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Showing results for tags 'Investigation'.
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News ArticleA review into the work of a locum consultant radiologist has so far identified "major discrepancies" affecting 12 cases. A full lookback review of 13,030 radiology images was launched last month. The doctor worked at hospitals run by the Northern Health Trust between July 2019 and February 2020. The review steering group chair said it was "images in levels one and two that we are most concerned about". "To date there are 12 level ones and twos [approximately 0.5% of the total number reviewed]," said Dr Seamus O'Reilly, the Northern Trust medical director. "Most of thes
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News ArticleThe boss of a NHS trust that asked hospital staff for fingerprints and handwriting samples as it hunted a whistleblower is stepping down. Dr Stephen Dunn will leave West Suffolk NHS Foundation Trust in the summer after seven years as chief executive. An independent inquiry into the way management handled the affair is expected to report in the autumn. In 2018, Jon Warby received a letter two months after the death of his wife, Susan. It claimed mistakes were made during her bowel surgery. An inquest into her death was subsequently told how she had been given glucose instead of s
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Content ArticleIn the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that
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Content ArticleSafety recommendations HSIB recommends that NHS England and NHS Improvement amends the ‘Saving Babies’ Lives care bundle version 2’ to enhance the role of the ‘fetal monitoring lead’ to include, training and competency checks of all maternity staff on the use and functionality of cardiotocograph (CTG) equipment. HSIB recommends that NHS England and NHS Improvement amends the ‘Saving Babies’ Lives care bundle version 2’ to remove specific references to DawesRedman and instead use a generic term such as ‘computerised cardiotocograph (CTG) analysis’. HSIB recommends that the Nat
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Root Cause Analysis: 1 day masterclass
Sam posted a calendar event in Community Calendar
The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. The course is fa -
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Clinical negligence: Update for clinicians & managers
Sam posted a calendar event in Community Calendar
This conference, which is Chaired by Simon Hammond, Director of Claims Management, NHS Resolution, will update clinicians and managers on clinical negligence with a particular focus on current issues and the COVID-19 pandemic and the impact on clinical negligence claims. Featuring leadings legal experts, NHS Resolution and experienced clinicians the event will provide an update on current claims the conference will discuss why patients litigate, The Coronavirus Act 2020 and Clinical Negligence Scheme for Coronavirus, responding to claims regarding COVID-19 and the implications of the coronavi -
Content ArticleThe Health and Social Care Select Committee’s report sets out conclusions and recommendations in three parts: Supporting maternity services and staff to deliver safe maternity care – considering the essential building blocks of safe care - first and foremost staffing numbers and funding, underpinned by leadership and training. Learning from patient safety incidents – considers the role of the Healthcare Safety Investigation Branch (HSIB); examines the current clinical negligence system and how to reform it to allow a more positive learning culture to take root. Providing safe
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CANDOR Part III: Evaluating CANDOR implementation
Sam posted a calendar event in Community Calendar
Panelists will discuss the key elements for successful CANDOR implementation after robust organisational current state assessment. Methods for timely and comprehensive reporting, steps for event investigation and analysis, alignment of ongoing education with communication, strategies to reduce caregiver burnout through peer support, and elements for CANDOR sustainability are recommended. Register -
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JCP Solicitors: NHS Redress Scheme
Patient Safety Learning posted an article in Legal matters
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Patient Safety Movement: Bleed Out film screening
Patient Safety Learning posted a calendar event in Community Calendar
Join the Patient Safety Movement for a unique opportunity to view the award-winning HBO hit film Bleed Out and talk with the filmmaker, Steve Burrows afterwards. Bleed Out is the harrowing HBO feature documentary film that explores how an American family deals with the effects of medical malpractice. After Judie Burrows goes in for a routine partial hip replacement and comes out in a coma with permanent brain damage, her son, Steve Burrows, sets out to investigate the truth about what really happened. The documentary film takes place in real time over a span of ten years. Tickets -
Content ArticleHSIB reviewed the NHS national reporting systems to understand how often the wrong patient receives the wrong procedure. It launched this national investigation because the evidence found suggests that incorrect identification of patients is a contributory factor to patients receiving the wrong procedure. Safety recommendation HSIB recommends that NHS England and NHS Improvement leads a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise. This should assess the feasibility to enhance or imple
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News ArticleThe Care Quality Commission may in future be notified when ‘secretive’ external reviews have looked at patient safety issues within trusts. Last summer, HSJ revealed guidance for trusts to publish summaries of royal colleges’ reviews was being widely ignored, with some even failing to inform the CQC. A recent BBC Panorama programme has again raised the issue, with Academy of Medical Royal Colleges chair Helen Stokes-Lampard saying she was “dismayed” the body’s guidance was not being followed. But she has now told HSJ of “advanced discussions” with the CQC about changes which wou
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News ArticleA second “mutilated” patient left with life-changing injuries after botched hospital surgery has described how she was left in urine-soaked bed sheets for days by nurses who called her lazy when she was unable to get out of bed. Lucy Wilson told The Independent she believes she would have been better looked after at a veterinary practice compared to the level of care she received from nurses at Norfolk and Norwich Hospital Trust in January last year. She was one of three patients harmed by surgeon Camilo Valero in the same week and almost died after Dr Valero and other staff failed t
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Cumberland Infirmary patient 'dropped' from operating table dies within weeks
Patient Safety Learning posted a news article in News
A woman has died after being "dropped" on the floor during surgery on her hip, which she had broken while in hospital. Jeannette Shields, 70, had been receiving treatment for gall stones in Cumberland Infirmary in Carlisle. North Cumbria Integrated Care NHS Trust said an investigation was under way "in relation to an incident involving a patient in one of our theatres". Mrs Shields' husband, John, said he told the hospital he would not be "pushing this thing under the carpet". His wife left her bed to go to the toilet by herself after getting no response to her buzzer, Mr S -
News ArticleSerious patient safety concerns have been raised about a third major specialty at a struggling acute trust, with inspectors also flagging wider leadership issues. The Care Quality Commission (CQC) has issued an immediate warning notice in relation to the stroke service at University Hospitals of Morecambe Bay Foundation Trust, following an inspection earlier this month. A full report will be published later this year, but the immediate issues have been outlined within various documents published ahead of the trust’s board meeting on 26 May. According to a summary within the pape
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News Article“Human error” resulted in a man having the wrong leg amputated at a major Austrian hospital. The error occurred when a healthcare employee marked the wrong leg for amputation during pre-surgical procedures. The mistake was not noticed anytime during the surgery, or even during the immediate postoperative period. It was recognised during a routine wound dressing change, about 48 hours postoperatively. “A disastrous combination of circumstances led to the patient’s right leg being amputated instead of his left,” the hospital’s statement said. “We would also like to affirm that we wi
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Contaminated blood inquiry: Matt Hancock to give evidence
Patient Safety Learning posted a news article in News
The health secretary will face questions about compensation for victims of the contaminated blood scandal on Friday afternoon. Matt Hancock will give evidence at a public inquiry into what's been called the worst NHS treatment disaster. Around 3,000 people have died after being given blood containing HIV and hepatitis C in the 1970s and 1980s. Ministers announced a public inquiry into the scandal in 2017 after decades of campaigning by victims and their families. Nearly 5,000 people with the blood disorder haemophilia were infected with potentially fatal viruses after being given a c
