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Content ArticleWhen Rupert was born he had to be immediately cooled after a difficult birth. Babies are cooled in certain circumstances in the hope of slowing down the processes that may cause brain damage. The Healthcare Safety Investigation Branch (HSIB) maternity investigators initiated an investigation to find out what went wrong. In this short video we hear from Rupert’s mum, Leila, who describes what it was like to be involved with a HSIB maternity investigation from a family point of view. Leila shares why she and her family wanted to be involved, how HSIB’s approach to them was welcomed and how they felt this contributed to improving safety for the benefit of other families in the future.
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The 15th annual HSJ Patient Safety Congress brings together more than 1000 attendees with the shared goal of advancing the national agenda for patient safety across health and social care. In this blog, Samantha Warne, the hub's Lead Editor, captures some of the key highlights and messages from day one of HSJ’s Patient Safety Congress. -
Content ArticleIn partnership with the Healthcare Safety Investigation Branch (HSIB) and Learn Together, NHS England has published its Guide to engaging and involving patients, families and staff following a patient safety incident alongside the Patient Safety Incident Response Framework (PSIRF). This guide sets out expectations for how those affected by an incident should be treated with compassion and involved in any investigation process. In this podcast, the speakers introduce the guide, discuss how it was developed, and talk about future plans in the area of work. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England National Patient Safety Team Lauren Mosley, Head of Patient Safety Implementation, NHS England National Patient Safety Team Lou Pye, Head of Family Engagement, HSIB Jane O’Hara, Learn Together research team, Professor of Healthcare Quality and Safety, University of Leeds and Deputy Director of the Yorkshire Quality and Safety Research Group.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines. Some drugs, such as those used in anaesthesia and pain management, can cause patients to stop breathing. After administration, these drugs should be flushed through cannulae and extension lines to make sure no residual quantities of the drugs are left. Despite the issuing of multiple safety alerts over the past ten years, residual drugs in cannulae and extension line events continue to happen. When these events involve drugs that cause the patient to stop breathing, there is a risk of hypoxic brain injury (where the brain is damaged after a period where it does not get enough oxygen) or death. The investigation was launched after concerns were reported to HSIB by a consultant anaesthetist at a district general hospital where a patient had stopped breathing several hours after undergoing an anaesthetic. It’s thought that a quantity of the drug Suxamethonium - a muscle relaxant - was retained in their cannula after the procedure. The cannula containing the drug was flushed on the ward by a nurse preparing to administer intravenous paracetamol around three hours after the patient had returned from his procedure. The event was witnessed by a doctor who immediately started manual ventilation. The patient began to breathe spontaneously a few minutes later and suffered no physical harm. However, they have been left with a significant psychological impact following their experience of being awake but unable to move or breathe.
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Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm. -
Content ArticlePrompt referral to early pregnancy services can make the difference between life and death in the diagnosis of ectopic pregnancies. This Healthcare Safety Investigation Branch (HSIB) report into the diagnosis of ectopic pregnancy found that differing levels of provision and a mismatch between capacity and demand in early pregnancy units (EPUs) heightens the risk that the diagnosis of this time-critical condition is delayed or missed.
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The truth for Gaia Young
Patient Safety Learning posted an article in Patient stories
Previously well, Gaia died aged 25 years of an unexplained brain condition hours after admission to University College Hospital London. Her death has been the subject of hospital investigations and an inquest. Over one year later her death remains unexplained. Why? This is her mother’s (Dorit) search for the truth: information is provided to stimulate medical crowd thinking – to ask the right questions and to get the right answers. Read the narrative of Gaia’s final illness in her mother’s story and in the memorandum from the link below. See also: Serious Incident Report: Unexpected deterioration of a young woman on the Acute Medical Unit: updated report (February 2022) -
Content ArticleIn 2021, a multi-professional staff support group was established under the Northern Care Alliance NHS Foundation Trust’s Freedom to Speak Up process which raised new questions and concerns around the probity and clinical standards of a Consultant Spinal Surgeon (“Consultant Spinal Surgeon A”) whilst they were employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) (“the Trust”). As a result, the Trust commissioned the Spinal Patient Safety Look Back Review (“SPSLBR”) and Investigation Group to evaluate these concerns, including obtaining independent expert advice.In January 2022, the Trust commenced the SPSLBR to investigate and manage patient safety concerns raised in respect of Consultant Spinal Surgeon A who was employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) between 1991 and January 2015. This report outlines the investigation carried out by the SPSLBR Investigation Group on behalf of the Trust to investigate and manage potential Serious Incidents (“SI”) caused by the errors and omissions attributable to clinics, surgery and/or consultations undertaken by Consultant Spinal Surgeon A within the scope identified in the Terms of Reference.
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Content ArticleThe latest Healthcare Safety Investigation Branch (HSIB) report focuses on the life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients.
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Content ArticleThe Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation explores the impact of ambulance delays on the emergency treatment of heart attack. The current preferred model of care in the NHS in England is for patients to receive primary percutaneous coronary intervention (PPCI), a procedure which involves widening a blocked artery and inserting a stent to keep the artery open. The effectiveness of PPCI is dependent on the timescale in which it can be carried out. National figures have identified increasing delays in ambulances taking people with a type of heart attack known as ST-elevation myocardial infarction (STEMI) to hospital so that PPCI can be provided within target timescales. This may lead to worse outcomes for these patients. Alternative treatment using thrombolytic medicine (medicines used to dissolve blood clots) is advised where specific timescales for providing PPCI may not be met. This investigation started after a patient notified HSIB of a delay in an ambulance attending him after suffering a heart attack (STEMI).
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Content ArticleIn April 2022, an investigation commenced into the communications provided to patients and/or their carers following placement on a waiting list in Northern Ireland. The primary focus of the investigation is the adequacy of Trust communications to patients, and/or their carers, across various stages of the waiting list process, with significant consideration being given to the content of the Integrated Elected Access Protocol (Department of Health guidance), and its application by the Trusts. The objective was to determine whether or not systemic maladministration has arisen within the communication practices of the Northern Ireland Health and Social Care Trusts (the Trusts) and whether improvements are required. It also aims to publicise what patients and/or their carers should expect from waiting list communications. The Investigative Methodology drew evidence from a wide range of sources. This included extensive queries and information requests to the Trusts and the Department; a General Public survey (with 646 responses); a General Practitioner (GP) survey (with 321 responses); follow up interviews with a number of General Public and GP survey respondents; and a number of Case Study reviews.
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Content ArticleThe objective of this investigation was to understand the context of magnetic resonance imaging (MRI) scanning under general anaesthetic and how care may be reasonably adjusted for patients with autism or learning disabilities. The ‘reference event’ was Alice, a teenage girl who had autism. Sadly, Alice died following her MRI scan under general anaesthetic. The findings and conclusions of this investigation may be applicable to other non-invasive procedures carried out on patients who are under general anaesthetic.
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Content ArticleThis national learning report from the Healthcare Safety Investigation Branch (HSIB) will highlight the themes emerging from their contact with families during their patient safety investigations. It is due to be published in spring 2020. HSIB's national learning reports describe common themes and findings that come out of their national investigation programme and their maternity investigation programme. The information in these reports is used to inform future HSIB investigations or programmes of work.
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Content ArticleSince April 2018, the Healthcare Safety Investigation Branch (HSIB) has been responsible for initiating over 1000 independent safety investigations in NHS maternity services in England. This report summarises eight prominent themes that have emerged through analysis of completed maternity investigations, and how HSIB will explore these themes in more detail during the coming year.
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Our son’s final days
Claire Cox posted an article in Patient stories
NHS investigators are to meet the family of a young, autistic man - left starving and desperately thirsty in hospital while waiting for a delayed operation. Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years. These are the harrowing events that came days before the needless, avoidable death of Mark Stuart. Mark was a young man with autism. -
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The Lampard Inquiry
Mark Hughes posted an article in Inquiries
The Lampard Inquiry is a statutory inquiry investigating mental health inpatient deaths in Essex, focused on services provided by the Essex Partnership University Foundation NHS Trust (EPUT) and the North East London Foundation Trust (NELFT) and their predecessor organisations. This Inquiry continues the work of the Essex Mental Health Independent Inquiry. This website provides information about the inquiry team, terms of reference and publications relating to this. -
Content ArticleThis three-hour online course introduces the concept and approach to thematic analysis in safety investigations. It builds on the concepts discussed in HSIB's Level 2 course A systems approach to learning from patient safety incidents, so attendees must have completed the Level 2 course prior to enrolling on this course. The course will run on the following dates: 11 June 2024 24 June 2024 10 July 2024 15 July 2024 HSIB courses are aimed at NHS staff in health and social care settings in England, who are involved in safety investigations for learning. Courses run online and are free of charge to attend for NHS staff.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
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Content ArticleAsthma is the most common lung disease in the UK. 1.1 million children are diagnosed with the condition. Healthcare Safety Investigation Branch (HSIB) looked at the risks involved in the management of children aged 16 years and under diagnosed with asthma. Diagnosis and the management of asthma, particularly in children and young people, can be complex. It is important to get it right, as otherwise significant harm or death can result. The investigation was launched after HSIB identified an event involving a 5 year old child. The child had numerous planned and unplanned (emergency) attendances at hospital with respiratory symptoms, before suffering a near fatal asthma attack. Prior to the event, the child had no formal diagnosis of asthma and issues had been identified (but not resolved) regarding adherence to treatment.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) have identified a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient stay. If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment. The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report highlights a gap between the NHS and other safety-critical industries in identifying and managing barriers to reduce the risk of serious incidents occurring.
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Content ArticleSussex Community NHS Foundation Trust share their patient safety newsletters with the hub.
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Content ArticleThe MHRA is aware of cases of increased intraocular pressure in patients recently implanted with EyeCee One preloaded and EyeCee One Crystal preloaded intraocular lenses (IOLs), which are manufactured by NIDEK and distributed by Bausch + Lomb. The root cause has not been identified and further investigations are ongoing with the manufacturer. Due to the potential risks for patient safety, you should stop using these IOLs and quarantine remaining stock immediately pending the results of further investigations. Additional communications will be issued shortly advising clinicians and affected patients on the next steps.
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Content ArticleThe Royal Society's science and the law programme brings together scientists and members of the judiciary to discuss and debate key areas of common interest and to ensure the best scientific guidance is available to the courts. The judicial primers project is a unique collaboration between members of the judiciary, the Royal Society and the Royal Society of Edinburgh. Designed to assist the judiciary when handling scientific evidence in the courtroom, the primers have been written by leading scientists, peer reviewed by practitioners, and approved by the Councils of the Royal Society and the Royal Society of Edinburgh. Each primer presents an easily understood and accurate position on the scientific topic in question, as well as considering the limitations of the science, challenges associated with its application and an explanation of how the scientific area is used within the judicial system. The primers are created under the direction of a Steering Group chaired by Dame Anne Rafferty and distributed to courts in conjunction with the Judicial College, the Judicial Institute, and the Judicial Studies Board for Northern Ireland.
