serious incident annual report april 2012 march 2013 · serious incident annual report april 2012...

1 Liz Gundel RCCG Governing Body 19 September 2013

Serious Incident Annual Report April 2012 – March 2013

1. Introduction

This report provides an analysis of information regarding Serious Incidents (SIs) reported to Nottingham North and East CCG as coordinating commissioner via the DH Strategic Executive Information System (STEIS) during the period 1 April 2012 to 31 March 2013. It aims to provide assurance of the robust system of monitoring, scrutiny, challenge and shared learning undertaken by NNE CCG on behalf of the south CCGs.

2. Putting patient safety first

Robert Francis QC – Mid Staffordshire NHS FT Public Enquiry

‘Patients must be the first priority in all of what the NHS does. Within available

resources, they must receive effective services from caring, compassionate and

committed staff, working within a common culture, and they must be protected from

avoidable harm and any deprivation of their basic rights’.

Sir Bruce Keogh – Review of 14 acute hospitals with persistently high mortality

rates

Ambition for improvement 1: ‘to make demonstrable progress towards reducing

avoidable deaths in our hospitals, rather than debating what statistics can and cannot

tell us about the quality of care hospitals are providing’.

Don Berwick – Improving the safety of patients in England

‘Place the quality of patient care, especially patient safety, above all other aims’ and

to ‘continually and forever reduce patient harm by embracing wholeheartedly an ethic

of learning’.

3. Serious incident definition

A serious incident is defined as ‘an incident that occurred in relation to NHS-funded services and care resulting in unexpected or avoidable death or serious harm to one or more patients, staff or members of the public; a provider organisation’s inability to continue to deliver healthcare services; allegations or incidents of physical or sexual assault or abuse; adverse media coverage and/or one of the core set of Never Events’.

4. Role and responsibility of the Quality and Patient Safety Team/CCG The NHS Midlands and East ‘Reporting and Management of Serious Incidents’ policy stated that ‘Commissioners must ensure that there are robust systems for reporting and monitoring performance of commissioned services’. There is an expectation that all serious incidents are thoroughly investigated and associated action plans implemented.

RCCG/GB/13/134


CCGs have responsibility to hold to account NHS funded acute, community, mental health and ambulance providers for their SIs and investigations. From April 2012 to March 2013, the Quality and Patient Safety Team at NNE CCG, on behalf of all three south CCGs, was responsible for the oversight, scrutiny and performance management of Serious Incidents reported by its commissioned and contracted services: NUH, County Health Partnerships, Whatton Prison and south-based Independent Contractors. NNE CCG as lead commissioner ensured that robust investigations were undertaken and that any organisational actions and learning were implemented and information shared to reduce the risk of re-occurrence.

5. Processes

Following an incident, the provider must report to local reporting systems, inform the patient, grade the SI and report to the commissioner via the STEIS system within two working days. The provider then commences an investigation, develops an action plan and submits a Root Cause Analysis report (RCA) within 45 days for grade 1 or 60 days for grade 2, or six months for a grade 2 incident involving independent investigation - in line with guidance from the Serious Incident Framework, March 2013 (Appendix 1, page 35).

NNE CCG reviews all submitted RCAs and action plans within 20 working days and has the responsibility to close or hold pending further investigation. The Director of Quality and Patient Safety ensures that providers evidence that all action points have been implemented and that they address the root cause/contributory factors. Additional scrutiny and discussion is undertaken via the provider Quality Scrutiny Groups, Pressure Ulcer Scrutiny Groups and CQUIN reviews.

6. Serious Incidents - ‘Never events/Prevented Never Events’ categories

Never Events are ‘serious, largely preventable, patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers’.

Incidents are considered to be Never Events if:

The incident either resulted in severe harm or death or had the potential to cause severe harm or death.

There is evidence that the never event has occurred in the past and is a known source of risk (for example through reports to the National Reporting and Learning System or other serious incident reporting system).

There are existing national guidance or safety recommendations, which if followed, would have prevented the incident from occurring.

Occurrence of the never event can be easily identified, defined and measured on an ongoing basis.

All Never Events are grade 2 and involve a 60 day RCA investigation timeframe. The 25 types of incident that currently meet these criteria are listed on Appendix 2.

Prevented Never Events – This category was defined in the Never Events Policy Framework with effect from October 2012.

‘Prevented never events provide vital warning signs to Provider organisations that the potential for actual never events exists in their organisation. In that respect they are possibly the most powerful signal that action needs to be taken and can be the most important factor in preventing the devastating consequences of an actual never event’.


Prevented never events are defined as incidents that may have been never events had action not been taken to avoid an incident meeting the never events criteria and where such action is not part of the specified preventative action detailed in the relevant associated guidance or safety recommendations. For example, it is a prevented never event where an opioid naïve patient receives an opioid overdose, but the error is rescued and severe harm or death is prevented through rapid naloxone administration.’

All Prevented Never Events are grade 2 and involve a 60 day RCA investigation timeframe.

7. Analysis of 2012/13 Serious Incident activity For the period 2012/13 Nottinghamshire-wide Serious Incidents were reported and monitored by the following providers/CCGs: Table 1: Provider/CCG overview for Nottinghamshire

Provider Lead CCG/PCT Nottingham University Hospitals Trust NNE CCG

CHP (County Health Partnerships, part of NHCT but monitored by NNE)

NNE CCG

Whatton Prison (part of NHCT but monitored by NNE) NNE CCG

Nottingham City Care Partnership Nottingham City CCG

Nottingham NHS Treatment Centre Nottingham City CCG

Nottinghamshire Healthcare Trust (Local Services, but excluding Whatton Prison and CHP)

Nottingham City CCG

Sherwood Forest Hospitals Foundation Trust Newark and Sherwood CCG

East Midlands Ambulance Service Erewash CCG

Nottinghamshire County PCT - Independent Contractors NNE and Newark & Sherwood CCGs

Nottinghamshire County PCT NCtPCT

Central Notts Clinical Services Newark and Sherwood CCG

NEMS Nottingham City CCG

From 2013/14 Whatton Prison Serious incidents fall under the remit of Offender Health at the Area Team. From 1 August 2013, the Nottingham NHS Treatment Centre will change its lead commissioner to NNE CCG.

Area Team data indicates that 893 SIs were reported across Nottinghamshire during 2012/13. This Annual Report focusses on SIs monitored by NNE CCG during 2012/13: NUH, County Health Partnerships, Whatton Prison and south-related Independent Contractors.

Table 2: Total number of SIs and by grade reported to NNE CCG 2012/13:

Provider Grade 1 Grade 2 Total

NUH 278 8 286

County Health Partnerships (covering all

Nottinghamshire County community services including Residential Care Homes - north and south)

226 0 226

Whatton Prison 4 0 4

Independent Contractors (south related) 2 0 2

Total 510 8 518


The eight grade 2 incidents comprised of: five Never Events, one IG breach, a screening issue and a wrong lens implant – all requiring a comprehensive investigation and RCA analysis within a 60 day timescale. Following RCA analysis, 65 of the 518 were found not to meet the criteria of an SI and were later removed off STEIS resulting in 453 ratified Serious Incidents. The majority of removals were Pressure Ulcers, with one C. Diff and one Communicable Disease and Infection. Reasons for removal included:

• Duplication of reporting • Skin damage was not related to Pressure Ulcer • Pressure Ulcer was inherited from a another provider and therefore no longer registered

to the reporter • Skin damage was unavoidable and should not have been reported on STEIS • Unsubstantiated rotavirus case • Found not to be an outbreak

Table 3: Themes by provider 2012/13 Themes by provider for 2012/13 (including those later removed by SHA)

Data collected from 1.4.2012 to 31.3.2013

CHP NUH Whatton Prison

Independent Sector (related to south )

Total

Pressure Ulcer (3, 3/4 & 4) 179 118 297

Commun disease/MRSA/C Diff/Norovirus 12 44 2 58

Maternity services - Intrapartnum death 3 3

Maternity services - intrauterine death 13 13

Maternal death 1 1

Maternity Services - maternal unplanned admission to ITU

4 4

Maternity Services - unexpected admission to NICU

6 6

Maternity services - neonatal death 5 5

Prisoner in receipt of care/inpatient/outpatient

4 4

Slip, trip or fall 49 49

NEVER EVENTS 5 5

Screening issue 1 1

Drugs incident 3 3

Confidential Information Leak 2 2

Other (wrong lens implant) 1 1

Sub-optimal care of deteriorating patient 1 1

Incident since removed by SHA from STEIS

35 30 65

Grand Total 226 286 4 2 518


Graph 4: Themes totals - 2012/13 (including those later removed from STEIS)

Graph 5: Total SIs reported by month 2012/13 (data in relation to the 453 ratified SIs)

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Graph 6 – Total SIs reported by month 2012/13 – split by provider

One would expect an average number of incidents to be reported each month however graphs 5 and 6 indicate a drop in reporting for CHP for June 2012 and zero reporting for NUH in December 2012. These were followed by a sharp increase in the following month. The decrease in June was due to CHP staff misunderstanding around avoidable/unavoidable reporting criteria. A backlog of 13 incidents was reported in July’s figures. During December 2012, NUH were unable to access STEIS due to an Information Governance warning around unsafe data. This was resolved in January 2013. 14 of the 46 incidents reported by NUH in January were related to December 2012.

8. Serious Incident Categories Table 3 and graph 4 highlights the most frequently reported categories of Serious Incidents in 2012/13: Pressure Ulcers, Falls, Healthcare Acquired Infections, Maternity-related and Never Events. a) Pressure Ulcers Pressure Ulcers were the highest category of serious incident reported on STEIS during 2012/13 with 297 incidents ratified. The CHP decrease for June and zero reporting for NUH in December are as explained in the previous section. Despite a rise in January for CHP no evidence was found to suggest any specific cause. An explanation of Pressure Ulcer grades is attached at Appendix 3.

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Graph 7: Total PUs by month/provider - grade 3 & 4

Graph 8: Total PUs by grade 3 265 out of the 297 Pressure Ulcers were reported and ratified as grade 3. 118 were attributed to NUH and 179 to CHP.

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Graph 9: Total PUs by grade 3/4 (category could not be defined between 3 or a 4)

Graph 10: Total PUs by grade 4 There were 24 grade 4 PUs reported, ratified and attributed to CHP. NUH reported no cases for 2012/13.

Avoidable pressure ulcer financial penalties As part of the SHA’s ambition to eliminate ‘avoidable’ stage 2, 3 and 4 pressure ulcers commissioners introduced penalties of £500 per avoidable grade 3 and 4 pressure ulcers from 1 January 2013. Quarterly data is shared with the providers and submitted to the contracting teams. There were 85 ratified grade 3 and 4 pressure ulcers for Q4 2012/13 and split as follows:

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Total PUs - Q4 2012/13

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Graph 11 - PU Root Cause Analysis – themes from 2012/13

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NUH PUs - Q4 2012/13

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Upon receipt and review of provider RCA reports, various themes were highlighted. It should be noted that RCAs can have no/multiple themes and the following graph is therefore an approximate guide. In February 2013, NNE CCG undertook a ‘deep dive’ of pressure ulcers for NUH and CHP. Key themes identified for NUH were:

Skin inspection

Repositioning regimes

Risk assessments (Braden Score system does not always give an accurate risk assessment when compared to clinical judgement)

A hot spot identified was the Critical Care Unit due to the number of unusual type of PUs reported: - pressure ulcers to the nostril, ears, back of neck and tracheostomy site. These were related to indwelling devices or tapes from oxygen masks. A subsequent quality visit to Critical Care did not find any key themes. NUH have since introduced a React to Red guide for staff which advises on protection from medical device related pressure ulcers. NUH also introduced several initiatives to reduce pressure ulcer prevalence such as the Taking the Pressure Off campaign which resulted in various actions such as re-positional regimes, creation of a clinical dashboard to review team compliance of PU risk assessment and care planning; and the re-launch of new documentation and Caring Around The Clock. NUH have reviewed the Braden risk assessment tool, piloted an accountability handover system to improve communication and ensure that risk assessments are completed at the close of each shift and appointed two PU Champions in January 2013. All grade 3 and 4 PUs are taken to the NUH Pressure Ulcer Operational Group which is chaired by the CEO. Themes identified for CHP were:

Incomplete assessment (usually due to the HCA visiting the patient rather than the RN)

Lack of training/education

Incorrect grading

Equipment

Staffing (including number of visits or skill mix)

Carer support/advice and education

Documentation issues Commissioners undertook a review of CHP PU management and governance in March 2012. An action plan and number of CQUINs were developed to support improvement. CHP provided a number of assurances of initiatives undertaken such as working with acute and care home colleagues, a focussed approach to the management of pressure ulcer prevent via the Trustwide PU Prevention and Management Group, focus on training, implementation of the MUST toolkit re nutrition, education of carers, patients and care home staff and a review of equipment used. Significant improvement has been made and focus is now on prevention rather than management. CHP hold monthly Prevention and Monitoring Steering Group meetings where Heads of Service undertaken confirm and challenge sessions.


Further themes have been identified (post-February 2013 deep dive) through the scrutiny of RCAs were:

NUH Pressure Ulcers caused by friction against a new type plaster cast used. A trend was highlighted by commissioners and the nurses caring for patients with plasters were alerted to prevent further incidents.

Poor discharge information. A flagging system is now in place for NNE CCG to report unsafe/poor discharges to a named officer at NNE for further action.

Education and Training. NUH have now increased awareness at ward level. Education sessions were undertaken for Pressure Ulcer Prevention, Basic wound management, new would care formulary, HCA training and the Link Nurse Programme was reviewed. A Harm Free Care Day took place in March 2013 with the afternoon dedicated to pressure ulcer root cause analysis key themes.

Lack of education/training/equipment in care homes. NNE CCG have set up a Care Home actions log and related RCA reports are sent to the Adult Safeguarding Leads for the north and south of county to ensure actions are completed and lessons learned.

In May 2012 the Intensive Support Team (SHA) visited providers to review PU management and compliance against the Ambition and made recommendations to:

Review training to be more competency based

Review the definition of a moisture lesion

Consider lessons learned from grade 3 and 4 RCA reports as opposed to undertaking in-depth investigations

A follow up visit to commissioners took place in October 2012 to review oversight, scrutiny and challenge. Commissioners were commended for their scrutiny and knowledge of their providers. A recommendation made was for all RCA reports to have executive sign-off within the provider. This is now in place with all providers. b) Slips/Trips/Falls Graph 12: Slips/Trips/Falls – 2012/13

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NUH 49 Slips/Trips/Falls serious incidents were reported by NUH in 2012/13. During April it was identified by NNE CCG that NUH had only reported deaths from falls and not ‘fractured neck of femur’. This was immediately rectified. During December, NUH were unable to log SIs due to the reasons mentioned earlier in this report. A significant rise was noted for January/February and this was investigated. Findings showed that due to a lack of an administration post, a backlog of incidents (7 in one weekend) had been entered onto STEIS. In response, NUH have recently recruited a band 4 administrator to commence in post who will support some of the key patient safety work streams including patient falls. From January 2013 NNE CCG began recording the type of fracture/injury. From April 2013 the NPSA level of harm and ward is logged to enable trends and hotspots to be identified. Table 13: Q4 2012/13 - 29 falls were recorded:

10 Fractured hips

1 Dislocation of prosthetic hip

3 Fractured humerus

1 Displaced fracture to LH humerus

1 Fractured shoulder

1 Fractured ankle

3 Fractured neck of femur

2 Fractured ribs

1 linear non-depressed occipital bone fracture

1 Fractured wrist

1 No fracture but head injury

4 No fracture recorded

Three of the 29 incidents related to Fleming Ward. One patient on this ward had two falls (28.1.2012 and 7.2.2012) resulting in a fractured humerus and fractured neck of femur. The NUH Falls Committee undertook an immediate review of staff numbers trained in falls management on Fleming ward. The Clinical Lead was requested to review dashboard results relating to falls and for urgent action to be taken for any deficiencies identified.

A recent NUH report highlighted that half of inpatient falls occurred in relation to accessing commodes or toilet areas. NUH will continue to increase focus on this as part of the action plan for 2013/14 and have several cohorting initiatives underway such as a Falls Team HCA for 24/7 patient support, Caring Around the Clock and Accountability Handovers. NUH set a 5% reduction target for inpatients falls for 2012/13; achieving an 8% reduction. For the category ‘falls resulting in harm’, a 10% target reduction target was set with a 4.2% reduction achieved. NUH figures indicate a 35% reduction in hip fractures and 23% reduction in deaths directly attributable to falls in 2012/13 compared to 2011/12. NUH has a Falls Prevention Strategy and Action Plan to reduce the numbers of falls and limit the severity of harm caused. The action plan is overseen by the Inpatient Falls Committee who reviews all falls RCAs associated with moderate/severe harm, the emerging themes and shared learning recorded. Learning is reviewed on a quarterly basis. A monthly review of directorate performance also takes place. In addition the Trust’s Chief Executive chairs a monthly Falls Operational Group to provide further scrutiny of performance and enable local and Trust-wide improvement.


NUH’s Falls Prevention Campaign aims to promote understanding of and compliance with good practice in falls prevention. This includes regular updates in newsletters and intranet, support and training for Falls Champions and Falls Prevention Team (a nursing resource deployed to support ward teams caring for high risk patients), education and training for junior doctors and ongoing improvements to nursing documentation and care planning. A Falls Prevention Dashboard is due to commence in July 2013. Toolkits for Falls Prevention and Diagnosis, Prevention and Management of Delirium were published in March 2013. NUH is to host a regionwide provider Falls Summit in autumn 2013 for EMAS, care homes, community and acute settings. Falls is one of the NUH priorities highlighted in their Quality Account. CHP CHP had no Slips/Trips/Falls serious incidents during 2012/13. The majority of patients at Lings Bar Hospital (a 72 bed community hospital providing rehabilitation for the older person) are rehabilitation patients following a fall and therefore not as acute as compared to NUH. Lings Bar has a robust patient assessment and monitoring system from admission which includes ongoing risk management of falls. Staff assess and cohort the care of high-risk patients with cognitive impairment into one single sex bay to ensure nursing care can be optimised. CHP works to the Nottinghamshire Healthcare Trust (NHCT) Slip, Trip and Falls Policy. Staff assess risks using the Guide to Action for Falls Prevention Tool and utilise the Nottinghamshire Falls Pathway for Older People. Patients identified at risk of falls are provided with specialist prevention equipment. NHCT provides a Falls and Osteoporosis Awareness Training Programme which is available for all nursing staff with contact with older people. c) Healthcare Acquired Infections All NUH HCAI SIs are scrutinised and closed on STEIS on behalf of NNE CCG by Elaine Cathcart, Quality Manager, Infection Control, Nottingham City CCG. Their IPC Annual Report 2012/13 is attached (Appendix 4).

All Countywide community HCAIs are scrutinised and closed on STEIS on behalf of NNE CCG by Sally Bird, Infection Control Matron, Public Health, Nottinghamshire County Council. Their IPC Annual Report 2012/2013 is attached (Appendix 5). 60 HCAI related infections were reported during 2012/13. Two were later removed from STEIS leaving 58 as ratified. Table 14: HCAIs by type and provider

CHP NUH Independent contractor

C Diff 3 8 1

Communicable disease and infections issue

1 30 0

MRSA 3 6* 1

Ward closure (Norovirus – Lings Bar Hospital)

2 0 0

Ward closure (Norovirus – Residential Care Home , Mansfield)

1 0 0


Ward closure (Enteric Infection – Lings Bar Hospital)

1 0 0

Ward closure (D&V– Lings Bar Hospital)

1 0 0

*Although 6 MRSA SIs were reported on STEIS, one case was later counted against NHS Nottingham City PCO’s target not

NUH’s; but NUH had reported on STEIS and led the RCA as there was no community input

Graph 15: - HCAIS reported by month - 2012/13

NUH MRSA The nationally set MRSA Objective was a maximum of four cases. The end of year outturn for NUH was five cases. *Although 6 MRSA SIs were reported on STEIS, one case was later counted

against NHS Nottingham City PCO’s target not NUH’s; but NUH had reported on STEIS and led the RCA as

there was no community input. By August 2012, NUH had reported four cases and therefore a contract query notice was issued in September 2012 by the Nottingham West CCG contracting team. NUH Norovirus The increased numbers of HCAIs reported by NUH in January and February were mainly attributable to Norovirus. The Health Protection Agency reported national variations in Norovirus activity throughout 2012-13. At times there was a 72% increase in reported Norovirus / Gastroenteritis outbreaks compared to the previous year. Nottingham University Hospitals Trust and Nottingham CityCare Partnership implemented Norovirus Escalation Plans.

The Infection Prevention Team advised that a Domiciliary Re-hydration Service could prevent care home residents being admitted to hospital with Norovirus / Gastroenteritis; reducing the risk of transmission throughout the hospital. Local laboratory data collection is on-going and will be triangulated with other local outbreak related information obtained from both primary and secondary care.

NUH – C Difficile (C Diff) The nationally set Clostridium difficile Objective was a maximum of 133 cases. The end of year outturn was 138 cases of which 8 were classified as serious incidents.

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Nottingham University Hospitals NHS Trust Clostridium difficile cases 2012-13

Actual Trajectory

Chart 16: An

External Expert Review C Diff at NUH took place in November 2012. A deep clean programme was planned and ultraviolet decontamination investigated which would work alongside the hydrogen peroxide procedure. An action plan was produced and monitored by the bi-monthly NNE CCG led NUH Quality Scrutiny Group for areas of concern, slippage and progress. Monitoring continues into 2013/14. CHP - C Diff The locally agreed trajectory was agreed as 1 case of C Diff for March 2013. CHP reported three actual cases for 2012/13. All cases of C Diff are followed up by the Infection Control Matrons to ensure early treatment is in place if required and to determine the likely cause and precautions needed for future prevention. Themes are gathered monthly to try and establish common causes and underlying co-morbidities which may then aid the development of future reduction plans. County-wide partnership working looked at ways of working to reducing numbers and reviewed local carriage rates of the infection. This was in response to data that highlighted high numbers of differing strains seen which indicated the rise was not due to direct cross-infection. CHP MRSA CHP reported 3 MRSA bacteraemia cases against a locally agreed trajectory of 1 for 2012/13. The Infection Control Matrons follow up all new and high risk patients who are colonised with MRSA and reside in a county care home. There is a funded MRSA screening post at NUH. This service is in place to provide follow up advice and collect surveillance data on new and chronically colonised MRSA patients who are discharged from hospital back into the community. Mandatory MRSA screening is in place across Nottingham University Hospitals Trust and rates are monitored to ensure compliance with national requirements. Admission screening is in place across four rehabilitation wards at Lings Bar Community Hospital where the care is provided by County Health Partnerships. Screening compliance has been 100% during the period 2012-13. CHP Norovirus During 2012-13 there were 37 reported outbreaks of diarrhoea and vomiting in Nottinghamshire County care homes with the majority of cases between November and April. Three ward closures were reported as serious incidents, two at Lings Bar Hospital and one at a Mansfield Residential Home. The root cause was unknown in all cases but thought to be likely cross-infection from visitors.


All incidents are followed up by the Infection Control Matrons to ensure the outbreak is managed appropriately to minimise spread, establish the cause by obtaining specimens, ensure patients are regularly reviewed and where possible adequately hydrated to prevent hospitalisation. A Norovirus pack and guidance was issued to care homes in October 2012 and later included a 15 minute fluid balance chart. The IPC team visited Royal Wolverhampton Hospital NHS Trust to establish any learning after they previously experienced high numbers of Norovirus outbreaks within their trust and local community. A number of measures made key improvements - one being the introduction of the 15 minute fluid balance chart in care homes to reduce the number of residents admitted for rehydration. When oral hydration failed a community based re-hydration service was made available reducing hospital admissions for Norovirus. Outbreak reviews established that admission of a patient with Norovirus from a care home for hydration often led to hospital outbreaks. d) Independent Contractors (south CCG related) Two serious incidents were reported in 2012/13 by independent contractors:

1. A C. diff case at a residential home 2. An MRSAb case from a nursing home

e) Maternity related incidents Thirty-two maternity related incidents were reported by NUH during 2012/13; the highest reported category being intrauterine deaths. NUH were unable to report to STEIS during December due to IG issues. February’s figures showed a sudden rise with 4 cases being reported on one single day. An investigation highlighted that NUH had reported a backlog of cases due to pressures caused by the lack of an administration post. In response, NUH have recruited a band 4 administrator to commence in post who will support some of the key patient safety work streams.

Graph 17: Maternity SIs by month

Graph 18: Maternity issues by individual type

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In September and December 2012, Dr Foster data suggested that NUH was ‘significantly worse than the benchmark’ for mortality in the category ‘other perinatal conditions’. NUH undertook a case note review of stillbirths for the period July 2011 to June 2012. Thirty-three stillbirths were highlighted from the review. Three were excluded due to incorrect coding. The antenatal care of women who experienced stillbirths was compared against NICE standards and local guidance. The conclusion was that there were some areas where the maternity service failed to adhere to NICE guidance on antenatal care. New patient information leaflets were developed to improve communication and guidance. However, in the majority of cases there was no evidence that failure to do so had contributed to the stillbirth. In four cases management issues were identified which might have contributed to the resulting stillbirth. Follow up actions and findings were monitored by the south CCG NUH Quality Scrutiny Group. In June 2013, the Derbyshire and Nottinghamshire Area Team undertook a ‘Focus on Maternity’ looking at maternity SIs from April 2012 to March 2013. The number of maternity SIs for Derbyshire and Nottinghamshire was n=66 with the remaining East Midland’s footprint at n=26. The report highlighted that high reporting levels did not necessarily indicate unsafe hospital or unsafe care and that reporting was encouraged to ensure systems were in place and lessons were learned. Table 19: Maternity SIs reported across the East Midlands, April 2012 – March 2013

Top 5 reported Maternity Serious Incidents (SIs) Type Chesterfield

Royal Hospital NHS Foundation Trust

Derby Hospitals NHS Foundation Trust

Nottingham University Hospitals NHS Trust

Sherwood Forest Hospitals NHS Foundation Trust

Milton Keynes General NHS Foundation Trust

Northampton General Hospital NHS Trust

United Lincolnshire Hospitals NHS Trust

University Hospitals of Leicester NHS Trust

Total

Intrauterine death 5 6 13 3 11 0 3 0 41

Unexpected admission to NICU 4 3 6 0 0 0 2 0 15

Unexpected neonatal 0 2 5 3 0 1 0 3 14

3

13

1 4

6

5

NUH 2012/13 Maternity services - Intrapartnumdeath

Maternity services - intrauterine death

Maternal death

Maternity Services - maternalunplanned admission to ITU

Maternity Services - unexpectedadmission to NICU

Maternity services - neonatal death


death

unplanned admission to ITU (M) 0 1 4 1 1 0 1 0 8

Intrapartnum death 0 3 3 0 0 1 0 0 7

Following a joint review of NUH maternity RCAs by NNE CCG and City CCG in December 2012 commissioners agreed to extend the RCA report deadline from 45 to 60 working days to allow maternity staff time to discuss cases thoroughly with the wider team.

f) Never Events NUH has 47 theatres with over 800 operating cases a week. During 2012/13 five Never Events were reported. Two of the Never Events occurred in 2011 but the Trust was only made aware in 2012 and duly reported to STEIS.

Table 20: Categories of Never Events reported

STEIS REF NUMBER

PROVIDER TRUST:

SI INCIDENT DATE

DATE REPORTED ON STEIS

BRIEF DESCRIPTION OF INCIDENT/THEME

2012/10233 NUH 18/04/2011 23/04/2012 Wrong site surgery

2012/11573 NUH 30/04/2012 10/05/2012 Drug incident (Chemotherapy)

2012/19867 NUH 25/05/2011 13/08/2012 Other (retained guidewire)

2013/974 NUH 09/11/2012 09/01/2013 Surgical Error (foot operation)

2013/984 NUH 21/12/2012 09/01/2013 Surgical Error - retained device

NUH has taken the following actions to reduce Never Events:

The Trust has an internal system of learning from Never Events, through their Safer Surgery Group and other patient safety groups. They have a Patient Safety Strategy and a dedicated Safety Manager

The Trust has attended the NHS Institute Leading Improvement in Patient Safety programme and is involved in a number of forums such as the Human Factors Group and Don Berwick Safety Streams

In conjunction with NNE CCG, the Trust has set up a Regional Shared Learning Group. This consists of commissioners and providers and meets three times a year

The WHO surgical checklist is embedded with regular compliance audits undertaken

The Trust holds an annual Patient Safety Conference and participates in all safety awareness campaigns such as Patient Safety First

For 2013/14, the Trust has a local CQUIN for improving theatre safety culture


Never Event penalties - historically the cost of the admission relating to a Never Event had been levied against providers; however new guidance allows CCGs to use judgement as not all Never Events cause additional stay or treatment in hospital. Two commissioner responsive visits took place in theatres in January 2012 and July 2013. Both visits concluded that theatre staff have committed to improve the safety of patients and commissioners were assured. The CQC also undertook a planned review in 2012 and found theatres to be fully compliant with essential standards. g) Whatton Prison Whatton Prison healthcare is provided by County Health Partnerships (part of Nottinghamshire Healthcare Trust). NNE CCG is the lead commissioner for CHP and reviewed all serious incidents for 2012/13. Whatton incidents have now transferred to the Offender Health Team at the Derbyshire/Nottinghamshire Area Team for 2013/14. Four serious incidents were reported by during 2012/2013. Two cases were related to ‘Prisoner in receipt of Care’ and two ‘Prisoner – unexpected death of outpatient in receipt’. Following an incident, the provider had 45 days to submit an RCA report for review by NNE CCG. In addition NNE CCG commissioned an independent clinical report by Dr Peter Billingsley, Scarborough CCG. All Prison incidents were investigated by the Prison and Probation Ombudsman and a final report was submitted to the lead CCG. Due to the complexity of cases and multi-agency involvement, final reports could take up to many months, or in certain cases years, to be completed before final closure could be actioned by NNE CCG. For 2012/13, three out of the four cases were reviewed and closed by NNE CCG. One prisoner death incident remains open and transferred to the Area Team in April 2013. As a result of the independent reports, recommendations were made to NUH around a review of reporting of chest x-rays and to undertake an internal audit. A recommendation was highlighted to the Contracting Team around a lack of facility for an Out of Hours GP visit after midday on a Saturday and subsequent unnecessary A&E GP assessment. An observation was made that following a fall and fractured hip, admission to hospital for an end of life prisoner could have been avoided.

9. Other Nottinghamshire Providers: SFHFT, EMAS and NHCT

The Director of Quality and Patient Safety and south Quality and Risk Committee have received regular oversight of SFHFT, EMAS and NHCT SI numbers and themes reported throughout 2012/13.

There were 103 SIs reported by SFHT and 127 by NHCT in 2012/13.

Graph 21: Total SI themes for SFHFT and NHCT for 2012/13


The Never Event reported by NHCT was drug related. The categories marked ‘other’ were SFHFT: Paediatric, Pathology lab testing errors, I.G. incident (records mislaid and found) and NHCT: keys compromise issue

Graph 22: Total SI themes for EMAS for 2012/13

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SFHFT & NHCT SI THEMES Period 1.4.2012-31.3.2013

SFHFT

NHCT


EMAS reported three local Never Events in 2012/13:

1. Equipment failure - Whilst transferring a patient to the helicopter the scoop became unclipped and the patient was lowered quickly/potentially fell through the stretcher.

2. Road Traffic Collision – called to attend a patient having experience a fall, whilst

en route to the hospital the ambulance came off the road and rolled into a ditch. The patient died on scene and it would appear was not secured on the stretcher.

3. Care Management – Whilst transporting a patient to hospital, the patient came

off the stretcher and appears to have not been strapped/secured in.

Local Never Events were identified by commissioners. This was subsequently removed

in 2013.

10. Analysis of NNE CCG monitoring of Serious Incidents

The Quality Support Officer at NNE CCG’s Quality and Patient Safety Team ensures that providers are sent a weekly reminder of due RCAs. Where providers are unable to meet this deadline, an extension request must be submitted prior to the due date for approval by the Director of Quality and Patient Safety. RCA reports received out of 45/60 day agreed timescale in 2012/13 A total of 453 RCAs were received from providers. Graph 23: NUH – Total received 256. 18 (7%) of RCAs were marked as outwith as these were reviewed by the Infection Prevention and Control team and not NNE CCG.

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EMAS Serious Incident Themes Period 1.4.2012 to 31.3.2013 -

Total incidents = 62


Graph 24: CHP – Total received 191

All Whatton Prison and Independent Contract RCAs were received within the agreed timeframes.

Numbers of extension requests received Total of RCAs late: 176 (this excludes all HCAI RCAs out of NNE remit) NUH: of the 88 late RCA submissions, 84 had no extension request. CHP: of the 88 late RCA submissions, 24 had no extension request. Graph 25: % of failure to apply for RCA extensions

58%

35%

7%

within timescale

out of timescale

outwith

NUH - RCA receipt

54%

46% within timescale

out of timescale

CHP - RCA receipt to

27%

95%

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CHP

NUH


A weekly reminder is sent out to Providers highlighting RCAs due and reminding that extension requests should be submitted before the deadline. Section 11 details the actions taken. The majority of CHP extensions were related to short-term sickness/absence of staff. NUH extensions were varied: extended leave of panel member, further work needed, ward events preventing RCA presentation to panel, sickness, delayed responses to panel, nurses unavailable for interview as out of country or on maternity leave. From April 2013, all extension themes are recorded by NNE CCG. RCAs returned pending further information Following scrutiny of the RCA reports, the Director of Quality and Patient Safety returned 56 cases as live - pending more detail/further assurance. 16 were attributed to CHP and 40 to NUH. All cases were later closed upon receipt of assurance and satisfactory action plans. CCG RCA review targets There is a robust system in place and all RCAs received are STEIS recorded by the Quality Support Officer (or Team Secretary in any absence) and passed to the Director of Quality and Patient Safety or the Head of Quality and Patient Safety for review and recommendation for closure. For the period 2012/13, 452/453 of the ratified cases were closed (one Prison SI transferred to the Area Team). 416 RCAs were received, logged, reviewed and responded to within the 20 working day guideline by NNE CCG. 37 RCAs were classed as outwith as they were Healthcare Acquired Infections which fell under the remit of the Infection Prevention and Control Teams for review and closure (referred to on page 12). It should be noted that the majority of RCAs reviewed by NNE CCG were undertaken within a 5 working day period. Open cases One Serious Incident from 2012/13 remains live due to ongoing independent review and is attributable to Whatton Prison and has now transferred to the Area Team on 1 April 2013.

11. Actions taken, lessons learned, service improvements Late reporting of SIs on STEIS and late submission of RCAs Monthly updates are provided to the Director of Quality and Patient Safety highlighting out of timescale reporting by providers. In December 2012 Nottingham West CCG as Co-ordinating Commissioner issued a contract query notice to NUH regarding reporting delays. Twenty six reports were outstanding on 30th November 2012 and exceeded the 45-working day deadline with no extension requests. A number of reports were over the deadline by a considerable time. In addition responses to RCA reports that could not be closed on first submission were prolonged. NUH was asked to provide a remedial action plan setting out steps towards full compliance, including the establishment of a more robust process for consideration of an incident before declaring and reporting it on STEIS. In addition commissioners requested implementation of the recommendation from the recent SHA Intensive Support Team review that all serious incidents (including pressure ulcer reports) were closed by an Executive Director.


NUH responded with a plan which focussed on improved training and awareness at Directorate level, with particular focus on teams who were required to undertake a more detailed investigation under the 2012 revised SI guidance than was previously needed (notably Maternity Services). A review of monitoring systems was undertaken to ensure that the Corporate Governance Team and Clinical Risk Committee could improve tracking of RCA development and sign-off. In addition NUH reviewed the contribution that Executive Directors made to RCAs and their accountability for them. The NUH CRC was chaired by a Deputy Medical Director, and the signed-off SI reports were received by the Quality Assurance Committee (a Board Committee chaired by a non-exec Director).

Steady improvement has been seen and for Q1 2013/14, overdue NUH RCAs stood at 11% with a maximum of only 2 days overdue for any one case. Issues remain regarding the lack of extension requests made and this will be addressed by NNE CCG going forward. Issues are ongoing for NUH regarding adherence to the two working day guidance for reporting to STEIS. 41.95% were reported late in 2012/13, the majority being PUs, maternity and Falls. Data from 2013/14 (1.4.2013 to 2.8.2013) showed that 35.63% of the total reported were late with falls and maternity SIs being the largest categories (41.93% and 25.80% respectively). This will be monitored by the NNE CCG going forward. NUH have recently recruited an administrator to assist with the reporting function and improvement is expected. Quality visits In addition to the bi-monthly quality visits to providers and as a result of hotspots identified from RCA reviews, commissioners organised visits to the following wards to seek assurance:

Ward F19 NUH (17.9.2012) – re falls and number of pressure ulcers reported. The root cause was said to be inadequate assessment of risk, and documentation not completed on time. Access to pressure relieving equipment was an issue, but this has been resolved. 94% of staff had received pressure ulcer prevention training. The remainder were said to be on sickness or maternity leave. They now undertake routine weekly reassessments of the patient’s risk of pressure ulcers. This is audited to ensure it is being done. They are working closely with the Tissue Viability Nurse and pressure ulcer care is included in the 3-week ward induction.

Ward D57 NUH – Visit following an RCA received on 29.3.2012 regarding a serious incident that occurred in October 2011. Commissioners requested a review of of action plan following the death of a 92 year old patient due to a fall. Visit requested on 30th March and action plan was received on 29th April. Notes of the visit highlighted:

Introduced to the ward sisters who are new in post Interviewed a member of staff about working on D57. This was

positive. Sat in a Better for You meeting Reviewed new admission and discharge assessments for nursing

staff. Reviewed Nursing Dashboard and falls information. Identified Dementia Champions


Further actions were identified: to monitor the action plan to completion, ensure sustainability of actions and progress, ensure lessons were learned from the incident on D57 and not repeated in the new observation unit in ED.

Monitoring of wards and care homes The Quality and Patient Safety team now routinely log all wards and care homes relating to serious incidents to highlight any hotspots and to take appropriate action. Care home issues are recorded and information shared with the Safeguarding Adult lead for the north of county. Avoidable PUs NNE CCG undertakes quarterly monitoring and reporting to Contracting Teams on all avoidable PUs. Falls From January 2013 the type of fracture was recorded, and from April the NPSA level of harm and ward are recorded to highlight any hotspots and trends. High level incidents (HLI) In January 2013 the Quality Scrutiny Group NUH reviewed all NUH High Level Incidents which did not fit the criteria for Serious Incident reporting on STEIS but that the Trust believed were significant enough to require full Root Case Analysis within the directorate. NNE CCG requested HLIs be moved to a standing item on the agenda in order to monitor and have assurance that future incidents did not meet the SI criteria. Never Events In conjunction with NNE CCG, the NUH has set up a Regional Shared Learning Group. This consists of commissioners and providers and meets three times a year. 12. Sharing the Learning NNE CCG as lead commissioner will continue to strive for a reduction in patient harm through the sharing of key learning and recommendations with associate commissioners and other NHS organisations. This is currently achieved via the following groups:

Regional Never Event meetings

Pressure Ulcer Ambition Working Group (providers and commissioners)

Quality Scrutiny Groups for CHP/NUH

Quality Surveillance Group/LAT

Quality visit reports

Quality and Risk Committee

Shared Learning Review Group

CQUIN review meetings

NUH Falls Summit 2013

Nottinghamshire-wide HCAI group

Information sharing with the Adult Safeguarding Lead in the north re Care Home SIs

Care Home Subgroup

Joint working between CHP and NUH re Falls management


13. Commissioner aims and objectives for 2013/14

1. To reduce the numbers of falls 2. To reduce the number of avoidable grade 3 & 4 pressure ulcers 3. To continue to support NUH in the reduction of Never Events 4. To improve the timeliness of SI reporting and submission of RCAs 5. To continue to scrutinise, highlight and monitor areas of risk to improve patient safety

and to ensure the learning is shared through our Patient Safety Strategy 6. To support and strive to achieve the Berwick report overarching goal in that ‘The

NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning’

14. Conclusion NNE CCG has put patient safety and reduction of patient harm at the forefront of its aims. This will be achieved through the implementation and quality monitoring of agreed CQUINs such as sepsis and pressure ulcers which will help to reduce avoidable harm by prevention of deterioration. Its continued robust scrutiny and quality monitoring will be paramount as will its support for providers to be encouraged to be open and transparent in their incident reporting and without fear of blame. We will continue to share the learning with our colleagues across the health and social care network to improve training and education and to play our part in the prevention and reduction of serious incidents. ‘The most important single change in the NHS (in response to the report) would be for it to become a system devoted to continual learning and improvement of patient care, top to bottom and end to end’. – Don Berwick report, August 2013.

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