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Showing results for tags 'Investigation'.
Found 1,563 results
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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.
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Content ArticleThis policy was written by Sussex Partnership NHS Foundation Trust. It is designed to ensure that concerns regarding the conduct or performance of staff which require formal investigation are investigated in a fair and consistent manner. Such an investigation may arise during the operation of other policies such as Dignity at Work, Grievance or Freedom to Speak Up. The outcome of the investigation may lead to further action such as a disciplinary hearing or use of the Managing Performance and Capability Policy. The policy identifies the circumstances in which an investigation will be necessary, the steps which should be taken in carrying out an investigation, the rights of staff during the process and potential outcomes.
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Content ArticleThe Parliamentary Healthcare Service Ombudsman published 'Ignoring the alarms: How NHS eating disorder services are failing patients' in December 2017. The families who brought forward their complaints helped uncover serious issues that required national attention. The failings catalogued in the report highlighted a systemic set of problems in relation to identifying, treating and monitoring eating disorders that require a systemic response. This encompasses raising awareness among clinicians, building greater specialist capability and ensuring adult eating disorder services achieve parity with child and adolescent services. This submission provides an overview of the report’s systemic findings and the responses seen to the systemic recommendations made to date.
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Content ArticleWritten by the safety team at Morecambe Bay Hospital NHS Trust. Introducing staff to the team, their governance hub, a new support system for staff involved in an investigation and what happens in an inquest by the legal team.
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Content ArticleCataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS. Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entirely preventable. Read the Healthcare Safety Investigation Branch's report on the insertion of an incorrect intraocular lens.
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Content ArticleBoth national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations. Here the Healthcare Safety Investigation Branch (HSIB) demonstrate how they involve families in their investigations.
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Content ArticleHealthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) launched an investigation following the referral of a case from an acute trust involving failure of oxygen delivery during a resuscitation. The case highlighted several issues related to the safe delivery of oxygen from portable systems.
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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 ArticleKeith Conradi, Chief Investigator at the Health Service Investigation Branch, presented at the Patient Safety Learning Conference on HSIB’s challenges and achievements in its first year.
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Content ArticleSacha Wells-Munro, Maternity Improvement Advisor at NHS Improvement and Professor Tim Draycott, consultant obstetrician and Health Foundation Improvement Science Fellow, present at the Patient Safety Learning Conference the lessons learned from the Morecambe Bay maternity scandal and changes needed to improve the safety of maternity services system wide.
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Content ArticleDr Bill Kirkup, Chairman of the Morecambe Bay Investigation, presented at the Patient Safety Learning Conference on the common themes that have emerged, and the lessons we need to learn, from the numerous high-profile inquiries in which he has played a leading role.
