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Weak signals in healthcare: The case study of the Mid-Staffordshire NHS Foundation Trust

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conference contribution
posted on 27.09.2018, 13:46 by Evi Carman, Michael FrayMichael Fray, Patrick WatersonPatrick Waterson
Most organisational disasters have warning signals prior to the event occurring, which are increasingly appearing in accident reports. In the case of the Mid-Staffordshire Disaster, the disaster was not as a result of component failure or human error but rather an organisation that drifted into failure with precursory warning signals being ignored. It has been estimated that between 400 and 1200 patients died as a result of poor care between 2004 and 2009. The aim of this study was to identify the precursory signals and their rationalizations that occurred during this event. Qualitative document analysis was used to analyse the independent and public inquiry reports. Signals were present on numerous system levels. At a person level, there were cases of staff trying to make management aware of the problems, as well as the campaign “Cure the NHS” started by bereaved relatives. At an organisational level, examples of missed signals included the decrease in the trust’s star rating due to failure to meet targets, the NHS care regulator voicing concern regarding the unusually high death rates and auditors’ reports highlighting concerns regarding risk management. At an external level, examples included negative peer reviews from various external organizations.



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Advances in Intelligent Systems and Computing




691 - 700


CARMAN, E-M., FRAY, M. and WATERSON, P., 2018. Weak signals in healthcare: The case study of the Mid-Staffordshire NHS Foundation Trust. IN: Bagnara S. ... et al (eds). Proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), Volume I: Healthcare Ergonomics. Springer: Cham, pp.691-700.


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This is a pre-copyedited version of a contribution published in Bagnara, S. ... et al. (eds.) 20th International Ergonomics Association (IEA2018): Volume I: Healthcare Ergonomics published by Springer. The definitive authenticated version is available online via

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Advances in Intelligent Systems and Computing;818