Patient safety investigations

This investigation focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.

This investigation looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation.

NHS Improvement issued a patient safety alert on medical devices in January 2018. It highlighted 400 incidents - including six deaths - over three years that involved the incorrect operation of oxygen cylinder controls. This investigation reinforces that alert and makes further safety recommendatio…

Cataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS. Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entire…

This investigation seeks to identify opportunities and systemic remedies to reduce the risk of wrong site anaesthetic nerve blocks occurring. Anaesthetic nerve blocks are injections to block pain in a specific region of the body.

This investigation relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery - a surgical never event. A never event is a serious incident that is entirely preventable.

We investigate how young people are supported in the transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) when they turn 18 years old.