Investigating for Improvement – building a national safety investigator for Healthcare

This thought paper explores how healthcare systems can develop a system-wide approach to investigating and learning from the most serious patient safety issues, and examines the organisational infrastructure that is needed to support this. Many safety-critical...

Wrong implant never event report

The NHS strives to learn from its mistakes but is often criticised for failing to investigate incidents properly, and for failing to share lessons learned more widely. This report is a redacted report from a Never Event investigation. The Trust involved wishes to...

Healthcare Safety Investigation Branch – Expert Advisory Group Report

The Government have published the Expert Advisory Group report which recommends how the new “Healthcare Safety Investigation Branch” in NHS England should be established. You’ll be aware that the CHFG have campaigned for many years for a robust independent...

Learning not Blaming

The government response to the Freedom to Speak Up consultation, the Public Administration Select Committee report ‘Investigating Clinical Incidents in the NHS’, and the Morecambe Bay Investigation. Download the...

‘Never?’ Report

This report, drawn up by the Clinical Human Factors Group, looks at nine wrong site surgery cases that were investigated last year, nine patients, nine families, nine clinicians and their teams all who thought it would never, could never happen to them. It then...