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Found 552 results
  1. Content Article
    On her admission to hospital, the patient had been assigned the NHS number of another patient, who had the same date of birth and a similar name. During her stay she initially received medication prescribed to her based on her own supply, brought in by her family. However, following a pharmacy review on day 7 of admission, the medications were changed to those of the patient whose NHS number she had been incorrectly assigned. The patient declined to take the incorrect medication and the error was subsequently identified by a pharmacist the following day. Findings The investigation ide
  2. News Article
    A doctor has accused England's health and care regulator of "moral corruption". Consultant orthopaedic surgeon Shyam Kumar says the Care Quality Commission misled the public over patient safety. Mr Kumar alleges he was unfairly dismissed from his role as a special adviser to the CQC because he acted as a whistleblower. His claims were made during an employment tribunal hearing in Manchester. Seconded by his employer, University Hospitals of Morecambe Bay NHS Foundation Trust, Mr Kumar had been giving the CQC expert advice on surgical departments during hospital inspections.
  3. News Article
    One hundred people with learning disabilities and autism in England have been held in specialist hospitals for at least 20 years, the BBC has learned. The finding was made during an investigation into the case of an autistic man detained since 2001. Tony Hickmott's parents are fighting to get him housed in the community near them. Mr Hickmott's case is being heard at the Court of Protection - which makes decisions on financial or welfare matters for people who "lack mental capacity". Senior Judge Carolyn Hilder has described "egregious" delays and "glacial" progress in finding h
  4. Content Article
    On 22 September 2021 the Health and Social Care Select Committee launched a new inquiry examining the case for reform of NHS litigation, identifying concerns regarding a significant increase in clinical negligence costs and missed opportunities for learning to improve patient safety. The Committee stated that the existing system was “failing to meet its objectives for both families and the healthcare system”.[1] Here we will provide an overview of our response to this Inquiry, which focused on four key areas: Learning from avoidable harm in healthcare Improving redress for p
  5. News Article
    A focus on “reputation management” was a factor in how an acute trust failed to properly investigate serious safety concerns in a dysfunctional department where consultants were “divided along ethnic lines”. An external review into the urology services at University Hospitals of Morecambe Bay Foundation Trust has identified 520 cases where patients suffered “actual or potential harm”, including several cases where patients died. The review, commissioned by NHS England, has found there were “multiple individual, team, organisational, and regulatory shortfalls which have resulted in a
  6. News Article
    Midwives across England are still not receiving enough essential safety training with the pandemic leaving hospitals delivering less training than three years ago. A new report from the charity Baby Lifeline, based on an investigation of 124 NHS trusts in England, found 9 in 10 units had training affected by the pandemic with staff shortages named as a major factor in preventing workers from taking time out for learning. This was cited by 72% of units as a problem. The average spend on maternity training was significantly lower in 2020-21 at £34,290 compared to £59,873 in 2017-18, w
  7. Content Article
    Students studying this course with HSIB will work with investigation science educators to explore the aspects of safety science, investigation processes and investigation skills which provide the foundations for the professional safety investigator. Students will be guided through the process of an investigation to identify the systemic factors which contribute to cause an unexpected incident. The teaching and learning will be multi-method online providing opportunity to collaborate with co-learners in exploring the practical application of investigation science in healthcare. Course date
  8. Content Article
    The course offers an overview of the principles which underpin a systems approach to investigative interviews. Students on this course will be part of a small group who undertake healthcare safety investigations. Students will be supported by HSIB Senior Investigation Science Educators through two hours of traditional lectures, interactive activities and discussions. They will be directed to specific activities designed to extend and consolidate knowledge. On completion of the course students gain a certificate in 'A Systems Approach to Investigative Interviewing'. Course dates
  9. Content Article
    This 30-hour, tutor-led course will run over 10 sessions from 20 January until 31 March 2022 on Thursday mornings, 9.30am - 12.30pm. Students will work with investigation science educators to explore the aspects of safety science, investigation processes and investigation skills which provide the foundations for the professional safety investigator. You will be guided through the process of an investigation to identify the systemic factors which contribute to cause an unexpected incident. The teaching and learning will be multi-method online providing opportunity to collaborate with your
  10. News Article
    The family of a woman who died after being repeatedly overdosed with paracetamol in an NHS hospital have demanded action over her death amid allegations of an NHS cover up. Laura Higginson, a trainee solicitor and mum of two, died after seeking medical help for sickness and pneumonia. She died two weeks later from multi-organ failure and sepsis. Whiston Hospital, in Merseyside, has admitted to the overdose but denied it caused her death and rejects any suggestion of wrong doing. But expert reports, seen by The Independent, including from a liver specialist, questions the trust’s
  11. News Article
    The widow of a top Scottish government official, who died after contracting Covid, believes the full details of his illness were concealed to protect the reputation of a troubled hospital. Andrew Slorance, Scottish government's head of response and communication unit, in charge of its handling of the Covid pandemic, went into Glasgow's Queen Elizabeth University Hospital for cancer treatment a year ago. His wife Louise believes he caught Covid there as well as another life-threatening infection. Andrew went in to the £850m flagship Queen Elizabeth University Hospital (QUEH) at
  12. News Article
    An inspection at a failing hospital trust has identified "some progress" but its services are still inadequate. The Care Quality Commission (CQC) inspected the Shrewsbury and Telford Hospital NHS Trust (SaTH) in August. The Trust has been in special measures since 2018 and its maternity services are subject of a review following a high rate of baby and maternal deaths. The CQC said SaTH still had "significant work to do" to improve its patient care and safety standards. Inspectors highlighted particular concerns around risk management at the Trust which it said was "inconsistent
  13. Content Article
    Background CPAP is often used to support a patient’s breathing in critical care or high dependency units, where there are high numbers of staff to patients. Staff in these units are trained and familiar with the use of non-invasive respiratory support. During the first and second waves of the COVID-19 pandemic, however, many more patients needed CPAP than there were beds in critical care and high-dependency units. Thus, hospitals had to create alternative areas and arrangements for delivering and caring for patients who needed CPAP. This investigation looked at the use of CPAP ou
  14. News Article
    A groundbreaking inquiry into sickle cell disease has found “serious care failings” in acute services and evidence of attitudes underpinned by racism. The report by the all-party parliamentary group (APPG) on Sickle Cell and Thalassaemia, led by Pat McFadden MP, found evidence of sub-standard care for sickle cell patients admitted to general wards or attending A&E departments. The inquiry also found widespread lack of adherence to national care standards, low awareness of sickle cell among healthcare professionals and clear examples of inadequate training and insufficient investm
  15. Content Article
    Key findings from the inquiry include: evidence of sub-standard care for sickle cell patients admitted to general wards or attending A&E departments (including a widespread lack of adherence to national care standards) low awareness of sickle cell among healthcare professionals and clear examples of inadequate training and insufficient investment in sickle cell care frequent reports of negative attitudes towards sickle cell patients and a weight of the evidence suggests that such attitudes are often underpinned by racism. The inquiry also found that these concerns
  16. News Article
    A boy who suffered "catastrophic brain injuries" when doctors failed to see he had a virus and sent him home after he had a seizure has been awarded £27m. The boy, who cannot be identified but is now 13, suffered seizures as a toddler more than a decade ago. Details of the settlement between the boy's father and Liverpool's Alder Hey Children's NHS Foundation Trust were published in a written ruling. High Court judge Mr Justice Fordham said it was a "sensible settlement". Trust bosses admitted "breach of duty" and "causation of loss and damage", the judge said. The jud
  17. News Article
    A woman took her own life on a ward after her move to a mental health hospital was not facilitated. Anne Clelland was found unconscious in the toilet of her room in Glasgow's Queen Elizabeth University Hospital and later died of a brain injury. Anne - who had a history of self-harm - was admitted following an overdose. She was due to be moved to a psychiatric hospital three days before her death but this did not take place because of a "failure of communication." NHS Greater Glasgow and Clyde pled guilty today to failing to conduct their undertaking in a way that a person would
  18. News Article
    There have been more than 30 serious security breaches at NHS hospital mortuaries in the past five years, The Independent can reveal. The figures come as local MPs demand a public inquiry into the crimes of NHS electrician David Fuller who sexually abused 100 corpses, including three children, over a period of 12 years. The calls for a full inquiry have also been backed by Labour’s shadow health secretary Jonathan Ashworth who said on Friday: “It is important the secretary of state listens to the concerns of the local MP and the families of those who have been involved, and establish
  19. News Article
    A man who murdered two women 34 years ago went on to sexually abuse 100 female corpses in hospital mortuaries, taking videos and images of his crimes, HSJ can reveal. David Fuller was employed as an electrician and later a maintenance supervisor at the now closed Kent and Sussex Hospital, in Tunbridge Wells, and later the Tunbridge Wells hospital in Kent. Over a period of 12 years from 2008 to 2020 he used his access to the hospital mortuaries to sexually abuse the bodies of women and girls. HSJ first learned of David Fuller’s crimes in June this year, but agreed to a request by Kent
  20. News Article
    A special Crown Office unit set up to probe Covid-linked deaths is considering 827 cases in Scotland's hospitals, latest figures show. The unit was set up to consider the circumstances of Covid-linked deaths such as those in care homes. But the prosecution service has also received reports of hundreds of hospital-related virus deaths. Prosecutors will eventually decide if these deaths should be the subject of a fatal accident inquiry or prosecution. As of 7 October, Crown Office figures show Scotland's biggest hospital, the Queen Elizabeth University Hospital in Glasgow, has the
  21. Event
    Have you been invited to participate in an HSIB maternity investigation? Are you unsure of what the programme is about? Do you have questions about HSIB maternity investigations? This webinar is primarily aimed at doctors in training but will be of interest to clinicians from any professional background and especially to those working within maternity and neonatal services. You will gain a high level overview of the programme, an understanding of our system approach to healthcare safety investigations and information about our investigation methodology. There will be a pane