In the guidance for Serious Untoward Incidents (SUI) from different hospital trusts that I’ve seen published on the web, a common example of the kind of adverse event that might start the process off is the death of a baby. Some trusts go as far as suggesting stillbirth - even as far back as [...]
People understand something by understanding its context, not by cramming the details of that thing into their brain. That is why making diagrams is such a useful technique for understanding complicated things; it puts all the details into some kind of context and helps you make sense of things.
Here is a timeline I built [...]
A Serious Untoward Incident is an investigation process in hospitals that happens following the death or harm of someone due to failures in care, the type of thing that might attract media interest, litigation etc. We have been involved in one following the death of our baby.
The idea behind it is that time and [...]
One of the important features of our baby’s death was something called a sub-aponeurotic haemorrhage. On the face of it, this is a relatively rare complication of vacuum assisted delivery - an invaluable technique in difficult births for delivering babies. As far as the hospital where our baby was born is concerned, this [...]
This is an extract from a report on healthcare professionals’ views about safety in maternity services, published in 2008. The report identifies, along with various staffing and management issues, that learning lessons from mistakes and near-misses is one of the key problems in maternity.
Learning from adverse incidents is one of the key components of [...]
Our hospital has used second class post to correspond with us throughout. This is very poor PR.
Second class post costs 9p per letter less than first class, and while it ‘aims’ to get there within three working days, it very often takes 10 days or more. For a bereaved family trying to make sense [...]
