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 podcast is a recording of a webinar, presented by Oonagh Gilvarry, Chief Research Officer at HCI. Oonagh provides 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.