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Showing results for tags 'Investigation'.
Found 1,565 results
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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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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 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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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 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 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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Sorry needn’t be the hardest word
Patient Safety Learning posted an article in Complaints
Nick Wright co-founder of the Apology Clause campaign wrote an article on why organisations need to say sorry The law supports apologies. The Compensation Act 2006 says “an apology, an offer of treatment or another redress, shall not itself amount to an admission of negligence or breach of statutory duty”. However, too many organisations put their fear of legal ramifications over what they see as their moral obligations. They fear if they apologise properly they will leave themselves open to legal action. That refusal to do the right thing can have serious and lasting impact on victims. A clear apology can lift the burden that victims very often carry for a long time after a trauma. It can enable them to move on. To stop blaming themselves. To stop re-living the most agonising moment. To rebuild. -
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 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 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 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 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 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 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 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 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 ArticleAt a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing root cause analysis and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
