Health Care Risk Report October 2009

Swine flu is continuously on the NHS agenda at the moment, and Health Care Risk Report presents a different view this month. Professor Hilary Pickles, a public health and risk expert, points out that lessons can be learned from the rush to set up antiviral distribution centres over the summer – not least that the distraction it caused posed a risk to normal NHS business. 

Health Care Risk Report editor Pat Anderson has opened a new LinkedIn group for HCRR readers, contributors and editorial board members. Please take a look, join and consider contributing to the forum. Click here.

 Also in the October issue of Health Care Risk Report :

 - how GPs reacted to using the Primary Care Trigger Tool to identify harm in their practices, by Dr Richard Jenkins and colleagues from the NHS Institute for Innovation and Improvement

- whether “Seven steps to patient safety” is too far for GPs to climb, by Dr Tayza Aung

- how the NPSA plans to take forward learning from serious incidents, by chief executive Martin Fletcher

- patient safety in the Netherlands and Pennsylvania, USA

- the Department of Health’s new consent guidance and changes to Lasting Power of Attorney forms.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 15 Issue 9 September 2009

The September 2009 issue of Health Care Risk Report  (HCRR) includes the following issues and articles that may be of interest to Healthcare Governance Review readers:

- Why questions remain in spite of an internal inquiry, complaint, and claim following a baby’s death, by Nicola Wainwright from Leigh Day & Co
- The effect of budgetary pressures on pressure sores and staff sickness absence at an NHS trust, by Helen Jones and colleagues from Loughborough University
- How an aviation manual on risk management could usefully be adapted for the NHS
- How lives have been saved through “Operation Life” in Denmark, and what named trusts in the English patient safety campaign are doing
- What the National Patient Safety Agency can tell us about healthcare-associated harm to children
- Why record-keeping is of vital importance even at the busiest times
- What the Parliamentary health committee’s report on patient safety recommends and how the NHS has responded.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 15 Issue 8 July/August 2009

Many of us look “across the water” for patient safety expertise, but as John Tingle explains in this month’s edition of Health Care Risk Report (HCRR), all is not well in the USA. The US Government has said that patient safety is declining, while consumers have given healthcare a “failing grade” on patient safety. Do we have a chance to do better over here?

 Also in the July issue of Health Care Risk Report : 

- The case of a young boy who was left disabled by meningitis and whose family secured for him a £5.5m payout;
- The failure of an attempted prosecution of the owners of a care home where 14 elderly residents died in a fire;
- How the National Patient Safety Agency plans to improve the way the NHS picks up and deals with serious incidents, by its chief executive Martin Fletcher;
- How airline pilot Martin Bromiley is helping the NHS to change its ways following the death of his wife during an attempted operation;
- The role that the Care Quality Commission is going to play in your working life;
- Risk management and “positive risk-taking” in mental healthcare;
- The difficulties of training staff to evacuate patients in an emergency; and
- Staff absenteeism levels in a flu pandemic.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol. 15, No 7, June 2009

How ready are you to really involve patients in your patient safety work? This is the question delegates at the Patient Safety Congress in May were encouraged to ask themselves, with patient champions telling delegates that they were “willing and fit” to take part in improving patient safety, if the NHS will only invite them.

This issue of Health Care Risk Report (HCRR) looks at another gap between aspiration and reality – that of being open with patients and relatives following an adverse event. As Professor Louise M Wallace and Susan Marshall describe, attempts to be more open strike at the very heart of healthcare professionals’ relationships with patients, so there is a lot more work to do.

 Also in the June issue of Health Care Risk Report :

- we look at the experience of “early adopter” sites for complaints reform, and the successes and challenges they relate.

- Part 2 of our essential guide to writing investigation reports, by Maria Dineen, director of Consequence UK

- an analysis of the “refocused” Care Programme Approach, by freelance risk trainer Andrew Wetherell

- how the Healthcare Commission performed during its lifespan, by John Tingle; and

- what the “great and good” told the health committee about patient safety (again)

The case reviews in this issue of HCRR cover a surgical complication that went unnoticed because the patient was on the wrong ward (leading to her death), falls from unsafe windows, and the case of the men who lost the chance to use their frozen sperm samples.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk report Vol.15, Issue 6, May 2009

Patient safety continues to be a focus at the highest level, with Parliament’s health committee grilling the great and good over care failings at the Mid Staffordshire Foundation NHS Trust. The Healthcare Commission’s report on this trust – one of the last that it produced before becoming part of the Care Quality Commission – shows that the NHS still far to go to achieve a true patient safety culture.

Clinicians and managers throughout the NHS are putting a lot of hard work into patient safety and it is to be hoped that as time goes on this work will bring results. However, improved safety has been hard to demonstrate in the USA, as John Tingle points out in this issue, in spite of their having started work on this issue earlier than us.

Also in this issue of Health Care Risk Report (HCRR), investigation expert Maria Dineen provides some useful pointers on report writing while Josephine Ocloo talks about the expertise and knowledge that patients and relatives have to offer patient safety work in the NHS.

Also in the May issue of Health Care Risk Report :

- An analysis of the Healthcare Commission’s report on NHS boards and patient safety, by Stuart Emslie, editor of Healthcare Governance Review

- The success of the Speedy Resolution Pilot in Wales

- Professional evidence to the health committee

- Medication safety and pharmacists’ new professional body

- Expert comment on “failure to refer” in general practice, the care and treatment of mental health service user Daniel Gonzales, and a fatal fall from a hoist in a care home.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Volume 15 Issue 5 April 2009

This issue of Health Care Risk Report (HCRR) contains the usual news, comments and resources along with the following articles:

- A review of complaints handling in the NHS
- Getting GPs involved in patient safety activities
- Advice on research in the NHS involving people who lack capacity to make decisions
- Guidance for NHS organisations on developing a framework for ensuring the competence of staff to deal with cases of suspected abuse
- An article imploring trusts that they should “respond appropriately” to late complaints made by patients and not use the ‘time elapsed’ or ‘ the doctors are now employed elsewhere’ as excuses not to demonstrate compassion.
- An article summarising some of the relative’s evidence to MPs on the health committee in relation to patient safety

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Volume 15 Issue 4 March 2009

According to the Leader page, this issue of Health Care Risk Report (HCRR) carries three views from three different experts on the question of how patient safety and clinical risk management do (or do not) fit together. There seems to be a perception among some people that patient safety is somehow replacing clinical risk management and that the latter has run its course.

According to HCRR editor, pat Anderson, “Patient safety has brought a welcome focus on the individual patient, enthusing staff who are more focused on people than figures and statistics. It offers new techniques and tools along with training course an, now, the national patient safety campaigns. The emphasis on measurement means that many trusts, particularly those involved in the Safer Patients Initiative, have been able to show real improvements in safety. However, all this does not invalidate the tried and tested techniques of risk management, which should not be left by the wayside. The wider universe of risk – encompassing everything from staff safety to business interruption – must not be forgotten. Hopefully most NHS organisations are sensible enough to encourage risk management and patient safety teams to work together for the benefit of all.”

Other matters appearing in this issue of HCRR include:

- An article by John Tingle, based on two Healthcare Commission report, that outlines what should be done to improve quality of care in accident and emergency departments.
- The first of two articles by Dr Tayza Aung, a GP from Essex, who asks whether the government’s reforms, or a drive from within the medical profession, are most likely to result in the desired improvements to the quality of primary care.
- The first of a two-part series that provides an overview of the systems and processes involved in managing the risks associated with research done in the NHS.
- An article describing what the changes to victims’ rights mean for the NHS.
- The second of two articles looking at decision making under the Mental Capacity Act 2005.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 15 Issue 3 – February 2009

This issue of Health Care Risk Report (HCRR) features, among other matters, the NHS’s commitment to ‘being open’. As Pat Leonard, editor of Health Care Risk Report (HCRR) comments in the journal’s Leader column, “Being harmed by healthcare treatment, or knowing a members of your family has been harmed in this way, is very distressing. However, many people also say that this distress is worsened by the way that healthcare organisations behave in aftermath of such an event. People want an explanation of what went wrong, and an apology – but this must be a real apology.”

Interesting, then, that the principles of the National Patient Safety Agency’s Being Open guidance are “acknowledging, apologising and explaining when things go wrong.” Yet the NHS Litigation Authority’s 2007 circular on apologies and explanations warns that “care should be taken in the dissemination of explanations so as to avoid future litigation risks.” To get an insight into this issue, read the article by Peter Walsh - CEO of Action against Medical Accidents - who asks the question “How real is the NHS commitment to Being open?”

Interestingly, this issue of HCRR reports on a review of the NPSA’s Being open guidance carried out by Professor Albert Wu from the USA’s Johns Hopkins University. He makes six recommendations, including that “NHS boards of directors should ensure that Being open is supported by non-punitive local policy and by staff training. 

Other matters appearing in this issue of HCRR include articles on:

- why NHS trusts need to address the issue of failure to detect and act on the signs of deterioration among hospital patients;
- patient safety in mental health;
- how to measure and improve in the context of England’s Patient Safety First Campaign;
- analysing falls management using failure mode and effect analysis;
- standards for occupational health and safety, including managing risk; and
- what the latest Health and Safety (Offences) Act 2008 means for the NHS.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 15 Issue 2 – December 2008/January 2009

This issue of Health Care Risk Report (HCRR) provides coverage of the key case of Birch v University College and its ramifications. The case shows that Mrs Birch, when asked to consent to an investigation which resulted in her having a stroke, was not given sufficient information before making a decision. She was asked to sign a form that did not accurately reflect the true picture of risk for her as an individual. Stuart Marchant provides a legal perspective and Dr Jeff McIlwain gives a clinical viewpoint on its implications for consent. As Dr McIlwain has previously pointed out in HCRR, such a form should be the conclusion of a proper discussion between clinician and patient, not a substitute for it.

Over the years the balance has swung away from medical paternalism and towards patient empowerment, as evidenced by both legal cases and society in general. The Department of Health (DH) is trying to ensure that society does not ignore the rights of the most vulnerable – those who do not have capacity to make decisions for themselves (whether temporarily or permanently). To this end, the independent mental capacity advocacy (IMCA) service has been introduced and has now been in operation for 18 months. Referrals to this have not been as high as expected so the DH is urging NHS clinicians to refer more often for serious medical treatment decisions. Where referrals are being made (by psychiatrists, psychogeriatricians or hospital social workers) patients are benefiting. Two case studies are contained in this issue of HCRR that provide evidence of this.

Frail older patients and those with learning difficulties are also vulnerable within the physical environment of care, and Phil Gifford looks at the issue of deaths associated with poorly-fitted bedrails. Injuries and deaths from this cause are a perennial problem for hospitals and for residential or nursing homes, and can lead to substantial fines as well as the personal cost to patients, their families and staff involved.

Also in this issue, Claire Bentley covers violence and aggression towards NHS staff, including a look at the important issue of violence by mental health service users. The DH code of practice to the revised Mental Health Act, which came into force in November 2008, contains useful guidance on this.

Last, but not least, HCRR also covers, in separate articles, patient safety in general practice and the issue of loss of patient data. Preserving patient confidentiality is essential and the information commissioner views general practice as a key area where data must be protected.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 15 Issue 1 November 2008

A mixed-bag of goodies awaits the reader in this issue of Health Care Risk Report (HCRR).

In the second of two ‘peer reviewed’ linked articles, Professor Louise Wallace describes two examples of successful use of patient safety newsletters, and recommends how such newsletters could be improved.

Sir Jonathan Michael, chair of the Independent Inquiry into Access to Healthcare for People with Learning Disabilitiesand Anne Richardson, head of offender mental health at the Department of Health, lay out the recommendations of the inquiry into healthcare for people with learning disabilities, and what these mean for the NHS.

John Tingle, a regular contributor to HCRR, looks at reports issues by the Royal College of GPs and the Medical Defence Union that provide important perspectives on proper medical practice and good risk management. He says that “It is difficult to make doctors accountable for their actions as they are used to a great deal of autonomy, public esteem and respect. They are used to being in control. The independent contractor status of most GPs compounds this. One of the reasons why the implementation of clinical governance in primary care has been very patchy is because it is difficult to tell self-employed professionals what do do.” Consequently, says John Tingle, “It is…..necessary for the protection of society to impose external accountability mechanisms to police the profession and to ensure proper standards.”

Dr Jiju Antony, professor of quality management at Strathclyde University, in the second of two articles looking at Lean and Six Sigma in healthcare, describes a pilot study of the effect of Lean and Six Sigma on service quality and safety in NHS trusts. He concludes that NHS Scotland “has quite a long way to go before Lean Six Sigma, or even any type of Six Sigma effort, becomes a normal part of the organisation.”

In a short article on the subject, Charles Hancock, director of healthcare programmes at Loughborough University Business School argues that nurses need better fire training. And an article by Stuart Emslie, Editor of Healthcare Governance Review, describes the Irish report on patient safety, which sets out a world-class healthcare governance framework.

Finally, and again in the second of two articles, this time looking at the Mental Capacity Act deprivation of liberty standards, solicitor Andrew Alonzi looks in more details at the code of practice.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 14 Issue 10 October 2008

Patient safety and risk management are the key themes in this issue of Health Care Risk Report.

Professor Louise Wallace describes a survey of trusts’ patient safety newsletters which reveals room for improvement. She also describes “an effective system of feedback” from incident reporting systems using her Safety Action and Information feedback from Incident Reporting (SAFIR) model.

Stephen Ramsden OBE, campaign director of the Patient Safety First Campaign for England, and chief executive of Luton and Dunstable NHS foundation trust explains what’s in the English national patient safety campaign for managers, staff and patients. A key aspect of the campaign is “leadership for patient safety – getting boards on board with patient safety, with the aim of demonstrating that it is the highest priority.”

Dr Jeff McIlwain takes a look at the consent process and argues that trusts need to rewrite consent forms if they are to elicit true consent and fit in with latest General Medical Council guidance.

Charles Hancock and Janette Midda offer some topics for debate on the ethical aspects of fire safety in the NHS. Meanwhile, Simon Greenfield explains why NHS trusts in London are getting tougher to improve fire safety including compliance with new legislation.

In the first of a two-part series, Dr Jiju Anthony explains the benefits that combining Lean and Six Sigma techniques in healthcare can have for organisations and their patients. While this, the first article gives a broad overview of Lean and Six Sigma, the second article will describe research carried out in NHS Scotland showing how the “use of Lean and/or Six Sigma was associated with a reduction in operational costs, reduction in patient waiting times, reduction in waste in processes, improved patient service delivery and improved understanding of the patient’s voice.”

The final article, and, again, the first of a two-part series, by Andrew Alonzi, a senior law lecturer, looks at the implications for practitioners of the Mental Capacity Act Deprivation of Liberty Safeguards (formerly known as the ‘Bournewoord’ safeguards) to be introduced in April 2009

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 14 Issue 9 September 2008

This issue of Health Care risk Report (HCRR), like so many others, has something for everyone.

The cause of healthcare governance is addressed in an article by Healthcare Governance Review editor Stuart Emslie. Essentially, Stuart reviews the new ‘governance between organisations’ debate paper and argues that it’s better management between organisations that is needed to improve services and reduce risks. Governance between organisations is, essentially, the “next taxi off the rank” in the wider world of ‘governance creep’.

There are three articles under the heading ‘risk management.’ The first explores how NHS trusts can use purchasing power to improve patient safety. The second argues that patients and trusts need a clearer view of the risks of infection. And the third provides guidance and advice to community nursing and other community staff on implementing the Mental Capacity Act and contains case examples.

Two legislation updates are provided. The first looks at the future of health care regulation in England, focusing on the role of the Care Quality Commission and the potential for confusion between the Commission and Monitor. The second provides an update on the Mental Health Act.

Finally there is the usual helping of helpful clinical negligence case reviews, plus an article looking at the health service ombudsman’s latest report on learning from complaints, which finds that poor communication is still a recurrent theme.

If you or your organisation do not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 14 Issue 8 July/August 2008

This issue of Health Care Risk Report (HCRR) focuses on the 60th anniversary of the NHS and has a distinctly ‘patient safety’ theme.

The tone is set in the Forword by Ann Keen MP, parliamentary under-secretary for the NHS, which is titled ‘Patient safety is our priority.’

Pat Anderson, editor of HCRR, reports from May’s Patient Safety Congress that patient safety is now a priority for MPs, managers and clinicians. As Pat says, David Nicholson, Chief Executive of the NHS, has “now made clear to NHS Chief Executives that quality and safety [is] central to their role….” He also said that the English patient safety campaign would not be part of performance management as this would “be the best way of killing it.” Pat completes finished her article on the English national patient safety outlining the national director, Stephen Ramsden’s, view that the campaign would be “led by the service for the service” and that its cause would be “to make the safety of patients  highest priority”, and its aim would be “no avoidable death, no avoidable harm.”

Martin Fletcher, CEO of the National Patient Safety Agency outlines three key patient safety challenges for the next 60 years – building stronger partnerships with patients; the opportunity – and risk – of new technology; and the opportunity for better design for safety.

Brian Capstick provides a short article on learning from incident reports. He concludes that the way forward is to have better quality data on incidents being recorded, and this date should include an account of how much incidents are costing the NHS.

Jackie Cresswell provides a useful summary and timeline around patient safety in the NHS, starting with the establishment of Action for Victims of Medical Accidents (now Action against Medical Accidents, or AvMA) in 1982, and ending up with the patient safety campaign launches in Wales and April in 2008.

Other articles include:

- 60 years of health and safety in the NHS;
- The NPSA’s ‘Foresight Training’ for nurses, which aims to enlighted nurses on factors that can predispose to errors; and
- Patient safety heros: a tale of ‘comic strip’ posters at Barts and the London NHS that include ‘good’ characters such as ‘Reporting Man’ and ‘Detective Investigation with his Root Cause Analysis Droid’, and ‘evil’ characters such as ‘The Punisher’ and ‘Blame Monster’. Intriguing, no?

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Health Care Risk Report Vol 14 Issue 7 June 2008

Governance of primary care trust (PCT) commissioning features in this issue of Health Care Risk Report (HCRR) with an article by Paddy Pearce and Rob McSherry (otherwise known for their excellent book on clinical governance). They believe that “PCTs require knowledgeable, skilled, competent individuals and teams who proactively embrace the principles of transformational leadership, to truly embed integrated governance into commissioning and thus assure the quality of services received by their local population. Commissioning governance” says Pearce and McSherry “can help PCTs provide evidence that they are truly world-class commissioners.”

John Tingle reviews the Healthcare Commission’s second report about complaints in the NHS in England and concludes that the themes and clinical issues identified in the report “are notable in the main for their simplicity and basic nature.” He further concludes that “these are recurring themes year after year. The NHS does not seem to ever to learn the simple, basis lessons of the past.”

Maria Dineen reviews recent National Patient Safety Agency (NPSA) guidance on the use of risk matrices and concludes that whilst the guidance brings together some useful concepts, careful thought is needed when actually using it.

Patient safety also features in this issue of HCRR. An article by Michael Weaver from Bromley Hospitals NHS Trust tells how the Trust has used the Manchester Patient Safety Framework Tool (MaPSaF) to aid compliance with safety standards and to research whether incident reporting rates were associated with perception of safety culture. The tool was found to be useful in revealing a lack of knowledge about incident reporting systems, but some staff felt inhibited in workshops when more senior staff were present. In a separate article by Pat Anderson, editor of HCRR, the national campaigns to improve patient safety in Scotland and Wales are highlighted.

Another article looks at Revising Consent Form 4 in line with the Mental Capacity Act and also in this issue there is the usual generous helping of news and legal case reviews to keep you up-to-date.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

May 2006 issue of Health Care Risk Report

This issue of Health Care Risk Report (HCRR) moves the journal on from being a professional journal, into the realm of incorporating peer reviewed articles. The single peer reviewed  in the current issue describes How NHS trusts could use patient safety indicators to help improve care and is written by Dr Alex Bottle and Dr Paul Aylin from the Dr Foster Unit at Imperial College Faculty of Medicine. Their research has found that US patient safety indicators, when applied to Hospital Episode Statistics data, will be of value in directing clinical audit towards important areas of potential harm, and helping trusts assess performance over time.

Other articles in the May issue of HCRR include:

- A review, by John Tingle, of the Healthcare Commission’s 2008 report Learning from investigations.

- An article titled Teams, staffing, training and governance: the recipe for safer births, by Sarah Davies and Dr Brenda Ashcroft of University of Salford, outlining the findings of Safe Births, Everybdy’s Business, the report of an independent inquiry into safety in maternity care

- Learning from homicides committed by mental health users. A review, by Pat Anderson, editor of HCRR, of NHS London work looking at 26 mental health homicides and also NPSA work relating to investigation of serious patient safety incidents in mental health services.

- An article, by Stuart Emslie, editor of Healthcare Governance Review, looking at extracting the learning from large patient safety databases.

- A review, also by Stuart Emslie, of the latest version of the Department of Health’s Integrated Governance Handbook, published by the Healthcare Financial Management Association; and

- A look at abortion law developments and professional bodies’ advice by Claire Bentley, solicitor and professional support lawyer.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

April 2008 issue of Health Care Risk Report

This issue of Health Care Risk Report (HCRR) has a patient safety theme. There are articles on how the NHS reacts to alerts sent via the Safety Alert Boradcast System; patient and public involvement in patient safety; and how the NPSA and anaesthetists are working together to promote safety. In addition, John Tingle looks at the Mental Health Act Commission’s twelfth biennial report and Phil Gifford looks at health and safety in NHS amubulance trusts. And there’s the second in a two part article on patient information – meeting the conditions of the Data Protection Act.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

March 2008 issue of Health Care Risk Report: A mixed bag of goodies

This issue of Health Care Risk Report (HCRR) will have something for everyone. John Tingle reports on a National Patient Safety Agency (NPSA) self-review of progress in patient safety during 2007 after the removal of the NPSA’s original joint CEOs in the wake af a damning Public Accounts Committee (PAC) report on the performance of the NPSA during its first 5 years. Whilst it is highly encouraging to note that Sir Liam Donaldson, Chief Medical Officer, believes that “at the end of the first year……..sound progress” has been made, it is also interesting to note that no mention is made on progress in relation to the NPSA’s original key objective, and the issue which incurred the wrath of the PAC, which was to establish a sound national reporting system for patient safety incidents.

On the subject of incident reporting, a topical article from Scotland describes “Critical success factors for electronic incident reporting systems.” This is followed by an article on hospital staff knowledge in the event of fire by a student and staff at Loughborough University Business School; and an article on maximising learning from serious untoward incidents. Phil Gifford, formerly with the Health and Safety Executive’s (HSE) health services national interest group, reports on HSE’s investigation of infection outbreaks at Stoke Mandeville and concludes that with the Corporate Manslaughter Act coming into force in April this year, “it would be most prudent for all trusts to get their houses in order in relation to C. difficile and healthcare-associated infection in general.”

The final article is the first of two linked articles by lecturers at Nottingham Law School looking at the General Medical Council (GMC) and Mental Capacity Act (MCA) guidance on access to patient information. Trusts need to make sure that staff understand the MCA and, in particular, are familiar with the rules governing access to information when a person lacks capacity set out in Chapter 16 of the MCA. Staff also need to be able to integrate the guidance in relation to patients who lack capacity within the wider common law, statutory and professional framework, including GMC guidelines.

In the ‘case reviews’ section of the journal there is a particularly noteworthy report on Colwill v Oxford Radcliffe Hospitals NHS Trust. A doctor failed to commence antibiotics quickly enough for an infection at the site of a cannula leaving a patient hemiplegic, almost blind and with severe cognitive impairment. The case was heard in the High Court in London in December 2007 and the court ruled that the claimant’s treatment was negligent. In arriving at the judgement on negligence, it was unfortunate for the defendant that the doctor involved in the incident was found to be “an unsatisfactory witness in that he didn’t listen to counsels’ questions, defended the actions of his junior colleagues without proper thought, was contradictory and sought to justify his answers with little or no evidential foundation, could not explain anomalies in his own notes, was careless in his statement and very defensive about personal criticism.”

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded at www.healthcareriskreport.com

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

February 2008 issue of Health Care Risk Report focuses on infection control

With concerns regarding the impending Corporate Manslaughter Act becoming more prominent on board member’s and senior manager’s radar screens, it is fitting that this month’s issue of Health Care Risk Report (HCRR - Volume 14 Issue 3) should devote two articles to a ’special report’ on infection control. The first, from Professor Hilary Pickles, director of public health, and director of infection prevention and control at Hillingdon PCT, looks at the substantial risk posed to patients and organisations by infection and ‘plots a course’ for the role of the risk manager. The second article is an account, by Pat Anderson, editor of HCRR, of an interview with the Health and Safety Executive’s (HSE) healthcare-associated infection policy lead – Ian Strudley. From a governance, as well as a risk management perspective, both articles are essential reading for board members and senior managers. For example, Ian Strudley re-affirms HSE’s position that matters of clinical judgment are outwith its remit, but asserts that HSE ”will pursue investigations where patients and staff are put at risk because of poor systems of work.” And in the news section of this month’s HCRR there is a warning from the Health and Safety Executive that NHS trusts “must have a contingency plan outlining what will happen in the event of an outbreak of infection with an organism such as Clostridium difficile.”

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded at www.healthcareriskreport.com

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.