Learning

Clinical Negligence – Time to turn to the tide

A new year and a new decade find many NHS trusts facing the same problems. In January this year the BBC released an article addressing the huge legal fees the NHS faces. The fees are to settle outstanding claims of clinical negligence, once again highlighting the failure of many organisations around the UK to tackle …

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Should we be worried about the end of the National Confidential Inquiry into Suicide and Homicide?

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 by patients in the care of NHS mental health services during …

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10 Important Things to Take Away from the New NHS Patient Safety Strategy

“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 only from the things that go wrong- but also …

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What does a good quality investigation look like and how can it be achieved?

When a serious incident occurs, it is vital that the investigation process is thorough and can stand scrutiny. Getting to the heart of what went wrong and putting solutions in place to reduce the chances of a repeat incident requires an acute focus on the whole investigation process. Investigation request The first issue is being …

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The power of investigations – ending the loop of ‘lessons must be learned’

‘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 families, regulators or media following a public shaming. But …

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Eva: A change is gonna come to serious incident investigation practices

Verita, one of the founding companies of Eva, has carried out hundreds of investigations in healthcare over the last 17 years. From Leeds paediatric cardiac surgery to Myles Bradbury to the death of Elizabeth Rourke at Jersey General Hospital. We have also undertaken numerous serious incident investigations or supported healthcare organisations to carry out their …

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