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Showing results for tags 'Patient death'.
Found 1,491 results
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Content ArticleThis study, published in BMJ Quality and Safety seeks to determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.
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Content ArticleWhen patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.
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Our son's final days: "It was like he didn't matter"
Patient Safety Learning posted an article in Patient stories
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. They tell their story to BBC News. -
Content ArticleA report from the Public Administration Select Committee looking at the investigation process, how it impacts those involved and how risk can be reduced through learning.
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Content ArticleIn our previous blog we shared some reflections about the recent case of Dr Gawa-Barba and the implications the case has for the promotion of a learning culture in healthcare. In light of the Gawa-Barba case, the Government set up a review to which we have submitted a paper.
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Reflecting on the Bawa-Garba case
PatientSafetyLearning Team posted an article in Legal matters
When an adverse event occurs in healthcare, the consequences can be catastrophic for patients and their families. In the aftermath of such events there are multiple needs, expectations and demands. This blog from our Patient Safety Learning website, looks at the case in which Dr Hadiza Doctor Bawa-Garba was convicted of manslaughter. -
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My experience in a coroner’s court – a nurse perspective
Anonymous posted an article in Florence in the Machine
This is the story of a nurse's experience when attending a coroner's court and how the Trust supported them through this difficult time.- Posted
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Content ArticleThis powerful blog by Sarah Seddon discusses her experience during a 'fitness to practice' hearing. Sarah is a clinical pharmacist, however , has now found herself as a witness following the tragic death of her son Thomas. This blog explains what it is like for the witness during the process and how it made her feel.
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Content ArticleIn the US, approximately 700 women die annually from pregnancy-related complications.The most frequent cause of severe maternal morbidity and preventable maternal mortality is obstetric haemorrhage — excessive blood loss from giving birth. As a result of this significant patient safety concern, The Joint Commission introduced two new standards, effective 1 July 2020, to address complications in maternal haemorrhage and severe hypertension/ preeclampsia. This Quick Safety provides background information around strategies for the management of maternal haemorrhage that are outlined in new Provision of Care, Treatment, and Services standard.
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The Shipman Inquiry (2002-2005)
PatientSafetyLearning Team posted an article in Other reports and inquiries
Harold Fredrick Shipman was convicted at Preston Crown Court on 31 January 2000 of the murder of 15 of his patients while he was a General Practitioner at Market Street, Hyde, near Manchester and of one count of forging a will. He was sentenced to life imprisonment. On 1 February 2000, the Secretary of State for Health announced that an independent private inquiry would take place to establish what changes to current systems should be made in order to safeguard patients in the future. The Inquiry's First Report was published on 19 July 2002 and its Final Report on 27 January 2005. -
Content ArticleA report for Norfolk and Suffolk NHS Foundation Trust by Verita. Verita is an independent consultancy that specialises in conducting and managing investigations, reviews and inquiries for regulated organisations.
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Content ArticleIn 2016, a national review by the Care Quality Commission (CQC) found that the NHS was missing opportunities to learn from patient deaths and that too many families were not being included or listened to when an investigation happened. A key recommendation from this review was that a national framework be developed, so that NHS Trusts have clarity on the actions required when someone dies in their care. The National Guidance on Learning from Deaths published by the National Quality Board (NQB) in March 2017, recommended all Trusts to publish a policy on how the organisation responds to and learns from deaths of patients who die under their management and care. The frameworks purpose is to initiate a standardised approach for reporting, investigating and learning from deaths in care.
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Content ArticleThe National Guidance on Learning from Deaths was published by the National Quality Board in March 2017 to initiate a standardised approach, ensuring that learning from a review of the care provided to patients who die should be integral to a provider’s clinical governance and quality improvement work. To fulfil the standards and new reporting, this policy identifies and highlights: The Trust’s governance arrangements. The Trust’s processes on reporting, reviewing and investigation of deaths, including those deaths that are determined more likely than not to have resulted from problems in care. The Trust’s processes, to share and act upon any learning derived from these processes.
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Content ArticleThe National Mortality Case Record Review Programme (NMCRR) aims to develop and implement a standardised methodology for reviewing the case records of adults who have died in acute hospitals across England and Scotland. As well as improve understanding and learning about problems and processes in healthcare that are associated with mortality.
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Content ArticleThis policy confirms the process for reviewing deaths within Lincolnshire Community Health Services (LCHS) to ensure a consistent approach is followed in order to identify if the patient’s needs were met during the end of life phase and that relatives and carers were supported appropriately. The aim of the mortality review process is to identify any areas of practice that require improvement and to identify areas of good practice. This process ensures that mortality within LCHS is managed and reviewed in a systematic way.
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Content ArticleNHS England published an independent report into the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust and highlighted a system-wide response. The report was commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust. Both Southern Health NHS Foundation Trust and the clinical commissioning groups (CCGs) that commission services from them have accepted the recommendations.
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Content ArticleThe Gosport Independent Panel was set up to address concerns raised by families over a number of years about the initial care of their relatives in Gosport War Memorial Hospital and the subsequent investigations into their deaths. The Report is an in-depth analysis of the Gosport Independent Panel’s findings. It explains how the information reviewed by the Panel informed those findings and illustrates how the disclosed documents add to public understanding of events at the hospital and their aftermath.
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Content ArticleAn independent review into the widespread failings by Liverpool Community Health Trust. The review conducted by Dr Bill Kirkup CBE, commissioned by NHS Improvement, looks into the issues at the Trust from November 2010 to December 2014. It also looks at the oversight of the Trust by the NHS Trust Development Authority, NHS England and commissioners.
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Content ArticleChaired by Robert Francis QC, this Inquiry was set up to examine the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Inquiry looked at why the serious problems at the Trust were not identified and acted on sooner, to identify important lessons to be learnt for the future of patient care.
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Content ArticleThe Inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary.
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Content ArticleEffective communication is critical to successful large-scale change. Yet, in our experience, communications strategies are not formally incorporated into quality improvement frameworks. The 1000 Lives Campaign was a large-scale national quality improvement collaborative that aimed to save an additional 1000 lives and prevent 50 000 episodes of harm in Welsh health care over a two year period. This research, published in the Journal of Communication in Healthcare, used the campaign as a case study to describe the development, application, and impact of a communications strategy embedded in a large-scale quality improvement initiative.
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Content ArticleConcern was raised about a number of deaths at Furness General Hospital leading to the establishment of the Morecambe Bay Investigation in September 2013, led by Dr Bill Kirkup. In May 2018 the Professional Standards Agency published a ‘Lessons Learned Review’ into the handling of concerns relating to the fitness to practise of nurses in Furness General Hospital (now part of the University Hospitals of Morecambe Bay NHS Foundation Trust) by the Nursing and Midwifery Council (NMC). Amongst other issues, the report identified problems with the handling of a document produced by the father of one of the babies who died at Furness General Hospital. In August 2018, the NMC commissioned Verita to carry out an independent audit to review the way the NMC handled the chronology. The audit was asked to focus on the NMC’s systems and processes in order to establish what happened to the chronology and to identify learning for the NMC from the case. Verita is a consultancy specialising in the management and conduct of investigations, reviews and inquiries. Peter Killwick and Kieran Seale carried out the investigation which was supported by Bethany Simpson.
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Content ArticleMany studies have investigated the presence of a ‘weekend effect’ in mortality following hospital admission, and these frequently use diagnostic codes from administrative data for information on co-morbidities for risk adjustment. However, it is possible that coding practice differs between week and weekend. This paper assess patients with a confirmed history of certain long-term health conditions and investigate how well these are recorded in subsequent week and weekend admissions.
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Safer outcomes for people with psychosis
Dorit posted an article in By patients and public
Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? -
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.
