Independent Neurology Inquiry. | PSNet

Provide Feedback |

Submit a Case

Register

Book/Report

Independent Neurology Inquiry.

July 20, 2022

Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022. ISBN 9781912313631.

Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity and mortality. This report outlines findings from an inquiry into one misdiagnosis attributed to one neurologist in Ireland and discusses the leadership, system, process, and communication failures which permitted misdiagnoses to go unchecked.

Related Resources From the Same Author(s)

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

April 26, 2006

Gosport War Memorial Hospital. The Report of the Gosport Independent Panel.

November 7, 2018

Coding for Success: Simple Technology for Safer Patient Care.

March 14, 2007

Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.

July 1, 2020

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review.

July 22, 2020

Patient Safety Incident Response Framework.

August 31, 2022

Good for You, Good for Us, Good for Everybody.

October 6, 2021

Digital Clinical Safety Strategy

October 20, 2021

Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review.

July 25, 2018

Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995.

April 25, 2007

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

December 9, 2020

Report of the Independent Inquiry into the Issues Raised by Paterson.

February 19, 2020

High Quality Care for All: NHS Next Stage Review Final Report.

July 16, 2008

Learning from Investigations.

February 20, 2008

Culture Change in the NHS: Applying the Lessons of the Francis Inquiries.

March 11, 2015

Hard Truths: the Journey to Putting Patients First.

November 27, 2013

Safely Home: What Happens When People Leave Hospital Care Settings?

August 26, 2015

Improving Patient Safety Culture – A Practical Guide.

August 2, 2023

Final Report of the Ockenden Review.

April 27, 2022

Oxford Professional Practice: Handbook of Patient Safety.

July 27, 2022

Avoiding Unconscious Bias: a Guide for Surgeons.

August 24, 2016

Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice.

May 29, 2019

Learning From Invited Reviews.

April 10, 2019

Learning Not Blaming.

September 9, 2015

Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery.

April 23, 2014

Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.

January 13, 2021

The Habits of an Improver. Thinking About Learning for Improvement in Health Care.

December 16, 2015

A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England.

August 21, 2013

The Report of the Short Life Working Group on Reducing Medication-related Harm.

March 28, 2018

Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.

April 2, 2014

State of Healthcare 2008.

January 7, 2009

Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005.

January 2, 2008

Saying Sorry.

March 26, 2014

Solutions from Professional Regulation and Beyond.

October 5, 2022

Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer.

December 4, 2013

Safety First: a Report for Patients, Clinicians and Healthcare Managers.

January 17, 2007

Raising and Responding to Concerns.

February 25, 2015

Safety and Ethics in Healthcare: A Guide to Getting it Right.

October 10, 2007

Safety First: One Year On.

January 9, 2008

Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS.

June 22, 2022

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

October 24, 2007

Systems Analysis of Critical Incidents: the London Protocol.

December 19, 2007

Acting on Concerns: Your Professional Responsibility.

March 6, 2013

Non-technical Skills and the Future of Teamwork in Healthcare Settings.

July 10, 2013

An Avoidable Death of a Three-year-old Child from Sepsis.

July 16, 2014

Guidance on Safe Medical Staffing: Report of a Working Party.

August 1, 2018

Using Safety Cases in Industry and Healthcare.

February 13, 2013

Openness and Honesty When Things Go Wrong: the Professional Duty of Candour.

July 15, 2015

Safety in Doses.

September 16, 2009

Review of Patient Safety for Children and Young People.

July 1, 2009

Continuous Improvement of Patient Safety: The Case for Change in the NHS.

November 25, 2015

The Report of the Morecambe Bay Investigation.

April 29, 2015

Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.

February 20, 2013

Patient Safety Culture: Theory, Methods and Application.

January 21, 2015

Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients.

March 28, 2018

Organizing Patient Safety: Failsafe Fantasies and Pragmatic Practices.

May 8, 2019

Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer.

June 4, 2014

Clinical Risk Management. Enhancing Patient Safety. 2nd ed.

March 27, 2005

Mounting drug shortages delay treatments for patients with bladder cancer

December 18, 2019

Learning From Mistakes.

August 31, 2016

Patient Safety and Managing Risk in Nursing.

January 15, 2014

How to Stay Safe When Entering the Healthcare System: A Physician Walks across the Country to Raise Awareness of the Need to Improve Healthcare Safety.

November 30, 2022

Improving Safety in Maternity Services: a Toolkit for Teams.

April 25, 2012

Complaints and Raising Concerns.

February 4, 2015

The Safety of Maternity Services in England.

August 25, 2021

Managing the Costs of Clinical Negligence in Trusts.

October 4, 2017

Noise: a Flaw in Human Judgement.

August 25, 2021

Managing Patients' Medicines after Discharge from Hospital.

November 11, 2009

The Measurement and Monitoring of Safety.

May 8, 2013

Investigating Clinical Incidents in the NHS.

May 6, 2015

PHSO Review: Quality of NHS Complaints Investigations.

June 22, 2016

Diagnoses Without Names: Challenges for Medical Care, Research, and Policy.

October 12, 2022

The International Forum on Quality and Safety in Healthcare.

April 10, 2024 - April 12, 2024

Safer Clinical Systems.

May 13, 2015

How Safe Is Your Hospital?

January 6, 2010

Designing Safer Rotas for Junior Doctors in the 48-Hour Week.

October 25, 2006

Involving Patients in Improving Safety.

January 30, 2013

Nearly 90 major medical mistakes logged at Utah hospitals in 2008.

July 8, 2009

Deaths in Acute Hospitals: Caring to the End?

November 25, 2009

National Safety Standards for Invasive Procedures (NatSSIPs2).

February 7, 2023

A Patient-Safe Future.

November 14, 2018

Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for the Department of Health.

November 5, 2014

Staff Care: How to Engage Staff in the NHS and Why It Matters.

February 5, 2014

National Training Survey 2013: Concerns about Patient Safety.

January 8, 2014

National Patient Safety Syllabus 1.0 Training for all NHS Staff.

March 4, 2020

State of Healthcare 2008.

November 15, 2008

An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer.

March 6, 2005

Diagnostic Excellence.

September 20, 2022

The Future of NHS Patient Safety Investigation.

April 4, 2018

Freedom to Speak Up: A Review of Whistleblowing in the NHS.

May 27, 2015

Please, write to me. Writing outpatient clinic letters to patients. Guidance.

September 26, 2018

Covid-19: Assessing the Risk to Public Protection Posed by a Doctor as a Result of Concerns about their Practice during the Pandemic.

September 30, 2020

The Power of Medical Malpractice Stories to Improve Patient Safety.

May 19, 2022 - May 19, 2022

Enhancing Patient Care: A Practical Guide to Improving Quality and Safety in Hospitals.

November 4, 2009

Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report.

August 7, 2013

Making Hospitals Safe for People With Diabetes.

October 31, 2018

Exploring the Potential Use of Safety Cases in Health Care.

March 4, 2015

Walgreens will stop judging its pharmacy staffers by how fast they work.

November 9, 2022

View More

Related Resources

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

April 3, 2024

2024 National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Report.

March 20, 2024

Prioritizing Patient Safety Through Quality Measurement.

March 6, 2024 - March 6, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure.

November 29, 2023

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

Your Safety in our Hands in Hospital.

April 20, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Listening, Learning, Responding to Concerns.

April 12, 2023

The prisoner.

March 29, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020.

March 1, 2023

National Patient Safety Board Act of 2022.

December 21, 2022

Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety.

December 21, 2022

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

December 14, 2022

Perspective

Measuring Patient Safety

December 14, 2022

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

The National Healthcare System Action Alliance for Patient and Workforce Safety.

November 14, 2022 - November 14, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

Examining the Status of VA’s Electronic Health Record Modernization Program.

August 10, 2022

Improving Diagnosis in Medicine Act of 2022.

July 20, 2022

Agency Information Collection Activities: Proposed Collection; Comment Request, "Hospital Survey on Patient Safety Culture Comparative Database.''

June 22, 2022

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.

May 25, 2022

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

May 4, 2022

Final Report of the Ockenden Review.

April 27, 2022

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

View More

See More About The Topic

Health Care Executives and Administrators

Epidemiology of Errors and Adverse Events

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364