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Showing results for tags 'Patient death'.
Found 1,495 results
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Content Article
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. -
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 Article
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 ArticleFollowing the inquest into the death of former patient Amy Allan and the subsequent Preventing Future Deaths report given to Great Ormond Street Hospital for Children, Chief Executive Matthew Shaw would like to outline how the hospital is learning from this and what action has been taken to address the concerns that have been raised.
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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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Content Article
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 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 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 ArticleGov.uk has produced guidance for registered medical practitioners on meeting their duties under the Notification of Deaths Regulations 2019. The Notification of Deaths Regulations 2019 came into force on 1 October 2019. A copy of the Regulations can be found on the legislation website.
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Community Post
Unexpected deaths in patients known to Mental Health Services
Catherine Evans posted a topic in Investigations, risk management and legal issues
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Does anyone have examples of templates they use for reviewing unexpected deaths in the community of patients known to mental health services?- Posted
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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 Article
The real second victims
Patient Safety Learning posted an article in Second victim
In many professions, specific terms – both old and new – are often established and accepted unquestioningly, from the inside. In some cases, such terms may create and perpetuate inequity and injustice, even when introduced with good intentions. One example is the term ‘second victim’. The term ‘second victim’ was coined by Albert W Wu in his paper ‘Medical error: the second victim’. Wu wrote the following: “although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims”. In his blog, Stephen Shorrick discusses the term second victim, what patients and families think of this term, and proposes that healthcare professionals are perhaps the 'third victims'. -
Content Article
Why investigate? The patient's perspective
Joanne Hughes posted an article in Investigations and complaints
A brief, heartfelt piece presented purely from the harmed patient's perspective and urging those involved in making decisions about whether or not to investigate to consider the impact of a good investigation on the ability of the harmed patient and their family to heal... Well received on twitter and described by a number of patients as 'you've said what I feel'. A reminder that a crucial purpose of the investigation is to give a harmed patient and their family a full explanation to help them understand, process and share for learning their experience. All necessary to their recovery. All necessary to their own 'safety' following an incident (we know poor responses cause additional suffering to those already harmed). The author also highlighted (via twitter) how much of this blog relates to the needs of staff involved in incidents too...- Posted
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Content ArticleThe Parliamentary and Health Service Ombudsman (PHSO) was set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. This report look at how a man died after excessive wait for cancer treatment.
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Content ArticleRob Hackett, Patient Safe Network, in the video below discusses the danger of Indistinct chlorhexidine which can easily be mistaken for other colourless solutions. He highlights the story of Grace Wang, who in 2010 had antiseptic solution injected into her epidural. She nearly died and was left paralysed. Indistinct chlorhexidine was mistaken for saline. The investigation recommended all skin antiseptic solutions to be coloured in a way that distinguished them. Sadly this recommendation isn't followed. Accidental chlorhexidine injections continue to occur and there are many more examples. This same error continues to play out again and again throughout the world. There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost.
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Content Article
Learning Disabilities Mortality Review annual reports
Claire Cox posted an article in Learning disabilities
The Learning Disabilities Mortality Review (LeDeR) programme was established to support local areas to review the deaths of people with learning disabilities, identify learning from those deaths and take forward the learning into service improvement initiatives. The LeDeR programme produces an annual report every year. Alongside each report is a webinar presentation of the key findings. -
Content ArticleThe Learning Disabilities Mortality Review (LeDeR) programme was established in May 2015 to support local areas across England to review the deaths of people with a learning disability, to learn from those deaths and to put that learning into practice.
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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.
