14 August NHS Fife Clinical Governance Report April June 2013 Q1 report summary

Transcription

1 ITEM 7F NHS Fife Clinical Governance Committee 14 August 2013 NHS Fife Clinical Governance Report April June 2013 Q1 report summary 1. Situation This report is a review of patient feedback received during the April - June 2013 quarter. The focus of the report is on feedback received that is clinical in nature or may impact on patient safety and wellbeing. It also provides information about cases considered/concluded by the Scottish Public Services Ombudsman during the quarter and any Fatal Accident Inquiries determined. 2. Background NHS Fife has an ongoing commitment to providing safe, effective and person centred care. Feedback and complaints provide a valuable source of information for identifying areas of good practice and also areas for improvement. Learning is a critical element of an organisation committed to doing the right thing for the people using its services and for the staff who provide that service. 3. Assessment 3.1 Overall activity for this period Apr, May, Jun 13 New Outpatients Seen Review Outpatients Seen Total OP Seen Maternity & Neonatal Admissions (IP & DC) 3193 Day Case Admissions (other than Mat & Neo) 5858 Emergency Inpatient Admissions 7919 Elective Inpatient Admissions 1977 Total IP/DC Community Hospitals (Adamson, Lynebank, St Andrews & Stratheden) - Outpatient Activity in the Financial Year 2013/14 Apr, May, Jun 13 New Outpatients Seen 3278 Review Outpatients Seen 9682 Total OP Seen All Community Hospitals (including Mental Health at QMH; excluding Hospital at Home) - IP/DC Activity in the Financial

2 Year 2013/14 Day Case Admissions 20 Emergency Inpatient Admissions 319 Elective Inpatient Admissions 440 Total IP/DC 779 A total of 140 thank you s were received during the quarter. The sum of donations for April June was 88, Complaints received The graphs below provide comparable data in relation to the numbers of complaints received, breakdown by local delivery units and general themes. Formal Complaints January February March April May June July August September October November December Formal Complaints by Delivery Units 1 April June April-June2010 July-Sept 2010 Oct-Dec 2010 Jan-Mar 2011 July-Sept 2011 April-June 2011 Oct-Dec 2011 Jan-Mar 2012 April-June2012 July-Sept 2012 Oct-Dec 2012 Jan-Mar 2013 Apr-June2013 Acute Services Division Dunfermline & West Fife CHP Glenrothes & North East Fife CHP Kirkcaldy & Levenmouth CHP NHS Fife Board 2

3 Complaints by Issue Type 1 April June 2012 Complaints by Issue Type 1 April June Delays In/At 9 Environment/Domestic 33 Procedural Issues 5 Staff 69 Transport Delays In/At 4 Environment/Domestic 34 Procedural Issues 6 Staff 69 Transport Treatment 65 Waiting Times Treatment 89 Waiting Times Key issues from complaints received The majority of complaints raised in the quarter were within the Emergency Care Directorate. Bed availability, delay in review and issues regarding co ordination of clinical treatment most commonly featured. In responding to complainants, information was shared from the Directorate s action plan to offer assurances. Specific clinical issues were addressed during complaints investigation and where necessary a Significant Event Analysis was undertaken to review systems and processes. In the CHP s, complaints were raised in relation to mental health services, the Out of Hours service, Community Dental Services and in relation to community equipment supply. 3

4 4. SCOTTISH PUBLIC SERVICES OMBUDSMAN (SPSO) Cases investigated reaching conclusion and reported Three cases reached determination during the reporting period concerning NHS Fife Board. A further three decisions were reached on cases concerning family health services. In case 1 - the patient was admitted to a community hospital, suffering from increased confusion and needing more pain relief. She was also on a high dose of steroids. She was transferred to an acute hospital nearly four weeks later, then back to the first hospital around three months after that. The patient s husband complained that she fell while in both hospitals and was concerned that these events had not been properly investigated. He was also concerned that his wife's medication was not properly monitored, that the nursing care in relation to her deteriorating condition and pressure ulcer was inadequate and that his complaints were inadequately handled. As part of the SPSO s review they sought independent advice from a medical adviser. The advice confirmed that the patient had a complicated medical history, however that she had an unacceptable number of falls in the first hospital, and that the assessment of her being at risk of falling was inadequate. In line with national guidance, staff should have done more to prevent her from falling. The SPSO upheld the complaint that she was not properly monitored or assessed for this. The SPSO did not uphold the other complaints and concluded that after each of the falls both hospitals treated the patient s symptoms appropriately. The SPSO found evidence showing that the patient was appropriately monitored and assessed for the medications she was prescribed, received good personal care from nursing staff, and an appropriate care plan was implemented for a pressure ulcer that developed. The SPSO also upheld Mr C's complaint about complaint handling, noting that, although the Board's responses to the complaints addressed the issues concerned and explained the reasoning behind treatment decisions, the Board should have tried to address the underlying issues when responding. In addition, the length of time it took the board to respond to the complaint was criticised. The SPSO made a number of recommendations which included; the offer of an apology for the failings identified ensure all relevant staff in the community hospital setting are aware of and implement appropriate falls prevention measures the Board remind relevant staff that when prescribing off label medications that the protocol is followed and there is a proper record and communication with the family. taking action to ensure timely responses to complaints and address any clear underlying issue causing distress The Board has now taken the necessary actions in relation to all the recommendations and has provided the SPSO with the required evidence. Case 2- the complaint was that the Board unreasonably referred a patient for gastric bypass surgery without ensuring that all necessary dietetic services were in place. Not having an established complex weight management and bariatric service, the Board referred the patient to Ninewells Hospital in In 2010 the patient was referred back to NHS Fife as a result of the Specialist leaving his post in Tayside which led to the discontinuation of the service. Fife then undertook a further assessment 4

5 which identified the need for psychology and dietetic input which was not fully complied with. By 2013 a business case for the creation of a complex weight management system, including bariatric surgery had been developed; however national guidance was awaited from the National Planning Forum. Fife had also undertaken a pilot project with a small number of diabetic patients. The SPSO sought the advice of a medical adviser in their consideration of the complaint. The Adviser stressed the need for the final decision regarding surgery to sit with the Multi Disciplinary Team with a working knowledge of the patient, to ensure support throughout the process. The Adviser noted that the patient had been accepted in Tayside before the surgeon left and the service was disbanded. He also noted that funding and services were available in Fife and therefore concluded that it was unreasonable for the Board not to find the dietetic input. The SPSO concluded that it would not have been appropriate to list the patient for surgery without having completed the psychology and dietetic support sessions. The SPSO commented on communications from the Board which they considered to be confusing. The SPSO concluded that in view of the clinical history and the fact that the patient had been passed between Boards then the Board should have followed through on their agreement. The fact that a pilot had been undertaken demonstrated to the SPSO that here was a service available, albeit with a specific purpose. The SPSO asked the Board to prioritise the completion of the patient s assessment and therapy sessions ensure that full multi disciplinary funding is available for the completion of the patient s therapy sessions and any surgical treatment subsequently required be approved in line with the Clinical Advisory Panel s approval apologise for the delay in progressing matters provide the SPSO with details of the actions taken The Board wrote to the patient in May 2013 to offer an unreserved apology and an appointment was made for the patient to attend the clinic in May The Board Medical Director followed up the discussions with the multi disciplinary team to ensure the availability of the required level of support to progress matters. Complaint 3 the patient complained about a number of issues in relation to his ophthalmology treatment in NHS Fife. He was specifically concerned about the availability of a suitably qualified clinician, the way in which his request was dealt with, the delay in reaching a decision following a request for a change of clinician and the delay in communicating that decision. The SPSO sought the view of a Medical Adviser in the consideration of the complaint. The Adviser was satisfied with the steps taken by the Board to address the complainant s issues and considered the decisions reached to be reasonable. The SPSO found strong evidence of the efforts made to reach resolve in this case and did not uphold any of the complaints made. The SPSO made no recommendations. Family Health Service Decisions Complaint 1 The Practice unreasonable delayed in diagnosing lung cancer. The SPSO reviewed the clinical information and complaints correspondence, including correspondence between the Practice and the hospital. Advice was sought from a specialist GP adviser and consideration given to SIGN Guideline 80 (Management of patients with lung cancer) and the Scottish Referral Guidelines 5

6 for suspected cancer. The SPSO concluded that the patient s care and treatment by the practice had been reasonable despite a delay from hospital services. The hospital issue is subject to a full SPSO published report which is currently awaited. Complaint 2 Raised three specific complaints: concern about worsening symptoms not being recognised by the Practice, worsening symptoms not treated with appropriate urgency by the Practice and the presenting issue of breathlessness on minor exertion not properly recorded by the Practice. The SPSO considered the complaint and sought and accepted advice that the Practice actively managed the patient s symptoms and provided a reasonable standard of care. In terms of worsening symptoms and not being treated with urgency, there was evidence of an appropriate referral indicating the Practice did take on board worsening symptoms and finally whilst the practice did not record breathlessness there was clear evidence of this being managed by the Practice. The SPSO did not uphold any f the complaints made. Complaint 3 Refusal of pharmaceutical consultant to dispense medication. In considering the complaint the SPSO established that there had been no NHS prescription to dispense the medication requested. The SPSO explained the position, making reference to documentation to support the Pharmacy and suggested that to the complainant that a complaint could be raised with the Practice if there was a concern about the prescription of medication. 5. Fatal Accident Inquiries No Fatal Accident Inquires reached determination during the reporting period. 6. Recommendations from this report 6.1 The Committee is asked to note the content of the report. 6.2 The Committee is asked to note the key clinical issues raised during the quarter and actions taken, and to identify any additional actions that may be required. Louise Ewing Patient Relations Manager 6