This website is intended for healthcare professionals
This website is intended for healthcare professionals
In his Broken Trust report from June 2023, the PHSO reviewed the most serious NHS complaints received by his office where avoidable death has resulted. The review highlighted an implementation gap,...
The call for Martha's Rule arose out of the tragic death of 13-year-old Martha Mills, who died from sepsis in 2021 at King's College Hospital, London. There was a failure to recognise that she...
‘Patients struggle to navigate the complaints system and it may take some time to find the correct organisation to complain to.’ .
‘… costs … have continued to grow at an eye-watering rate. Ten years ago, the NHS paid £900 million in damages; last year it was £2.17 billion – equivalent to the annual running costs of the biggest...
Improvement recommendations are made after a patient safety crisis, often repeated ones, but the system does not change much or at all. Errors are repeated, lessons go unlearnt. This might seem a...
‘I have discovered that we need a seismic shift in the way that patients' and families' voices are heard. This requires changes in legislation, regulation, policy, commissioning, education,...
‘Trusts receive too many safety-related messages from too many different sources. The trusts we spoke to said there needed to be better communication and coordination between national bodies, and...
Rob Behrens, the Parliamentary and Health Service Ombudsman (PHSO), gave evidence to the Times Health Commission (Sylvester, 2023a; 2023b). This was a controversial session during which the PHSO...
‘SO1: Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere.’ .
In terms of patient safety improvement practices and culture development, a recent report published by Healthcare Excellence Canada (Gilbert et al, 2023) provides some interesting and valuable...
When we use concepts such as patient empowerment, we need to be as specific as we can about what we mean and understand about the term. We don't want the words to be just seen as a convenient ‘clarion...
One issue she discusses are the professional silos and hierarchies, for example:.
In a clinical negligence case, for example, the court must carefully unpack and analyse the level of care given to determine whether there was any negligence. Lawyers discuss with clinical experts the...
‘It would be quite wrong to conclude that the NHS as an organisation is incapable of learning and improving, but the evidence suggests that learning generally takes a long time and that...
In the light of the above, is it fair to characterise NHS efforts to handle patient safety crises and develop policy and practice in the area as akin to being on a patient safety merry-go round? It is...
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