Investigation in Clinical Practice

​Context - NHS Trust required independent review of internal SI review after post-operative patient death. [2018]

Brief- To review internal SI report and determine it’s adequacy in addressing care delivery problems identified.

Delivery- Independent single reviewer

• Agreed TOR with Executive MD
• Interviewed relevant parties including bereaved spouse and medical practitioner
• Read relevant clinical documentation including surgical records and hand over notes
• Deployed national level guidance on SI investigations to benchmark internal review.
• Submitted draft report
• Made required amendments and submitted final report

Outcome - Trust was able to gain assurance that their internal review had been robust and benchmarked favourably against national guidance

Key Learning- NHS Trusts need to better understand the system level factors that militate against patient safety and to have pro-active mitigation strategies to address them.