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Found 199 results
  1. Content Article
    This qualification is for anyone who wants to carry out incident investigations effectively. Employers, supervisors, SHE champions, union and safety representatives will benefit. Attending the course will enable you to: Independently investigate simple incidents. Gather evidence including conducting witness interviews. Produce an action plan to prevent a recurrence of an incident. Contribute to team investigations for large scale incidents Positively impact the safety culture in your organisation.
  2. News Article
    The coroner investigating the botched birth of a baby boy who died from hypoxia has strongly criticised the Healthcare Service Investigation Branch (HSIB) over its report on his death. Karen Henderson, who conducted the inquest into the death of baby Theo Young in May 2018 at East Surrey Hospital said that the HSIB had asked Surrey and Sussex Healthcare NHS Trust not to undertake its own investigation, “effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths.” Read full story (paywalled) Source: BMJ, 19 May 2020
  3. Content Article
    Key findings: The nursing staff provided exemplary care to the six patients on the ward; they were compassionate, professional and worked to ensure the patients were provided with the best care possible. The decision to transfer the residents was made quickly on a Friday, and staff had a short time to plan and respond putting together a COVID-ready ward. The patients required full nursing care and deteriorated relatively quickly. Consequently, nurses needed to spend long periods of time at the patients’ bedsides. There was no way for nursing staff to communicate with staff outside the patients’ rooms which increased the frequency of donning and doffing PPE. Full PPE was available to staff at all times. However, there were problems with the usability of the PPE and changes in types of PPE provided, which was stressful for staff.
  4. News Article
    The deaths of more than 50 hospital and care home workers have been reported to Britain’s health and safety regulator, which is considering launching criminal investigations, the Guardian has learned. The Health and Safety Executive (HSE), which investigates the breaking of safety at work laws, has received 54 formal reports of deaths in health and care settings “where the source of infection is recorded as COVID-19”. These are via the official reporting process, called Riddor: Reporting of Injuries, Diseases and Dangerous Occurrences. Separately, senior lawyers say any failures to provide proper personal protective equipment (PPE) may be so severe they amount to corporate manslaughter, with police forces drawing up plans to handle any criminal complaints. Despite weeks of pleading, frontline medical staff complain that PPE is still failing to reach them as hospitals battle the highly contagious virus. Senior barristers say criminal investigations should be launched, and that there are grounds to suspect high-level failures. Read full story Source: The Guardian, 10 May 2020
  5. News Article
    Inquests into coronavirus deaths among NHS workers should avoid examining systemic failures in provision of personal protective equipment (PPE), coroners have been told, in a move described by Labour as “very worrying”. The chief coroner for England and Wales, Mark Lucraft QC, has issued guidance that “an inquest would not be a satisfactory means of deciding whether adequate general policies and arrangements were in place for provision of PPE to healthcare workers”. Lucraft said that “if there were reason to suspect that some human failure contributed to the person being infected with the virus”, an inquest may be required. The coroner “may need to consider whether any failures of precautions in a particular workplace caused the deceased to contract the virus and so contributed to death”. But he added: “An inquest is not the right forum for addressing concerns about high-level government or public policy.” Labour warned the advice could limit the scope of investigations into the impact of PPE shortages on frontline staff who have died from COVID-19. “I am very worried that an impression is being given that coroners will never investigate whether a failure to provide PPE led to the death of a key worker,” said Lord Falconer, the shadow attorney general. “This guidance may have an unduly restricting effect on the width of inquests arising out of Covid-19-related deaths.” Read full story Source: The Guardian, 29 April 2020
  6. News Article
    We don’t yet know the number of NHS staff who have lost their lives in the battle against COVID-19. On Wednesday, Dominic Raab put the figure at 69, but the true figure is considered to be far greater. These deaths are not “natural” casualties of the coronavirus pandemic. In fact, they may be the result of a failure in the government’s duty to care for NHS staff, which is why it is vital it is properly investigated under the law. Since the pandemic reached the UK, we have heard countless reports of doctors and nurses raising the alarm over the lack of personal protective equipment (PPE) when treating COVID-19 patients. How many of these deaths could have been prevented had sufficient PPE been provided to NHS workers? And if there is a lack of PPE, how did this happen? The health secretary, Matt Hancock, says the biggest challenge is “one of distribution rather than one of supply”. Should more have been done to meet this challenge, and if so what? Does the government have a legal duty to do more to protect the lives of healthcare workers? There must be investigations into the individual deaths of NHS workers, out of respect to them, and also so that future deaths can be prevented. The evidence appears to be that the government has failed to protect them from risk to their lives, and if that is the case then an investigation will be required by law. Read full story Source: The Guardian, 25 April 2020
  7. News Article
    More than 16% of people who had tested positive for coronavirus when they died were from black, Asian and minority ethnic (BAME) communities, new data shows. On Monday, NHS England released data showing the ethnic breakdown of people who have died with coronavirus for the first time. The statistics come days after a review was announced to examine what appears to be a disproportionate number of BAME people who have been affected by Covid-19. Last week Downing Street confirmed the NHS and Public Health England will lead the review of evidence, following pressure on ministers to launch an investigation. Discussing the review, Professor Chris Whitty, the chief medical officer for England, said ethnicity is "less clear" than three others factors in determining who is most at risk from coronavirus. Read full story Source: The Independent, 21 April 2020
  8. News Article
    The NHS should expect a “huge number” of legal challenges relating to decisions made during the coronavirus pandemic, healthcare lawyers have warned. The specialists said legal challenges against clinical commissioning groups and NHS providers would be inevitable, around issues such as breaches of human rights and clinical negligence claims. Francesca Burfield, a barrister specialising in children’s health and social care, told HSJ’s Healthcheck podcast: “I think there is going to be huge number of challenges. If and when we move through this there will not only be a public enquiry, [but] I anticipate judicial reviews, civil actions in relation to negligence claims and breach[es] of human rights….” She said criminal proceedings by the Care Quality Commission or Crown Prosecution Service would also be a possibility, around issues such as deprivation of liberty, neglect, safeguarding, and potential gross negligence manslaughter. Read full story Source: HSJ, 20 April 2020
  9. News Article
    An acute trust in the Midlands has contacted 136 women who received major treatment from a gynaecology consultant, after initial investigations revealed “unnecessary harm” to several patients. Read full story (paywalled) Source: HSJ, 17 April 2020
  10. News Article
    The health service has been promised “whatever it needs” to deal with the coronavirus pandemic, but government spending choices reveal possible long-term changes to funding and policy. Having initially promised the health service “whatever it needs, whatever it costs” on 11th March, the government made this official when Matt Hancock issued a ministerial direction allowing the Department of Health to “spend in excess of formal Departmental Expenditure Limits”—effectively providing a blank cheque. But while the government’s actions are designed for the immediate crisis, they may be difficult to reverse once the peak of coronavirus has passed. Indeed, they could yet change how the health service operates on a permanent basis. Read full story Source: Prospect, 7 April 2020
  11. News Article
    “Recurrent safety risks” around clinical care at an embattled NHS trust’s maternity service have been identified in a report published on Tuesday. The Healthcare Safety Investigation Branch (HSIB) has been investigating East Kent hospitals university NHS foundation trust since July 2018 after a series of baby deaths. Among those treated at the trust was Harry Richford, whose death was “wholly avoidable”, seven days after his emergency delivery in November 2017, an inquest found. Speaking on Tuesday, Harry’s grandfather Derek Richford said it is clear that sufficient lessons were not learned from his death. The independent report, published on Tuesday by the Department of Health and Social Care, discusses 24 maternity investigations undertaken since July 2018, including the deaths of three babies and two mothers. It said: “These investigations have enabled HSIB to identify recurrent safety risks around several key themes of clinical care in the trust’s maternity services.” Read full story Source: The Guardian, 8 April 2020
  12. Content Article
    This HSIB summary report provides an overview of: the referrals caseload under the maternity investigations programme for East Kent Hospitals University NHS Foundation Trust the themes which were identified as indicative of patient safety risk to mothers and babies the engagement and escalation process that HSIB undertook with the trust and the wider system in response.
  13. Content Article
    This report will set-out our family engagement process. It will also summarise the feedback received to date from the families who have been involved in HSIB investigations. The purpose is to for HSIB to share their family engagement process with other healthcare organisations involved in patient safety investigations and raise awareness of the value of an effective family engagement process in such investigations. The report will: Describe HSIB’s approach to family engagement in our investigations and what has informed our practice. Describe what has worked well in our approach to family engagement. Summarise what families and staff tell us about our approach. Explain what we have learned and plans for future work.
  14. Content Article
    The investigation identified: There is an opportunity to clarify the consent requirements for diagnostic imaging facilitated by a general anaesthetic. There is variation in the information given to patients regarding anaesthesia at the point of referral for an MRI scan under general anaesthetic. The observations and examinations to be routinely performed in pre-anaesthetic assessment are not defined nationally. The investigation found variation in the hospitals it visited. Children coming into hospital for an MRI scan who had been assessed as fit for anaesthetic were perceived as “well” by ward staff. Children with autism, learning disabilities and/or learning difficulties often find clinical environments distressing, which may be reflected in their physiological observations. This may result in diagnostic overshadowing, where problems such as autism (or a medical condition) are attributed as the cause of other new problems, rather than considering other underlying causes, thereby leaving other co-existing conditions potentially undiagnosed. Children with autism, learning disabilities or learning difficulties may benefit from reasonable adjustments being made when attending hospital. Electronic flagging systems can help staff identify patients who may benefit from reasonable adjustments. Hospital passports provide valuable information to assist with implementation of these adjustments. The model of care for learning disability nursing teams is not standardised nationally. There is an opportunity to enhance the existing published guidance available to assist clinicians involved in general anaesthetics to prepare for adverse events in the MRI scanning environment. Professional networks for anaesthetists provide the opportunity for shared learning and consensus regarding best practice. It is challenging to comply fully with the existing published standards for anaesthetic equipment used in MRI environments.
  15. News Article
    A doctor who worked at the same private healthcare firm as rogue breast surgeon Ian Paterson has been suspended, it has emerged. Spire Healthcare said Mike Walsh – a specialist in trauma and orthopaedic surgery – was suspended in April 2018 over concerns about patient treatment. Almost 50 of his patients from its Leeds hospital had been recalled. The details emerged following an independent inquiry into Paterson, who is serving a 20-year jail sentence. Earlier this month, an inquiry into the breast surgeon found that a culture of "avoidance and denial" had allowed him to perform botched and unnecessary operations on hundreds of women. Spire said in a statement that it acted after concerns were raised about Mr Walsh's work at its hospital in Leeds in 2018. The company, which contacted the Royal College of Surgeons to assist with its investigation, said it had reviewed the notes of fewer than 200 patients, of which "fewer than 50" had been invited back for a follow-up appointment. "Where we have identified concerns about the care a patient received, we have invited the patient to an appointment with an independent surgeon to review their treatment," a spokesman for Spire Healthcare said. "This is a complex case and the review is ongoing." It said that Mr Walsh, who was immediately suspended after the concerns were raised, was no longer working with Spire Healthcare. The company said any patients at its Spire Leeds Hospital who had concerns about their treatment under Mr Walsh should contact the hospital. It said its findings had also been shared with the Care Quality Commission and the General Medical Council (GMC). Read full story Source: BBC News, 17 February 2020
  16. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
  17. Content Article
    In a blog in the Patient Safety Movement newsletter, James Titcombe talks about his son's death and how speaking out can save lives.
  18. News Article
    Complaints about NHS care cannot always be investigated properly because of medical records going missing, the public services watchdog has said. Ombudsman Nick Bennett said many people were left "suspicious" and thought there was a "darker motivation". One woman whose notes went missing said she no longer trusted what doctors said and had lost faith in NHS transparency. The Welsh NHS Confederation said staff were "committed to the highest standards of care". In a report called Justice Mislaid: Lost Records and Lost Opportunities, Mr Bennett found 70% of 17 cases he looked at in Welsh NHS hospitals and care settings could not be properly investigated because of lost documents. Read full story Source: BBC News, 10 March
  19. Content Article
    Working with early adopters To test the PSIRF, NHS Improvement are first working with a small number of early adopters who are using an introductory version of the framework in their organisations. This testing phase will be used to inform the creation of a final version of the PSIRF which is anticipated to be published in Spring 2021. At that point, other providers of NHS funded care in England who are not early adopters will also begin adopting the new framework. All NHS organisations are expected to have transitioned to using the new framework from Autumn 2021. Introductory version of the PSIRF While NHS Improvement are not asking organisations other than the early adopters to transition to the PSIRF, they will help providers outside of the early adopter areas to plan for this change. They have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2021. Until instructed to change to the PSIRF (likely from Spring 2021), non-early adopter organisations must continue to use the existing Serious Incident Framework.
  20. Content Article

    Marking your own homework

    I read the recent blog from a fellow nurse, ‘Silent witness’, and I too am frustrated with the current system of ‘datixing’. Reporting is a good thing. We must report incidents; we do report incidents to try to keep our patients and staff safe. Many of us, I think, feel comfortable in reporting incidents. However, the frustration with me is different. Yes, the feedback and the way that the reporter gets ‘missed out’ of inquiries is wrong, but the outcomes and the ‘learning’… that is where my frustration lies. I should point out at this stage of my blog; I am raging. I am so angry and frustrated at this system I could scream. I have been a nurse now for over 20 years. I have probably filed hundreds of Datixes over the years. Some I have received feedback on, some I have not. I want to give you an insight on what I see. Not how it should be, not how you think it should be, this is how I see the system working where I am and how it makes me feel. At present I am angry in what I see. Organisational structure Where I work (in an NHS Trust) we have divisions: Medicine, Women and Children, Surgery, etc. Each one of these divisions has a head of nursing who is responsible for the safety and quality of their area, then, moving down the hierarchy, there are the matrons and then the ward managers – these are the people who would ‘investigate’ the incident that has happened, overseen by the safety and quality team (who are non-clinical). Competition time These divisions have meetings. The frontline staff – nurses, doctors, AHPs and support staff – are not invited to these meetings. From being curious, I have determined what goes on in these meetings by shadowing my manager. In these meetings they discuss how many falls, how many acquired infections, how many serious incidents, pitching against each other to see who has performed best or better than last time. So, by investigating the incidents that happen in your division while attempting to keep your numbers for falls, acquired infections and serious incidents low, by untrained investigators, how can these investigations be rigorous and unbiased? In come the safety team. I’ve never met anyone from our safety team. I don’t know where their office is. I wouldn’t know them if they walked past me in the corridor. I have no idea if they have a clinical background, but what I do know is that they do not have experience in what it is like to work in the department where I work. They don’t know the nuances, the culture, the normal deviance of behaviours or the workarounds that we use to get the work done. Perhaps if they understood... Real life examples I would like to share with you a few events to demonstrate how this safety process is not set up to keep patients safe; it's set up to keep the numbers of serious incidents low in that area. As I mentioned earlier, this is how it looks from my lens. Incident 1 – Tracheostomy and laryngectomy patients Looking after patients with tracheostomies or laryngectomies are sometimes tricky. They are high risk patients and require staff to have specialist training to care for them safely. These patients are cared for on specific wards so that patients are cohorted and cared for by staff who look after them on a regular basis. One of these wards was a surgical ward – the ward where I work. There was an incident on this ward with a patient with a tracheostomy. The patient received significant harm and ended up on the intensive care ward as a result. One of the outcomes from this incident was not to have laryngectomy or tracheostomy patients on this ward. At no point was learning from the incident disseminated to staff about the causes of the incident – just remove this cohort of patients from this ward. I don’t know what we did wrong. If the situation arose again, could we do anything different? We will never know as we don’t care for these patients here now. Incident 2 – Swallowed foreign object An incidental finding on a chest X-ray showed that an elderly lady had swallowed her wedding ring. It was stuck in her throat. This finding was found at 23:00 at night. It was removed at 12:00 midday the following day. A Datix report was filed as a concern was raised about the process of out of hours ENT services at my hospital. The investigation was completed. The response was that the incident was downgraded to low and that this lady was not compromised and that the ring was removed safely. This did not address the system failure. If this was a child in our hospital, what is the provision for removing a foreign object from the throat? Opportunity for changing and improving the current system/process was overlooked. Incident 3 – Dehydration death and downgrade A patient undergoing palliative bladder surgery died of dehydration on a ward less that 24 hours post-operation. The patient was not written up for any fluids, was not on a fluid balance chart and was not correctly monitored. Despite gallant efforts to rehydrate the man over the course of the night, the patient had a cardiac arrest and died. This Datix was graded as catastrophic by the reporter, but down graded to low by investigators. When questioned about this, the response was "his surgery was for comfort, he was going to die anyway". Surely anyone post-operation should have fluids written up and be monitored – otherwise what is the point? Again, system failure has been overlooked and opportunities for future learning quashed. The work we do as clinicians is complex. There needs to be an understanding of what we do and why we do it, or, sometimes, why we don’t do it. Investigating harm from an office about procedures and processes you don’t understand is ludicrous. For my friends and family, I will not recommend this hospital I work in. It’s not a case of we don’t learn from mistakes, it’s a case of we don’t want to learn from our mistakes – it's too much effort. I don’t trust them to do the right thing.
  21. News Article
    Executives in charge of the health secretary’s crisis-hit local hospital are facing calls to step down after The Sunday Times raised serious questions about attempts to cover up catastrophic medical mistakes. West Suffolk Hospital in Bury St Edmunds had placed Dr Patricia Mills, one of its most senior consultants, under disciplinary investigation after she had voiced concerns about blunders that had killed one patient and left another seriously brain-damaged. A number of doctors have claimed that a bullying management culture has led to staff being too afraid to speak up about patient safety concerns at the hospital. Executives were accused of being obsessed with maintaining the hospital’s “outstanding” status in annual Care Quality Commission. One of the governors said their were "frustrations and concerns" among his fellow council members that they were being kept in the dark by the hospital's executives. Read full story (paywalled) Source: The Sunday Times, 8 March 2020