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The new National Patient Safety Agency (NPS) has set itself (and NHS organisations) an ambitious agenda. The success of the new reporting system will depend not only on concerned staff’s awareness about what constitutes an adverse incident but also on the convergence of their individual judgements of what grading to apply to those incidents. Medical Protection Society (MPS) experience indicates that raising staff awareness alone is a monumental task. Achieving convergence in the grades they assign to such incidents is likely to present even greater difficulties. Draft guidance was published in August 2001, but it does not address the crucial issue of consistency within and across organisations. The system, as envisaged, would also discourage organisations from allocating “red” codes to more serious incidents.

From April 2004 doctors’ letters will be copied to patients. This article examines the potential benefits and pitfalls of the initiative. The issues are discussed from both the health professional’s and the patient’s perspective, with particular reference to consent and confidentiality.

Examines the issues faced in the implementation of the National Service Framework for Older People from the perspective of the risk manager in secondary care. It suggests that a paucity of published data about clinical risks and incidence of errors in this age group make it difficult to gauge the level of risk to older people within the UK’s health‐care system. The themes of patient safety and risk management are given insufficient emphasis in the NSF. By neglecting the role of the clinical risk manager in the safe implementation of the NSF, many opportunities for learning from adverse events could be lost. An efficient means to assess, disseminate, learn and progress from the problems encountered in caring for older people is called for.

Responding to a commitment made in the NHS plan, the Department of Health produced a series of documents (not yet widely distributed and discussed) during 2001 aimed at improving the process of obtaining consent in the NHS and aiming for consistent practice across the NHS, so that patients and health care professionals will be familiar with the process as they are looked after by or work for different organisations. Trusts have a very tight timescale for the introduction and use of the new style consent forms and the implementation of the model policy. While the basics are there, feels debate is necessary within each organisation as to how best these forms should be used. Discusses these issues, and claims the new standards currently are not achievable within an under‐resourced service. Concludes that those agencies established to assess the quality of health care need to be mindful of the severe constraints that exist in attempting to push forward this initiative by the end of 2002, before criticising trusts for their failure to do so.

This article examines the substance and recommendations of the Laming Report into the death of Victoria Climbié. It discusses the implications from a risk‐management perspective, for clinical and non‐clinical professionals involved in child healthcare. It examines relevant recent literature, concerning general principles in adverse clinical outcomes, and discusses the specific advice of the Laming Report. It focuses on information handling, active and latent failures and record keeping. It aims to provide a framework in which to consider change in paediatric healthcare and system management, in order to decrease the risk of adverse outcomes of the type experienced in the case of Victoria Climbié.

Reporting a death to the coroner by a doctor is not a statutory duty. It is, however, expected good practice. This article discusses some of the concerns arising out of current everyday practice that can lead to problems for doctors and their employing organisations. The author considers the importance of risk management, clinical audit and clinical governance in identifying what systems may need to be addressed within hospital and primary care trusts to ensure that deaths arising out of, or occurring during, medical care are investigated appropriately. As part of risk management and controls assurance, NHS Trusts should be able to demonstrate that lessons are learnt from adverse outcomes. This article explores the roles of postgraduate tutors, risk managers and the protection organisations in promoting good practice from the start of a doctor’s career.

NHS trusts are required to have a resuscitation policy in place by April of this year. Chief executives were sent guidance in September 2000, to ensure that policy takes account of patients’ rights and that appropriate arrangements are in place to supervise resuscitation decisions, to audit practice and develop staff training. Existing clinical risk management standards assessed by the NHS Litigation Authority also require that staff are competent to perform basic life support whenever called upon to do so, as there is a “public expectation that clinical staff can undertake basic life support”. This article explores some of the current risk management and clinical governance issues in relation to developing and maintaining a robust policy on resuscitation that aims for high standards of practice, alleviates public concern and will be supportable within the Human Rights Act 1998.

Since 1990, the National Confidential Enquiry into Perioperative Deaths (NCEPOD) has published a total of 14 reports. These are intended to assist clinical staff in applying the lessons learned from the analysis of post‐operative deaths to help prevent future incidents. However, anecdotal evidence suggests that the dissemination of this information does not always take place. Access to these reports should be encouraged and perhaps considered more formally during surgical training. Their use is also advocated in the multidisciplinary setting and as part of clinical audit. Unacceptable standards of medical record keeping are frequently highlighted in the NCEPOD reports. All health‐care professionals have a responsibility to raise these standards such that clinical documentation conforms with a basic acceptable standard that does not compromise patient care. Risk managers should also make use of the NCEPOD reports in meeting the requirements of Clinical Negligence Scheme for Trusts (CNST) standards.

This article has been withdrawn as it was published elsewhere and accidentally duplicated. The original article can be seen here: 10.1108/14664100010362006. When citing the article, please cite: Jane Cowan, (2000), “Clinical risk – minimising harm in practical procedures and use of equipment”, British Journal of Clinical Governance, Vol. 5 Iss: 4, pp. 245 - 250.

This article has been withdrawn as it was published elsewhere and accidentally duplicated. The original article can be seen here: 10.1108/14664100010344042. When citing the article, please cite: Jane Cowan, (2000), “Consent and clinical governance: improving standards and skills”, British Journal of Clinical Governance, Vol. 5 Iss: 2, pp. 124 - 128.