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Showing results for tags 'Investigation'.
Found 1,561 results
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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.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation explores the impact of ambulance delays on the emergency treatment of heart attack. The current preferred model of care in the NHS in England is for patients to receive primary percutaneous coronary intervention (PPCI), a procedure which involves widening a blocked artery and inserting a stent to keep the artery open. The effectiveness of PPCI is dependent on the timescale in which it can be carried out. National figures have identified increasing delays in ambulances taking people with a type of heart attack known as ST-elevation myocardial infarction (STEMI) to hospital so that PPCI can be provided within target timescales. This may lead to worse outcomes for these patients. Alternative treatment using thrombolytic medicine (medicines used to dissolve blood clots) is advised where specific timescales for providing PPCI may not be met. This investigation started after a patient notified HSIB of a delay in an ambulance attending him after suffering a heart attack (STEMI).
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Content ArticleIn April 2022, an investigation commenced into the communications provided to patients and/or their carers following placement on a waiting list in Northern Ireland. The primary focus of the investigation is the adequacy of Trust communications to patients, and/or their carers, across various stages of the waiting list process, with significant consideration being given to the content of the Integrated Elected Access Protocol (Department of Health guidance), and its application by the Trusts. The objective was to determine whether or not systemic maladministration has arisen within the communication practices of the Northern Ireland Health and Social Care Trusts (the Trusts) and whether improvements are required. It also aims to publicise what patients and/or their carers should expect from waiting list communications. The Investigative Methodology drew evidence from a wide range of sources. This included extensive queries and information requests to the Trusts and the Department; a General Public survey (with 646 responses); a General Practitioner (GP) survey (with 321 responses); follow up interviews with a number of General Public and GP survey respondents; and a number of Case Study reviews.
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Content ArticleThe objective of this investigation was to understand the context of magnetic resonance imaging (MRI) scanning under general anaesthetic and how care may be reasonably adjusted for patients with autism or learning disabilities. The ‘reference event’ was Alice, a teenage girl who had autism. Sadly, Alice died following her MRI scan under general anaesthetic. The findings and conclusions of this investigation may be applicable to other non-invasive procedures carried out on patients who are under general anaesthetic.
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Content ArticleThis national learning report from the Healthcare Safety Investigation Branch (HSIB) will highlight the themes emerging from their contact with families during their patient safety investigations. It is due to be published in spring 2020. HSIB's national learning reports describe common themes and findings that come out of their national investigation programme and their maternity investigation programme. The information in these reports is used to inform future HSIB investigations or programmes of work.
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Content ArticleSince April 2018, the Healthcare Safety Investigation Branch (HSIB) has been responsible for initiating over 1000 independent safety investigations in NHS maternity services in England. This report summarises eight prominent themes that have emerged through analysis of completed maternity investigations, and how HSIB will explore these themes in more detail during the coming year.
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Content Article
Our son’s final days
Claire Cox posted an article in Patient stories
NHS investigators are to meet the family of a young, autistic man - left starving and desperately thirsty in hospital while waiting for a delayed operation. Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years. These are the harrowing events that came days before the needless, avoidable death of Mark Stuart. Mark was a young man with autism. -
Content Article
The Lampard Inquiry
Mark Hughes posted an article in Inquiries
The Lampard Inquiry is a statutory inquiry investigating mental health inpatient deaths in Essex, focused on services provided by the Essex Partnership University Foundation NHS Trust (EPUT) and the North East London Foundation Trust (NELFT) and their predecessor organisations. This Inquiry continues the work of the Essex Mental Health Independent Inquiry. This website provides information about the inquiry team, terms of reference and publications relating to this. -
Content ArticleThis three-hour online course introduces the concept and approach to thematic analysis in safety investigations. It builds on the concepts discussed in HSIB's Level 2 course A systems approach to learning from patient safety incidents, so attendees must have completed the Level 2 course prior to enrolling on this course. The course will run on the following dates: 11 June 2024 24 June 2024 10 July 2024 15 July 2024 HSIB courses are aimed at NHS staff in health and social care settings in England, who are involved in safety investigations for learning. Courses run online and are free of charge to attend for NHS staff.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
