Significant event log failures
Failure to adequately record, review, and log significant events at clinical meetings, hindering learning and improvement.
35 items
1 source
10 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
74match
R11 - Incident report on monitoring alarm failure
We recommend that in the event of failure of an alarm on monitoring equipment, an untoward incident report should be completed and the equipment serviced before it is used again (para 5.11.6).
Matched on
terms: event, failure
Inquiry recommendation
70match
MAI-84 - Review NWFC incident log information storage
North West Fire Control should review the way it captures and records key information on its incident logs in order to ensure that the information is stored in one place and is readily accessible at all times by those who need it
Matched on
terms: log
Inquiry recommendation
65match
COVID-M1.4 - UK-wide Civil Emergency Strategy
The UK government and devolved administrations should together introduce a UK-wide whole-system civil emergency strategy (which includes pandemics) to prevent each emergency and also to reduce, control and mitigate its effects. The strategy should: be adaptable; include sections dedicated to each potential whole-system civil emergency; consider a wide range of potential scenarios for each type of emergency; identify...
Matched on
terms: event, log
Inquiry recommendation
57match
F98 - National Patient Safety Agency functions
Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.
Matched on
terms: significant
Inquiry recommendation
57match
MAI-152 - Recording equipment for incident commanders
The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that all those who may be required to take up a command position in the event of a Major Incident are issued with a means to record what they say, hear and see unless there are good reasons why...
Matched on
terms: event
Inquiry recommendation
53match
COVID-M1.6 - Triennial Pandemic Exercises
The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years. The exercise should: test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak to multiple waves over a number of years; include a broad range of those involved in pandemic preparedness...
Matched on
terms: event
Inquiry recommendation
45match
R16 - Missed care incident reporting
If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.
Matched on
classifier match
Inquiry recommendation
45match
MAI-81 - Improve NWFC Major Incident record-making
North West Fire Control should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice
Matched on
classifier match
Inquiry recommendation
45match
MAI-71 - Improve NWAS Major Incident record-making
North West Ambulance Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Matched on
classifier match
Inquiry recommendation
45match
MAI-38 - Improve GMP Major Incident record-making
Greater Manchester Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Matched on
classifier match
Inquiry recommendation
45match
MAI-33 - Improve GMFRS Major Incident record-making
Greater Manchester Fire and Rescue Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Matched on
classifier match
Inquiry recommendation
45match
MAI-19 - Provide recording equipment to control room personnel
Consideration should also be given by those organisations to the provision of such equipment to key personnel within control rooms.
Matched on
classifier match
Inquiry recommendation
45match
MAI-14 - Improve BTP Major Incident record-making
British Transport Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice
Matched on
classifier match
Inquiry recommendation
44match
12 - Review incident investigation structures
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements for additional training. The Trust should ensure that robust documentation is used, based on a recognised system, and...
Matched on
classifier match
Inquiry recommendation
44match
F114 - Complaints handling
Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Matched on
terms: event
Inquiry recommendation
41match
R12 - Single written channel for serious incident reports
We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved (para 5.4.12)
Matched on
classifier match
Inquiry recommendation
41match
F99 - National Patient Safety Agency functions
The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.
Matched on
classifier match
Inquiry recommendation
41match
POH-17 - Establish standing public body to administer future redress schemes
As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Matched on
classifier match
Inquiry recommendation
41match
POH-13 - Close HSS Dispute Resolution Procedure when HSSA opens
The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA opens should be eligible to join the Dispute Resolution Procedure.
Matched on
classifier match
Inquiry recommendation
40match
IHRD-17 - Recording Changes in Accountability
Any change in clinical accountability should be recorded in the notes.
Matched on
classifier match
Inquiry recommendation
40match
25 - Duty to report external investigation findings
We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the operation of the Trust, including prompt notification of relevant external bodies such as the Care Quality Commission and Monitor. The Care Quality Commission should develop a system to...
Matched on
classifier match
Inquiry recommendation
39match
IHRD-45 - Post-Mortem Documentation Checklist
Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.
Matched on
terms: log
Inquiry recommendation
39match
IHRD-32 - SAI Reporting as Disciplinary Offence
Failure to report an SAI should be a disciplinary offence.
Matched on
terms: failure
Inquiry recommendation
36match
F100 - National Patient Safety Agency functions
Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.
Matched on
classifier match
Inquiry recommendation
36match
23 - Clear standards for incident reporting in maternity
Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there is a strong case to include a requirement that investigation of these incidents be subject to a standardised...
Matched on
classifier match
Inquiry recommendation
35match
IHRD-48 - Mortality Meeting Recording and Audit
The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
Matched on
classifier match
Inquiry recommendation
35match
IHRD-37 - Family Involvement in SAI Investigations
Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the opportunity to become involved in setting the terms of reference for an investigation. (iii) Families should, if they...
Matched on
classifier match
Inquiry recommendation
32match
IHRD-31 - SAI Reporting Understanding
Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').
Matched on
classifier match
Inquiry recommendation
32match
F42 - Use of information about compliance by regulator from: Serious untoward incidents
Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.
Matched on
classifier match
Inquiry recommendation
31match
CLAR-3 - Remind agencies to keep detailed, accurate records, especially mortuary documentation
We would like to remind all agencies of the importance of keeping detailed and accurate records. Particular attention should be given to the correct documentation of proceedings in the mortuary.
Matched on
classifier match
Inquiry recommendation
31match
IHRD-70 - Board Meeting Minutes Preservation
Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.
Matched on
classifier match
Inquiry recommendation
31match
11 - Raise awareness of incident reporting and duty of candour
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with the duty of candour of professional staff, and incorporate into the programme compliance with the refreshed policy. This...
Matched on
classifier match
Inquiry recommendation
27match
IHRD-29 - Record Keeping Audit
Record keeping should be subject to rigorous, routine and regular audit.
Matched on
classifier match
Inquiry recommendation
27match
IHRD-24 - Blood Test Result Documentation
All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.
Matched on
classifier match
Inquiry recommendation
22match
SHI-4 - Standard form for derogations from guidance
The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use throughout the NHS in Scotland would be beneficial. This would ensure that derogations are captured and recorded in a uniform way. This would result in consistent and uniform practices. It would also bring clarity to how...
Matched on
classifier match