Webinar: Patient Safety – More than a Promise: A review of the 2023 UK Parliamentary and Health Service Ombudsman Report into patient safety incidents that resulted in avoidable deaths within the NHS

Introduction

In June of this year, the UK Parliamentary and Health Service Ombudsman released a report summarizing their findings of their review of 22 patient safety incidents that were identified as avoidable deaths, with the aim of highlighting failings in systems and, support learning from the analysis.

The report identified repeated broad themes of clinical failings leading to these deaths and also several factors that contributed to compounded harm experienced by the families of these patients following the deaths of their loved ones.

This webinar will present a summary of these clinical failings, and the resulting compounded harm, that provide learnings that are applicable across all of the health and social care sectors internationally.

Presenter

Oonagh Gilvarry, Chief Research Officer, HCI

As Chief Research Officer, Oonagh is responsible for the development of Quality and Safety Management Systems that effectively address organisational regulatory requirements while meeting business needs. Through her evaluation of emerging research, tools and technologies, Oonagh ensures that best-in-market techniques are utilised throughout HCI services.

Oonagh has been central to HCI’s work with regulatory bodies in the development of standards for key health and social care areas. Oonagh has substantial experience in the development and delivery of training programmes in the areas of Internal Quality Auditing, Clinical Auditing, Patient and System Tracers, Policy and Procedure Development, Governance and Management, Incident Reporting and Management of Serious Incidents, Complaints Management and Risk Management.

Oonagh has lectured extensively within NUIG and is a qualified ISO Lead Auditor.