Jump to content

Search the hub

Showing results for tags 'Investigation'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous


  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Learning news archive
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous
    • Health care
    • Social care
    • Jobs and voluntary positions
    • Suggested resources


  • News

Find results in...

Find results that contain...

Date Created

  • Start

Last updated

  • Start

Filter by number of...


  • Start



First name

Last name


Join a private group (if appropriate)

About me



Found 597 results
  1. Community Post
    Have you had first-hand experience of a serious safety incident? Were you aware of what support was available following this? What support do you think is needed for staff following a serious safety incident? Patient Safety Learning and SHBN are collaborating with patient safety experts and frontline staff to produce a manual to support staff, provide good practice and ‘how to’ tools to improve staff wellbeing following serious safety incidents. If you work in healthcare we would welcome views on this, by completing our short survey and/or sharing your thoughts below.
  2. News Article
    A group of survivors and relatives of people who died in the infected blood scandal are suing a school where they contracted hepatitis and HIV after being given experimental treatment without informed consent. A proposed group action lodged by Collins Solicitors in the high court on Friday alleges that Treloar College, a boarding school in Hampshire that specialised in teaching haemophiliacs, failed in its duty of care to these pupils in the 1970s and 80s. The claim could result in a payout running into millions of pounds, and is based on new testimony given by former staff at the sc
  3. News Article
    Hundreds of nurses, paramedics, health and care workers have been disciplined over allegations of sexual assault, including incidents involving child sexual abuse, The Independent can reveal. It comes as the government begins a year-long inquiry into the sexual abuse of dead patients by “morgue monster” David Fuller. Charities claim the true scale of the issue is likely to be hidden by “vast underreporting” while safeguarding experts say there is no “uniformity” in how NHS trusts handle such cases. The Health and Care Professions Council (HCPC), which regulates just under 300,00
  4. Content Article
    The investigation identified the following learning points that could potentially offer benefits at a national level: The correct identification of patients relies on staff checking patient details and therefore will not always occur effectively. There may be opportunities for further engineered or technological barriers to help mitigate the risk of incorrect identification. The investigation recognises that a single hospital trust may receive patients from multiple ambulance trusts, and ambulances from a single ambulance trust may attend several hospital trusts. Pathways and pro
  5. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version. Local systems and organisations outside of the early adopter areas are free to use the already published version
  6. Content Article
    The research found that ethnic minority GPs reported poor experiences of the inspection process and its outcomes.There was a feeling that their inspection outcomes could be “harsh” and “unfair”. They felt that CQC does not understand or appreciate the unique challenges that ethnic minority-led practices face. In the survey of GP practices, ethnic minority-led practices were more likely to report that GPs in their practice experienced adverse impacts on their physical and mental health, a negative impact on their personal and/or family life, and had seen an increase in staff sickness as a
  7. News Article
    Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip rep
  8. Content Article
    In this report, the Coroner states their concerns as follows: No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Heath NHS Trust since 2018, there remains no requirement to utilise such a tool. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient's welfare passed between the two teams but no targeted que
  9. News Article
    “Unacceptable” failures by a mental health hospital to manage the physical healthcare of a woman detained under the mental health act contributed to her starving to death, The Independent has learned. A second inquest into the death of a 45-year-old woman, Jennifer Lewis, has found that the mental health hospital to which she was admitted “failed to manage her declining physical health” as she suffered from the effects of malnutrition. Ms Lewis had a long-term diagnosis of schizophrenia. Her family described how she had lived a full life, completed a degree, and given lectures about
  10. News Article
    A six-year-old girl thought to have died from sepsis was in fact suffering from a blood condition triggered by E coli infection, an inquest has found. Coco Rose Bradford was taken to the Royal Cornwall hospital in the summer of 2017 suffering from stomach problems and later transferred to the Bristol Royal hospital for children, where she died. The following year an independent review flagged up failings in her care in Cornwall and the Royal Cornwall hospitals trust apologised for how it had treated her. Her family were left with the belief she had died of sepsis and could have
  11. Content Article
    In 2009, Steve Burrows’ mother, Judie, an active and independent retired teacher, fell while riding her bike and was rushed to the hospital for hip surgery. After months of painful recovery, she fell again. Then, after eight days in the hospital and a second hip surgery, in which she lost approximately half her blood, the 69-year-old fell into a coma and suffered permanent brain damage. Questioning whether his mother received adequate care in surgery and in the hospital’s “e-ICU” unit, in which doctors sometimes monitor patients remotely by camera, Burrows consulted friends and lawyers, e
  12. Event
    The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths during the Covid pandemic and how mortality investigation should be managed in these cases. The conference will discuss the role of Medical Exami
  13. News Article
    East of England Ambulance Service Trust has launched an ‘independent investigation into the circumstances’ surrounding the death of a staff member, its chief executive told a board meeting today. Nick Lee, 46, from Ovington in west Norfolk, died on 3 December. The cause of death is yet to be officially established. He was a leading operations manager for west Norfolk, and hospital ambulance liaison officer at Queen Elizabeth Hospital King’s Lynn Foundation Trust and had worked for the ambulance trust for nearly 20 years. This is not the first time the trust, which has faced significa
  14. News Article
    Two paramedics have been sentenced to five years in prison for stealing medication from terminally ill patients. Ruth Lambert, 33, and Jessica Silvester, 29, of the South East Coast Ambulance Service (Secamb), preyed specifically on people receiving end-of-life care packages, Kent Police said in a statement. The pair, who live together at Gap Road in Margate, accessed addresses of patients in the east Kent area through their work and posed as nurses to gain access to patients’ homes to steal morphine and other painkillers. They worked in tandem, one researching the addresses and
  15. News Article
    A nurse who was struck off for refusing to admit a woman to a mental health unit before she killed herself said 'leave her, she will faint before she dies' before he kicked her out of the facility. Paddy McKee allegedly made the comment as Sally Mays, 22 - who had mental health issues - tried to strangle herself when she was refused admission. Ms Mays killed herself at home in Hull in July 2014 after being refused a place at Miranda House in Hull by McKee and another nurse. Despite her being a suicide risk, they would not give her a place at the hospital after a 14-minute assess
  16. News Article
    A surgeon who burned his initials on to the livers of two patients during transplant surgery has been struck off the medical register. Simon Bramhall, 57, admitted using an argon beam – used to stop livers bleeding during operations and to highlight an area to be worked on – to sign “SB” into his patients’ organs in 2013 while working at Birmingham’s Queen Elizabeth hospital. On Tuesday, a review by the Medical Practitioners Tribunal Service (MPTS) concluded Bramhall’s actions were “borne out of a degree of professional arrogance” and that they “undermined” public trust in the medica
  17. News Article
    An inmate gave birth to a stillborn baby in shocking circumstances in a prison toilet without specialist medical assistance or pain relief, an investigation by the Prisons and Probation Ombudsman (PPO) has found. A prison nurse who did not respond to three emergency calls from a prison officer to come to the woman’s aid when she developed agonising stomach cramps has been referred to the Nursing and Midwifery Council. Louise Powell, 31, was unaware that she was pregnant. She gave birth on a prison toilet on 18 June 2020 at HMP & YOI Styal in Cheshire. She previously said she
  18. News Article
    The government has been criticised for failing to respond to a damning parliamentary report that accused ministers of mishandling the early stages of the pandemic. The report, compiled by the Health and Science and Technology Committees, found the government’s initial response to Covid-19 “amounted in practice” to the pursuit of herd immunity, with the delayed decision to lock down ranking as one of the “most important public health failures the United Kingdom has ever experienced”. More than 50 witnesses contributed to the cross-party report, including ministers, NHS officials, gove
  19. News Article
    Authorities were aware of discrepancies in Covid test results across England one month before the lab responsible was ordered to shut down its operations, legal papers show. An estimated 43,000 incorrect false negative tests were processed for the NHS by the Immensa laboratory in Wolverhampton between 8 September and 12 October. UK Health Security Agency became aware of an “unusual spike” in suspicious test results on 14 September, with large numbers of people testing positive on lateral flow devices but negative via PCR. It took a month before the UKHSA determined that the “lik
  20. News Article
    A care home with some of the highest Covid death rates recorded in the pandemic is facing whistleblower claims over unsafe conditions. Golfhill Nursing Home, in Dennistoun in Glasgow's East End, Scotland, is run by Advinia Healthcare, which confirmed a "large scale" investigation was taking place. A report by the Crown Office, published in April, showed Golfhill care home recorded 11 deaths related to coronavirus, among the highest rates. The Care Inspectorate investigation is said to have followed "months of complaints" about sub-standard and unsafe conditions at the home, incl
  21. News Article
    A whistle-blower in the case of an autistic man who has been detained in hospital since 2001 says he feels complicit in his "neglect and abuse". A BBC investigation found 100 people with learning disabilities have been held in specialist hospitals for 20 years or more, including Tony Hickmott. His parents are fighting to get him rehoused in the community. A support worker at a hospital where Mr Hickmott has been detained said he was the "loneliest man in the hospital". Mr Hickmott was sectioned under the Mental Health Act in 2001. His parents, Pam and Roy Hickmott, were told he
  22. News Article
    A whistleblower at the centre of a bullying scandal at West Suffolk hospital says she will “never be the same again” after being “pursued” by NHS managers when she raised concerns about a doctor injecting himself with drugs while on duty. Dr Patricia Mills was exonerated last week in an independent NHS review that was highly critical of the way she was ignored and then subjected to disciplinary investigation that verged on “victimisation”. The review, by Christine Outram, chair of the Christie NHS foundation trust, said Mills’s concerns about the self-injecting doctor were “well foun
  23. News Article
    The government has rejected advice from an independent inquiry into the actions of disgraced surgeon Ian Paterson to suspend all healthcare professionals who are suspected of posing a risk to patient safety. The Department of Health and Social Care today published its response to 15 recommendations from the inquiry, which found Mr Paterson, jailed for 20 years in 2017 for 17 offences of wounding with intent, may have conducted up to 1,000 botched and unnecessary operations over a 14-year period. Of its 15 recommendations, the DHSC accepts nine in full, five in principle, rejects one