This website is intended for healthcare professionals
This website is intended for healthcare professionals
‘Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians,...
‘In health we focus too much on the consequences, looking backwards at what has gone wrong. We need leaders to stop harm in advance, identifying and managing the causes and the controls.’
‘Staff were disrespectful to women and disparaging about the capabilities of colleagues in front of women and families. A family member heard a consultant describe the unit they were in as “unsafe”...
Henrietta Hughes, the Patient Safety Commissioner, has shared her ideas on several patient safety matters (Hughes, 2023). These include the need to hear more of the views of patients at trust board...
‘All these symptoms, according to NICE guidelines, should have immediately raised a red flag for sepsis (blood poisoning) in children under five. In the hospital's own Serious Incident Report, a...
I see this happening in some debates about reforming clinical negligence litigation. We often hear clarion calls for clinical negligence reform and the need to safeguard scarce NHS resources, which is...
Never Event data show the issues of poor NHS communication strategies in a tragic light. Many of these terrible events would not have happened had good communication strategies been in place. NHS...
‘If it is rolled out widely, scientists say people will be able to diagnose themselves with the illness without going to the doctor and costs for the NHS should fall.’
The key issue for me is the extent to which the advice and recommendations made in the reports are acted on in the NHS and whether safer practice results. As we closed the year, the Institute of...
‘This unsustainable situation is driven by an outdated legal system rather than deteriorating clinical standards. Legal reform is desperately needed.’
The first report to cause me to pose these questions is the long-awaited report by Dr Bill Kirkup (Kirkup, 2022) into the events at the maternity and neonatal services in East Kent. This has just been...
According to NHS Resolution (2022a) missed fractures can occur at sites throughout the body but one injury in particular, hip fractures in older patients with a history of a fall, stood out when cases...
‘Too often, valid lessons are drawn from adverse events but their implementation throughout the NHS is very patchy. Active learning is mostly confined to the individual organisation in which an...
The COVID-19 pandemic is still with us as we have moved into the new normality of coping with the virus. There is now time for reflection on how events developed and progressed from a patient safety...
One way to reflect on errors is to look at closed legal claims and examine the causes of litigation. This is a valuable exercise, as it enables a wealth of important detail to be obtained. Solicitors...
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