Tag Archives: Incident Reporting

Recent Information on Restraint in Mental Health Trusts, Plus Statistics on Other Safeguarding Topics (BBC News / NHS Digital)

Posted on November 21, 2017 by Dementia and Elderly Care News

Summary Freedom of information requests made by the Liberal Democrats have revealed that the use of restraint by mental health trusts in England has increased yearly since 2013, despite repeated calls over recent years for restraint to be minimised. It … Continue reading →

Posted in Acute Hospitals, BBC News, Commissioning, Community Care, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Management of Condition, Mental Health, National, NHS, Person-Centred Care, Quick Insights, Standards, Stroke, UK, Universal Interest | Tagged Abuse, Abuse of Vulnerable Adults, Acute Care, Adult Safeguarding, Adult Safeguarding Concerns and Enquiries, Adult Social Care Analytical Hub, Avoidable Harm, Community and Mental Health Trusts, Councils with Social Services Responsibilities, Culture of Zero-Harm, De-Escalation Techniques, Deprivation of Liberty Safeguards, Deprivation of Liberty Safeguards (DoLS), DoLS in Hospitals, Dr Sridevi Kalidindi: Royal College of Psychiatrists, Ethical Considerations, Ethical Dilemmas, Ethics and Decision-Making, Experimental Statistics, Face-Down Restraint, FOI: Freedom of information, Freedom of Information, Government Policy on Adult Safeguarding, Harm Free Care, Human Rights, Human Rights and Nursing, Identification and Reporting of Problems, Incident Reporting, Least Restrictive Principle, Liberal Democrat MP Norman Lamb: Former Health Minister (Coalition Government), Liberal Democrats, Making Safeguarding Personal (MSP), Medical Ethics, Mental Capacity, Mental Health Hospitals, Mental Health Trusts, Mental Healthcare, Mind, Neglect and Acts of Omission, NHS Digital, NHS Digital (Formerly the Health and Social Care Information Centre), NHS Digital: Annual Report for England (2016-17), NHS Digital: Safeguarding Adults Collection (SAC), NHS Mental Health Trusts in England, Norman Lamb MP, Openness and Transparency, Openness. Transparency, Physical Restraint, Physical Restraint in Hospital Settings, Physical Restraint in Mental Healthcare, Psychiatric Hospitals, Recording and Reporting, Reporting Culture in the NHS, Restraint, Restraint in Health and Adult Social Care, Restraint in Mental Health Trusts, Restrictive Practices, Safeguarding, Safeguarding Adults at Risk, Safeguarding Adults Collection, Safeguarding Adults Collection (SAC): Annual Report for England (2016-17), Safeguarding Adults Principles, Safeguarding Adults Reports, safeguarding Adults Reviews, Safeguarding Adults Reviews (SARs), Safeguarding Older People, Transparency, Transparency and Accountability, Unintended Consequences, Use of Reasonable Force, Vicki Nash: Mind | Leave a comment

Latest NHS Whistleblowing Policy (NHS Improvement)

Posted on April 21, 2016 by Dementia and Elderly Care News

Summary NHS Improvement has released a summary of NHS whistleblowing policy, in the form of a practical handbook. The aim is to promote an open and supportive culture which encourages staff to raise concerns about patient care quality or safety … Continue reading →

The Foundations for a Patient-Centred NHS Learning Culture? (Department of Health)

Posted on July 21, 2015 by Dementia and Elderly Care News

Summary This “Learning Not Blaming” report presents the government’s response to (i) the Francis Freedom to Speak Up review, (ii) the Morecambe Bay Investigation, and (iii) the Public Administration Select Committee’s report on clinical incidents. The common theme for addressing … Continue reading →

Posted in Acute Hospitals, Commissioning, Community Care, Department of Health, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), In the News, Integrated Care, Local Interest, Management of Condition, National, NHS, Non-Pharmacological Treatments, Patient Care Pathway, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest | Tagged Authority Gradients vs Freedom to Speak Up, Aviation Industry, Avoidable Harm, Avoidable Mortality, Avoidable Premature Mortality, Capacity and Capability of Regulators, Care Quality Commission, Care Quality Commission (CQC) Inspection Regime, Care Seven Days a Week, Clinical Incident Investigations, Clinical Incidents in the NHS, Clinical Risk Recognition and Planning, Comfort Seeking Organisations, Commons Public Administration Select Committee (PASC), Complaints and Raising Concerns, Complaints Handling, Complexity in the Complaints System, Consequences of the Francis Inquiry Report, Continuous Learning Culture, Corporate Self-Interest (Ahead of Patients), Cover-Ups (Attributed), Culture, Culture and Leadership, Culture Change in the NHS, Culture of Candour, Culture of Safety, Cumbria, Cumbria Partnership NHS Foundation Trust, Delayed Problem Recognition, Doctor Hadiza Bawa-Garba, Dr Bill Kirkup CBE, Dr Mike Durkin: NHS England’s Director of Patient Safety, Dr Mike Durkin: Patient Safety Investigation Service, Duty of Candour, Elevated Weekend Hospital Mortality, Five Year Forward View, Five Year Forward View (NHS England), Former Health Secretary Jeremy Hunt, Francis Freedom to Speak Up Report, Freedom to Speak Up (FTSU) Report, Freedom to Speak Up Guardian, Freedom to Speak Up Guardians, Freedom to Speak Up Report, Freedom to Speak Up Report: Principle 1: Culture of Safety, Freedom to Speak Up Report: Principle 2: Culture of Raising Concerns, Freedom to Speak Up Report: Principle 7: Raising and Reporting Concerns, Freedom to Speak Up? (Whistleblowing Review), Furness General Hospital, Furness General Hospital Dementia Unit, Furness General Hospital in Cumbria, Furness General Hospital: Ramsay Unit, Health Systems in Transition (HiT), Healthwatch, Honesty and Transparency, Hospital Mortality, Hospital Mortality Rates, House of Commons Public Administration Select Committee (PASC), Implications of the Francis Inquiry Report, Improving Services For Patients: Not Defending the System, Incident Reporting, Independent National Officer, Independent National Officer (INO), Independent Patient Safety Investigation Service, Independent Patient Safety Investigation Service (IPSIS), Intelligent Transparency, IPSIS: Independent Patient Safety Investigation Service, Just Culture, Learning Culture, Learning for Improvement, Learning from Complaints, Learning From Errors and Failures in Care, Learning Not Blaming, Listening to Patients Families and Staff, Local Freedom to Speak Up Guardians, MBRRACE-UK (Mothers and Babies – Reducing Risk Through Audits and Confidential Enquiries Across the UK), Monitor, Morecambe Bay Inquiry, Morecambe Bay Investigation Report, Mortality at the Weekend, National Clinical Assessment Service (NCAS), Negative Culture, Never Events, NHS Accountability, NHS Corporate Self-Interest, NHS Culture, NHS England Never Events Taskforce, NHS Five Year Forward View (5YFV), NHS Improvement, NHS Managerial Self-Interest, NHS Micro-Climates, NHS Patient Safety Culture, NHS Trust Development Authority (NHS TDA), NHS Trust Development Authority (NTDA), NHS Trust Development Authority (TDA), No Harm Culture, Open and Honest Incident Reporting, Open and Supportive Culture, Openness, Over-Complexity, Over-Reliance on External Approval, Over-Reliance on External Judgments, Over-Reliance on Judgments of Others, Parliamentary and Health Service Ombudsman, Patient Safety, Patient Safety in the NHS, Police: Complaints, Preventable Hospital Mortality, Problem Sensing, Problem Sensing Organisations (Versus Comfort Seeking Organisations), Public Administration Select Committee (PASC), Public Administration Select Committee Report into Clinical Incident Investigations, Recommendations for the University Hospitals of Morecambe Bay NHS Foundation Trust, Reducing Complexity, Reduction in Bureaucracy, Regulating Healthcare Systems, Regulating Healthcare Systems: Monitor, Regulation, Regulators, Regulators Sharing Information, Regulatory and Professional Bodies, Regulatory Gaps in Healthcare, Regulatory System, Repercussions From the Francis Inquiry Report, Report Into Maternity Care at Cumbria’s Furness General Hospital, Report of the Morecambe Bay Investigation, Reporting Culture, Reporting Mistakes, Rhona Flin: Aberdeen University, Rt Hon Jeremy Hunt MP: Former Secretary of State for Health, Scrutiny of Perinatal and Maternal Deaths, Second Mid Staffs: Furness General Hospital Parallels, Serious and Untoward Incidents (SUIs), Service Redesign, Seven Day Care in England, Seven Day Services, Small Business Enterprise and Employment Act 2015 (SBEEA), Speaking Up: Resolving NHS Complaints and Preventing Problems Recurring, Surgical Never Events, Target Culture, Target-Chasing (Hitting the Target Missing the Point), Transparency, Transparency and Accountability, Transparent Learning Culture, University Hospitals of Morecambe Bay NHS Trust, Unnecessary In-Hospital Deaths, User Complaints, Valuing Complaints, Weekend Effect, Weekend Mortality Rates, Weekend Services, Weekend Working, Whistleblowing, Workplace Culture | Leave a comment

Professional Duty of Candour: Openness and Honesty When Things Go Wrong (NMC / GMC / Nursing Times / BBC News)

Posted on July 2, 2015 by Dementia and Elderly Care News

Summary The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) have jointly published guidance explaining the standards expected of doctors, nurses and midwives in the UK when things go wrong during healthcare. Professionals, in turn, require the … Continue reading →

Posted in Acute Hospitals, Community Care, For Doctors (mostly), For Nurses and Therapists (mostly), In the News, National, Northern Ireland, Person-Centred Care, Practical Advice, Quick Insights, Scotland, Standards, UK, Universal Interest, Wales | Tagged Apologising to Patients, BAPEN: British Association of Parenteral and Enteral Nutrition, British Association of Parenteral and Enteral Nutrition (BAPEN), Buckinghamshire Healthcare Trust, Candour, Candour: Safety and Improvement, Common Professional Standards (NMC / GMC), Consent, Consent: Patients and Doctors Making Decisions Together, Consequences of the Francis Inquiry Report, Culture Change in the NHS, Culture of Candour, Culture of Raising Concerns, Culture of Reflective Practice, Culture of Safety, Dehydration, Dehydration in Frail Older People, Duty of Candour, Ethical Considerations, Face to Face Explanations / Apologies from Doctors Nurses and Midwives, Freedom to Speak Up Report: Principle 1: Culture of Safety, Freedom to Speak Up Report: Principle 2: Culture of Raising Concerns, Freedom to Speak Up Report: Principle 7: Raising and Reporting Concerns, General Medical Council (GMC), GMC: General Medical Council, GMC’s Good Medical Practice, Good Medical Practice, Hampshire Hospitals Foundation Trust, Health and Social Care Services in Northern Ireland, Healthcare Quality Strategy for NHS Scotland, Honesty, Honesty and Transparency, Hospital Nurse Staffing and Quality of Patient Care, Hydration and Nutrition, Implications of the Francis Inquiry Report, Incident Reporting, Incidents Errors and Near Misses, Learning Culture, Learning From Mistakes, Misdiagnosis, Moderate Harm, National Health Service (Concerns Complaints and Redress Arrangements) (Wales) Regulations 2011, Near Misses, NHS Culture, NHS Patient Safety Culture, Nurse Staffing Levels, Nursing and Midwifery Council (NMC), Open and Honest Working Environment, Openness, Openness and Honesty When Things Go Wrong, Openness and Honesty When Things Go Wrong (GMC / NMC), Openness and Transparency, Patient Harms, Patient Safety, Professional Duty of Candour, Professional Duty of Candour: NMC's Nursing Case Studies, Professional Standards, Professional Standards and Ethics, Professional Standards of Practice and Behaviour for Nurses and Midwives, Prolonged Psychological Harm, Protection From Unfair Criticism Detriment or Dismissal, Repercussions From the Francis Inquiry Report, Reporting Culture in the NHS, Reporting Systems, Scottish Patient Safety Programme, Severe Harm, Severe Harm Attributable to Problems in Healthcare, Severe Harm Leading to Death, Statutory Duty of Candour, Statutory Duty of Candour For Care Organisations (UK), Transparency, Transparency and Public Trust, Transparent Learning Culture, Welsh Government’s Health and Care Standards Framework | 1 Comment

Government Consultation on Francis Freedom to Speak Up Report (Department of Health)

Posted on March 13, 2015 by Dementia and Elderly Care News

Summary The Government has launched a public consultation to assess recommendations from the Francis Freedom to Speak Up review, to support NHS staff in speaking up about poor care and patient safety. This open consultation allows staff, patients and the … Continue reading →

More on the NHS Culture of Openness: Lessons From Two Francis Inquiries (Department of Health)

Posted on February 13, 2015 by Dementia and Elderly Care News

Summary The Government has published a report explaining progress in the NHS since the Francis Inquiry report (February 2013) . It supports the full adoption, in principle, of Freedom to Speak Up review recommendations to protect whistleblowers who raise legitimate … Continue reading →

Posted in Acute Hospitals, Commissioning, Community Care, CQC: Care Quality Commission, Department of Health, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Local Interest, Management of Condition, National, NHS, Patient Care Pathway, Person-Centred Care, Practical Advice, Quick Insights, Standards, UK, Universal Interest | Tagged Acute Care, Acute Hospitals, Assessing Risk of Harm (Not Just Past Harm), Avoidable Harm, BBC Health News, Behaviours to Enable Whistleblowing, Berwick Review, Berwick Review of Patient Safety, Better Care for Older Patients With Dementia, Building Capability, Candour, Care Certificate, Cavendish Review, Centrally-Driven Proposals, Challenges of Reconfiguration, Character Assassination of Whistleblowers, Closed Ranks Culture (Mid Staffordshire Public Inquiry), Clwyd and Hart Review Into Hospital Complaints, Code of Conduct for Healthcare Support Workers, Commonwealth Fund, Compassion in Practice, Compassionate Care, Configuration of Services, Consequences of the Francis Inquiry Report, Culture Change, Culture Change in the NHS, Culture Change in the NHS: Lessons of Two Francis Inquiries, Culture of Compassionate Care, Dementia Care in Acute General Hospitals, Dementia Care in Acute Settings, Dementia Care in General Hospitals, Dementia Care in Hospitals, Duty of Candour, EU Council’s Recommendations on Patient Safety and Health Care Associated Infections, Fit and Proper Persons Requirement for Directors, Francis Effect, Francis Inquiry, Francis Inquiry Report, Francis Report, Francis Report: Part of a Linked Set of Reports on Quality, Freedom and Responsibility to Speak Up (Francis Review Whistleblowing), Freedom to Speak Up Guardians, Freedom To Speak Up Review (Sir Robert Francis QC), Freedom to Speak Up? (Whistleblowing Review), Fundamental Standards, General Hospitals, General Medical Council (GMC), Government Response to Francis Inquiry Report, Harassment of Whistleblowers, Hard Truths, Health Education England Commission on Education and Training for Patient Safety, Health Education for Safety, Helene Donnelly OBE: Ambassador for Cultural Change at Staffordshire and Stoke on Trent Partnership NHS Trust, Honesty, Honesty and Transparency, Implications of the Francis Inquiry Report, Incident Reporting, Initiatives and Reviews into Quality of Hospital Care 2012/13, James Titcombe: National Advisor on Patient Safety and Culture & Quality at Care Quality Commission, Jane Cummings: Chief Nursing Officer for England, Keogh Mortality Review, Listening to Patients, Listening to Staff, Local Patient Safety Collaboratives, Medical Schools Council, Mid Staffordshire NHS Foundation Trust, Mid Staffordshire NHS Foundation Trust Inquiry, Mid Staffordshire NHS Foundation Trust Public Inquiry, Mistreatment of Whistleblowers, MyNHS Website: Comparing Safety Data, National Patient Safety Alerting System (NPSAS), NHS Culture, NHS England National Patient Safety Alerting System, NHS Leadership Academy’s Executive Fast Track Programme, NHS Litigation Authority, NHS Managerial Self-Interest, NHS Reform, NHS Safe Staffing, NHS Trust Development Authority, NHS Trusts and Foundation Trusts in Special Measures: 18 Months On, Nurse Staffing Levels, Nursing and Midwifery Council (NMC), Nursing Standards, Open and Honest Incident Reporting, Open Culture, Openness, Openness and Transparency, Outcome Metrics, Overbearing NHS Managerial Style, Patient Safety, Patient Safety Collaboratives Programme, Patient Safety Improvement, Patient-Centred Leadership, Patients First and Foremost, Person-Centred Model of Care for Patients with Dementia, Preventing Poor Care, Professor Don Berwick, Professor Sir Mike Richards: Former Chief Inspector of Hospitals (CQC), Professor Sir Norman Williams: President of Royal College of Surgeons, Professor Steve Field: Chief Inspector of General Practice (CQC), Public Interest Disclosure (Prescribed Persons), Putting Patients First, Quality Improvement, Quality Standards, Quality: Above Money, Raising Concerns, Reactions to the Francis Inquiry Report, Reconfiguration of Emergency Care System, Repercussions From the Francis Inquiry Report, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Reporting Culture, Reporting Culture in the NHS, Review of NHS Complaints System, Safe Staffing, SAFE: Safety Action for England, Safety Action for England Team (SAFE), Safety and Quality Standards, Safety Metrics, Safety Surveillance, Salford Royal NHS Foundation Trust, Serious Incident Framework, Sign Up to Safety Campaign, Sir David Dalton: Chief Executive of Salford Royal NHS Foundation Trust, Sir Robert Francis QC, Speaking Up Charter, Special Measures, Staff Whistleblowing Rights, Staffing, Standards of Care, State of Care 2013/14 (CQC), Structures to Enable Whistleblowing, Surgical Never Events Task Force Reference Group, Systems to Support Whistleblowing, Technology Enhanced Learning, Transparency, Ward Staffing Levels, Whistleblowing, Whistleblowing Helpline, Whistleblowing in the NHS | Leave a comment

Whistleblowing in the NHS: Light at the End of the Tunnel? (BBC News / NHS England)

Posted on February 11, 2015 by Dementia and Elderly Care News

Summary The review of NHS reporting culture led by Sir Robert Francis QC, which has been working achieve better protection of NHS whistleblowers who raise concerns, will report later today. The “Freedom and Responsibility to Speak Up” review was expected … Continue reading →

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