The Healthcare Safety Investigation Branch has launched its fourth investigation after being alerted to a patient’s death after they presented to hospital two weeks after surgery.
A full investigation by the new patient safety body, which started work in April, will look at the care for the patient who deteriorated soon after returning to hospital following their surgery. Investigators will look at issues surrounding the recognition of and response to critically unwell patients.
HSIB said in a statement: “The focus of the investigation will be on understanding the contextual, organisational and human factors that are influential in determining the severity of a patient’s condition.
“The investigation will review strategies and identify opportunities to facilitate clinical decision making.”
HSIB has not named the trust or patient involved in the incident, in line with its policy, but is expected to publish an interim report setting out more details.
The branch, which aims to take a human factors safety systems approach to investigating incidents in the NHS, has already launched three investigations looking at:
- care for critically ill patients being transferred between hospitals;
- wrong site surgery interventions; and
- care of mental health patients who present at accident and emergency departments.
Health secretary Jeremy Hunt set up HSIB following the Morecambe Bay care scandal and the government has introduced a draft bill in Parliament to give HSIB statutory independence.
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