Just Culture and Media

This page contains Just Culture related cases, which were published on news media websites. The content of this page is split in 4 categories, as it follows:

Aviation

The High Court’s imminent decision on whether to grant the police access to confidential AAIB records reignites the debate about ‘just culture’ and criminalisation in air accident investigations.

BALPA 's involvement in the Shoreham  case.

When we think about just culture, we usually think about accidents and incidents, associated ‘honest mistakes’ and ‘negligence’, as well as official responses to these, at company and judicial level.

The human brain is fallible. In emergency situations it can be easily overloaded with information or be unable to override social rules of hierarchy and deference. This can have disastrous consequences, particularly in scenarios like aeroplane failures or surgical emergencies.

EU Regulation 376/2014 requires aviation organisations in the European Union to adopt and maintain a proactive, evidence-based Just Culture.

ATM safety is at the heart of what we do.Improving safety implies learning from accidents or incidents so as to take appropriate action to prevent repeating them.

Healthcare

James Hughes, 66, died in 2010 at the Clementine Churchill Hospital in Harrow, having suffered a perforated bowel after a routine knee replacement. Sellu ignored his condition and carried on with his clinic, the court heard.

A patient died because of "serious errors in judgment" by a senior doctor at a private hospital in north-west London, the Old Bailey has heard.

David Sellu, 69, was handed a two-and-a-half-year prison term after being convicted of manslaughter by gross negligence in November 2013.

James Hughes, 66 (patient), was under Mr Sellu's (surgeon) care when he died at the Clementine Churchill Hospital in Harrow in 2010. David Sellu, 69, served 15 months of a two-and-a-half-year prison term for manslaughter by gross negligence.

As Sir Robert Francis prepares to publish the first independent review of the treatment of whistle-blowers in the NHS, we look at some of those whose disturbing experiences led to the review.

NHS whistleblower Dr David Drew writes an open letter to Sir Robert Francis, whose report on whistleblowing was published.

A landmark report into NHS whistleblowing failed to help medics who have already suffered for speaking out, and sends out "exactly the wrong message", a prominent whistleblower has claimed.

Government pledges to change employment laws so NHS whistleblowers are not discriminated against, in response to report from Sir Robert Francis QC, but safety campaigners say plans to do not go far enough.

NHS and social care watchdog the CQC appears to be ignoring or even suppressing information from whistleblowers - and failing to protect staff who speak out.

More Scottish health boards should be prosecuted when preventable deaths occur or patients are harmed, the parents of a girl who died as a result of health board failings have said.

In candid and sometimes painful detail, UHN President and CEO, Dr. Peter Pisters, Chief Medical Officer Dr. Charlie Chan, and Dr. Joy Richards, VP Patient Experience & Chief Health Professions, discuss a moment in their career they will never forget.

Witnesses: Dr Steve Shorrock, European Safety Culture, Programme Leader, and Scott Morrish, father of late Sam Morrish and Member of Healthcare Safety Investigation Branch Expert Advisory Group.

The climate of fear is created by the health secretary. It’s no wonder doctors and other frontline staff increasingly feel like quitting.

A heart surgeon who was dismissed from a hospital after exposing concerns about patient safety has been awarded £1.22m in damages.

An employment tribunal has found cardiologist Raj Mattu was unfairly dismissed in 2010 after raising concerns about patient safety.

"On these pages I discuss the clinical law on which our nursing and medical staff rely when caring for our patients" ,Mr Robert Wheeler, director, department of clinical law.

The trial has started of a doctor who has denied manslaughter by gross negligence following the death of a popular primary school teacher during childbirth.

A breast surgeon has pleaded not guilty to 20 counts of unlawfully & maliciously wounding patients with the intent to do grievous bodily harm.

Last year it was revealed that the NHS had failed to investigate an astonishing number of ‘unexpected deaths’: more than 700 within a single trust. Sara Ryan’s son was one of those overlooked.

A London nurse made a series of mistakes which led to the death of as patient, being given type AB blood during a transfusion, instead of 0 group.

A West Midlands hospital has sacked four members of staff, after the death of a man who collapsed outside its accident and emergency department.

Police are considering bringing corporate manslaughter charges against the Shrewsbury and Telford Hospital Trust in UK. An interim report into the trust revealed ​a catalogue of clinical failures which listed the deaths of dozens of babies and mothers as well as more than 50 children who were left permanently disabled.

Rail

A train crash at 200 km/h, in the Spanish region of Galicia- this terrible accident has its roots in a period when all of Spain bought into oversized dreams of fast money and fast trains.

A recording of a phone call made by the driver of a train that derailed in northern Spain, killing 79 people, in the immediate aftermath of the accident has emerged.

The driver of the train that sped off the rails outside the northern city of Santiago de Compostela, killing 79 passengers, admitted to a judge that he had been "distracted" while at the controls.

The driver of a train that crashed in northern Spain in 2013, killing 80 people, is set to be the only person to face criminal charges over the accident, prosecutors have announced.

Public prosecutors on Tuesday called for a four-year jail term for the train driver involved in one of Spain's worst rail disasters, in which 80 people died in 2013.

It is well known that rail accidents always have a chain of interlinked precursor issues; it is never only one person who is completely responsible. Following publication of the CIAF report on the Santiago de Compostela high-speed derailment in Spain – which blamed driver Garzón Amo in full for the accident – a number of people expressed unease with the conclusion reached.

Pennsylvania has filed criminal charges against the driver of an Amtrak train which derailed in 2015 in Philadelphia.

Maritime

The Spanish government calls him a criminal and won't let him leave the country. But tomorrow Apostolos Mangouras, captain of the Prestige, which sank off the coast of Spain in 2002 spilling tonnes of oil, could be named seaman of the year. What's going on?

The trial has begun in northern Spain of the captain of the Prestige oil tanker that sank in 2002, causing the country's worst environmental disaster.

Spain's Supreme Court sentenced the captain of the Prestige oil tanker, which sank off Spain's northwestern coast in 2002, covering thousands of kilometres of coastline in fuel oil, to two years in prison on tuesday,january 2016.

Spain's state prosecutor asked the Supreme Court to overturn a lower court's decision to acquit three men over the 2002 Prestige tanker spill, one of Europe's worst environmental disasters.

An oil tanker captain was acquitted of the central charge in what's widely considered Spain's worst environmental disaster -- a spill that blackened hundreds of miles of coastline.

The trial of Capt. Francesco Schettino has resumed in Italy, in a Tuscan theater not far from where, last year, he allegedly wrecked the Costa Concordia cruise ship through gross negligence and incompetence, killing 32 people and injuring many more. The trial raises an interesting question: When, if ever, should “pilot error” be considered a crime?

The Costa Concordia last week. A risky effort to right the ship, which capsized off the Tuscan coast last year, is set for September. One Italian official wants it delayed. Residents say the wreck has crushed the local economy.

Florence’s appeals court has upheld the 16-year jail term for Francesco Schettino, the captain of the cruise ship, which sank off Italy in 2012 leaving 32 people dead.

The captain of the Costa Concordia, the cruise ship that ran aground off the coast of Italy in 2012 killing 32 people, has been found guilty of manslaughter.

Disgraced skipper Francesco Schettino has begun his battle to avoid prison for a 2012 cruise ship disaster off Italy in which 32 people died, with his lawyers arguing that others should take the blame.

“You gotta challenge all assumptions. If you don’t, what is doctrine on day one becomes dogma forever after.” Colonel John Boyd, USAF

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