Recommendation · source text
Improve recognition of documentation of differential diagnosis
Source · Investigations in the NHS
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud Nazir: Published July 2025
North East and Yorkshire
Published 01 Jul 2025
Subject Patient S
Index summary
Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud Nazir Appendices The report has also been published on the following websites:
Recommendations
Recommendation · source text
Systematically embed caregiver concerns into clinical assessment and decision-making.
Recommendation · source text
Introduce structured documentation protocols for recording parental concerns.
Recommendation · source text
Address the impact of work pressures, including rest breaks and downtime.
Recommendation · source text
Strengthen cultural competence, psychological safety, and civility in practice.
Recommendation · source text
Clarify processes around patient choice and communication.
Recommendation · source text
Implement comprehensive vascular access guidelines, including cannula insertion and fixation
Recommendation · source text
Conduct a medicines management policy review.
Recommendation · source text
Review and standardise the prescription chart format.
Recommendation · source text
Enhance PEWS training, with clear escalation pathways.
Recommendation · source text
Support NIHR research into: How caregiver concerns are raised, received, and acted upon.
Recommendation · source text
Support NIHR research into: Tonsillitis complications and the management of secondary infections
Recommendation · source text
To ensure families are informed that when their children are on ventilators, they may still be able to hear, and should be encouraged to talk to and interact with them
Recommendation · source text
To ensure that any items such as clothing or equipment can be saved so families can keep as memories when a child dies.
Recommendation · source text
Consultant Oversight: Explore a national workforce plan to support sustainable consultant-led oversight, including realistic weekend cover models in paediatrics.
Recommendation · source text
Parental Access to Records: Consider national guidance on giving parents visibility of their child’s medical records during admission, similar to maternity-held notes.
Recommendation · source text
Paper Record Use: Review the continued use of paper-based records in paediatric care, due to potential risks to continuity and safety.
Acceptance status
No Response Published
17
Total recommendations
17