“When things go wrong”

– Serious Incidents – what do we know about them and how can they help to improve practice?

Friday December 5th 2014

Dr Colin Dale

Chief ExecutiveCaring Solutions (UK) ltd

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Defining Serious IncidentsDefining Serious Incidents

sudden, unexpected death of a community patient in sudden, unexpected death of a community patient in receipt of services or who has been involved with services receipt of services or who has been involved with services within the last six months, within the last six months,

inpatient suicides inpatient suicides unexpected death of an inpatient unexpected death of an inpatient suspected suicides of community patients suspected suicides of community patients serious safeguarding allegations serious safeguarding allegations any incident that is perceived to have possible media any incident that is perceived to have possible media

attention attention absconds from secure unitsabsconds from secure units serious self-harm serious self-harm

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Consistent Failings Identified in Consistent Failings Identified in InvestigationsInvestigations

Inadequate application of CPAInadequate application of CPA Risk assessment and managementRisk assessment and management Inadequate discharge planningInadequate discharge planning Record keepingRecord keeping Observation and engagementObservation and engagement Communication – transition pointsCommunication – transition points SafeguardingSafeguarding Inadequate response to non engagement or did Inadequate response to non engagement or did

not attend (DNA’s)not attend (DNA’s)

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Consistent failings 2 Poor liaison and engagement of families Poor liaison and engagement of families

(ignoring families warnings)(ignoring families warnings) Substance misuse / dual diagnosisSubstance misuse / dual diagnosis ConfidentialityConfidentiality Safety at nightSafety at night Mobile phones/textsMobile phones/texts Borderline personality disorder/ social Borderline personality disorder/ social

difficultiesdifficulties Lack or inappropriate use of the Mental Lack or inappropriate use of the Mental

Health ActHealth Act

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Concerns over Investigation ProcessConcerns over Investigation Process

Excessive bureaucracy – reporting, Excessive bureaucracy – reporting,

investigation and reviewinvestigation and review How panels are establishedHow panels are established How they are managed:How they are managed:

– No terms of referenceNo terms of reference– No detailed RCA, or links with facts,No detailed RCA, or links with facts,

conclusions and recommendationsconclusions and recommendations

Variable reports, structure, depth, quality, Variable reports, structure, depth, quality, timeliness, documentationtimeliness, documentation

Length of time and costs – including Length of time and costs – including opportunity costs (clinicians)opportunity costs (clinicians)

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Concerns over investigation Process Concerns over investigation Process (cont’d…)(cont’d…)

Key individuals, agencies not interviewed – family, GP, Key individuals, agencies not interviewed – family, GP, police, victimspolice, victims

Dominant focus on practitioner actions or omissions rather Dominant focus on practitioner actions or omissions rather than adequacy of systems, process, environment, skill mix, than adequacy of systems, process, environment, skill mix, management or leadershipmanagement or leadership

Inadequate analysis and identification of common themes, Inadequate analysis and identification of common themes, trends and patternstrends and patterns

Incorporating lessons back into organisation as a wholeIncorporating lessons back into organisation as a whole Dissemination of lessons learntDissemination of lessons learnt How action plans are tracked and monitoredHow action plans are tracked and monitored Corporate responsibilities and Trust Board quality assuranceCorporate responsibilities and Trust Board quality assurance Blame orientation versus not acceptance of poor Blame orientation versus not acceptance of poor

performanceperformance

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Capacity & Capability of InvestigatorsCapacity & Capability of Investigators

Investigators qualities of assertiveness, objectivity,

empathy, tenacity, and interviewing skills might not be

present

May not understand legal process or safeguarding issues

May not possess report writing and communication skills

Significant workload demands – no back fill

Lack of awareness of National guidance

Implementing Action PlansImplementing Action Plans The Action Plan arising from the The Action Plan arising from the

recommendations is often at the lowest recommendations is often at the lowest level of assurance.level of assurance.

The NHSLA Framework allows for 3 levels The NHSLA Framework allows for 3 levels of assurance: (1)Policy or Guidance; of assurance: (1)Policy or Guidance; (2)Audit of implementation; (3)Action (2)Audit of implementation; (3)Action based on Audit findingsbased on Audit findings

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What is Going Well?What is Going Well?

Reassurance to the publicReassurance to the public

Some standardisation of approach (RCA)Some standardisation of approach (RCA)

Independent opinionIndependent opinion

Involvement of service users and carersInvolvement of service users and carers

Sharing of informationSharing of information

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Dr Ian Clarke 2008Dr Ian Clarke 2008

““Incorporating Lessons back into the Incorporating Lessons back into the organisation as a whole seems the most organisation as a whole seems the most difficult objective to achieve”difficult objective to achieve”

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A Learning Organisation / CultureA Learning Organisation / Culture

‘‘A learning organisation A learning organisation is one which relishes is one which relishes curiosity, questions and curiosity, questions and ideas, which allows ideas, which allows space for experiment and space for experiment and for reflection which for reflection which forgives mistakes, and forgives mistakes, and promotes self promotes self confidence.’confidence.’

(Hardy)(Hardy)

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Characteristics of a Learning Characteristics of a Learning OrganisationOrganisation

Leaders facilitating the formation of a clear vision for the Leaders facilitating the formation of a clear vision for the

organisation’s future organisation’s future

An open culture of trust, with employees able to communicate, An open culture of trust, with employees able to communicate,

experiment and learn without fear of criticism or punishmentexperiment and learn without fear of criticism or punishment

A strong sense of community and caring in the organisationA strong sense of community and caring in the organisation

The structure of the organisation helps not hinders the The structure of the organisation helps not hinders the

employees in carrying out the organisation’s businessemployees in carrying out the organisation’s business

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A Learning Organisation / Culture A Learning Organisation / Culture (cont’d…)(cont’d…)

Other perceived benefits include:Other perceived benefits include:

– Encourages innovation and adaptabilityEncourages innovation and adaptability

– Captures the knowledge of individuals and retains it when people Captures the knowledge of individuals and retains it when people

leaveleave

– Anticipates changeAnticipates change

– Facilitates continuous learning and a proactive response to the Facilitates continuous learning and a proactive response to the

changing environmentchanging environment

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Ideas for Dissemination, Learning & Ideas for Dissemination, Learning & ImplementationImplementation

Regular briefings / monthly newsletters: short and snappy sent Regular briefings / monthly newsletters: short and snappy sent

to all clinical leaders and managersto all clinical leaders and managers

‘‘Information not saturation’Information not saturation’

Use patient stories / vignettes to heighten interestUse patient stories / vignettes to heighten interest

Develop a culture of openness, reflection and learningDevelop a culture of openness, reflection and learning

Accountability, expectation to discuss, share, engage, explain – Accountability, expectation to discuss, share, engage, explain –

not just passing on informationnot just passing on information

Solution groupsSolution groups

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Ideas for Dissemination, Learning & Ideas for Dissemination, Learning & Implementation Implementation (cont’d…)(cont’d…)

Feedback to service user / carer meetingsFeedback to service user / carer meetings

Formal feedback to universities and those responsible for Formal feedback to universities and those responsible for

internal programme developmentinternal programme development

Establish a web site and promote local discussion groups on Establish a web site and promote local discussion groups on

hot topics emerging from SUI’s hot topics emerging from SUI’s

Selective critical incident email measures – red for alerting to Selective critical incident email measures – red for alerting to

areas of concern, blue for lessons to learnareas of concern, blue for lessons to learn

Text messages to key senior clinical / managerial staff to alert to Text messages to key senior clinical / managerial staff to alert to

critical incidentcritical incident

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Specific Issues Arising from SUI’s to be Specific Issues Arising from SUI’s to be discussed at key meetingsdiscussed at key meetings

Trust BoardTrust Board

Clinical governanceClinical governance

Ward meetings – staff and patient / staff forumsWard meetings – staff and patient / staff forums

Professional groupsProfessional groups

Acute Care ForumsAcute Care Forums

Hand-oversHand-overs

– Signing when read arrangementsSigning when read arrangements

IncludingIncluding

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Ideas for Dissemination, Learning & Ideas for Dissemination, Learning & Implementation Implementation (cont’d…)(cont’d…)

Clinical supervision and reflective practice – group and Clinical supervision and reflective practice – group and

individualindividual

Develop an approach to analysis and learning from near missesDevelop an approach to analysis and learning from near misses

Organise positive practice eventsOrganise positive practice events

Peer review – structures, purposeful, single issue or bundlePeer review – structures, purposeful, single issue or bundle

Benchmark with other OrganisationsBenchmark with other Organisations

Regular review of, and revision of, policy and practice guidanceRegular review of, and revision of, policy and practice guidance

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Ideas for Dissemination, Learning & Ideas for Dissemination, Learning & Implementation Implementation (cont’d…)(cont’d…)

Crucial job rotations for learningCrucial job rotations for learning

Cards, crib sheets, screen saversCards, crib sheets, screen savers

Appoint and develop safety champions / enthusiastsAppoint and develop safety champions / enthusiasts

Intensive, comprehensive focus on a small number of issuesIntensive, comprehensive focus on a small number of issues

Use video for analysisUse video for analysis

Use case studies, real or fictional, as training, and get a panel to Use case studies, real or fictional, as training, and get a panel to

undertake a review to see if their findings match those of the undertake a review to see if their findings match those of the

original paneloriginal panel

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WHO Safer Surgery ChecklistWHO Safer Surgery Checklist

With the use of the checklist, surgery With the use of the checklist, surgery complications were reduced by more complications were reduced by more than one-third and deaths reduced by than one-third and deaths reduced by almost half (from 1.5% to 0.8%) in test almost half (from 1.5% to 0.8%) in test hospitals compared to control hospitals compared to control hospitals.hospitals.

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A Safer Mental Health Checklist?A Safer Mental Health Checklist?

What would we include?What would we include? When would we complete it?When would we complete it?

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