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Showing results for tags 'Investigation'.
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Content ArticleThis is the transcript of an oral statement to the House of Commons by Steve Barclay MP, Secretary of State for Health and Social Care, on improving safety in mental health in-patient services across England.
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Content ArticleThe Department for Health and Social Care has launched an investigation into allegations made by 22 former patients of mental health units run by private firm The Huntercombe Group. The group ran at least six children’s mental health hospitals between 2012 and 2022. In this Independent article, young women who were subject to humiliating and sometimes abusive treatment talk about their time as inpatients. Some of the experiences they recount are harrowing: "I would get awoken by staff members restraining me out of bed and dragging me down to the de-escalation room to force-feed me." "Patients were left naked in their rooms under anti-ligature blankets because they wouldn’t buy anti-ligature clothing." "I distinctly remember someone saying ‘if you hit me again, I’ll hit you back ten times harder because there are no cameras in here and you can’t cry to [name of nurse] about it’."
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Content ArticleIn this issue of HSJ's fortnightly briefing, Emily Townsend looks at why we are still not listening to patients and their families after harrowing reports of abuse and poor care at NHS mental health facilities surfaced last year.
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Content ArticleThis report by the charity INQUEST, which provides expertise on state related deaths and their investigation to bereaved people, highlights that families are facing persistent challenges following the death of a loved one in mental health services. Based on conversations at one of INQUEST’s Family Consultation Days, the report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and that processes are not delivering the change required. The Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.
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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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Oliver's Campaign
Patient Safety Learning posted an article in Learning disabilities
Paula McGowan is a Multi Award-winning Activist who following the preventable death of her teenage son Oliver, has dedicated her life to campaigning for equality of Health and Social Care for Learning Disabled people and Autistic people. She is an Ambassador for several charities and organisations. Paula launched a parliamentary petition asking for all doctors and nurses to receive mandatory training in Learning disability and Autism awareness. She ferociously argued that autism must be included. On 22 October 2018, her petition was debated and gained cross party support. As a direct consequence Government announced that all NHS and Social Care Staff would receive The Oliver McGowan Mandatory Training in Learning Disability and Autism. On the Oliver's Campaign website you can find support, resources and blogs. -
Content ArticleThe Right Honourable Sir Anthony Hooper was asked by the General Medical Council (GMC) on 5 September 2014 to conduct an independent review of how the GMC engage with individuals who regard themselves as whistleblowers. The terms of reference were: “To conduct a review of how the General Medical Council handles cases involving individuals who regard themselves as whistleblowers and who have appropriately raised concerns in the public interest. These are individuals: whose fitness to practise is being investigated or determined under the General Medical Council (Fitness to Practise) Rules 2004; or who have reported such a concern to the GMC.” This is the report by the Right Honourable Sir Anthony Hooper to the GMC presented on the 19th March 2015.
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Content ArticlePrisons and Probation Ombudsman (PPO) Sue McAllister has published the independent investigation into the death of a baby (Baby B) at HMP Styal on 18 June 2020. The PPO was concerned that there were missed opportunities to identify the urgent clinical attention that Ms B, the baby’s mother, needed during that evening. The investigation found gaps in prison nurse training about reproductive health, long-acting reversible contraception and recognition of early labour, and the PPO has made recommendations to remedy these issues in all women’s prisons. View the report
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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. -
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Healthcare Safety Investigation Branch Annual Review 2019/20
Sam posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) has published their third annual review. During 2019/20: 109 patient safety referrals received. 515 maternity investigation reports completed. 15 national investigation reports published. 58 national safety recommendations made. 88% of families engaging with the maternity investigations and 87% with the national investigations. Family information available in over 20 languages to ensure greater inclusivity. Keith Conradi, Chief Investigator, said: “There has been a huge amount of hard work from everyone within the HSIB during this period and I want to thank them and acknowledge the support of our stakeholders in the wider healthcare sector, and in particular to all the organisations who responded promptly to our safety recommendations.” -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation and part two, with a focus on the clinical diagnosis of aortic dissection, is due to be published in Spring 2019.
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Content ArticleLack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In this Healthcare Safety Investigation Branch (HSIB) report, the reference case patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired. The HSIB investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report highlights that there are innovative measures implemented by some trusts that have reduced the risk, but this good practice is yet to be implemented more widely.
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Content ArticleThis report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a local pilot, which has been launched to evaluate HSIB’s ability to carry out effective investigations occurring between specific hospitals and trusts. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB. On her admission to her local emergency department (ED) after a fall at her nursing home, Mrs E, a woman aged 93 with dementia, was booked into the ED with incorrect patient details, resulting in a new patient record being created. She was discharged that day but readmitted the next day after a second fall. She was booked into ED with the new patient record (which contained the incorrect patient details) and had an x-ray which confirmed she had a broken hip, subsequently being admitted to hospital for surgery. Mrs E had surgery the next day, during which the pathology department identified a problem with the accuracy of her patient identification information and following surgery her two sets of patient records were merged.
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Content ArticleThis masterclass, facilitated by Peter Walsh, Chief Executive Action against Medical Accidents (AvMA), and Carolyn Cleveland, Founder and Owner C & C Empathy Training Ltd, will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Staff with responsibility for implementing the duty of candour and responsible for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending this one day masterclass. For more information see the flyer attached. The next events are on the 18 July, 17 October and 12 December.
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Content ArticleThe aorta is the largest artery in the body. Acute dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, which may then rupture with catastrophic consequences. There are about 2,500 cases per year in England, with around 50% of patients dying before they reach a specialist centre for care and 20-30% of patients dying before they reach any hospital. This Healthcare Safety Investigation Branch (HSIB) report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. Although sudden severe chest or back pain is the most common symptom, the picture can vary or mimic other conditions, which may lead to an incorrect diagnosis or delays in recognising a life-threatening condition which needs urgent treatment.
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HSIB: Oxygen issues during COVID-19 pandemic
Patient Safety Learning posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) has been investigating piped oxygen gas supplies in hospitals and have produced an early interim bulletin to help trusts deal with oxygen flow issues in their organisations. -
Content ArticleThis Healthcare and Safety Investigation Branch (HSIB) report explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat a number of medical conditions, including migraine, cardiovascular problems and the physical effects of anxiety. The case that prompted the investigation was Emma, a 24-year old woman, took an overdose of both propranolol and citalopram (an antidepressant). She called an ambulance, but her condition quickly worsened. Despite resuscitation efforts from both paramedics and medical staff in the hospital she was transferred to, Emma sadly died. There has been a steady rise in the number of propranolol prescriptions issued to NHS patients. Between 2012 and 2017 there was a 33% increase in the number of deaths reported as being linked to propranolol overdose, with 52 deaths recorded as having been linked to propranolol overdose in 2017.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) carried out a themed review of their maternal death investigations during the coronavirus (COVID-19) pandemic. The national learning reports can be used by healthcare leaders, policymakers, and the public to: Aid their knowledge of systemic patient safety risks. Understand the underlying contributing factors. Inform decision making to improve patient safety. Explore wider patient safety processes.
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Content ArticleWhen Rupert was born he had to be immediately cooled after a difficult birth. Babies are cooled in certain circumstances in the hope of slowing down the processes that may cause brain damage. The Healthcare Safety Investigation Branch (HSIB) maternity investigators initiated an investigation to find out what went wrong. In this short video we hear from Rupert’s mum, Leila, who describes what it was like to be involved with a HSIB maternity investigation from a family point of view. Leila shares why she and her family wanted to be involved, how HSIB’s approach to them was welcomed and how they felt this contributed to improving safety for the benefit of other families in the future.
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Content ArticleIn partnership with the Healthcare Safety Investigation Branch (HSIB) and Learn Together, NHS England has published its Guide to engaging and involving patients, families and staff following a patient safety incident alongside the Patient Safety Incident Response Framework (PSIRF). This guide sets out expectations for how those affected by an incident should be treated with compassion and involved in any investigation process. In this podcast, the speakers introduce the guide, discuss how it was developed, and talk about future plans in the area of work. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England National Patient Safety Team Lauren Mosley, Head of Patient Safety Implementation, NHS England National Patient Safety Team Lou Pye, Head of Family Engagement, HSIB Jane O’Hara, Learn Together research team, Professor of Healthcare Quality and Safety, University of Leeds and Deputy Director of the Yorkshire Quality and Safety Research Group.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines. Some drugs, such as those used in anaesthesia and pain management, can cause patients to stop breathing. After administration, these drugs should be flushed through cannulae and extension lines to make sure no residual quantities of the drugs are left. Despite the issuing of multiple safety alerts over the past ten years, residual drugs in cannulae and extension line events continue to happen. When these events involve drugs that cause the patient to stop breathing, there is a risk of hypoxic brain injury (where the brain is damaged after a period where it does not get enough oxygen) or death. The investigation was launched after concerns were reported to HSIB by a consultant anaesthetist at a district general hospital where a patient had stopped breathing several hours after undergoing an anaesthetic. It’s thought that a quantity of the drug Suxamethonium - a muscle relaxant - was retained in their cannula after the procedure. The cannula containing the drug was flushed on the ward by a nurse preparing to administer intravenous paracetamol around three hours after the patient had returned from his procedure. The event was witnessed by a doctor who immediately started manual ventilation. The patient began to breathe spontaneously a few minutes later and suffered no physical harm. However, they have been left with a significant psychological impact following their experience of being awake but unable to move or breathe.
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Content ArticlePrompt referral to early pregnancy services can make the difference between life and death in the diagnosis of ectopic pregnancies. This Healthcare Safety Investigation Branch (HSIB) report into the diagnosis of ectopic pregnancy found that differing levels of provision and a mismatch between capacity and demand in early pregnancy units (EPUs) heightens the risk that the diagnosis of this time-critical condition is delayed or missed.
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Content ArticleIn 2021, a multi-professional staff support group was established under the Northern Care Alliance NHS Foundation Trust’s Freedom to Speak Up process which raised new questions and concerns around the probity and clinical standards of a Consultant Spinal Surgeon (“Consultant Spinal Surgeon A”) whilst they were employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) (“the Trust”). As a result, the Trust commissioned the Spinal Patient Safety Look Back Review (“SPSLBR”) and Investigation Group to evaluate these concerns, including obtaining independent expert advice.In January 2022, the Trust commenced the SPSLBR to investigate and manage patient safety concerns raised in respect of Consultant Spinal Surgeon A who was employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) between 1991 and January 2015. This report outlines the investigation carried out by the SPSLBR Investigation Group on behalf of the Trust to investigate and manage potential Serious Incidents (“SI”) caused by the errors and omissions attributable to clinics, surgery and/or consultations undertaken by Consultant Spinal Surgeon A within the scope identified in the Terms of Reference.
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Content ArticleThe latest Healthcare Safety Investigation Branch (HSIB) report focuses on the life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients.
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Content ArticleThe Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
