Complaints, Litigation, Incident & PALS (CLIP) Summary Report Q1 April - June 2010

Size: px

Start display at page:

Download "Complaints, Litigation, Incident & PALS (CLIP) Summary Report Q1 April - June 2010"

Rosamund Townsend
5 years ago
Views:

1 Agenda 137/ Public Board Meeting, September Complaints, Litigation, Incident & PALS (CLIP) Summary Report Q1 April - June Presented by: Natalie Forrest 1. Purpose The following provides an overview summary of the detail set out in the main CLIP report in respect of complaints, incidents, claims and PALs. It then goes onto focus on complaints. Future reports will provide a focus on a single area of the main CLIP report. 2. Overview Incidents that are noted as pending on DatixWeb are incidents that have occurred during the reporting quarter but have yet to be approved by the appropriate manager and submitted to the main datix risk management system. Q4 Jan Apr Q1 Apr Jun Reporting Complaints 7 98 Decrease of 9 (please note provisional figure only, as triage has not been completed for some June complaints yet). Claims Decrease of 1 ALL Incidents on Main Datix Increase of 4 ALL Pending Taking into account the Incidents (on incidents on DatixWeb the total Datix Web) for Q1 will be 22 representing an increase of 272 compared with Q4. PALS Decrease by 2 Themes Identified Across Incidents, Complaints & PALS Q4 January March Incidents Formal Complaints (Primary Subject Recorded) PALS 1. Other Clinical Treatment Communication/ Information to patients 2. Fall from Height (Bed or Chair) Communication/Information to patients Appointments/Delayed/ Cancelled IPD 3. Lack of Suitably Trained/Skilled Staff Admissions, discharge and transfers Appointments/Delayed/ Cancelled OPD 4. Fall on Level Ground Staff Attitude Clinical Treatment The quality of coding for incidents has decreased as the use of the code Other is the top code. The division which used the Other code the most was the division of Medicine. A review has taken place and identified that most of the incidents which were coded as Other the majority could have been given a specific code. The problem of mis coding is being addressed by the division. 1

2 3. Focus On Complaints Complaints over the last 12 months Number of Complaints Number July Aug Sept Oct Nov Dec Jan ' Feb Mar Apr May Jun Date Total Mean Upper Control Limit Lower Control Limit The average number of complaints received per month is 38. Total No of Complaints Received by Division There has been a slight decrease in the number of formal complaints received during Quarter one. Medicine and Surgery have remained almost the same but there has been an increase in Women s and. Please note that the total number of complaints is not a final figure as we are not yet in a position to confirm the final number due to the Triage process. Total No of Compliants Received by Division AMCD CLIN CLINI FINANCE CNMQ FACIL SURG WACS Jan - Mar Apr - June Top 6 Complaints by Subject The data reported in this table has drawn on the number of times an issue/subject has been recorded for all formal complaints, informal concerns/enquiries and where we have been required to provide comments to another organisation. It is not a reflection of the number of actual complaints/concerns received. 2

3 Top 6 Subjects Communication Clinical Practice Nursing Care Admissions. Appointments and Waiting Times Facilities & Estates Staff Attitude Analysis of Issues Raised by Subject Matter of all Complaints/Concerns Received Communication: Issues raised range from inadequate information being given to the patient or their family, failures in communication between staff, a failure to listen to the patient or their family, and general levels of poor communication. Approximately 5% of communication issues raised related to medical and surgical staff at all levels, followed by administrative staff, nursing staff and then midwives both in the hospital and the community. There were also a couple of issues raised about communication with radiology staff. Nearly 5% of concerns raised were recorded for Medicine, followed by Surgery and Women s and Clinical Practice: 9 issues raised related to the medical diagnosis, 13 to the medical treatment provided. The majority of problems highlighted within Medicine were noted to have occurred within A&E and AAU. Within surgery 7 issues were recorded about the diagnosis and 14 issues recorded in regards to the treatment provided. A further issue raised about the retention of equipment is being taken forwards as an SUI, occurring in ITU. 5% of the issues raised in regards to the treatment provided are recorded against theatres, indicating dissatisfaction with the outcome of the surgical procedure undertaken. There was 1 issue raised within paediatrics in relation to a misdiagnosis. Within gynaecology there were 2 reported issues in relation to complications and infection following surgery and 1 reported concern about the surgical treatment provided. Lack of pain relief was reported on 2 occasions and 1 issue was noted in relation to an accidental injury during surgery. Concerns about the treatment of a fracture were raised 3 times. Within physiotherapy one issue has been recorded in relation to the assessment and car provided. Nursing Care: Within medicine 67% percent of the issues raised related to care being provided in AAU1 and AAU3. The rest of the concerns raised related to Letchmore, Sarratt, Stroke unit, Cassio, Croxley, CCU and Aldenham wards. As well as a general dissatisfaction with the overall nursing care being provided issues were also recorded in regards to food and nutrition, including a lack of monitoring of fluid balance and nutritional intake, and a lack 3

4 of assistance given to help the patient eat. A couple of issues were raised about the use of call bells, privacy and dignity and poor communication in regards to patient handover. Within surgery, issues were raised about the care provided on Flaunden and Cleves wards in relation to the general level of nursing care provided, privacy and dignity, personal and oral hygiene and continence, bladder and bowel care. However, it must be noted that these issues have arisen from one complaint for Cleves ward and three for Flaunden. We also received 6 complaints about End of Life Care, which raised issues about family support, symptom control, communication with the patient and family, nursing care and a delay in the care of the dying pathway being implemented. 67% of these complaints related to care being provided in AAU. Admissions/Appointments/Waiting Times: Issues noted are in relation to the cancellation or delay in elective operations, with one patient having their surgery cancelled on more than one occasion, arrangements about outpatient appointments relating to the waiting times for appointments or investigations and the cancellation of appointments. A couple of issues were also raised about the waiting time to be admitted to or assessed within AAU and A&E. Approximately 5% of the issues raised related to the surgical division, covering orthopaedics and general surgery in the main. Facilities: Four issues were raised about the provision of food and catering, 2 about car parking and charges, the level of noise on AAU1, the ambient temperature on AAU1, the cleanliness on AAU3 and the cleanliness of the toilet/bathroom facilities on Aldenham ward. Staff Attitude: Of 16 complaints received raising this as an issue, 7 were reported in medicine, 7 in women s and children s and 2 within surgery. 5 complaints were about nursing staff, 3 about consultants, 3 about other grades of medical and surgical staff, 3 about midwives, 1 about a secretary and one about a sonographer. 88% of the complaints made about the attitude of staff relate to face to face communication. by Division April Figures: Information for noting: can potentially reach 8% on the basis that those complaints outstanding are completed on time. Division Total No of Complaints Received Ack 72 Hours to within agreed response time Total No to Acute Medical Care % 12 53% Clin Informatics/Patient Access Surgery & Anaesthesia Women s & 1 1 % 1 % (confirmed) % % 9 9 % % Total 39 98% 23 58% 4

5 May Information for noting: can potentially reach 96 % on the basis that those complaints outstanding are completed on time. Division Total No of Complaints Received Ack 72 Hours to within agreed response time Total No to Acute Medical Care 9 9 % % Surgery & Anaesthesia 8 8 % % Women s & % % Total % % Divisional Learning/Actions Taken Following Complaint Investigations Clinical Support: Following complaint about non provision of drinking water in pathology fresh water dispenser has been provided Communication failings between pharmacy and haematology team have been addressed with the introduction of regular meetings. Medicine: Following missed diagnosis of dislocated shoulder case to be reported at Clinical Governance session and used at teaching points for emergency department staff. Emergency cord not working; staff have been informed to follow best practice if a bell fails again during ward meeting and inclusion in staff news letter. Late transfer; all transfers and discharges after 19. hours to be escalated to Clinical Site Practitioner. The capacity manger to review all after 19. hours discharges to ensure it was appropriate. Following issues raised by patient s family not knowing who they could raise concerns with, matron for AAU to provide a poster with photograph and contact details included. Surgery: Following blistering on area of wound, consultant has discussed with theatre nurses the need for caution when removing theatre drapes. Consultants to be reminded of the need to introduce all staff in attendance in clinic. 4. Recommendation The Board is asked top note the report. Natalie Forrest Director of Nursing and Patient Champion 5

Complaints, Litigation, Incident & PALS (CLIP) Summary Report Q2 July September 2009

Agenda 24/1 Public Board Meeting, 28 JAN 21 Complaints, Litigation, Incident & PALS (CLIP) Summary Report Q2 July September Presented by: Colin Johnston, Medical Director 1. Purpose The following CLIP