Top Tweets for #LearningFromDeaths
2) 65% of NHS mental health trusts are now "requires improvement" or "inadequate" on the Safety domain, with one trust unrated because it is under investigation (Notts Healthcare)
https://t.co/4Tvdfo8WaH
#LearningFromDeaths
@WeAreLSCFT @LSCftImprove great to come together with LSCFT ImprovementFellows @LancasterUni to mark the PGCert milestone. Great to hear how learning has been applied to real world project. This opportunity has helped improve #learningfromdeaths processes ๐
This...#learningfromdeaths... families want action for improvement when raising concerns, not retribution. Insightful blog on the impact of delays in end of life care #dyingmatters
Lessons not learned: A family's lengthy efforts to turn complaints into improvements - a new blog on the hub this week https://t.co/Y9dioDVCLt #pslhub #patientsafety #patientcomplaints
Great to catch up with @Richards_G_C today and discuss all things related to #learningfromdeaths #regulation28s and general improvements to relationships of the #NHS and #coroners #LEDER https://t.co/LxfmGwJqON.
Many NHS trusts have not implemented child death review fully & don't share all relevant information with CDOP. Some areas have not fully commissioned SUDIC services. #learningfromdeaths
The Grant Thornton report on NSFT's mortality recording and reporting NHS bodies are still all counting mental health deaths differently
What a dog's dinner...and what a great way to fudge
#LearningFromDeaths #PatientSafety
https://t.co/O43cNW4gRF
Grant Thornton review of Norfolk and Suffolk Foundation Trustโs mortality recording and reporting
May 2023 Hundreds of deaths shortly after discharge.
And the trust had no clue of true number of deaths.
#LearningFromDeaths #PatientSafety
https://t.co/O43cNW4gRF
The Association of Child Death Review Professionals (ACDRP) are holding a two day conf (Nov.16/17) aimed at all professionals working in child death review.
For further info or to register please visit our website https://t.co/hWfZZrJLhr
โGoodโ CQC Well Led rating after a possibly avoidable death of a man with Downโs Syndrome was not internally reviewed by the care provider. Death of Peter Seaby.
A Priory Group home
#AdultSafeguarding #LearningFromDeaths #Mazars
https://t.co/QMxNwIRoQ6
Really like this infographic depicting QI meths. #learningfromdeaths applies to multiple domains. Privileged to be able to grow knowledge through the @LSCftImprove #safetyImprovementFellowship to invest in future projects/developments
The link between #clinicalaudit and other improvement methodologies is not always easy to fathom! We have finally updated this graphic - let us know what you think! Happy to make changes if people can identify improvements (after all that is what it is all about)!
@NCMD_England This should be a really helpful tool to ensure all CDOP are consistent. Without this we can't learn
#learningfromdeaths
Powerful...#learningfromdeaths reinforcing the importance of essential adjustments, best interests decision making and the key role of learning disability nurses to champion the needs of people with learning disabilities. Thoughts go out to those affected https://t.co/d0KbKdpOJE
Reflecting on a fulfilling and productive working week punctuated by some motivating speakers #justculture #Improvementfellowship #inqueststudyday #medicalexaminersystem #learningfromdeaths bookended by ๐ด๐ช๐ง๐งถ #WorkLifeBalance Welcome distraction from fledgling heading to uni.
#LearningFromDeaths #QI @Gemgemlynch @KarenPKemp @Erikadenton6 @barbcliffe looks interesting @samriley thank you
This looks like a very useful session : how to turn learning from deaths into quality improvement for the living. Will be of interest to clinicians, clinical coders and analysts ๐@B2Moro_LfD @TraceyJSparkes https://t.co/U4BTmTSpp8
Excellent #CAAW22 lunch and learn session on the importance of aligning #clinicalaudit with #patientsafety and vis versa - great slide below from @nqican Chair Vicky Patel.
Well done to all involved ๐๐
#learningfromdeaths #medicalexaminers #CORP #SUIs #neverevents
Wow - what a start to #CAAW22 - well done everyone for sharing this morning๐๐
Currently on @nqican lunch and learn with chair @VickyPatelSTH @J_Thompson17 @HQIP @josieoheney and over 170 #clinicalaudit network colleagues ๐
#patientsafety
Walk of shame. Corporate NHS v bereaved families
@NHSResolution FOi disclosure on legal fees for coroners' inquests by NHS trust
Manchester Univ NHSFT received ยฃ745,875 between 2013-2020
#OurNHSPeople #JustCulture #FTSU #LearningFromDeaths
https://t.co/q78DMnINvJ
How has @sajidjavid assured Julie Dent's track record on clinical learning & governance & satisfied himself that it is a good fit with leading the Notts Maternity Review?
#NHSPeople #MaternitySafety #OckendenReport #LearningFromDeaths
https://t.co/QQWp1uMzmT
Sheffield Teaching Hospitals NHS Foundation Trust - scene of of whistleblower reprisals & more recently, downrated /cos of serious maternity failings
CQC has the bird's eye view but often keeps those concerned compartmentalised
#FTSU #LearningFromDeaths
https://t.co/TMTiGAvnmC
And PFDs are issued variably & on a discretionary basis. There is also no clear mechanism for what happens if a coroner is dissatisfied with the formal organisational responses received after a PFD is issued. It is an administrative dead end.
#LearningFromDeaths
"Nationally, there is no structured process for monitoring the implementation of safety recommendations contained in a PFD report."
@jones_celia @JuliaLa52988125 Very true.. I attended #learningfromdeaths after the GIP Report was published, it was at the Oval and those running it under the DOH never heard of #Gosport and many more.. it takes some believing
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