CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 9.1 Report of: Professor R C Pearson, Medical Director Paper prepared by: Ann Parker-Clements, Head of Clinical Audit and Risk Management Date of paper: September 2015 Subject: Patient Safety Indicate which by Information to note Purpose of Report: Support Resolution Approval Consideration of Risk against Key Priorities: (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) Achieving the highest standards for patient safety and clinical quality Recommendations: At present serious incidents are reported to the board via the Intelligent Board which focuses on numbers of serious harm incidents. Following any Never Events a summary report is provided to the Board, it is proposed that in addition for any level 5 actual harm incidents a summary of the investigation findings and action plan are provided for the Board members information) and a monthly overview report on incidents and claims is also provided. Contact: Name: Sarah Corcoran, Director of Clinical Governance Tel: Page 1 of 18

2 1. Introduction This is the annual report on Patient Safety for the year (herein referred to as last year) which includes summary information on Patient Safety Incidents including the work of the Patient Safety Forum and the HLI Panel. The report also includes an update on Sign Up to Safety initiatives, Duty of Candour / Being Open and proposals for reporting of serious harm incidents to Board level. 2. Patient Safety Incidents and Harm 2.1 Reporting culture The National Reporting and Learning System (NRLS) changed the manner that data is calculated and compared between organisations this year. In particular they have amalgamated a number of cluster groups so we are now compared with all acute trusts. Despite this the Trust remains one of the top reporters nationally (4 th ) reporting incidents per 1000 bed days. However, we are the highest reporter of no harm / near miss incidents nationally (93.8%) which is an indicator of a good reporting culture. 2.2 Actual harm Levels There was a small increase in serious harm (4-5) incidents observed last year, however this still equates to the same rate of incidents (0.11 per 1000 bed days), this is demonstrated below. Year Actual Harm 4 / 5 (Excl. #Hip) #Hip Following fall Total As % of Incidents reported Serious Harm per 1000 bed days Table 1 - Serious Harm Analysis last 6 years (2009 to 2015) The division with the most general serious harm incidents last year was St Marys which correlates to an increase in maternity / neonatal serious harm incidents observed during the year. Medicine and Community reported the most falls with fractured hip. Level 4/5 exc. Total Serious harm by Division #Hip #Hip St Marys Medicine and Community Specialist Medicine Surgery Trafford RMCH Eye Table 2 - Serious Harm by Division Page 2 of 18

3 In relation to incidents resulting in any level of harm this has increased as summarised below. The increase observed is at level 2 and can be primarily accounted for by the implementation of Catheter Acquired UTI as an incident type. Year Harm Total % Harm Harm Per 1000 bed days * Table 3 - All harm incidents last 3 years ( ) *Increase in Level 2 attributable to now reporting Catheter Acquired UTI as an incident. 2.3 Serious Untoward Incidents Last year the Trust reported 126 incidents as SUIs via the Strategic Executive Information System (StEIS), 55 of which were a mixture of externally and internally attributable grade 3 or 4 Pressure Ulcers (the majority being external) and 11 external safeguarding incidents which were not related to the Trust. Of the remaining 60 general incidents reported during the year 32 were confirmed as actual harm level 4 to 5, with the remainder being downgraded following investigation. In the current year ( ) Serious Incidents have been redefined in the new Serious Incident Framework as Incidents that occurred in relation to NHS funded services and care, which could result in unexpected or avoidable death, serious, permanent or prolonged harm, major surgical intervention, abuse, prevention of delivering care and or services and adverse media coverage. Moving forward this is likely to increase the number of incidents that are reported via this route and a meeting with Manchester CCG has identified a need for improved clarification of the requirements. 2.4 Never Events Never Events are serious, largely preventable patient safety incidents that should not occur if available preventable measures have been implemented. Last year there were 3 Never Events reported by the Trust, this was a small decrease from previous years. All of these have been procedure related incidents such as wrong patient, wrong site or retained items and have occurred in a number of settings including ward and outpatient areas. Number of Never Events by year 2012/ / / /16 to July 15 2 Total 17 Table 4 - Never Events The national list of Never Events has been updated from April, in particular the need for harm to have occurred has been removed which may result in an increase in events meeting the Never Event criteria. However, so far, we have not yet seen any impact of these changes as both incidents this year (2015/16) would still have been reportable under the old list. Page 3 of 18

4 2.5 Themes The top 5 patient safety incident types reported last year are detailed below. Top 5 Incident Types - All Incidents Clinical Assessment (Diagnosis, Scans, Tests) Falls General Patient Care Documentation Communication Table 5 Incident Types All Incidents 2014/15 In relation to serious harm incidents the key types are slightly different as detailed below. Top 5 incident types - Serious Harm Incidents Previous 2 years average Falls Maternity / Neonatal Care 9 3 General Patient Care 6 4 Clinical Assessment (Diagnosis, Scans, Tests) 4 7 Procedure / Surgery 3 6 Table 6 Incident Types Serious Harm Incidents 2014/15 There was a change observed last year with a significant increase in serious harm relating to Maternity / Neonatal care. This is the subject of review and is being addressed through an Obstetrics Improvement Plan supported by Sign Up to Safety funding. Further details can be found within the Safety Improvement Plan. 3. Learning and progress with actions. 3.1 Sign Up to Safety The Trust has committed to the Sign Up to Safety campaign which aims to halve avoidable harm over the next 3 years and save 6000 lives as a result. The key patient safety work streams identified by the Trust as part of this initiative are as follows. 1. Improving safety culture 2. Improving safety in Theatres 3. Obstetrics Improvement Project 4. Patient Information Improvement Project 5. Communication of test results improvement 6. Improvement in anti-coagulation management and the prevention of VTE To support these plans a range of bids were submitted for funding from the NHSLA and the Trust was successful in acquiring funding to support the obstetrics improvement work (3.). This potentially puts at risk some of the other proposed work streams and the Safety Improvement Plan is currently being reviewed in light of this. Page 4 of 18

5 3.2 Never Events The Never Events Working Group developed an action plan during the year and this is being implemented with a number of actions completed including update of the Safer Surgery Checklist Policy and Procedure, update of counting procedures, completion of risk assessments on all invasive procedures undertaken outside theatre settings and where required implementation of safety checks. A number of actions are still on-going including development of posters for Speak Out Safely, audit of compliance with new policy and development of a training video. 3.3 Falls The Trust has a falls prevention working group with representatives from each division. Each division holds harm free care meetings in which falls that occur within the organisation are investigated and action plans are put in place. There is an e-learning package available on the intranet to educate staff on the risk of falls and how to reduce the risk of patients falling. Technology such as low rise beds and patient alarms are in place and a trial of new non-slip hospital issue patient slippers is currently taking place. A new falls investigation template has been developed to improve understanding of contributory factors to enable a targeted approach to falls reduction. The Trust has recently participated in the Royal College of Physicians falls audit, from preliminary results improvements are now being targeted towards a visual acuity screen for patients at risk of falls and working collaboratively with the dementia care group. 3.4 Communication of Test Results With the implementation of ICE in June the foundations for improving the communication of test results have now been laid. These will be further developed over the coming year to improve safety in this area. There has also been considerable work on improving the early detection, escalation and treatment of acute kidney injury (AKI). 3.5 Health Care Records Clinical Audits have demonstrated little improvement in the quality of records within the Trust over the last few years. Work is progressing with the development of Chameleon (EPR) however the implementation of this will be staged over the next few years and there is a need to make improvements to records now. Therefore the Trust is taking a new approach and has launched a Call to Action with an awareness raising campaign around records which asks staff to use the following 3 key questions to focus on work locally identifying improvements that they can make in their clinical areas. The questions are: 1. Are my patients records stored safely? 2. Can I find all the information I need to care for my patients? 3. Do my records meet basic record keeping standards? 3.6 Mortality Mortality rates including HSMR and SHMI are used as one of the indicators of Patient Safety, the review of deaths occurring can support improvements. Each division has processes for review of deaths and there is a Trust wide Mortality Review Group. There is a separate annual report which details progress in this area. Page 5 of 18

6 3.7 Patient Safety Award The winner of the Best Patient Safety Initiative competition this year was Ben Grey, Consultant Urological Surgeon for innovative developments with the Urology Ward Round. This included an introduction of Registrar of the week and a checklist amongst other improvements in the ward round that has demonstrated improvements in patient safety, productivity and patient and staff experience. 3.8 Information to support Patient Safety Improvement Patient safety information was shared via a number of methods, including CARM Fair, Lessons Learned publication and the safety alert system. In the current year, there is an increased use of Wednesday Weekly News and the development of the use of Twitter account to enhance the dissemination of patient safety messages across the Trust. This supports the provision of general staff feedback and work is planned in the current year to implement a process within Safeguard for providing improved feedback to staff following reporting of incidents. 3.9 Action plan completion The key aspect of incident investigations is to identify actions that will reduce the risk of recurrence and improve safety. Following the completion of investigations the action plans are added to the Safeguard Incident System this enables monitoring of progress. The current divisional progress with actions is as detailed below. Serious Incident % Actions overdue % Action plans not added to system Surgery 33% 4% Corporate 28% 0% Medicine and Community 8% 2% Royal Manchester Children s Hospital 8% 0% St Mary's Hospital 8% 23% Specialist Medical Services 8% 26% Clinical & Scientific Services 7% 6% Trafford Hospitals 2% 0% Dental Hospital 0% 0% Manchester Royal Eye Hospital 0% 0% Table 7 Action plan position as of end of July Patient Safety Training Patient Safety training was originally developed by the Trust in 2006 to increase awareness of human factors, improve patient safety and reduce harm to patients. Since then, over 2000 staff have been through this training and attendance levels continue to be high. 4. Being Open and Duty of Candour The Trust has had a process for being open with patients for a number of years, and monitoring of the completion of this process has also been undertaken on a regular basis. In 2014 the Statutory Duty of Candour was put in place and the Trust has recently updated its processes in light of this. The completion of these processes is now incorporated in Safeguard Incident Reporting system, which will support more accurate monitoring and improved information. The current position for 2015 is included in the Page 6 of 18

7 table below this identifies that more work is required to improve performance on documentation of completion of the process on Safeguard incident system to improve monitoring of compliance. Number of Incidents Duty of Candour applies 137 Number of initial Duty of Candour / Being Open completed on Safeguard 73 Number of completed investigation reports that should have been shared 29 Number where investigation report has been documented as shared 18 Table 7 Duty of Candour recording on Safeguard in 2015 (To July 2015) To support improvements in Being Open a training package has been developed and is now incorporated in to Patient Safety Training with a plan to run this as a separate course as well. 5. Patient Safety Forum Report The structure of the Patient Safety Forum changed in October 2013 to enable a wider participation of clinical staff and more detailed feedback on incidents, trends and learning. To encourage wider participation open invitations to attend are now included in Wednesday Weekly News. Last year there were 6 meetings and the themes for these included Never Events, Communication of Test Results, Fluid Balance / Acute Kidney injury, VTE, Listening to Patients, Building Patient Safety into Planning and Hoist Safety. 6. High Level Investigation (HLI) Panel Report The HLI Panel was established a number of years ago to enable an early senior review of serious incidents and to support divisions in the identification of investigation team members and agreement on plans for communication with patients and relatives. All divisions with an involvement in the incident are invited which is particularly useful when incidents fall across a number of divisions. Incidents are invited to panel based on the initial incident report received. This includes most but not all level 5 incidents. Last year there were 95 incidents called to the HLI Panel as indicated in the table below. Stillbirths or early neonatal deaths were not initially invited to panel however this changed earlier this year. Final Actual Harm level Major 2 5 Catastrophic 14 To be confirmed 1 External 1 Total 95 Table 8 HLI Panel Incidents Attending with Final Actual Harm Page 7 of 18

8 The attendances by division are as detailed below. Surgery and Medicine and Community were the divisions with the most attendances last year. Agenda Item 9.1 Division Surgery (MRI) 18 Medicine And Community Services 16 Royal Manchester Children s Hospital 13 Specialist Medical Services 13 Clinical Scientific Services 12 St Marys Hospital 12 Trafford Hospitals 9 Manchester Royal Eye Hospital 2 Total 95 Table 9 Divisions Attending HLI Panel Proposal for Future Reporting Arrangements At present serious incidents are reported to the board via the Intelligent Board which focuses on numbers of serious harm incidents, the metrics for this are currently being reviewed. Following any Never Events a summary report is provided to the Board, it is proposed that in addition for any level 5 actual harm incidents a summary of the investigation findings and action plan are provided for the Board members information (template attached as Appendix 2) and a monthly overview report on incidents and claims is also provided. An annual Patient Safety Report will also be produced. The Board are asked to review and agree this proposal. Page 8 of 18

9 Appendix 1 Action Plan Summary - Actual Harm 4/5 (excl. fractured hip) and Never Events ( and ) Incident Number, Date and Details Harm Key Actions Status /04/ Re-iterate responsibility of prescriber to check INR before prescribing Treatment / Clinical Care Delay/Failure Recognising Complication Of Treat Management of INR above 10, there was a delay in treating. Patient had cerebral haemorrhage and died. warfarin Reinforce international normalized ratio (INR) results being checked and recorded daily. Audit compliance with checking and recording INR results Issue guidelines re actions to be taken when ward staff cannot be contacted about abnormal results. Review anticoagulant guidelines Arrange teaching session for Junior doctors Share with Divisional Informatics Group to propose IT solutions for the communication of Clinically significant abnormal results. Share with authors of Policy on General management of bleeding and /04/2014 Fall - Found On Floor Patient fractured hip patient subsequently died /05/2014 Maternity / Neonatal Care Delivery Not On Labour Ward Still birth - Woman in labour sent home from triage, baby was born at home with support of ambulance staff however due to difficulties delivering the baby was stillborn. excessive anticoagulation in adult patients on Warfarin 5 Undertake a review staff understanding of applying the Guidelines for the Management of Hospital Acquired Head Injuries. Review ward processes/board rounds after weekends to ensure that Allied Health Professionals (AHPs) are informed of route of external transfers, Undertake audit of safety huddle completion Undertake a review of training and education provided to staff regarding flat lift hoist 5 Clarify the Born Before Arrival guideline and include a flow chart for staff Review the radio room process including: Review the care currently provided to women in the latent stage of labour Page 9 of 18

10 Incident Number, Date and Details Harm Key Actions Status /05/ Implement the Trust Acute Kidney Injury (AKI) guidelines Treatment / Clinical Care Failure To Respond To Patient Deterioration Delay in detecting and responding to deterioration patient with chronic kidney disease admitted with poor renal function. Discussion at the Clinical Model Review Group the appropriateness of AKI patients being treated at Trafford. Develop an action plan to improve standards of record keeping. Review the Locum Handbook to include AKI Guidelines Review assessment of renal function prior to intravenous contrast. Review current processes for collecting of urgent bloods. Undertake a risk assessment on the High Dependency Unit. Implement process re telephone advice given to GP s. Review admission processes in Acute Medical Unit (AMU). Continue to recruit to vacant medical staff posts to reduce locum use /04/2014 Maternity / Neonatal Care - Still Birth Baby was identified as small for dates however all appropriate actions not taken /04/2014 Fall - From Toilet/Commode Head injury patient subsequently died /04/2014 Maternity / Neonatal Care Fetal Death In Utero Lack of recognition small for dates, delay in triage and identifying pathological CTG /04/2014 Maternity / Neonatal Care Cord PH <7.05 Arterial Or 7.1 Venous Baby born in poor condition - delay in triage and commencing CTG. Agree an escalation process re poor urine output. 5 Review the reduced fetal movements Develop local guidelines for smoking cessation in antenatal period Review fetal growth restriction guideline Develop care plan for attending the placenta clinic. 5 Carry out audits of documentation to ensure it is fully completed and handed over by Intermediate Care to ambulance/hospital staff. Carry out audits of documentation in Emergency Department. 5 Reinforce use of stickers to document classification of CTGs Reinforce the role of the Triage coordinator via the core huddle, Review the patient flow through Triage Review and amend the fetal monitoring guideline Review mandatory training to include assessment of antenatal CTGs Review Triage documentation Provide midwives with rulers to plot the growth with greater accuracy 4 Implement a standard process for communicating Inform staff to ensure that the CTG is reviewed in a timely manner Review the process for triaging women and improve patient flow through triage (transformation group) On-going Page 10 of 18

11 Incident Number, Date and Details Harm Key Actions Status /04/2014 Transfer - Unsafe Transfer Recognition and response to deterioration and unsafe transfer of patient from Salford. 5 Develop, agree and implement a Standard Operating Procedure governing arrangements for the transfer of acute bleeds into the Trust Develop and implement a procedure for when the surgical team are busy and are unable to review a deteriorating patient /06/2014 Maternity / Neonatal Care Fetal Death In Utero Fetal death in utero - management of induction of labour /06/2014 Fall - Found On Floor Patient fractured hip and subsequently died /06/2014 Clinical Assessment Inc. Scree Tests - Failure / Delay To Undertake Early neonatal death - Baby developed haemolytic disease of newborn omissions during antenatal care. Audit the attendance of Critical Care Team in response to alerts 5 Review the process for offering women a lower segment caesarean section (LSCS) within 24 hours/ appropriate monitoring when Induction of Labour fails. Review the transfer times to Delivery Unit for women requiring Artificial Rupture of Membranes to identify ways to improve patient flow. Develop ante natal fetal monitoring guideline 5 Undertake monthly audits on the compliance of measures put in place for patients who are at falls risk. Undertake random checks of Bedman handover sheet. Carry out an audit to identify that patients observations are recorded and are reviewed according to the early warning score policy and to ensure patients are receiving analgesia, that pain scores are reviewed and recorded post administration of analgesia. 5 Assess how many women referred for a consultant opinion are seen by or discussed with the consultant to identify if women are being reviewed appropriately Clarify the roles and responsibilities of the specialist midwife within the Peri Natal Mental Health clinic Review process for generating a consultant appointment in early pregnancy Review the process for automatically generating a routine anti natal anti D prophylaxis appointment and for the management of women with antibodies. Page 11 of 18

12 Incident Number, Date and Details Harm Key Actions Status /05/2014 General Patient Care Lack Of Clinical / Risk Assessment Review and action on abnormal blood tests, management of potassium levels 5 Raise awareness of need for daily monitoring and review of blood tests in recovering AKI through medical and nursing education teaching sessions. Raise awareness of the need to document ward round and medical reviews appropriately. Undertake audit of ward round documentation /07/2014 Transfer Delay/Failure Delay in transfer of congenital cardiac patient from DGH during which time patient deteriorated /08/2014 Maternity / Neonatal Care Cord PH <7.05 Arterial Or 7.1 Venous Baby born in poor condition - delay in categorisation of CTG and recognising extent of bleeding /08/2014 Procedure / Surgery Unexpected Clinical Outcome Management of patient pre-transplant contributing to failed kidney transplant /08/2014 Treatment / Clinical Care Diagnosis - Delay/ Failure Ammonia sample rejected and delays in repeating led to a delay in recognising and treating hyper ammonaemia. Child subsequently died. to monitor progress and response to abnormal electrolyte results 5 Actions not added to system 5 Introduce multidisciplinary teaching sessions on Delivery Unit including the issues identified during recent incidents Introduce formal training in telephone triaging to enable standardisation of advice being given, including the development of algorithms. Review if there needs to be a procedural policy that will highlight the importance of the direct transfer to theatre in the presence of fetal bradycardia 4 Develop and implement an standard operating procedure for the management of transplant patients from referral to admission Reinforce the importance of clearly documenting all discussions with patients / families and members of the surgical team. Purchase weighing scales to ensure that nursing staff are able to accurately determine weight. 5 Deliver a Paediatric Grand Round presentation Share learning with District General Hospitals who see children rarely Develop North West Transport Service guidance for the unconscious child to include measuring ammonia as part of primary work up. Convene a task and finish group to implement reviewed ammonia testing procedures Consider purchase of a bedside Point of Care Testing machine Highlight importance of pre-booking a porter for Code Blue samples Page 12 of 18

13 Incident Number, Date and Details Harm Key Actions Status /07/2014 Procedure / Surgery Infusion injury (extravasation) Problems with position of central line not detected, baby died from complications related to position of central line. 5 Review the potential benefits of the use of echocardiogram in addition to linograms for central venous catheter (CVC) complications. Develop a medical documentation pro-forma to be used for patients with CVC in situ. Undertake a review of existing Trust CVC policies so that acceptable line position and management of lines are consistent. On-going /09/2014 Maternity / Neonatal Care Fetal Death In Utero Fetal growth restriction not detected /10/2014 Clinical Assessment Inc. Scree Test Results/Report Failure/ Delay To Receive Delay in reporting of MRI scan which identified tumour and therefore delay in access to treatment /09/2014 Treatment / Clinical Care Delay in replacing pacemaker, problems with regular pacemaker checks, patient discharged and unfortunately died before planned procedure /10/2014 Procedure / Surgery Unexpected Death Management of child with severe burns 5 Re-educate staff regarding the use of customised growth charts Amend current documentation for community smoking cessation. Review process for Specialist Midwifery support Review and amend the process for documenting care offered and provided by the Specialist Midwifery Service 4 Write protocol for use at Withington Community Hospital Deliver an educational session to feed back the findings Improve the primary care service - Appoint substantive consultant Rollout the new electronic notification tool, 'communicator' Introduce internal data quality checks to ensure scan/results are carried out within the agreed timescale Improve the induction of agency / locum consultants. Improve management of MREH patient demand: Improve scheduling of requested investigations and appointments: Merge of both picture archiving and communication system (PACS) (Trafford and Central site) 5 Ensure educational input on acute medical grand rounds and local education sessions to improve awareness of access to pacemaker physiology team Audit and subsequent action plan of medical documentation Develop departmental pacemaker follow up DNA protocol 5 Develop a combined pathway for the management of patients with major burns Review need for availability of haemodialysis in RMCH Theatres Consider taking planned breaks in long Burns procedures. Review current training material. On-going. Page 13 of 18

14 Incident Number, Date and Details Harm Key Actions Status /11/2014 Treatment / Clinical Care Delay/Failure To Monitor Delay in moving the patient to the ward and starting thrombolysis resulting in leg amputation 4 Develop a protocol for the management of lysis in acute ischaemia. Review feasibility of commencing thrombolysis in Radiology. Develop a protocol to escalate delays in transferring urgent patients. Provide additional training to ensure all staff are competent in the administration of Thrombolysis On-going /11/2014 Fall - Slip Or Trip Patient fractured cervical spine, delay in identifying fracture. Patient subsequently died /11/2014 Medical Device Failure Of Device/Equipment/Product Equipment failure during surgery - device cut artery but did not simultaneously staple. 5 Review the training in relation to falls assessment and care planning for nursing staff on the Acute Medical Unit and all other wards caring for patients at high risk of falling. Assess the adequacy of current safeguarding training. Provide training and education to nursing staff in calculation of the Early Warning Score. Organise training in relation to management of C-spine injuries. Produce a pathway for the management of C-spine injuries. Review the current medical cover to ensure satisfactory levels of junior medical staff are available. Develop an induction package for locum doctors within the trust. 4 Review and trial alternative devices currently available on the market with a view to switching manufacturer. Reinforce with theatre staff that when devices fail, they and their component parts should be retained to facilitate further investigation. Discuss report at the Trust Medical Devices Committee Develop an addendum to attach to theatre staff medical device training documentation to acknowledge that they have an understanding of the importance of retaining devices and their component parts when they fail. On-going On-going Page 14 of 18

15 Incident Number, Date and Details Harm Key Actions Status /01/2015 General Patient Care Lack Of Clinical / Risk Assessment Deterioration delay in identifying and lack of recognition of sepsis 5 Review the current sepsis training package for clinicians and nursing staff. Develop a simple and clear pathway of care for patients referred for assessment or admission by the Emergency Department and other groups. Guided by SAFER Standards project Develop a simple and clear pathway for patients referred for assessment or admission by the Emergency Dept. Introduce a specific training package for the Acute Abdomen Pathway into Clinical Mandatory Training. Review the Trust guidance on management of sepsis. Establish a group of specially educated nurses to specifically support On-going /03/2015 Maternity / Neonatal Care Maternal Death Collapse of post natal lady several days after delivery. Delay in recognising and responding to deterioration reliable care for patients with sepsis 5 Provide educational update on the use of and response to Maternal Early Warning Score (MEWS). Provide ward based training in the use of Patientrack. Investigate all delayed responses to raised MEWS scores Review processes to ensure that only MEWS (not EWS) can be used Review provision of the Acute Illness Management (AIMS) course to be mandatory for all midwives working in the obstetric directorate Source an appropriate course for medical staff to aid recognition and management of general medical problems in pregnant women Remind all consultant obstetricians of the value of discussing women at the Sick Mum's Forum Discuss development of a Consultant Obstetric Physician role Update guidelines for the admission to obstetric critical Introduce clear sign on resuscitation trolley on how to obtain Alteplase On-going Page 15 of 18

16 Incident Number, Date and Details Harm Key Actions Status /03/2015 TBC Remind staff within the Discharge Team to ensure that patient details On-going General Accident Found With Injury - Cause Unknown Patient in intermediate care following vascular surgery found with profuse bleeding, later died despite transfer to MRI. It is not yet known whether this is as a result of trauma or of recognised complication of graft breakdown. are checked and any amendments communicated to colleagues and PAS updated. Implement process for intermediate Care that at least 2 telephone numbers are taken at the point of referral. Discuss with the relevant management team about further training regarding involvement of relatives in discharge planning Implement a weekly checklist for regular checks of BUPA defibrillator /03/2015 Maternity / Neonatal Care Baby born in poor condition - misinterpretation of 4 Actions not on system CTG /12/2014 Clinical Assessment Inc. Scree Test Results/Reports Incorrect Transoesophageal echocardiogram misreported and extent of cardiac disease and risk level unknown prior to surgery. 4 Review system to ensure senior physiologists are not required to supervise a trainee during a dobutamine stress echo session Allocate protected time for physiologists countersigning. Establish weekly lunchtime meetings/local peer reviews. Consider routine review of echo images at Cardiology MDT meetings. Report unreliable server to IT. Incident details for ongoing investigations - pending 4/5 harm Treatment / Clinical Care - Awaiting Report 25/02/2015 detected 07/05/15 Child with cardiomyopathy discharged home subsequently re-admitted unwell and died Diagnosis - Awaiting Report 19/09/2014 Detected 07/08/15 Delay in identifying the extent of PDA and in access to treatment. Child requires heart and lung transplant Diagnosis - Awaiting Report 31/12/2014 detected 10/08/15 Possible delay in diagnosis of oesophageal cancer from endoscopy. Page 16 of 18

17 Never Events and to date in Incident Number, Date and Details Harm Key Actions Status /08/14 Treatment Procedure wrong patient Central Line inserted on wrong patient 3 Introduce process whereby patient identity is formally checked before leaving the ward for a procedure. Introduce pre-procedure checklists with renal medicine. Undertake audit of compliance with checks. Ongoing /12/14 Treatment Procedure wrong Site Dental surgery wrong site opened June 2014 detected 07/04/15 Treatment Procedure retained item Part of device retained in patient following procedure this was not detected until it had migrated to heart several months later /06/15 Treatment Procedure wrong device Wrong strength lens inserted in to eye /07/15 Treatment Procedure wrong site Botox injection in to stomach rather than intended site of oesophagus the Trust wide work on safe procedures 2 Pilot a second verbal time out check to confirm the site to be operated on immediately before the surgery. Ensure whole Oral surgery team are aware of the process to mark the correct side of the external skin of the cheek Ensure a team member is released to complete admission documents 3 Still being investigated 1 Still being investigated 3 Still being investigated Page 17 of 18

18 Appendix 2 Board Summary Report Actual Harm 5 Incidents Incident Number: Incident Date: Division: Incident Type: Being Open arrangements Trust Liaison Contact Staff support and feedback arrangements Arrangements for sharing learning Investigation Summary What happened? Key Findings Problems and contributory factors Root Cause(s) Conclusion Action Plan Action(s) What is the barrier to reduce / eliminate risk of recurrence Deadline Page 18 of 18