1.1.2 Performance over time

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1 01/ / / / / / / / / / / / / / / /2016 Number of Cardiac Arrests 01/04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/2016 Number Cardiac Arrests per 1000 Admissions Board Integrated Quality & Governance Report March/April SAFE CARE 1.1 CARDIAC ARRESTS Current Performance Cardiac Arrests per 1000 admissions was 1.43 in April, decrease on March to below the NCCA national average of Performance over time The Sign up to Safety campaign has set an additional measure to reduce the number of patients who have a cardiac arrest by 50% from baseline by December 2016, with a stretch target of less than 1/1000 admissions by Performance over 2015/16 has averaged 1.42/1000 admissions. Performance for April is within control limits and below the confidence line. Data for number of cardiac arrests demonstrates that since the introduction of medical emergency calls rather than cardiac arrest calls that variability has decreased and there remains a downward trend. For April, performance was below the lower control limit. The trajectory for was a reduction in cardiac arrests down to the national average of 1.54 arrests per 1000 admissions. Whilst the NCCA performance shows an increasing trend, the UCLP data excluding ED, CTC and CCU demonstrates a decreasing trend. This indicates an increase in cardiac arrests within the excluded areas which require further analysis. The Trust also measures the actual number of cardiac arrests that occur in the hospital, which supports the notion of a decreasing trend Sharing the learning & implementing change The following is a summary of the actions taken to reduce cardiac arrests, and improve outcomes for patients at risk of deterioration, through the Sign up to Safety Deteriorating Patient Group: A revised NEWS observation chart has been piloted along with review of the escalation process. There has been a refocus on how Treatment Escalation Plans are used. Weekly peer reviews of all cardiac arrests to identify themes and emerging trends, 90% reviews have been completed within medicine. The review is now to be extended to the assessment units. Real time feedback of the cardiac arrest review audits is now being provided to wards UCL, LCL, 7.452

2 1. SAFE CARE A review and therefore greater understanding of arrest calls activated from ED and CCU. Focused support for areas that have a higher incidence of patients who deteriorate. A programme running concurrently, but not as part of the deteriorating patient campaign, is to introduce a system for the electronic recording of patients observations in all adult in-patient areas; the system automatically escalates patient s NEWS score and those at risk of deterioration are automatically escalated to a nominated 1st responder bleep holder. It is anticipated that this will ensure patients are escalated and reviewed appropriately and should reduce the number of cardiac arrests. Roll out has occurred on Elizabeth Fry Ward and Florence Nightingale ward with all adult in-patient wards to be completed by the end of August SEPSIS CARE Current Performance The Sepsis Board have agreed KPIs for , cross referenced to the Trust s CQUIN programme. The forth coming years sign up to safety work programme will be driven by the CQUIN targets, which includes timely identification and treatment for Sepsis in ED for adult and paediatrics, and extending this across acute inpatient settings. Work commenced in ED to track the percentage of patients who were screened for Sepsis in Majors and Paediatrics with a target of 90%. Performance across 2015/16 has been consistently above 94%, with the last 3 months achieving 100% compliance. For those patients presenting with severe Sepsis, performance regarding the provision of antibiotics within 1hr improved from 0% across April to June 2015 to 80% in July. Performance since has been variable, however, from November to March has seen an improving trajectory, reaching 100% year end, and meeting the 2015/16 CQUIN tar Quality Improvements The following actions have been implemented to ensure that patients with sepsis are identified and receive the appropriate intervention: A lead nurse for Sepsis has been identified within ED, supported by the QI team. 3 Sepsis trollies have been purchased for use in ED and AMU. The Terms of Reference and membership of the Sepsis Board has been reviewed. The development of a Maternity and paediatric Sepsis care bundles. Participation in the UCLP collaborative continues. Agreement to fund a Trust wide practice development role specifically focusing on Sepsis and AKI. A Sepsis module is to be developed as part of the E observation system, to go live by October ACUTE KIDNEY INJURY Current Performance In 2015/16, there was a steady decrease in the percentage of patients identified with AKI, who had more than 3 alerts; however, the planned trajectory has not been met. Performance from December to year-end was between 25% and 30% against a planned target of 15%. The quality Improvement team have been supporting the project team to define more specific KPI s, to refocus key mile stones for 2016/17 and seek better clinical leadership and engagement in order to drive further improvement. Since August 2015, less than 7% of patients whose creatinine levels have been measured were identified as having AKI, an improvement on 10% at the beginning of the year and below the 8% trajectory. Since November, the Trust has achieved 100% compliance with AKI being correctly documented in patient s records. For 2016/17, UCLP outcome measures have been adopted by the Trust and data submission has commenced. The new measures include reduction of mortality following AKI by 25% from the baseline, and increase in patients who recover renal function at 30 days by 25% and improved patient experience and wellness scoring. Once a baseline has been established theses measures will be reported as part of Stepping up Board.

3 04/ / / / / / / / / / / / / / / / / / / / / / / / / /2016 Number of Avoidable pressure Ulcers Number Avoidable Grade 2 Pressure Ulcers 1. SAFE CARE Quality Improvements A significant amount of work has already been undertaken in relation to the AKI CQUIN work and further actions have now been defined for the forthcoming year. Achievements to date include:- Development of an alert system for both medical and pharmacy staff to inform them when patient s blood tests show an AKI level of 1, 2 or 3. This prompts a joint medication review to be undertaken. The development of a drop down tab on the electronic discharge letter - notifying the GP of the diagnosis of AKI and treatment interventions. The development of AKI care bundle. Participation in the UCLP AKI collaborative- submission of monthly data. 1.4 TREATMENT ESCALATION PLANS (TEP) Current Performance Treatment Escalation Plans (TEPs) were introduced 18 months ago across the Trust. TEPs have contributed to the decrease in ward-based cardiac arrests. Divisional performance is variable, with average compliance for completion in Medicine being 96%, where the initial focus and need for TEPS was. The Surgical Services, however, achieve an average of only 40%. The TEP Group has been re-constituted to explore how more consistent compliance can be achieved, with enhanced support for surgery. The work plan for 2016/2017 will include involvement of other stakeholders in the use of TEP s such as community carers and GP s. There is the intention to also explore how TEP and DNARCPR can be combined. Initial work will focus on review of the current forms and audit process and to set achievable trajectories for improvement. New national guidance is anticipated. 1.5 PRESSURE ULCERS Current Performance Avoidable pressure ulcers per thousand bed days remains above target for April The average monthly rolling average performance equates to 0.237, slightly above the 0.2 threshold. The Serious Incident report into the roll out of the new hybrid mattresses will provide a background as to the root causes of the spike during the November to April period. A draft report has been submitted to the Executive Review Group in May, which is subject to amendment and quality assurance processes Performance over time UCL, CL, LCL,

4 1. SAFE CARE Until the recent spike in avoidable pressure ulcers, there had been an improvement month-on-month in performance, with less variation. This spike was reflected within grade 2 and 3 avoidable pressure ulcer incidents plus the inclusion of some pressure ulcers which had previously been excluded from the figures associated with ulcers caused by nasal cannula. Since December 2015 both have reduced, in particular grade 3 which demonstrates less harm, whilst there has not yet been a return to last year s baseline, the SPC chart shows a return to below the upper confidence limit. A new realistic baseline and performance trajectory is to be agreed as part of the quality priorities for 2016/ Pressure Ulcer benchmarking The PST measure for pressure ulcers shows the Trust was below the national average in February and March for hospital acquired pressure ulcers and community acquired pressure ulcers. The chart demonstrates that there was a reduction in the number of patients that came into hospital with pressure ulcers in February and March 2016, as well as a reduction in those reported within the Trust. Current performance replicates performance in February and March The sign up to safety programme continues to deliver against its key milestones, which will support improvement. No data is yet available for April Analysis of performance Performance against the Trust s stretch target of 3 per common month was not achieved in April (or yearend) with 6 avoidable pressure ulcers (3 x grade 2s and 3 x grade 3s). All grade 2 and above pressure ulcers are subject to RCA investigation and are reviewed by the Harm Free Care Scrutiny Group. Below provides a summary of the root causes identified and the actions being taken to address deficiencies in care Review of RCA s: Trends and lessons learnt Pressure Ulcers occurring in April are subject to RCA. Of the avoidable ulcers in March, there were a total of 7 heel ulcers, 4 sacrum/buttocks ulcers, 1 spine and 1 foot ulcer. The RCAs identified the following areas that require improvement:- Lack of, or inconsistent, evidence of repositioning and documentation Lack of evidence that SSKIN care bundle being implemented and reviewed Delayed identification of bony prominences Lack of, or inconsistent, evidence of heel floatation using off-loading devices (pillows or boots) Prolonged periods sitting in a chair For the grade 4 sacral ulcer - there was delayed escalation of the ulcer Sharing the learning & implementing change The recommendations and actions arising as a result of the RCA analysis include:- Heel floatation Heel floatation continues to be inconsistently implemented and/or documented by ward staff. Repose boots and pillows are now readily available for use. The following actions have been further implemented:- In-service training has been organised by the TVN service this month in the use of heel floatation

5 04/ 05/ 06/ 07/ 08/ 09/ 10/ 11/ 12/ 01/ 02/ 03/ 04/ Falls per 1000 bed days RCP data 1. SAFE CARE devices. Link Nurse training has been conducted on heel anatomy and physiology, contributory factors and prevention of heel ulcers. They have also been tasked to conduct mini-audits on heel floatation on their wards. An elearning package is under development by TVNs for nursing and HCA staff. Repositioning Regular 2-4 hourly repositioning for dependent bedbound patients continues to be a challenge, particularly during Black Alert or due to staff shortages. The following actions have been further implemented:- A trail of a revised repositioning charts has commenced. Ward managers continue to check and challenge in their respective wards Link nurses tasked to under mini-audits of repositioning. Linford Ward Linford has been identified an area requiring improvement in pressure ulcer prevention. Challenges include high patient acuity and dependency, staffing levels and nursing compliance with the SSKIN bundle. Being identified as an area with high incidence of pressure ulcers, a programme of high support, challenge and training was implemented on this ward which has contributed to there being no hospital acquired pressure ulcers declared for March (avoidable or unavoidable). To sustain and support the improvement, the TVN service continues to collaborate with Linford ward, and has implemented the following quality improvement strategies:- Audits on heel floatation, repositioning and selection of mattresses and observations of nursing handover 1.6 FALLS Current Performance The Royal College of Physicians national audit report published in October 2015; provides a new national average benchmark figure of 6.63 falls per 1,000 bed days and 0.19 injurious falls per 1,000 bed days, against which the Trust can compare itself. The Trust is currently reporting 3.92 falls per 1,000 bed days and 0.08 for injurious falls. This indicates that the Trust is below the national benchmark for both falls generally and injurious falls Performance over time The SPC chart demonstrates the number of injurious falls since May There were no injurious falls in February, 2 in March and 0 in April. The Trust has achieved the injurious falls trajectory for 2015/16, with 19 severe impact injurious falls against a target of 21. Falls per 1000 bed days remains within confidence limits for April. 7 6 UCL, LCL,

6 1. SAFE CARE Of the 19 injuries, there were 7 fractured hips, 2 with additional fractures; this year has seen the highest level of cerebral haemorrhage events post fall, with a total of 7, where previously 1 or 2 were being reported annually. There is no indication yet of the cause for this except potentially some links to thromboembolic therapy Falls with harm benchmarking Falls with harm is benchmarked between organisations using the PST. Data is collected on one day each month and reports every level of harm from minor (bruise/laceration), moderate (laceration that requires suturing or a small bone fracture) and severe (cerebral haemorrhage, fracture of large bone i.e. hip) or an injury that results in significant longterm disability. It does not provide a constant assessment of the overall level of injury in particular those falls that result in severe harm Analysis of performance An update on the Fall Safe Project and Sign up to Safety campaign was presented at QPSC meeting informing the Trust s progress in reducing falls that result in harm and improving the quality of care provided to our patients at risk. A report is produced monthly by the Advanced Nurse Specialist Falls & QI, to provide assurance and evidence of the continued falls improvement work. The contents of the March report have been used to populate updates for this quality report to QPSC. The Falls Safe Project team are delivering against their expected key milestones, which include: 85% of staff on Lister ward have been trained in falls safe practices. Engagement remains a challenge due to the number of temporary staff on shifts. There is an average of falls alert alarms in circulation each week. The tracking devices have now been ordered. Additional alarm stock (permanently sited in the toilets on high risk wards) has been received. An Inpatient Falls Information Leaflet is in the final stages of development. An education strategy, including a competency framework for falls has been developed and tested. This is due to be implemented on Kingswood Ward in early April. A trial to illuminate the toilet entrance at night was completed and a product chosen. The lighting will be incorporated into the plan to improve toilet safety initially on Kingswood ward. 1.7 Infection Prevention & Control Current Performance There were no MRSA bacteraemia reported in February, March or April. There were also no occurrences of hospital attributed Clostridium difficile infection Performance over time The two graphs below show the Trust performance threshold for MRSA and Clostridium difficile. All cases of MRSA and C. Difficile infections are subject to detailed RCAs which ascertain if there were any aspects of care which failed to meet the required standards.

7 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 Number Hospital Aquired C.Dif ficile Inf ections MRSA Bacteraemia (Cumulative) Target 0 1. SAFE CARE Analysis of performance MRSA bacteraemia There was one case of MRSA bacteraemia investigated during January. Following a post infection review (PIR) and scrutiny by the CCG, this was assigned to the Trust. Whilst the focus of the bacteraemia could not be prevented, the investigation identified some missed opportunities for screening; however, this did not impact on the patient s outcome. It was recommended that when prescribing antimicrobials, previous MRSA colonisation should be considered to avoid the risk of subsequent colonisation with MRSA. Clostridium difficile The C.difficile objective for 2015/16 was 31 post 72 hour cases, of which there have been 37 cases to year end. Root cause analysis (RCA) has been undertaken on all cases and these are scrutinised at multi -disciplinary review panels. For January and February some themes have been identified; such as missed opportunities for stool sampling and precautionary isolation. Inappropriate prescribing of antibiotic was identified in one case. Of the 10 cases reviewed, it was deemed that lapses in care are likely to have contributed to two cases. E Coli bacteraemia Mandatory surveillance of bacteraemia due to E coli is undertaken monthly, however there are currently no reduction targets set. For February and March 2016, 2 hospital attributed cases were identified in each month. MSSA bacteraemia Mandatory surveillance of bacteraemia due to methicillin sensitive Staphylococcus aureus (MSSA) is undertaken monthly, there are no reduction targets set. During January there was 1 hospital attributed case identified. There were 0 cases identified during February and 1 case in March. 2. EFFECTIVE CARE 2.1 MORTALITY Current Performance The Crude mortality rate for the rolling 12-month period is 1.93%, remaining below the 2% threshold. The in-month figure was 2.2 in February and 2.1 in March. April Data not yet available SHMI The SHMI preview has been released for October 2014 to September 2015 and is at being below the 100 threshold for the third consecutive month.

8 2. EFFECTIVE CARE Performance over time Crude Mortality The Crude mortality rate for the rolling 12-month period April 2015 to date is 2.00 which is the target 2% target threshold. The in-month figure for April was 2.00, Which is a reduction from 2.1 in March. HSMR The latest published position HSMR for the 12-month rolling period is (February 2015 to January 2016) is 88.09%, which is lower than expected. This figure is likely to change as the data is taken from HED before the actual freeze data is included. Trend overall appears to be static. SHMI The SHMI has been released for October 2014 to September 2015 and is at 92.38, the banding is within expected range. For the fourth consecutive period the Trust remains below the 100 threshold. The SHMI proxy indicates the next quarter result will remain static.

9 2. EFFECTIVE CARE 2.2 VENOUS THROMBOEMBOLISM Current Performance There have been a total of 16 venous thrombolytic events reported in 2015/16, half of which have occurred in 2016 perceived to be as a result of increased awareness of reporting requirements by Imaging and the Anticoagulation Service. 2 of the 16 were deemed to be avoidable. One case concerned the incorrect advise being given regarding stopping anticoagulation medication pre and post diagnostic procedure and the other due to non-compliance (or lack of documented evidence of) the application of compression stockings. Both cases have been subject to RCA investigation with actions taken to increase staff awareness of pre and post procedure management of patients who routinely take anticoagulants and in ensuring compliance with anticoagulation therapy, including use of stockings. The Trust s VTE task and finish group will be re-established to review current position, national guidance and to drive further improvements. The Trust monitors compliance in relation to the administration of appropriate prophylaxis to inpatients. Monthly audits assess whether a risk assessment has been undertaken on admission, if the appropriate prophylaxis has been prescribed as per Trust protocol and whether it has been administered. The Trust standard to be achieved is 90%. For the month of January the standard measuring VTE risk assessment completed increase from 89% in February to 98% in March. April has seen a reduction to 93% but remains above trajectory. The compliance for appropriate prophylaxis prescribed as per Trust protocol was 98% in March an increase on 90% in February. However, this has dropped to 81% as a result of prescribing errors which were identified before administration and is subject to review. The percentage of adult inpatients receiving appropriate prophylaxis was 86% in April a drop in performance from 90% in March. which was a significant increase from previous month which was 75%. The 10% patients who did not receive appropriate prophylaxis were correctly prescribed but were not administered TEDs. There was a significant drop in the completion of the risk assessment section of the new EoE drug chart with only 46% having correct and complete documentation in all required fields. 54% were incomplete with one or more of the following information not being available on the summary of thromboembolism (VTE) risk assessment section of the new drug chart: VTE risk factors, concurrent anti-coagulants and bleeding/contraindication to anticoagulants. In March 74% patients had a complete and correct documentation in all required fields. Recommendations are being carried out to improve compliance through training of medical staff on using the new drug chart.

10 3. PERSONAL & RESPONSIVE CARE 3.1 PATIENT SATISFACTION Current Performance Data for Complaints, incidents and Litigation not yet available for April 2016 The Trust uses a variety of sources of information to assess how we could do things differently to improve patient experience, capturing patient feedback via Friends & Family Test (FFT), We re Listening comment cards, NHS Choices, BTUH Feedback address, Facebook, Twitter, Complaints, PALS and Plaudits. Friends & Family Test (FFT) The Inpatient response rate (40%) was again not achieved at 30% in March and April; representing a reduction from 36% in February. Poor compliance in some areas is attributed to lack of commitment from those areas. The Director of Nursing has requested all Heads of Nursing to develop a responsive action plan which details how their areas will improve performance; the Head of Patient Experience is providing support to areas in the terms of volunteers and raising awareness. 14 in-patient areas achieved above 40% in April and 14 did not. With the exception of Burstead Ward which consistently performs well above trajectory, wards in Surgical Services Division require improvement and has been raised with the Head of Nursing & Quality. Burstead, James Mackenzie and Chelmer were the top three wards this month. Maternity has seen a reduction in performance to 37% in April from 79% the month prior. Systems for collection of touch points one and four have been reviewed to improve response rates in these areas but a further review has been initiated to determine why there has been such a significant reduction. The A&E response rate increased in April at 25% (17% in March), meeting the target of 20%. The FFT results for April are shown below (results for March in brackets):- Recommend Not recommend Inpatients 97% (96%) 1% (1%) A&E 72% (70%) 17% (19%) Maternity 95% (98%) 1% (1%) Outpatients 92% (92%) 3% (3%) Paediatrics 87% (80%) 0% (13%) Day Units 96% (97%) 2% (2%) Key issues highlighted via the free text in April have yet to be validated. Comments for included: nothing food/drink for inpatients; staff, waiting times and care in A&E; and waiting times for out-patients and day units The most common positive responses in March were about: the care patients received, staff everything for inpatients and the Day Unit; waiting times in A&E and outpatients; information Following the March results, the Head of Patient Experience printed and personally distributed the patient feedback on FFT to each area. These were given to the senior sister or ward manager to share with all staff. All areas are encouraged to display some of the comments and any actions they have taken as a

11 3. PATIENT EXPERIENCE result of them. NHS England FFT Patient Experience Conference The Head of Patient Experience was personally invited to present at the conference on the Trust s reporting of FFT and how the results within the hospital are shared, e.g. FFT Stepping Up (15 th of each month). The presentation was well received. FFT Spotlight Week: March 2016 As part of a national public-awareness raising week, the FFT was in the spotlight with a series of local events and other initiatives to let people know how they can have their say on the NHS other than through formal patient surveys or making a complaint. The Trust promoted the importance of FFT to staff, patients and visitors to the Trust. A display stand was in the hospital foyer on 14 March at which the importance of FFT was promoted to staff patients and visitors to the Trust. NHS Choices There were 7 NHS Choices reviews posted about the Trust in February and 7 in March. 9 of these were 5 star ratings. Comments included:- My elderly relative was brought into A+E at the weekend very poorly. The staff were fantastic; we were kept informed and updated on her condition. She was treated kindly and respectfully throughout. She was then promptly transferred to Florence Nightingale ward and eventually into Marjorie Warren ward. Both wards were clean, organised and exemplary in their care. I am very proud to call Basildon my local hospital. Thank you to everyone who make such a difference to those in need. I attended the cardiac unit in the main building to have a pacemaker inserted. From the very beginning of Plaudits A total of 26 plaudits were logged in February and 43 in March. Data for April has not yet been validated. A total of 438 formal plaudits were logged during 2015/16. The graphs shows an upward trend. Plaudits related to the standards of care provided to patients by nursing and medical staff. The highest proportion of plaudits received in the last two months related to Surgical Services. In addition to those logged, individual wards/departments also receive a number of cards and letters that are displayed on their areas. 3.2 COMPLAINTS & PALS Current Performance The Trust experienced a slight increase in the number of complaints received with 62 in March compared to 61 in February. The Trust s year-end total is 658 (700 in 2014/15), equating to a 6% reduction. There was a 7% reduction in PALS cases logged with 275 in March compared to 296 in February. The year-end total of 3222 (3107) equating to a 3.7% increase.

12 3. PATIENT EXPERIENCE Complaints March Comments Medical care/treatment 16 (12) There was a reduction in complaints relating to medical Communication 9 (12) care/treatment. This is the highest category during 2015/16 with 161 (24% of total complaints). There was Medical judgement/diagnosis 5 (9) a notable increase in complaints relating to Communication and Medical Judgement/ Diagnosis. These are the second and third top categories during the year. PALS Appt delay/cancellation OPD 99 (95) Concerns relating to delay/cancellation OPD remain the Clinical Treatment 32 (34) highest category. There was a total of 860 during 2015/16, equating to 27% of total PALS concerns). Communication 29 (46) Many of these in latter months have been related to difficulties in reaching clinical departments to discuss appointments. Communication and Clinical Treatment are Diagnostic Tests 29 (31) the second and third top categories with 479 and 361 respectively in 2015/16. PALS Appt delay/cancellation OPD 99 (95) Concerns relating to delay/cancellation OPD remain the highest category. There was a total of 860 during 2015/16, equating to 27% of total PALS concerns). Many of these in latter months have been related to difficulties in reaching clinical departments to discuss appointments. Communication and Clinical Treatment are the second and third top categories with 479 and 361 respectively in 2015/16. Imaging remains the department with the highest proportion of PALS concerns received with 14% of the total received. However, the department experienced a reduction from 52 in February to 38 in March. There was a reduction in PALS for Laindon Ward West from 10 in February compared to 1 in March. It is envisaged that this is due to the appointment of a Band 7 on the ward. Acknowledgements 100% of complaints received in February and March were acknowledged within the statutory 3 working day target. 100% of PALS concerns received in February and March were acknowledged within the Trustimposed 24 hours target. Responded to on time Target (90%) for complaints responses sent within agreed date was exceeded with 100% in February (all

13 3. PATIENT EXPERIENCE 52 responses sent in target) and 93% (68 responses sent, 63 in target) The Trust achieved 86% in both February and March against the Trust imposed target of resolving 90% of PALS concerns within 5 working days. The PALS Team continue to work with divisions in closing cases more timely and this is evident in the improved response rates in the last few months. Complaints Upheld There was a slight reduction in the percentage of upheld complaints with 38% (26 of 68 complaint responses) in March compared to 39% (22 of 52 responses) in February. The highest proportion of upheld complaints in February related to Women and Childrens Services and in March the highest proportion related to Services Services and Acute Medicine. Trends Identified in Complaints Actions taken Stage Drug administration errors Matrix Reflection Completed Medical Training Car park pay machines constantly out of New pay machines to be installed ongoing order long queues to make payment Delays and waiting times for a blood test New appointment system in place however not all patients are aware. No actions in place yet Waiting time and triage in A&E + possible mis-diagnosis of ailments A&E are aware however this may be due to black alert No actions in place yet Difficulties in contacting Imaging Imaging are aware and are reviewing ongoing staffing levels and procedures PPCs communication to patients Divisions are aware No action in place yet Discharge Arrangements Divisions are aware ongoing Communication on Wards Divisions are aware No actions in place yet Complaints reopened There was an increase in the requests for additional investigation on closed complaints with 10 in March and 6 in February. All complainants are given the opportunity to meet clinicians to discuss their experience, their concerns and to explain the content of complaint responses. There were a total of 5 requests for local resolution meetings in February, and 4 in March

14 3. PATIENT EXPERIENCE 3.3 LITIGATION & INQUESTS Claims received in month A total of 11 new clinical negligence claims were received in March (10 in February and 3 personal injury claims). 7 Letters of Claim were also received (3 in February). In each of the 13 cases the Trust had already been notified via either a Letter before Action, or disclosure of records that a potential claim was pending. All were reported within 24 hours to the NHS Litigation Authority (NHSLA) Claims received in month Of the claims closed in February and March (with damages paid), the themes for claims closure recommendations were: 1 x Audit/review of practice 1 x Nurse/midwifery training 3 x policy review 1 x Record keeping medical Division Theme Recommendation & outcome Ser- Surgical vices Policy Review Recommendation: Surgeons reminded of the need to ensure that patients are fully informed of the potential risks and benefits of conservative vs. surgical treatment. Outcome: Ser- Surgical vices Reflection Recommendation: As incident occurred in 2012 it is anticipated that all appropriate measures are now in place to avoid repetition. Outcome: Closed 24/2/16 Acute Medicine Environment & Infrastructure Medicine Emergency Care & Nurse/ midwifery training Audit/review of Practice Policy review Recommendation: To be shared at the appropriate governance meeting to highlight the consequences of not reviewing the patient holistically and addressing each presenting problem, whether or not it is decided that treatment is appropriate. If this had been undertaken and noted in the records it would be evident that the alleged failings were not an omission and may have been due to a clinical decision at the time. Outcome: Recommendation: Given the historic nature of this claim no recommendations are made for General Medicine, particularly as the ward no longer exists. Estates Department has been copied in to ensure robust measures are maintained to eradicate Legionella from the water supply. Outcome: closed Recommendation: The SI report recommended that there should be a standardised trust-wide consent process for the insertion of tesio lines and all central venous catheters. In June 2011 it was noted that a new policy and information leaflet covering Tesio lines had been drafted but were not in circulation. It is recommended that the relevant information leaflets and policy are reviewed to ensure they are current and appropriate. Historical claim but the division may wish to refresh the importance of nursing staff acting on risk assessments and following the Falls Prevention policy. Outcome: closed

15 3. PATIENT EXPERIENCE Surgical Services Clinical Support Services Inquests Record keeping Medical Reflection Recommendation: All relevant clinicians to be reminded of the importance of obtaining written consent and making a full note of discussions which have taken place regarding alternative procedures and their risks and benefits. Outcome: Recommendation: Case to be shared at the appropriate divisional governance meeting to allow reflection and learning. Outcome: 1) Specialist Medicine. Conclusion: narrative conclusion critical of management of care in residential home and at the Trust. A leg plaster applied in Diabetic Foot Clinic but there was ineffective handover upon discharge as to the management/removal of the cast. This case was also subject to a safeguarding alert against the Trust and the residential home and it is likely that it will be partially or fully substantiated. An action plan in relation to the findings is being developed. 2) Clinical Support Services Conclusion: Accidental. A PFD report has been issued to BTUH and associated partner organisations regarding sharing key clinical information PHSO There are currently 16 PHSO cases awaiting investigation and final decisions. In January, there were 2 partly upheld and 2 not upheld and the PHSO found failings in: The care and treatment in The Emergency Department, this is in relation to pain relief and failure to notice an elbow wound compensation was given The course of treatment provided at the time was appropriate and there were no failings in the clinical care and treatment provided. However, they decided that the Trust did not deal with the complaint in a reasonable manner and the complainant was not provided with adequate explanations about the care and treatment that was provided to him 150 compensation was given. 3.4 INCIDENTS Total Incidents There was a 0.6% reduction in the number of incidents reported, with 1099 in March (1092 in February). There is a small upward trend in the incidents being reported since April 15 equating to 2% Degree of Harm There has been minimal variance month-onmonth in the proportion of incidents reported between grades 1 and 2 and those graded at 3 and 4. There continues to be a slight downward trend in the number of incidents which are reported as having caused moderate or severe harm since April For March 2016, 1.46% of incidents were graded as causing moderate to severe harm, and in February 2.01%. The top cause groups for incidents were the same for February and March were:

16 3. PATIENT EXPERIENCE February Tissue Viability Slips/Trips/Falls Maternity March Tissue Viability Slips/Trips/Falls Violence & Aggression (verbal and physical) For Tissue Viability incidents, all pressure ulcers regardless of where they originated are reported through the incident reporting system and includes all grade 2, 3, and Serious Incidents reported trends In March 13 Serious Incidents were reported (12 in February). In addition, 7 Level 0 (internal investigations) were reported (9 in February). One incident reported in February has been classified as a Never Event associated with the wrong blood product being given to a patient. This is currently under investigation and actions have been taken to strengthen checking procedures within the laboratory. Tissue Viability, Treatment and procedures, Clinical Assessment and Diagnosis and Cardiac Arrest are the highest reported cause groups for SIs in February and March 16. General Medicine Division reported the highest proportion of serious incidents in March, which has some correlation with the size of the service. Despite some considerable variation YTD, there has been a downward trend in the Divisions level of reporting since April Acute Medicine and Clinical Support Services demonstrated an upward trend. All other clinical services demonstrate a downward trend. Clinical Assessment & Review remains one of the top areas of concerns; the increase in identification of cases is thought to arise out of better systems for mortality and cardiac reviews, and therefore escalation to the SI review group. March 2016 February x Clinical Assessment & Review/ Treatment or Procedure/ Cardiac Arrest 4 x Clinical Assessment & Review/ Treatment or Procedure/ Cardiac Arrest 2 x Admission, Discharge 1 x Information Security 1 x Communication 1 x Maternity 1 x Blood Transfusion 2 x Safeguarding 2 x Medication 1 x Security/V&A 2 x Slips/Trips/Falls 2 x Slips/Trips/Falls 1 x VTE 1 x Tissue Viability

17 3. PATIENT EXPERIENCE Duty of Candour The Trust achieved 100% of Duty of candour being delivered against the target of 100% within 10 days. Where Duty of Candour cannot be delivered due to realistic reason, this is agreed with the CCG. i.e. to allow for sensitive face to face disclosure Serious Incident Action Plans closed within 60 days Serious incident reports and action plans must be submitted to the CCG within 60 working days of the incident being reported, unless an independent investigation is required, in which case the deadline is 6 months from the date the investigation commenced. There has improvement in performance year to date, however, month on month it remains variable. Performance improved in February, however there was a dip in March. The Executive Review Group review performance at every meeting and patient safety managers support Divisions to improve compliance.