologist, addresses University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT). He speaks of the significant and damaging challenges faced by himself and others who raise concerns about patient safety, including bullying, harassment and abuse. He argues that whistleblowers are suffering personally and professionally when they speak up on behalf of patients. Duffy states: "There remain safety critical issues that the governors need to hold the Board to account over, if the Board is to regain the full confidence of staff and patients".
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Content ArticleThe Parliamentary Under-Secretary of State for Health and Social Care, Ms Nadine Dorries, responds to the Paterson Inquiry in the House of Commons. It is followed by questions from MPs in the chamber and Ms Dorries' responses.
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Content ArticleThe Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high quality care and we encourage care services to improve. Their role: They register health and adult social care providers. They monitor and inspect services to see whether they are safe, effective, caring, responsive and well-led, and we publish what we find, including quality ratings. They use our legal powers to take action where we identify poor care. They speak independently, publishing regional and national views of the major quality issues in health and social care, and encouraging improvement by highlighting good practice.
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Content ArticleThe Committee of Inquiry was set up in 1967 by the Welsh Hospital Board at the request of the Minister of Health, to investigate allegations of ill-treatment of patients and of pilfering by staff which had been made by a nursing assistant employed at the hospital. The Committee was also asked to make their own examination of the situation in the hospital at the time of their inquiry.
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Content ArticleIn this article, published by Birmingham City University, Criminologists Professor Elizabeth Yardley, Professor David Wilson and Emma Kelly discuss the report found that 450 patients died after being given powerful painkillers inappropriately at Gosport War Memorial Hospital. "To kill multiple people requires not just the presence of a determined killer but the absence of protectors and guardians. When no one is looking out for the interests of the vulnerable, the vulnerable become the victims. Within organisations, failed protectors and guardians find strength in each other, denying responsibility, eschewing accountability and playing ping-pong until (they hope) people will just go away and stop demanding answers."
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GOSH response to error: a blog by Joanne Hughes
Claire Cox posted an article in Keeping patients safe
In this blog, Joanne Hughes, founder of Mother's Instinct and hub topic leader, gives her response to the recent news that childrens' deaths at Great Ormond Street Hospital (GOSH) have not been investigated properly. Amid claims GOSH put reputation above patient care, former health secretary, Jeremy Hunt, urged it to consider a possible "profound cultural problem". Joanne's daughter, Jasmine, died in 2011 following failures in her care. Soon after Joanne set up Mother’s Instinct with the ambition to provide a source of support specifically for families whose children die following medical error, and a platform to share their stories and experiences for learning to improve patient safety for children, patient engagement in patient safety, and care of avoidably bereaved parents. -
Content ArticleMedical errors are the third leading cause of death in the United States. Putting patients first — listening to their own and their families’ concerns — can help eliminate medical errors altogether. A patient-centric approach encourages patients to communicate their ‘gut feelings’ when something seems wrong, thereby working to end the pervasive and dangerous culture of silence and fear in hospitals.
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Content ArticleBetween 25-30 April 2020, three nurses working at Waitakere Hospital, New Zealand tested positive for coronavirus (COVID-19). In the week prior to testing positive, the nurses had been working on a ward caring for a group of elderly patients with COVID-19. The patients were from an aged residential care (ARC) facility in West Auckland.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) has been investigating East Kent Hospitals University NHS Foundation Trust since July 2018 after a series of baby deaths. The report discusses 24 maternity investigations undertaken since July 2018, including the deaths of three babies and two mothers. It said: “These investigations have enabled HSIB to identify recurrent safety risks around several key themes of clinical care in the trust’s maternity services.”
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Content ArticleSerious incidents not only have a considerable human impact, but they are also detrimental to NHS reputations and finances. The current Serious Incident Framework (SIF) is a reactive, bureaucratic process, where opportunities to reduce the recurrence of a harmful incidence is often missed. With a ‘Get It Right First Time’ mentality, the new PSIRF framework was road-tested by a number of nationally appointed ‘early adopter’ Trusts and commissioners working to implement it during the course of 2021. Now a wider implementation across the NHS is planned, starting spring 2022, with guidance informed by the early adopter pilots. This blog was written by Sian Williams, NHS Team Lead & Managing Consultant, and Paul Binyon, who in a recent assignment has worked with an NHS Trust contributing to an early adopter PSIRF pilot rollout.
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Content ArticleThis guide developed by Learn Together and Bradford Teaching Hospitals NHS Foundation Trust has been designed to help patients and families understand what to expect from patient safety investigations and how they can be involved in the process. It includes quotes and advice from patients who have been through patient safety investigations and spaces to record experiences, questions and reflections. The guide provides an outline of the investigation process, broken down into five stages: Understanding you and your needs Agreeing how you work together Giving and getting information Checking and finalising the report Next steps
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Content ArticleNHS England has published the new Patient Safety Incident Response Framework (PSIRF). Dr Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England, and Aidan Fowler, National Director of Patient Safety and Deputy Chief Medical Office at NHS England/DHSC, discuss the new framework, the preparation behind it, and how they see PSIRF fundamentally changing the NHS’s approach to patient safety incident response, supporting learning, improvement and compassion, to make care safer for our patients.
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Content ArticleOrganisations should uphold the patient safety incident response standards to ensure they meet the minimum expectations of the Patient Safety Incident Response Framework (PSIRF). The standards cover the following aspects of PSIRF: policy, planning and oversight competence and capacity engagement and involvement of those affected by patient safety incidents proportionate responses. This document provides the complete list of patient safety incident response standards, and where relevant refers to specific PSIRF documentation.
