for information agenda item 2.5 13 december 2011 putting … · putting things right/nhs redress -...

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Putting Things Right/NHS Redress - Quality and Safety Committee Concerns of 25 13 December 2011

AGENDA ITEM 2.5

13 DECEMBER 2011

PUTTING THINGS RIGHT/NHS REDRESS - CONCERNS

Report of

Executive Nurse Director

Paper prepared by

Assistant Director of Patient Safety and Quality

Executive Summary

The UHB continues to develop and strengthen its arrangements for the management of complaints, claims and incidents. Known now collectively as Concerns. New regulatory arrangements for the consideration and management of ‘Concerns’ related activity aligned with ‘Putting Things Right / NHS Redress’ came into force in April 2011. In readiness for the new Regulations, Committee have received reports and a presentation on the related implications and the approach being taken within the UHB to respond to this increasing agenda. The UHB continues to improve its processes and performance in managing the concerns agenda, systems are being developed to collate both performance information and sufficient detail to enable thematic analysis of the trends and improve the focus on putting things right. A Concerns Panel has been established to closer monitor and scrutinise this area of

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work. The information contained within this report relates to the period 1 April 2011 to 30 September 2011.

Action/Decision required

To NOTE the information provided within the report and the actions being taken to develop the learning from reported concerns and improve performance.

Link to other Board Committee (s) and sub-committees

Detailed activity within this agenda area is further considered and scrutinised through the Complaints Claims Panel, Chaired by the Chair of the UHB.

Link to Standards for Health Services in Wales

Standard 23, Dealing with concerns and managing incidents

Link to Public Health Agenda

Capturing the experience of patients from compliments, complaints, claims and incidents across all services provided by the UHB will help inform the UHB work in relation to its Public Health agenda including capturing the learning from reviewing reported ‘concerns’.

Link to UHB Strategic Direction and Corporate Objectives / Legislative and Regulatory Framework

Supports and strengthens systems in place to improve the quality and safety of patient care

Link to relevant evidence base

Standards for Health in Wales All Wales Complaints Management Guidance Interim Guidance for the handling of Concerns in NHS Wales ‘Putting Things Right’ / NHS Redress

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PUTTING THINGS RIGHT/NHS REDRESS - CONCERNS

INTRODUCTION The UHB is committed to improving the experience, quality and safety of patient care. Concerns (complaints, claims and incidents) along with compliments are one area where the UHB has an opportunity to capture valuable patient experience and make changes where appropriate in response to it. The overall coordination and management of complaints, claims and incidents sits corporately with the department of patient safety and quality, although Divisions also have arrangements in place to respond to this agenda and the corporate team also support Primary Care contractor concerns management. Since April 2011, new Regulations relating to Putting Things Right/NHS Redress have been implemented across the UHB. Arrangements relating to the implications of the new Regulations have previously been presented to Committee, the key change being one investigation primarily based on Root Cause Analysis (RCA) with an increased emphasis on putting things right. The introduction of the new Regulations, whilst welcome, has significant implications for the UHB, which primarily relate to a combination of an increased volume of activity and more detailed related processes. A Concerns Panel, Chaired by the UHB Chair has been established to guide and monitor the work of this agenda, with a focus on improving performance and considering the corrective actions taken in response to reported themes. INFORMATION SYSTEMS The UHB along with most other NHS Wales Health Boards/Trusts, use Datix, an I T software programme, to capture compliments, complaints, claims and incidents. The reconfiguration of the Datix system towards the end of last year has enabled improved monitoring of related Divisional activity, each division now also utilises a share drive where they can see at a glance what concerns are active in their division, who the investigating officer is, and the target dates for completion etc. this is proving extremely helpful in monitoring progress.

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The UHB has developed a business case to consider implementing e-datix, the latest web based Datix software that supports electronic incident reporting, monitoring and management. These discussions will also take into account consideration of the data capture implications of the new Regulations. CONCERNS PERFORMANCE AND REPORTED TRENDS The new arrangements include the requirement to respond to those raising concerns within 30 (previously 20) working days of the concern being raised. The performance response times relate to formal and informal concerns, for the purposes of this report, this relates primarily to concerns raised via what was formerly the complaints process. Formal concerns by division (the data captures all concerns recorded and closed on the Datix System) 501 concerns in total for this period 175 responded to within 30 days (50%) 177 responded to in excess of 30 days but within 6 months. 111 still active. 38 withdrawn. Pals (informal concerns) 318 for this period The conversion rate of Pals concerns to formal for this 6-month period has been 7% (22 concerns). This is very encouraging and reflects positively on the active engagement of staff with patients and carers in order to try and resolve concerns as early as possible. Breakdown of methods used to raise informal concerns

Method Number E-mail 48Verbal Complaint Form 13Letter 72In Person 5Telephone 247Totals: 385

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The following table shows Formal complaints by Division.

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The Pals, (informal concerns) are categorised by Division and Subject.

Table to show categories of formal concerns raised 1/4/2011 – 30/9/2011

Subjects of formal concerns (KO41 Categorisation) No Admissions, discharge and transfer arrangements 29Aids and appliances, equipment, premises (including 12All aspects of clinical treatment 222Appointments, delay/cancellation (in-patient) 26Appointments, delay/cancellation (out-patient) 60Attitude of staff 50Communication/information to patients (written and 52Complaints handling 1Consent to treatment 2Failure to follow agreed procedure 2HA/PCG commissioning (including waiting lists) 2Hotel services (including food) 11Independent sector services commissioned by Health 1Others 21Patients' privacy and dignity 4Patients' property and expenses 1Personal records (including medical and/or complaint 3Policy and commercial decisions of trusts 2Total 501

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PALS Subjects No

Cancellations of appointments, admission and surgery 4 Clinical diagnosis and treatment 34 Communications between staff and patients 39 Deficiency of treatment/facilities 3 Loss of case notes 1 Nursing care 10 Operational services 13 Other (Complaints Subjects) 6 Waiting times 45 Car Park 4 Discharge/Follow up care 4 Environment 14 Facilities 5 Food 10 Hygiene and Cleanliness 5 Information 10 Other 9 Staff 97 Understaffing 3 Waiting List 2 Total 318

TRENDS IN COMPARISON TO THE SAME PERIOD DURING 2010 Formal Concerns The rise in formal concerns in this reporting period compared to the same quarter in 2010 has been significant particularly April-June when a 70% increase was demonstrated. It is felt that this correlated with the wide promotion and awareness of the new Regulations. Over the six month period, there has been a 25% increase (100 cases) in formal concerns when compared with the same period in 2010.

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Key concerns themes raised via the ‘former’ complaints process and actions taken - April to September 2011.

Theme Actions Neurosciences-prolonged waiting times for patients with pituitary tumours as only one neurosurgeon in Cardiff was undertaking this complex surgery

The division sent out a letter to all patients on the waiting list explaining that the list was to be organised by clinical priority and that 2 further neuro surgery consultants were appointed in June 2011 with one commencing immediately and the second one in September. Patients were provided with the opportunity to change consultants and have a shorter waiting time. The pro active approach of the division has had a significant impact as the number of complaints regarding waiting times for this speciality has decreased over the 6 months

IVF Wales –Concerns about communication, treatment and staff attitude

Administrative support has been increased in the department so that phone calls are answered more promptly. Concerns have been discussed with Clinical staff regarding the importance of clear communication and empathy when liaising with service users. Concerns regarding staff attitude have decreased

End of life care There have been several concerns where End of life Care has been discussed, many of these have been addressed through the families meeting with clinical staff. However, a reoccurring theme has been the communication with family members and often

Communication and documentation seems to be improved when the End of Life Pathway has been used in a timely manner.

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the lack of documentation regarding this communication. Also issues with timely discharge and support for people to be able to die at home.

Rapid discharge pathway is being used to facilitate a safe discharge within 24-48 hours if the patient has been commenced on the End of Life pathway and expresses a wish to be at home.

The 352 concerns responded to in this period have been categorised using the All Wales grading process.

Whilst progress has been made over the last 18 months, there needs to be an even stronger emphasis on early intervention to avoid concerns escalating and; when things go wrong, to put things right. Public Service Ombudsman for Wales (PSOW) In this period 12 new cases (around 1.5% of all formal and informal concerns raised (not including staff reported patient safety incidents) were referred to PSOW, with 5 being accepted for further investigation. It was felt that in the other 7 cases the UHB had undertaken a robust investigation, managed the concern effectively and responded to the concerns raised. During December 2011, the Chief Executive and Executive Nurse Director will be meeting with the Ombudsman to discuss related matters and the UHB concerns management process. Putting Things Right Regulations – Staff Training The concerns department is working with Divisions to raise awareness of the new arrangements, although the pace of this is limited by the resource available.

1. Degree of harm Claims Complaints 1 - No harm 142 2 - Low (minimal harm - patient(s) required extra observations or minor treatment) 117 3 - Moderate (short term harm - patient(s) required further treatment or procedure 84 4 - Severe (permanent or long term harm) 9 5 - Death Total 0 352

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Awareness relating to the reported trends, the patient and economic costs involved is being targeted and the Divisional quality and safety meeting will be one of the fora used to share organisational wide information and specific Divisional data. 27 training sessions have been undertaken since 1st April by the concerns team to staff groups including; pre registration, nurses of all bands, divisional and directorate teams, therapy groups and community dentists, to increase awareness of the new Regulations and in particular concerns avoidance. 6 half day workshops have also been attended by UHB staff which were supported by NHS Wales Shared Services Partnership (Legal and Risk Services). The concerns manager also shares relevant cases with the Equality Steering Group and is working with the group to improve the collection and collation of equality related data with regards to concerns. CLINICAL NEGLIGENCE CLAIMS The UHB received 39 new claims during the reporting period, which is broadly in line with previous comparative periods. The highest number of claims received (7) relate to the Surgical Services Division followed by 6 new cases in the Specialist Services and 2 new cases each in the Medicine and Children and Women’s Division. Not every claim received by the UHB is conceded. During the reporting period, the UHB has been successful in defending around a third of all claims which is a fall against the previous year’s activity. This is probably due to claims being better researched and presented, or have been the subject of earlier investigations where concessions of substandard/poor quality care have been made by the UHB, usually as part of the complaints process. The impact of Redress has also influenced the pattern of settled claims. The ability of the Claims Manager to keep legal costs down to a minimum is heavily dependent upon the availability of quality information from within the UHB, i.e. Divisional Root Cause Analyses (RCAs), incident, inquest or complaint investigations. Such information greatly assists the Claims Manager to process new claims promptly whereby keeping down overall legal costs.

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As the Divisional structures continue to mature, it is anticipated that more internal investigations of selected cases will be undertaken that should result in less reliance upon external expert clinical and legal advice. The introduction of Redress provides an alternative mechanism for dealing with compensation requests following internal investigation of patients’ treatment where quantum is assessed at below £25,000 including costs. A small number of claims have been concluded by the UHB without the need for any litigation where no legal/expert costs have been incurred. Patients are being advised of this alternative dispute procedure in routine correspondence generated during the concerns investigation stage. On reviewing the new claims received, it is apparent that they span a fairly wide range of clinical specialties and are few in number as compared to overall clinical activity. In view of this, a review of new clinical negligence claims received during the last 6 months has shown the following themes;

Theme Actions Nursing care - inadequate nursing care that has resulted in patients developing pressure sores that have required, on occasion, remedial surgery and delayed patients’ overall recovery and/or contributed to the development of other symptoms

Introduction of the Skin bundle in response to a zero tolerance to hospital acquired pressure damage. A significant amount of work is being undertaken to role out the ‘Skin Bundle’, progress relating to this has been reported at a recent Q&S Committee. Whilst the Q&S Dashboard reports an overall reduction in coded pressure damage, this needs to be considered in the context of incident reporting, where staff are being encouraged to report all grades of damage through the incident reporting process.

Wrong site surgery / retained swabs / patient ID – the UHB still receives claims relating to wrong site surgery, retained swabs post procedure and administration of treatment to the wrong patient despite a number of initiatives that have been introduced to prevent the occurrence of such incidents.

The patient safety department continues to work with Divisions to ensure learning from incidents of this nature is spread widely across the UHB.

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Inadequate pre-operative counselling and/or lack of sufficient written information in respect of elective procedures.

An expansion of the availability and use of printed patient information leaflets has helped to enhance and better inform the patient consent process.

The standard of clinical record keeping is often targeted by Solicitors when reviewing the quality of care that has been provided to patients. The quality of Medical and Nursing records continues to form a key element in the defence of most clinical claims. In litigation, it is accepted that good records make good defence. Courts tend to take the view that unless events/activities are actually recorded, then they are likely not to have occurred.

The UHB continues to focus on good quality record keeping and documentation as part of the general induction (corporate and departmental) and as part of the learning following the feedback from claims where this is a related feature. The UHB is exploring the option for ‘peers’ who are renowned for the quality of their documentation to support the learning of others.

Other related improvement initiatives Promotion of improved cleanliness standards and strict personal hygiene for all clinical staff in order to reduce incidences of cross infection. There has been a noticeable reduction in receipt of claims for the contraction of MRSA and Clostridium Difficile infections which has been influenced by this initiative.

The development of Early Warning Patient Scoring systems has served to help medical and nursing staff to identify the deteriorating patient more quickly so that an appropriate plan of action can be agreed to provide the required treatment and care to such high risk patients. Furthermore, more timely clinical decision making is likely to see a reduction in claims for alleged delay in the diagnosis and treatment of patients’ conditions whilst in our care. Information is being exchanged with Divisions in order to raise awareness in relation to claims related activity and the learning that has resulted from conceded claims.

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Table to show ‘Open’ claims by Directorate and Categories – as at 30/09/2011

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Children and Women's Services Division 0 1 0 0 12 0 0 1 21 3 38 Children's Services 0 0 0 0 8 0 0 0 0 1 9 Obstetrics and Gynaecology 0 1 0 0 4 0 0 1 21 2 29 Dental Services Division 0 0 0 0 0 0 0 0 0 1 1 Hospital Dental Services 0 0 0 0 0 0 0 0 0 1 1 Clinical Diagnostics and Therapeutic Division 1 0 0 1 2 0 0 1 0 0 5 Laboratory Medicine and Toxicology Laboratory 0 0 0 1 1 0 0 0 0 0 2 Radiology, Medical Physics and Clinical Engineering 1 0 0 0 1 0 0 1 0 0 3 Medicine Services Division 0 0 0 0 19 1 0 3 0 1 27 Scheduled Pathways Medicine 0 0 0 0 2 0 0 1 0 1 4 Unscheduled Pathways Medicine 0 0 0 0 3 1 0 1 0 0 5 Unscheduled Care 0 0 0 0 17 0 0 1 0 0 18 Mental Health Services Division 0 0 0 0 1 0 0 0 0 0 1 Adult Mental Health 0 0 0 0 1 0 0 0 0 0 1 Other Organisations 0 0 0 0 1 0 0 0 0 0 1 Health Board/Trust or Private Health Care 0 0 0 0 1 0 0 0 0 0 1 Primary, Community and Intermediate Care Division 0 0 0 0 0 0 0 0 0 1 1 Community Nursing 0 0 0 0 0 0 0 0 0 1 1 Specialist Services Division 2 0 0 0 11 1 0 5 0 10 29 Cardiothoracic & Critical Care 1 0 0 0 4 1 0 2 0 5 13 Critical Care 0 0 0 0 0 0 0 1 0 0 1 Haematology, Immunology & Genetics 0 0 0 0 1 0 0 0 0 0 1 Nephrology and Transplant 0 0 0 0 0 0 0 1 0 1 2 Neurosciences 1 0 0 0 6 0 0 1 0 4 12 Surgical Services Division 1 1 0 2 12 0 1 7 0 42 66 General Surgery and Urology 0 0 0 1 6 0 1 1 0 15 24 Ophthalmology and Head and Neck 0 0 0 0 2 0 0 0 0 3 5 Ophthalmology 0 0 0 0 1 0 0 0 0 0 1 Surgery Support Services 0 1 0 0 0 0 0 0 0 3 4 Trauma and Orthopaedics 1 0 0 1 3 0 0 6 0 21 32 Dental Division 0 0 0 0 0 0 0 0 0 1 1 Hospital Dental Services 0 0 0 0 0 0 0 0 0 1 1 Mental Health Division 0 0 0 0 0 0 0 1 0 0 1 General Mental Health 0 0 0 0 0 0 0 1 0 0 1 Women and Children Division 0 1 1 0 2 0 0 2 13 2 21 Children's Services 0 0 0 0 2 0 0 2 0 1 5 Obstetrics and Gynaecology 0 1 1 0 0 0 0 0 13 1 16 Totals: 4 3 1 3 60 2 1 20 34 61 189

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Personal Injury Claims Whilst staff related PI claims are not covered within the new Regulations, this agenda is managed within the central Concerns department. As at 30th November 2011, the UHB has 132 ‘Open’ Personal Injury Claims. The average period for a Personal Injury Claim to remain open is about 18 months, although there are several cases that will span a greater period, particularly where there are complex issues in determining causation and prognosis, particularly where an injury effects future employment prospects. The UHB receives on average around 6 new Personal Injury Claims a month. The following tables show the number of new Personal Injury Claims (47) received in the period 1 April to 30 September 2011 by 2 quarters. The tables identify claims by Division and the main category applicable to the claim. There has been a greater number of Needle stick Injury claims received in this period, mainly concerning operational services employees. Where identifiable, the areas concerned are informed of the wrongful disposal of a sharp object and are required to take a number of actions to avoid future incidents. This issue is reported through the Health & Safety Committee. The third table in this section shows the number of ‘Open’ Personal Injury Claims. The highest categories of PI claims are, slipping incidents, which in the main relate to spillages, the UHB continues to remind staff of their duty to report spillages when spotted and to make sure appropriate warning signs are placed in areas until they are cleaned away. Similarly with tripping hazards, staff are also reminded of the need to report defective flooring when spotted and Estates staff make every effort to cordon off areas or warn of a hazard until a full repair can be completed. Defective Equipment claims also feature; however, the equipment concerned varies widely, across various Divisions. In the main defective equipment is taken out of service as soon as an incident occurs either for repair or replacement, staff are reminded of the need to report defective equipment as soon as possible in order to avoid any related staff incidents. During the last financial year, 57 PI cases concluded at a cost of £907,200 the UHB received reimbursement from the WRP of £178,511 in that period for cases that were over £25,000 resulting in a net loss of £728,689 to the UHB in Personal Injury Claims.

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NEW PERSONAL INJURY CLAIMS IN PERIOD April 11 – June 2011 Q1 – April 2011 to June 2011

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Children and Women's Services Division 0 0 0 0 0 0 0 0 0 1 0 0 0 1 Children's Services 0 0 0 0 0 0 0 0 0 1 0 0 0 1 Clinical Diagnostics and Therapeutic Division 0 0 0 0 1 0 0 0 0 0 0 0 0 1 Radiology, Medical Physics and Clinical Engineering 0 0 0 0 1 0 0 0 0 0 0 0 0 1

Executive Nurse Division 1 1 0 0 0 2 0 1 3 0 1 0 1 10

Patient Experience 1 1 0 0 0 2 0 1 3 0 1 0 1 10 Executive Services 1 0 0 0 0 0 0 0 0 0 0 0 0 1 Planning 1 0 0 0 0 0 0 0 0 0 0 0 0 1 Medicine Services Division 1 0 0 1 2 0 0 0 1 0 0 0 1 6 Unknown (to be changed later) 0 0 0 0 1 0 0 0 0 0 0 0 0 1 Unscheduled Pathways Medicine 1 0 0 1 1 0 0 0 0 0 0 0 0 3 Unscheduled Care 0 0 0 0 0 0 0 0 1 0 0 0 1 2 Mental Health Services Division 0 0 1 0 0 0 0 0 0 0 0 1 0 2 Adult Mental Health 0 0 1 0 0 0 0 0 0 0 0 1 0 2 Other Divisions (within the UHB) 0 0 0 0 1 0 0 1 0 0 0 0 0 2 Artificial Limb and Appliance Service 0 0 0 0 1 0 0 1 0 0 0 0 0 2 Primary, Community and Intermediate Care Division 0 0 0 0 0 0 1 0 1 0 0 0 0 2 Older Persons and Intermediate Care 0 0 0 0 0 0 1 0 0 0 0 0 0 1 Primary Care 0 0 0 0 0 0 0 0 1 0 0 0 0 1 Specialist Services Division 0 0 0 0 0 0 1 0 0 0 0 0 0 1 Nephrology and Transplant 0 0 0 0 0 0 1 0 0 0 0 0 0 1 Surgical Services Division 0 0 0 0 0 0 0 0 0 1 0 0 1 2 General Surgery and Urology 0 0 0 0 0 0 0 0 0 1 0 0 1 2 Totals: 3 1 1 1 4 2 2 2 5 2 1 1 3 28

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Claims by Directorate and Categories Q2 - July 2011 to Sept 2011

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Children and Women's Services Division 0 0 1 0 0 0 0 0 0 0 1 0 0 2 Children's Services 0 0 1 0 0 0 0 0 0 0 0 0 0 1

Obstetrics and Gynaecology 0 0 0 0 0 0 0 0 0 0 1 0 0 1

Clinical Diagnostics and Therapeutic Division 0 1 0 0 0 0 0 0 0 0 0 0 0 1 Laboratory Medicine and Toxicology Laboratory 0 1 0 0 0 0 0 0 0 0 0 0 0 1 Executive Nurse Division 0 0 1 0 1 1 2 1 1 0 0 1 1 9 Patient Experience 0 0 1 0 1 1 2 1 1 0 0 0 1 8 Unknown (to be changed later) 0 0 0 0 0 0 0 0 0 0 0 1 0 1 Executive Services 1 0 0 1 0 0 0 0 0 0 0 1 0 3 Planning 1 0 0 1 0 0 0 0 0 0 0 1 0 3 Primary, Community and Intermediate Care Division 0 0 1 0 0 0 0 0 0 0 0 0 0 1 Older Persons and Intermediate Care 0 0 1 0 0 0 0 0 0 0 0 0 0 1 Surgical Services Division 0 0 0 0 0 0 0 0 0 0 1 0 0 1 General Surgery and Urology 0 0 0 0 0 0 0 0 0 0 1 0 0 1 Facilities and Clinical Support Service Group 0 0 0 0 0 1 0 0 0 1 0 0 0 2 Operational Services 0 0 0 0 0 0 0 0 0 1 0 0 0 1

Therapy Services 0 0 0 0 0 1 0 0 0 0 0 0 0 1

Totals: 1 1 3 1 1 2 2 1 1 1 2 2 1 19

The following table identifies the number of current ‘open’ PI Claims, by the Division and shows the relevant category of claim concerned. There are some claims that will fall into two or three categories but are recorded by the main contributing factor. There are 132 ‘Open’ PI claims, the majority fall under Patient Experience and Estates Services, due to environmental aspects involved in these claim such as inclement weather conditions that have lead to slipping incidents.

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Claims by Directorate and Categories

PI CLAIMS 'OPEN' AS AT 30th SEPTEMBER 2011

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Children and Women's Services Division 0 0 0 0 0 0 3 0 0 0 0 0 0 1 0 0 0 2 1 0 0 0 7 Children's Services 0 0 0 0 0 0 3 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 5 Obstetrics and Gynaecology 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 2 Clinical Diagnostics and Therapeutic Division 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 Laboratory Medicine and Toxicology Laboratory 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Radiology, Medical Physics and Clinical Engineering 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 Executive Nurse Division 1 2 0 1 0 0 2 0 0 3 0 5 6 5 1 1 0 5 0 1 3 1 37 Patient Experience 1 2 0 1 0 0 2 0 0 3 0 5 6 5 1 1 0 5 0 1 2 1 36 Unknown (to be changed later) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 Executive Services 5 0 0 0 0 0 1 0 1 2 0 1 0 2 0 0 0 3 0 0 2 0 17 Finance 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 Planning 5 0 0 0 0 0 1 0 1 2 0 0 0 2 0 0 0 3 0 0 2 0 16

FOR INFORMATION


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Medicine Services Division 1 0 0 1 1 2 2 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 11 Unknown (to be changed later) 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Unscheduled Pathways Medicine 1 0 0 1 1 1 1 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 7 Unscheduled Care 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 3 Mental Health Services Division 0 0 1 0 1 2 0 0 0 0 2 0 1 0 0 0 0 3 0 0 1 0 11 Adult Mental Health 0 0 1 0 1 2 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 6 Mental Health Services for Older People 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 2 0 0 1 0 5 Other Divisions (within the UHB) 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 1 0 0 0 0 4 Artificial Limb and Appliance Service 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 2 Pharmacy 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 2 Primary, Community and Intermediate Care Division 0 0 0 0 0 0 3 0 0 0 2 0 1 0 0 0 0 0 0 0 0 0 6 Community Nursing 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 Older Persons and Intermediate Care 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 3 Primary Care 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 2

FOR INFORMATION


Specialist Services Division 0 0 0 1 0 1 0 0 0 0 2 0 0 1 0 0 0 0 0 0 0 0 5 Cardiothoracic & Critical Care 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 4 Nephrology and Transplant 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 Surgical Services Division 0 0 0 0 0 0 1 0 0 0 0 1 0 3 0 0 0 5 0 0 3 0 13 General Surgery and Urology 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 3 Surgery Support Services 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 1 0 0 2 0 6 Trauma and Orthopaedics 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 3 0 0 0 0 4 Facilities and Clinical Support Service Group 0 1 0 0 0 0 0 0 0 0 0 2 0 0 0 0 1 0 0 0 4 0 8 Estates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 4 Operational Services 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 3 Therapy Services 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 Medicine Service Group 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 3 Neurosciences 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Rehabilitation 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 Unscheduled Care 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 Mental Health Service Group 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 4 General Mental Health 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 4 Surgery Service Group 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 2 Surgery Support Services 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 Urology 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 Women and Children Service Group 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Obstetrics and Gynaecology 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Totals: 7 3 1 4 2 9 14 2 1 5 7 11 9 13 1 1 1 24 1 1 14 1 132

FOR INFORMATION


PATIENT SAFETY Acute staffing shortages generally in the Patient Safety Team has impacted significantly over the last four months, two senior staff have recently joined the patient safety team on a secondment basis. During the reporting period, the UHB reported 6,111 patient safety incidents. Due to a backlog in data entering reported incidents, there are around 1000 incidents not included in the figures, although the content of all forms has been reviewed and where appropriate actioned. Severity of incident reported April – September 2011.

1. Degree of harm Incidents 1 - No harm 3781 2 - Low (minimal harm - patient(s) required extra observations or minor treatment) 1988 3 - Moderate (short term harm - patient(s) required further treatment or procedure 225 4 - Severe (permanent or long term harm) 98 5 - Death 19 Total 6111

There needs to be caution in interpretation of harm categories, particularly death. E.g. a number of incidents reporting the unexpected death of a patient are subject to ongoing investigation, including sudden infant deaths and HM Coroner investigations. More often than not, the patient’s death is unrelated to any inappropriate care and/or treatment provided by the UHB. The broad organisational data continues to indicate that the vast majority (95%) of reported incidents do not cause any or low harm to patients. This is in line with data from other organisations, as regularly published by the National Patient Safety Agency (NPSA). Staff are encouraged to report ‘No harm’ events as they can provide early warning of areas of risk and assist with clinical risk management processes.

FOR INFORMATION


Table to show incidents reported by category 1/4/11 – 30/09/2011 Incident Category No

C01 Patient - Access, admissions, transfer, discharge (incl. missing patient) 315C02 Patient - Clinical Assessment (incl. diagnosis, scans, tests, assessments) 175C03 Patient - Implementation of care and ongoing monitoring/review 671C04 Patient - Treatment, procedure 351C05 Patient - Medication 367C06 Patient - Consent, communication, confidentiality 244C07 Patient - Documentation (incl. records, identification) 213C08 Patient - Device/equipment (Medical) 222C09 Patient - Self harming behaviour e.g. attempted suicide 88C10 Patient - Accident e.g. slips, trips and falls 2393C11 Patient - Obstetric 66C21 VA - Verbal Abuse / Inappropriate Communication 30C22 VA - Aggressive/Threatening Behaviour/Abuse 63C23 VA - Assault 138

C24 VA - Inappropriate Sexual Behaviour 11

C25 VA - Challenging Behaviour/Intoxification 146

C26 VA - Violence & Aggression - Other 18

C66 Other - Infection Control Incident e.g. isolation of patients 48

C67 Other - Problems with infrastructure (incl staffing, facilities) 552

Total 6111 Patient accidents e.g. slips, trips and falls, remains by far, the highest (40%) category of incidents reported across the UHB. The UHB continues to strengthen its processes to assess and respond to patients who present with an increased risk of falling. The majority of patient accidents result in no harm, many as a consequence of robust risk assessment that has helped to reduce the potential for harm.

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HM Coroners Rule 43s Rule 43 of the Coroners’ Rules states that: “A Coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the Inquest is being held may announce at the Inquest that they intend reporting the matter in writing to the person or authority who may have power to take such action.” In essence, this Rule provides a Coroner with authority to issue formal letters of advice following the completion of investigations that contain recommendations for practice changes and/or improvements in order to try and prevent the potential for future similar deaths. Such letters are issued directly by a Coroner following the completion of an Inquest. It must be noted that the Coroner has no power to enforce/impose and/or sanction any recommendations. Since July 2008, there is a requirement on an Organisation to respond formally to a Rule 43 letter within 56 days. Organisations are encouraged to give very careful consideration to any Coroner’s recommendations and implement appropriate plans of action to reduce the potential risk for future fatalities as a matter of good practice. This is especially relevant to the NHS where many patient deaths are referred to the local Coroner for investigation by way of an Inquest. The Rule 43’s and responses also are shared with the deceased’s family and copied to the Lord Chancellor. All Rule 43’s are now entered onto the Datix (incident reporting) system which enables lessons learned from Rule 43’s to be integrated with critical incidents, complaints and claims. During the reporting period, HM Coroner issued 1 Rule 43 report. It related to the failure to respond in a timely and appropriate manner to a blood result telephoned through to the department that was caring for a patient who was critically ill. A response has been provided to HM Coroner. A corrective action plan is also in place.

FOR INFORMATION


CONCLUSION The UHB has responded to a significant change agenda as a consequence of the introduction of new Regulations relating to this agenda -‘Putting Things Right/NHS Redress’ (April 2011). Whilst good progress has been made in responding to the new Regulations, further work is required from a corporate and divisional perspective. The key areas of further work relate to the need to improve performance against the various targets and the requirement to better align staff reported patient safety incidents, the vast majority (95%) of this agenda. Also integral will be further consideration of introducing e-datix to improve timely reporting and help strengthen related processes and ownership of this agenda. The UHB needs to continue to develop a concerns avoidance approach and should, where patients and/or carers raise concerns, proactively engage and respond. The ‘Concerns’ Panel, established last year, will continue to guide and scrutinise this growing area of the UHB work. RECOMMENDATION The Quality and Safety Committee is asked to:

• NOTE the report for information.

FOR INFORMATION


IMPACT ASSESSMENT Health Improvement

Ensuring arrangements are in place to learn from reported ‘concerns’ as well as sharing good practice when compliments are made, will have a positive impact on health improvement.

Workforce

Reducing waste variation and harm by implementing quality improvement initiatives will impact positively on the workforce.

Education and Training

Education and Training plays a key part in ensuring staff are skilled in ‘concerns’ avoidance in the first instance or where staff or systems failures are identified.

Financial

Strengthening the organisations arrangements for quality improvement and patient safety and reducing waste, variation and harm will improve effectiveness and resource utilisation.

Legal

Failure to implement and embed quality and safety initiatives within the UHB has a high legal risk attached.

Equality

Ensuring the delivery of safer services will impact positively on all citizens accessing services.

Environmental

Ensuring learning from incidents, complaints and claims will impact positively on the environment.

RISK ASSESSMENT Clinical/Service

Ensuring high quality and safe delivery of services will reduce the risks to patients and staff and improve service delivery.

Financial

Implementing quality and safety improvement initiatives will reduce financial risk.

Reputational

Reduction in the reputational risk to UHB if learning results from complaints, claims and incident reporting.

FOR INFORMATION


Acronyms and abbreviations

UHB – University Health Board UHL – University Hospital Llandough PSOW – Public Services Ombudsman Wales MRSA – Methicillin Resistant Staphylococcus Aureus RCA – Root Cause Analysis HA/PCG – Health Authority/Primary Care Group

CONSULTATION AND ENGAGEMENT Divisional Quality and Safety Groups SOURCES OF INFORMATION ‘Putting Things Right’ – Welsh Assembly Government ‘Interim’ Guidance Standards for Health in Wales, 2009. All Wales Complaints Management Guidance Interim Guidance for the handling of Concerns in NHS Wales, 2010.

for information agenda item 2.5 13 december 2011 putting … · putting things right/nhs redress -...

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