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A year after the Infected Blood Inquiry’s final report, serious transfusion risks persist. Trusts must act now to improve safety, reduce waste, and address inequality, warns Cheng Hock Toh in this HSJ article. In May 2024, the UK Infected Blood Inquiry (IBI) published its final report into the devastating failures that led to approximately 30,000 people in the UK being infected with HIV or hepatitis C through transfused blood and blood products. This tragedy has so far claimed more than 3,000 lives. One year on, the UK government has formally accepted all 12 of the report’s recommendations, either in full or in principle. Although rigorous testing has made blood itself safer, serious risks around transfusion practice remain. The government rightly acknowledges that more must be done to prevent future harm. There are already troubling signs, and trusts and commissioners must act urgently to assess and improve the quality, safety, and equity of blood transfusion care across the system.

Operational guidance to support health boards boards undertaking perinatal adverse event reviews incorporating the additional reporting required of maternity services. See also Maternity and neonatal (perinatal) adverse event review process for Scotland: Operational guidance to supplement the HIS national framework

Presentation from David Osborn, health and safety consultant and member of the Covid Airborne Transmission Alliance (CATA), to the Safer Healthcare Biosafety Network. You can watch the video of the presentation and download the pdf presentation slides below. David Osborn, health and safety consultant and member of the Covid Airborne Transmission Alliance (CATA), has given an account of CATA’s journey through the Covid-19 Public Inquiry to the Safer Healthcare Biosafety Network (SHBN). This has been in two parts: His first presentation was delivered on 3 December 2024, just as the public hearings for module 3 (impact of the pandemic on healthcare systems) were drawing to a close. In this second presentation (28 March 2025) David updates the group on CATA's current position and summarises their final submissions to Baroness Hallett. The detail in CATA’s closing submissions to the Inquiry may be found in its written statement at this link. Links are provided in the last two slides of the attached PDF file to CATA’s letters to the Chief Nursing Officers and Ministers. 2025-03-28 SHBN Presentation.pdf It should be noted that, as at 19 May 2025: No reply has been received from the Chief Nursing Officers to CATA’s letter of 4 March. No reply has been received from the Minister (Rt Hon Ashley Dalton MP) to CATA’s letter of 18 March. CATA has therefore written again to the Rt Hon Ashley Dalton MP. The letter is attached below: cata-letter-to-ashley-dalton-mp-1-may-25 (1).pdf

The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review (AAR) in particular, are very varied. In this article, Judy Walker looks at the the variation in executing AARs and why this risks jeopardising the very essence of the AAR. *This article was first published in The After Action Review Newsletter May 2025 written by Judy Walker Associates Ltd. The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review in particular, are very varied This is not surprising and is not concerning, as the PSIRF is purposefully designed to empower healthcare providers to implement in the framework in the way that suits their context best. However, I am concerned that the variation is also being manifested in the approach taken within the execution of the AAR itself, which risks jeopardising the very essence of the AAR. One of the risks is to the quality of the engagement and accountability with those who are attending the AARs. It was an excellent article published by Psychological Safety, on the Spectra of Participation which explores these concepts that gave me the idea for a framework for describing what I have observed that is a concern. Participation doesn’t guarantee engagement Looking at the IAP2 and other frameworks, the article explores the idea that participation doesn’t always guarantee engagement. The quality of engagement is a direct result of the goal of the process and the amount of psychological safety present. This analysis got me thinking about creating a scale of participation to bring to life the variety seen in AARs and is designed to help those leading AARs to be clear on the what their goals are. This table below sets out the five levels of participation that I’ve developed. Involve, Facilitate and Empower are all possible and healthy uses of the After Action Review approach. Organisational requirements will impact on how the AAR approach is deployed in each context and the full “Empower” approach where AAR participants are given full scope to act on the learning and their own recommendations, may not be appropriate for AARs taking place within a PSIRF governed process. However, it is a legitimate and valuable approach in project teams and other contexts. The continuum When you look at the continuum, you can see there is a shift from left to right of the AAR Conductor having knowledge of the event to needing to have very little. The Inform position is one where the AAR Conductor already has knowledge and is inviting participants to contribute to enrich the knowledge already held. This is not genuine engagement and along with the Consult approach, can be experienced as a tokenistic application of the AAR. The Facilitate and Empower positions, are those where the AAR Conductor needs have little knowledge prior to the AAR since the work is centred around the participants’ contributions and responses the AAR questions alone. This ensures meaningful engagement with the participants and requires skill in creating the psychological safety for honest conversations and asking the searching questions. The Empower position is different in that the aim is not to hand back the responsibility for action and reporting to the AAR Conductor, but to enable the participants to be ready to take the learning forward. Examples of the types of questions asked along the continuum Inform – “Did you have enough staff on duty?”, “ Was the NatSSIPS process followed?” Consult – “How did the patient respond?”, “Why weren’t the police called?” Involve – “What else was happening on the ward at the time?”, “What might prevent this happening again?” Facilitate – “Communication between agencies has been mentioned a few times: what might improve communication between agencies in future?” “Which of these ideas would make most impact?” Empower – “What do you want to do with this learning?” What support do you need to put this into action?” In summary As an AAR Conductor, you have to operate within your organisations’ context but it is vital to build trust in the AAR process. You will do this by ensuring your actions match your stated intentions and you are transparent about the level of participation you’re aiming for. Getting this right isn’t just about the integrity and standardisation of the AAR approach, it is also about maximising the potential for improvements in patient safety. Those AARs where Involving, Facilitating and Empowering are the goal, increase the level of accountability for change owned by the participants. We know from the research that when staff are fully engaged in the AARs they attend, their behaviour changes and patients are safer as a result.

Expectations of patient and family involvement in investigations of healthcare harm are becoming conventional. Nonetheless, how people should be involved, is less clear. Therefore, the “Learn Together” guidance was co-designed, aiming to provide practical and emotional support to investigators, patients and families. This study evaluated the use of the Learn Together guidance in practice—designed to support patient and family involvement in investigations of healthcare harm. Findings The guidance supported the systematic involvement of patients and families in investigations of healthcare harm and informed them how, why, and when to be involved across settings. However, within hospital Trusts, investigators often had to conduct “pre-investigations” to source appropriate details of people to contact, juggle ethical dilemmas of involving vs. re-traumatising, and work within contexts of unclear organisational processes and responsibilities. These issues were largely circumvented when investigations were conducted by an independent body, due to better established processes, infrastructure and resources, however independence did introduce challenge to the rebuilding of relationships between families and the hospital Trust. Across settings, the involvement of patients and families fluctuated over time and sharing a draft investigation report marked an important part of the process—perhaps symbolic of organizational ethos surrounding involvement. This was made particularly difficult within hospital Trusts, as investigators often had to navigate systemic barriers alone. Organisational learning was also a challenge across settings. Conclusions Investigations of healthcare harm are complex, relational processes that have the potential to either repair, or compound harm. The Learn Together guidance helped to support patient and family involvement and the evaluation led to further revisions, to better inform and support patients, families and investigators in ways that meet their needs (https://learn-together.org.uk). In particular, the five-stage process is designed to centre the needs of patients and families to be heard, and their experiences dignified, before moving to address organisational needs for learning and improvement. However, as a healthcare system, we call for more formal recognition, support and training for the complex challenges investigators face—beyond clinical skills, as well as the appropriate and flexible infrastructure to enable a receptive organisational culture and context for meaningful patient and family involvement. Related reading on the hub: The Learn Together programme (part A): co-designing an approach to support patient and family involvement and engagement in patient safety incident investigations