Jonathan Zito and Christopher Clunis? Mary Povey and Raymond Sinclair? Lin and Megan Russell and Michael Stone? I wouldn’t be surprised if these names didn’t mean anything to you. Why should they? Well, Jonathan, Mary, Lin and Megan were all victims of homicides committed...
“We are not here to curse the darkness, but to light the candle that can guide us through that darkness to a safe and sane future.” (John F Kennedy, 1960) At its heart patient safety is all about making sure we are continuously learning - not...
Data protection is tricky … even for those with the deepest minds! The Information Commissioner’s ruling in 2017 that the Royal Free Foundation Trust failed to comply with the Data Protection Act when it gave Google access to its patient data must have sent shivers down...
'Lessons must be learned' It is a sad fact that in many parts of the public sector the phrase ‘lessons will be learned’ has become seriously devalued. There is no doubt that senior leaders are genuine when they include this phrase high-up in their response to...
The Eva Investigation Application reached two important milestones this month as it has been accepted as a listing on the government’s G-Cloud 11 framework and on Microsoft’s AppSource platform. These listings will simplify and streamline the access to this important tool for serious incident investigations...
“Making improvements to patient safety comes second place to sorting out problems with the investigative process" A director of nursing of a large teaching trust told me this late last year. The CCG and her own governance team were weighed down with questions about the...
A few months back I wrote a blog that touched upon Mathew Syed’s book – ‘Black Box Thinking’. It discusses the “willingness and tenacity to investigate thelessons that often exist when we fail, but which we rarely exploit.”Furthermore, “It is about creatingsystems and cultures that...