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Showing results for tags 'Investigation'.
Found 1,558 results
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Content ArticleThis New Scientist article explores various safety incidents that have occurred in oil companies due to failings in their organisational structures. Lessons can be learnt and applied to safety in healthcare.
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Content ArticleHealthcare Safety Investigation Branch (HSIB) looked into the suitability of equipment and technology used within maternity departments to conduct continuous fetal heart rate monitoring during labour and birth. Although there are multiple methods used to monitor fetal heart rate, the main equipment used is a continuous fetal heart rate monitoring is the cardiotocograph (CTG) machine. There has been some common safety issues identified with availability of equipment and functionality, staff understanding of the equipment and its purpose and an inability to understand and interpret the fetal heart rate. HSIB conducted an investigation into how cardiograph machines are used, any problems staff experienced while using them and problems that staff using them and how the equipment was purchased experienced, and how staff are trained and assessed as being competent to use them.
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Content ArticleThis video, produced in conjunction with Royds Withy King Solicitors, provides a quick overview of AvMA’s services and how volunteers help them to deliver the vital support people need after experiencing medical harm.
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Content ArticleThis is the report of an inquiry conducted by the Health and Social Care Select Committee in 2020/21 which examined the ongoing safety concerns with maternity services and the action needed to improve safety for mothers and babies. It suggests that improvements to maternity services have been too slow to date and recommends several changes, including increasing in the budget for maternity services and reforming existing to litigation processes.
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Content ArticleNever Events are defined by the NHS as patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. This study considers how effective using of the absolute number of Never Events that take place at English hospital trusts, without accounting for hospital workload, is for judging their underlying safety performance and safety culture. In its conclusions the authors suggest that there are flaws in the current approach regulators take to using Never Events data to judge hospital performance.
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Content ArticleIn this blog, published on the Learning from Excellence website, author AP introduces the philosophical theory of determinism and the implications for patient safety investigations.
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Content ArticleThis video, from the Healthcare Safety Investigation Branch (HSIB), will help clinical staff to understand what to expect when asked to take part in an HSIB maternity investigation interview. You will meet some of the HSIB maternity investigation team, who'll talk you through the interview. You will also hear from NHS staff, who will talk you through their experience of being involved in a maternity investigation.
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Content ArticleIn order to obtain compensation for harm arising out of medical treatment received within the NHS in Scotland, the elements needed to establish negligence under the law of delict must be satisfied. The Scottish government has expressed the view that a no-fault compensation scheme in relation to clinical negligence claims made against the NHS in Scotland could be simpler than the existing litigation system and could support the development of the concept of a mutual NHS, as well as a positive feedback and learning culture. With this in mind, the government considers that such a scheme is the favoured way forward for the NHS in Scotland. This report reviews and analyses existing no-fault schemes in a number of countries/jurisdictions: New Zealand (NZ); Nordic countries (Sweden, Finland, Denmark, Norway); and the schemes operating in Virginia and Florida (United States) for birth-related neurological injury.
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Content Article
JCP Solicitors: NHS Redress Scheme
Patient Safety Learning posted an article in Legal matters
The NHS Redress Scheme, also known as the “Putting Things Right Scheme,” is a method of handling and investigating complaints about the NHS service within Wales. In NHS Redress claims, redress may consist of an apology, or a financial award of compensation of up to £25,000.00 (The limit for the NHS Redress Compensation claims). JCP Solicitors explains the Redress Scheme and how to claim under the scheme. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive the right clinical procedure. In the last 10 years the number of patients treated in outpatient clinics has nearly doubled. Many minor surgical procedures can now be carried out in an outpatient clinic, whereas in the past they would have been carried out in an inpatient theatre setting. The high number of patients treated in an outpatient clinic requires efficient management. Clinical consultation and delivery of the required intervention often needs to be completed within a 15-20-minute appointment. In a single outpatient waiting area there may be patients arriving for different clinical interventions. Staff need to make sure that all patients are seen in the right place, at the right time and (if required) receive the right procedure. Outpatients are not provided with any physical means that staff can use to identify them. This is different to inpatients where a wristband is worn following an initial check of the patient’s identity. Checking the identity of a patient in an outpatient department typically relies on staff speaking to patients. There is a risk of patients being missed or misunderstood due to the environment, work demands, language or cultural barriers.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) held a webinar on 12 May to discuss asthma management in children, to support the launch of their recent publication: Management of chronic asthma in children aged 16 years and under. For those of you who missed the event, HSIB have made available the webinar recording, presentation slides and Q&As.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) has analysed its first 22 HSIB national investigations to identify the recurring patient safety themes and to explore the impact so far of the 85 recommendations they have made to address them.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS's approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety It is intended to support one of the key aims of the NHS Patient Safety Strategy, to help the NHS improve its understanding of safety by drawing insight from patient safety incidents. This will replace the Serious Incident Framework with organisations expected to transition to PSIRF within 12 months of its publication, by Autumn 2023.
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Content ArticleThis investigation from the Healthcare Safety Investigation Branch, focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
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Content ArticleProviders led by GPs of an ethnic minority background have raised with the Care Quality Commission (CQC) concerns that they do not receive the same regulatory outcomes from CQC as providers led by GPs of a non-ethnic minority background. To investigate and respond to these concerns, CQC started a programme of work in February 2021. The focus of this has been on how CQC's regulatory approach affects ethnic minority-led GP practices and how it can improve its methods to address any inequalities identified.
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Content ArticleSurekha Shivalkar was a 78-year-old woman who was scheduled for elective total hip replacement revision surgery. Following surgery she suffered a cardiac arrest and subsequently died. The conclusion of the inquest was that died from multi-organ failure and complications arising during anaesthesia and hip revision surgery, which led to hypotension and hypoperfusion in a woman with ischaemic heart and chronic obstructive pulmonary disease. In his report, the Coroner raises concerns about the lack of a use of a formal risk assessment tool prior to her surgery, communication failures between the orthopaedic surgical team and the anaesthetist and the departure of the Senior Consultant surgeon prior to the surgeries conclusion.
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Content Article
Bleed Out: HBO documentary (2018)
Patient Safety Learning posted an article in Investigations and complaints
Medical error is the third leading cause of death in the U.S. After a routine partial hip replacement operation leaves the mother of filmmaker and comedian Steve Burrows in a coma with permanent brain damage, what starts as a personal video diary becomes a citizen’s investigation into the state of American healthcare. -
Content ArticleOn 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. Here is the Association of Personal Injuries Lawyers' response to the call for evidence for the Health and Social Care Select Committee Inquiry. Related reading Patient Safety Learning's response to the NHS Litigation Reform AvMA's response to the NHS Litigation Reform
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Patient Safety Learning and the Safer Healthcare and Biosafety Network (SHBN) are undertaking a project, working with patient safety experts and frontline staff, to produce a manual to support staff after a serious safety incident. As part of this work, we are asking healthcare staff to complete a short survey relating to experiences of a serious safety incident. -
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West Suffolk Review (9 December 2021)
Patient Safety Learning posted an article in Other reports and inquiries
Findings from an independent review, commissioned by NHS Improvement in February 2020, at the request of the Department for Health and Social Care, into the handling of whistleblowing at West Suffolk NHS Foundation Trust. -
Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to recognition of the acutely ill infant and child, recognising the difficulty in distinguishing between simple viral illnesses and life-threatening bacterial infections in very young patients. This Healthcare Safety Investigation Branch investigation reviewed the case of Mohammad, a baby who had become unwell and was taken to an emergency department by ambulance following a call to NHS 111. He arrived at 8.04pm and was considered to have a mild viral illness, subsequently being transferred to a paediatric observational ward, and discharged at 11.45pm with a diagnosis of likely bronchiolitis. At approximately 3.40am his mother contacted the ward as his condition worsened, which resulted in a 999 call. The ambulance crew did not consider that Mohammad was seriously ill so did not conduct a ‘blue light’ emergency transfer to hospital. Mohammad was admitted to the emergency department at approximately 4.40am and suffered a respiratory and then cardiac arrest at 5:28am, with attempts to resuscitate unsuccessful and stopped at 6:10am. Mohammad died of septicaemia caused by meningococcus (serogroup B) bacteria.
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Content ArticleProviding high-quality care means putting patient safety at the forefront of every action and decision made in the provision of healthcare services. To achieve this requires the conditions of close cooperation, good communication and the application of effective systems, processes and controls - through good governance. This investigation carried out by Niche Health and & Social Care Consulting describes a complex and evolving set of circumstances where these conditions were not met at Morecambe Bay and which played-out negatively over many years, resulting in uncontrolled legacy. A primary objective of this investigation has been to seek a full and validated understanding of any patient harms or clinically untoward outcomes in Urology. Particularly, but not exclusively, to validate concerns raised publicly in the ‘whistleblowing’ publication Whistle in the Wind. The investigation found a multi-faceted set of contributory issues which cannot, in many cases, be singularly applied to individual Consultant failings.
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Content ArticleThe People’s Covid Inquiry, chaired by the human rights lawyer Michael Mansfield QC, began in January 2021 to learn lessons quickly after the government rejected calls for a public inquiry. The Government was informed of the inquiry on 23 February 2021 and invited to take part. No response was received. The first session of the People’s Covid Inquiry began on 24 February and convened in live sessions fortnightly until 16 June 2021. The Inquiry took evidence over nine sessions from over 40 witnesses including international and UK experts, frontline workers, bereaved families, trade union leaders, and representatives of disabled people’s and pensioners’ organisations.
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Content ArticleDr Nick Woodier, HSIB National Investigator, reflects on the challenges associated with joint surgical care of patients and shares learning that can aid the NHS and the private sector as new national agreements come into force.
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Content Article
A case study in denial (Roger Kline, 3 February 2022)
Patient Safety Learning posted an article in Culture
A recent highly critical NHSEI External Review of The Christie NHS Foundation Trust was prompted by whistleblowers. The Review was provided with detailed evidence that there were very significant (and distressing) problems with the Trust’s approach to race discrimination, bullying and the response when concerns were raised. The External Review (Paragraph 2.2.6.) states In this blog, Roger Kline considers whether the Trust’s own data supports the assertions in the Trust Chair’s email to staff in response to the Review. He considers how the NHSEI Review addressed the issues. He suggests that the Trust’s response; the shortcomings of the NHSEI Review response to the issue of race discrimination; and the NHSEI response to the Review once published mean that further scrutiny of the Trust and NHSEI’s response is required if staff are ever again to risk raise legitimate concerns in this Trust – or rely on NHSEI to support staff who do so.
