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Showing results for tags 'Investigation'.
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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.
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- Investigation
- Legal issue
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Content ArticleDr Sara Ryan is a senior researcher and autism specialist at Oxford University's Nuffield department of primary health sciences. Her son, Connor Sparrowhawk, died in a residential unit, aged 18.
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- Qualitative
- Investigation
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Content ArticleA protocol for liaison and effective communications between the NHS, Association of Chief Police Officers (replaced in 2015 by a new body, the National Police Chiefs' Council) and Health and Safety Executive (HSE). Although now archived in The National Archives, much of the protocol is still relevant today. The protocol took effect in circumstances of unexpected death or serious untoward harm requiring investigation by the police, or the police and the HSE jointly. The protocol sets out the general principles for the NHS, police and HSE to observe when liaising with one another. It focused on investigations in NHS Trusts, although the principles and practices it promotes should apply to other locations where healthcare is provided and the NHS is required to investigate under its performance management and other duties.
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- Patient death
- Patient harmed
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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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- Investigation
- Patient / family involvement
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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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- Just Culture
- Accountability
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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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- Recommendations
- Investigation
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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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- Patient safety incident
- Investigation
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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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- Medicine - Ophthalmology
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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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- Medication
- Prescribing
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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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- Investigation
- Risk management
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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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- Investigation
- Recommendations
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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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- Investigation
- Patient safety incident
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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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- Maternity
- Organisation / service factors
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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.
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- Maternity
- Patient death
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