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Showing results for tags 'Patient death'.
Found 1,490 results
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Content ArticleInfographic summarising the key messages from the MBRRACE-UK 2018 report 'Saving Lives, Improving Mothers’ Care'.
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Content Article
Each Baby Counts (RCOG, 2019)
Patient Safety Learning posted an article in Maternity
Each Baby Counts is the Royal College of Obstetricians and Gynaecologists (ROCG's) national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. -
Content ArticleA framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care set out by the National Quality Board in 2017.
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Content ArticleThe Parliamentary Healthcare Service Ombudsman published 'Ignoring the alarms: How NHS eating disorder services are failing patients' in December 2017. The families who brought forward their complaints helped uncover serious issues that required national attention. The failings catalogued in the report highlighted a systemic set of problems in relation to identifying, treating and monitoring eating disorders that require a systemic response. This encompasses raising awareness among clinicians, building greater specialist capability and ensuring adult eating disorder services achieve parity with child and adolescent services. This submission provides an overview of the report’s systemic findings and the responses seen to the systemic recommendations made to date.
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Content ArticleThis pack is for acute, specialist, mental health and community trust boards and specifically trust non-executive directors (NEDs) and non-clinical executive directors. It explains what boards are expected to do in relation to the Learning from Deaths framework.
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Content ArticleBoth national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations. Here the Healthcare Safety Investigation Branch (HSIB) demonstrate how they involve families in their investigations.
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Content ArticleWas a lack of situational awareness a contributing factor in the outcome of this 'routine operation'? In this human factors video, Martin Bromiley, a pilot, explains what happened that day and what measures need to be in place to prevent other similar incidents.
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Content ArticleThis document is the second version of the Saving Babies’ Lives Care Bundle, which has been produced by NHS England to help reduce perinatal mortality across England. The second version of the care bundle brings together five elements of care that are widely recognised as evidence-based and/or best practice: reducing smoking in pregnancy, risk assessment, prevention and surveillance of pregnancies at risk of fetal growth restriction; raising awareness of reduced fetal movement; effective fetal monitoring during labour; reducing preterm birth.
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Content ArticleFourth MBRRACE-UK Perinatal Mortality Surveillance Report providing information on UK perinatal deaths for births from January to December 2016. The report focuses on the surveillance of all late fetal losses (22+0 to 23+6 weeks gestational age), stillbirths and neonatal deaths, with data presented by country, by geographical area, by health care provider and by Local Authority.
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Content Article
WHO Safe Childbirth Checklist (December 2015)
Patient Safety Learning posted an article in WHO
Of the more than 130 million births occurring each year, an estimated 303 000 result in the mother’s death, 2.6 million in stillbirth, and another 2.7 million in a newborn death within the first 28 days of birth. The majority of these deaths occur in low-resource settings and most could be prevented. The World Health Organization (WHO) has produced a safe birth checklist. -
Content ArticleSacha Wells-Munro, Maternity Improvement Advisor at NHS Improvement and Professor Tim Draycott, consultant obstetrician and Health Foundation Improvement Science Fellow, present at the Patient Safety Learning Conference the lessons learned from the Morecambe Bay maternity scandal and changes needed to improve the safety of maternity services system wide.
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Content ArticleDr Bill Kirkup, Chairman of the Morecambe Bay Investigation, presented at the Patient Safety Learning Conference on the common themes that have emerged, and the lessons we need to learn, from the numerous high-profile inquiries in which he has played a leading role.
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News Article
Man dies after being sucked into an MRI machine
Patient Safety Learning posted a news article in News
An unfortunate series of events involving a magnetic resonance imaging (MRI) machine led to the death of a man at a hospital in India. Rajesh Maruti Maru, a 32-year-old, was thrust into the MRI machine while he was visiting an elderly relative at the BYL Nair Charitable Hospital in Mumbai, India. As the Hindustan Times reports, the man was apparently told by a junior member of staff to carry a metal cylinder of liquid oxygen into a room containing an MRI machine. Unbeknownst to everyone, the MRI machine was turned on. This caused Maru to be suddenly jolted pulled towards the machine, causing the oxygen tank to rupture and leak. The man later died after inhaling large amounts of oxygen. His body also bled heavily as a result of the accident. "When we [the hospital staff] told him that metallic things aren't allowed inside an MRI room, he said 'sab chalta hai, hamara roz ka kaam hai' [it's fine, we do it every day]. He also said that the machine was switched off. The doctor, as well as the technician, didn't say anything,” Harish Solanki, Maru's relative, told NDTV. "It's because of their carelessness that Rajesh died," Solanki added. Police are currently examining the CCTV footage of the incident and have arrested at least two members of hospital staff for the negligence. The local government has also awarded the man's family 500,000 rupees ($7,855) in compensation. Read full story Source: IFL Science, 29 January 2018 -
Content ArticleExternal Lead Advisor to WHO’s Patients for Patient Safety network, Margaret Murphy, telling the story of her son’s death and how she has used this experience to improve how healthcare organisations work with those who suffer patient harm.
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Content ArticleLearning from deaths of people in their care can help providers improve the quality of the care they provide to patients and their families, and identify where they could do more. A CQC review in December 2016, 'Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England' found some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care. This video from the NHS Improvement national patient safety team is a guide for NHS trusts in England on developing and implementing learning from deaths policies within their organisations.
