This investigation followed the Healthcare Safety Investigation Branch being notified of an 18-year-old who died by suicide shortly after transitioning from child and adolescent to adult mental health services. The investigation identified possible issues regarding the transition process.
The Healthcare Safety Investigation Branch (HSIB) has published its first investigation report relating to a surgical never event.
The patient is a 63-year-old man who underwent hip replacement surgery. During this surgery, incompatible components were used. The error was identified when data from the procedure was recorded in the National Joint Registry.