D R A F T Annual Concerns & Claims Report 2013-2014
Contents Definitions Page TO BE COMPLETED Executive Summary Background to NHS Redress Regulations 2011 Arrangements for the handling of concerns External Assurance Welsh Risk Pool Assessments Internal Audit Concerns - Patient Safety Incidents Serious Incidents Never Events Concerns - Complaints Complaints - Activity and Performance Compliments Referrals to the Public Services Ombudsman for Wales (PSOW) Internal Audit NHS Redress Claims Inquests Lessons Learnt Next Steps Priorities for improvement 1
Definitions CLAIM Legal perusal of action against a party to compensate for losses incurred. CONCERN A complaint, a notification of an incident concerning patient safety or a claim for compensation. COMPLAINT Any expression of dissatisfaction. DIRECTORATE/ LOCALITY Subdivided areas within the Health Board s organisational structure which manage the provision of services within its scope of responsibility. The Health Board has 10 directorates and localities providing patient services, these are: Surgical Specialties Regional Services Women & Child Health Musculo-skeletal Clinical Support Services Mental Health Learning Disability Services Bridgend Locality Neath Port Talbot Locality Swansea Locality Integrated Pharmacy & Medicines Management In addition, the Health Board has corporate directorates which oversee the management of functions such as Finance, Planning, Workforce and Informatics. INCIDENT Any unexpected or unintended incident, which did lead, or could have led to harm for a patient. NON-OFFICER MEMEBER A member of the Board who is not an employee of the Health Board. OFFICER MEMBER A member of the Board who is an employee of the Health Board. PATIENT The person who received or has received services from the Health Board. PUBLIC SERVICES OMBUDSMAN FOR WALES PUTTING THINGS RIGHT If a person raising a concern remains dissatisfied after raising a concern with a Health Board, they can request an independent review by the Public Services Ombudsman for Wales (PSOW). Guidance produced by Welsh Government for the NHS in Wales to enable health organisations to handle concerns in accordance with the NHS Redress Regulations. 2
REDRESS QUALIFYING LIABILITY Redress relates to situations where the patient may have been harmed and that harm was caused by the NHS in Wales. Redress can comprise of: a written apology; a report on the action which has or will be taken to prevent similar concerns arising; the giving of an explanation, and the offer of financial compensation and/or remedial treatment, on the proviso that the person will not seek to pursue the same through legal action. Where a Welsh NHS body has BOTH (1) failed in its duty of care to a patient, and that the breach of duty of care has been (2) causative of the harm that the person has suffered. It is only when both these tests are satisfied that a payment of compensation under the NHS Redress Regulations should be considered. EXECUTIVE SUMMARY This annual report details the Health Board s progress in implementing the requirements of Putting Things Right, the third year of implementation. During the year it became apparent that the Health board was not responding to the public in respect of Redress Cases and furthermore the quality was not as expected. In recognition of these failings the Health Board has taken action and reduced the delay in responding to concerns and improve the quality of the responses with the assistance of clinical staff. The Health Board recognises that further work is required to ensure the stability of the changes made is committed to supporting these changes in recognition of the importance of ensuring timely investigations are carried out and lesson learnt at the earliest stage. The report advises on the organisational arrangements for the management of concerns. It also details the number of cases managed within the period and whether they arose as patient safety incidents or as complaints. Setting this information against the number of patient contacts we have as an organisation demonstrates that complaints and incidents are rare and that the vast majority of the people we see are satisfied with the care and treatment we provide. The report reviews key topics of complaints, relatively unchanged from previous years with our greatest numbers arising as a result of patients feeling unable to access services and being seen in a timely manner. This year, our provision of care, monitoring and review of patients was also a common factor across complaints, this has made it the subject of many improvement actions on wards across our hospitals. All concerns provide an opportunity for learning, they are a valuable method of us knowing where we can improve, but clearly we want to reduce these wherever 3
possible and to give patients and our staff a service they can be proud of. There are occasions where things go wrong and we want to be open and honest when this happens. We have had three public reports during the period which relate to complaints about our service that the Public Services Ombudsman for Wales has looked into, we have also had two Rule 43 reports issued by Her Majesty s Coroners. Although these cases are deeply regrettable, they have all resulted in learning which has been shared across the organisation. 1. Background to the NHS Redress Regulations 2011 The NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 came into force on the 1st April 2011. These Regulations apply to all Welsh NHS bodies, primary care providers in Wales and independent providers in Wales providing NHS funded care. These regulations require a proactive approach to acknowledging and putting things right when patients have suffered harm or poor experience. They were designed to streamline the handling of Concerns. Under the new Putting Things Right arrangements, ABMU Health Board has improved its performance against the principles of the guidance, to "investigate once, investigate well", ensuring that concerns are dealt with in the right way, the first time round. Concerns are issues identified from patient safety incidents, complaints and, in respect of Welsh NHS bodies, claims about services provided. 2013/14 was the third year following the implementation of the NHS Redress Regulations 2011. These Regulations apply to Welsh NHS bodies, Primary Care Providers in Wales and Independent Providers in Wales providing NHS funded care. The arrangements represented an opportunity for significant culture change for the NHS in Wales in the way in which it deals with things that go wrong. This included introducing a single and consistent method for grading and investigating concerns, as well as more openness and involvement of the person raising the concern. ABMU Health Board is committed to delivering excellent care and excellent clinical outcomes and experience for all patients all the time. However, sometimes things do go wrong and when this happens the Health Board has a process in place to instigate review and investigate. A review of internal processes has been completed to ensure that concerns are investigated by the right people, at the right time, that the right lessons are learned, improvement actions applied and success of these verified by audit cycles. The Health Board is working hard to improve the quality and timeliness of investigations and also ensure that action is taken to minimise the likelihood of reoccurrence. The Health Board values patients and staff raising concerns as they provide an opportunity to learn lessons. We are committed to using the results of investigations to develop changes to processes, procedures and behaviour aimed at improving the quality of care provided. 4
2. Arrangements for the handling of concerns The Health Board s Non Officer Member who has oversight for the handling of concerns is Mr Paul Newman. He is also the Chairman of the Quality & Safety Committee. His role is to ensure the Board are provided with an appropriate level of assurance in respect of managing concerns. The Director of Nursing and Patient Experince is responsible for ensuring compliance with NHS Redress and is supported by the Assistant Director of Nursing who was seconded into the Patient Feedback Department to implement changes in terms of the way the Department works and operates. While the Director of Nursing has direct responsibility for the management of the Department the Medical Director and the Director of Nursing share responsibility providing leadership and support in the handling of concerns and claims. The Health Board s reporting arrangements for concerns is demonstrated within the below flowchart. Concern received by Health Board Investigation undertaken. Findings and recommended learning/actions reported Senior Directorate / Locality Governance Meeting Approval of investigation, actions and learning. Onward reporting of serious concerns Assurance and Learning Group Approval of serious concern investigations, actions and learning. Monitoring of Directorate/ Locality concerns. Onward reporting of serious concerns ABM University Health Board Review of actions and learning arising through concerns. Scrutiny of performance and quality in the Health Board s management of serious concerns and claims. Review of Public Service Ombudsman reports and externally commissioned investigations. Provides assurance upwards to the Board. ABM University Health Board Quality & Safety Committee 5
3. External Assurance Welsh Risk Pool Assessment Welsh Risk Pool Services (WRPS) is a mutual organisation which provides indemnity to all Health Boards and Trusts in Wales. It reimburse losses over 25,000 arising out of claims for negligence and is funded through the NHS Wales Healthcare budget. In addition to the reimbursement role, the Welsh Risk Pool undertake annual risk management assessments, including one which looks at arrangements for the management of concerns and claims. Their assessment findings are captured under three primary headings: Concerns Management To ensure that all NHS bodies have an effective process for managing concerns raised by patients and staff in accordance with the NHS Redress Regulations. Compensation Claims Management To ensure that Health Boards have an effective process for managing legal claims for financial compensation brought against them by patients and staff. Learning from Events To ensure that good organisational learning arises from all events - including concerns and compensation claims. The Health Board s assessment scores for 201/14 are presented in the table 1 below, alongside scores from last year s preliminary assessment. Table 1: Welsh Risk Pool Assessment Concerns & Claims Management Standard Area for Assessment 2011/12 Preliminary Assessment 2012/13 Assessment 2013/14 assessment Variance 1-13 Concerns Management 14-23 Compensation Claims Management 24-26 Learning from Events Entire Standard 77.14% 84.65% 71.80% -12.85% 77.19% 87.62% 80.62% -7.02% 40.67% 53.08% 33.40% -19.68% 67.00% 75% 61.10% -14% 6
While the Health Board is disappointed to have reduced scores against the three elements of this standard, the Health Board, prior to the assessment, took steps to review the processes in place for the management of concerns and claims and has taken action to change the way the Health Board investigates and learns. The action taken includes telephoning the public and trying to deal with their concerns at the earliest opportunity and offering meetings with staff to discuss concerns. The Health Board has seen improvements in the timeliness and quality of responses as a result of changes, although recognises this work is in the early stages of the change and the priority for 2014/15 will be to embed the changes into our practice to enable sustainability. Concerns Training Days have been undertaken to provide staff involved with response writing, the skills to formulate responses that are fit for purpose and respond to the complainants concerns in a positive light and provide reasoned comments. Personal Development Reviews for the Patient Feedback Team are now being progressed and a number of training and development sessions have been held which include: Root Cause Analysis Training, Team Building Days, How to deal with Concerns training and Customer Care Training. 4. Concerns - Safety Incidents A total of 17,597 safety incidents were reported during the year the majority of which, 89% related to no harm incidents. The degree of harm and level of harm is provided in the Table 2 below. Table 2 Green Yellow Amber Red Incident Reported Date No/V Low Harm/ Damage Minor Harm/ Damage Moderate Harm/Damage Severe or V Severe Harm/Damage (incl Death) 2013/2014 89% 8.3% 1.56% 0.66% To improve feedback to staff when they report an incident, the Health Board s online reporting system was improved with a new field specifically created for feedback. This new facility enables those responsible for authorising incidents to feed back details of actions taken in response to an incident directly to the reporter s e-mail address. We also made it a compulsory for feedback to be a specified action in any action plans developed in response to complaints, incidents and claims. 7
5. Serious Incidents The Health Board submits details of 'serious incidents' to the Welsh Government. Welsh Government define a Serious Incident to include incidents where there is media interest, never events (such as chemotherapy drugs given via the wrong route, wrongly prepared high risk injectable medication, maladministration of Insulin) and unexpected deaths. The reporting criteria are not based purely on the level of harm. During the year, 117 serious incidents were reported to Welsh Government, these included reports of bed closures due to outbreaks of infection within our hospitals. 5.1 Never Events during 2013/14 A never event is a serious, largely preventable patient safety incident that should not occur. ABMU introduced a specific policy in September 2012 to ensure rapid investigation and reporting of the never event, resulting actions and learning to the Health Board. During this reporting period 6 never events were reported and investigated, as demonstrated within the table below. Lessons Learned from Never Events: include: Increasing staff awareness; Training; Revision to standard operating procedures; Increased audit. 6. Concerns Complaints Complaints can be received at any place across the organisation, and not all complaints are resolved using the formal process. The Department of Investigation and Redress has been re-named the Patient Feedback Team, this title covers all functions within the Department. The Health Board is required to report performance against compliance with the timescales recommended within the NHS Redress measure and via the Putting things Right Guidance. A grading system is in place which considers the severity of the concern this allows a suitable level of investigation to take place Concerns graded- Green or yellow, or Multi yellow are subject to 30days maximum target timescale, this can be extended in complex cases as is often the case in Multi yellow concerns Amber/ Red /Dark Red are subject to a 30day target timescale but by the very grade this is often extended to 6 months. A number of changes have been undertaken for Concerns/ complaints since the last Annual Report 8
The Department of Investigation and Redress has been renamed to the Patient Feedback Team Since the 3 rd March 2014 the Princess of Wales Hospital have been managing their own complaints through a dedicated team utilising an immediate contact philosophy SNAP 11 Web based Patient experience software is being technical implemented and a Project manager sort Datix Web fully integrated Datix system purchased and implementation is being progressed A dedicated Ombudsman Co-ordinator has been appointed for 6 months, this person has the responsibility to effectively manager Ombudsman cases and provide the link with the offices of the Ombudsman and the Health Board. This Co-ordinator will review how the Concern was managed in order that learning points can be cascaded allowing a more effective and efficient system Benchmarking has been undertaken with other Organisations.Benchmarking in NHS Grampian Scotland, and Bart s Hospital NHS England Keith Evans (who has the responsibility of conducting a review of Complaints Management across Wales) has visited the Department and commended the work being undertaken to culturally change the approach to complaints Clarification of Roles within the Patient Feedback Department has been undertaken, this has paved the way to introduce clinical personnel to support complaint handling. As part of the departments restructuring it has been agreed that there will be some dedicated medical sessions which would seem appropriate medical for medical oversight and opinion in relation to complaints The Assistant Director of Nursing has been overseeing the Patient Feedback Team, and provided oversight to all formal complaints received. This has allowed and ensured there is clinical leadership and oversight of all complaints both Clinical and non clinical. The Department has now initiated a process where Complainants are now contacted on receipt of a concern, and a meeting offered to the complainant. Complainants are now updated regularly on the Complaint progress The quality of complaints responses is under review. There can be significant variation in the standard of response and key requisites of the complaint response has not been met. This will require a total rewrite of the response before it can be sent for signatory. In a number of cases due to the complexity of the response, contact is now being made with the complainant prior to sending out the response to try and encourage a meeting being arranged to go through the response 9
In complaints where harm or possible harm is cited, the response must also identify if the Health Board has breached its Duty of Care and if there is Qualifying Liability CONCERNS CLINICS Concerns clinics were piloted in Princess of Wales Hospital during February and March 2014. The clinics were well received and afforded people the opportunity to have their concerns heard by a member of the Board member and a Senior Clinician. These clinics have now been held in Neath Port Talbot Hospital and Morriston, Singleton Hospitals, monthly concerns clinics are planned throughout 2014/15. On the Spot Concerns The most important aspect of dealing with complaints is that the person raising their concern has the matter resolved to their satisfaction, and many complaints are resolved by front line staff as they arise. Front line staff are encouraged and trained to take a proactive approach to handling concerns. Formal Process The Health Board also has a formal complaints process. All written complaints and verbal concerns of a serious nature are graded for their severity, based on the information provided. The person who makes the complaint is then provided with a single point of contact that should update them on progress and be a consistent point of contact throughout investigation to final response. 6.1 Complaints Activity and Performance During the year 2013/2014 the Health Board received 1,399 formal complaints. Patients may make complaints themselves or can ask a range of people and organisations to deal with the matter on their behalf, with their explicit consent this is reflected in the graph below. The majority of complaints were made by the patient (57%) followed by a relative of the patient (36%). 10
Many complaints have more than one element of dissatisfaction. However, each complaint tends to have a primary subject. The following graph shows the Top 5 subject types arising from the complaints received during the period. 6.2 Type of Complaint Received The top five types of complaints received are provided in the pie chart below, 39% relate to Access/Appointment/Admission/Transfer/Discharge and 36% relate to the implementation of care or ongoing monitoring/review. To meet the requirements of the NHS Redress Regulations, the Health Board aims to respond to complaints within 30 working days. If there are reasons why this cannot be achieved for example in cases where the complaint is serious or requires a full investigation to be undertaken - a reasonable timescale is agreed with the person raising the complaint. This should be no longer than 6 months. The Health Board s compliance with those concerns expected to achieve a response within 30 working days was 47% Compliance with responding to those more serious concerns within a 6 month target was 67% The Minister for Health & Social Services has also commissioned a further review into care provided at the Princess of Wales Hospital and at Neath Port Talbot Hospital. This is an additional review and its remit will include consideration of how the Health Board responds to complaints, particularly looking at how complaints are handled and how professionals are held to account for lapses in care identified through investigation of complaints (including POVA investigations). 11
6.3 Compliments A total of 2056 compliments were recorded on the Health Board s database, which included formal letters/correspondence expressing gratitude and appreciation for treatment. Many more cards, letters, and gifts were also sent directly to clinical teams and wards from grateful patients and relatives, which have not been formally recorded. Here are some extracts of the compliments we have received about our services during 2012/13. A&E Morriston I d like to give all the staff at Morriston Hospital a massive thank you for saving Dad s life after he had a stroke in March 2012...the A&E consultant and nurses were great at keeping us informed. I d especially like to thank a young nurse from Merthyr who cared for my dad when he was moved to the ward, she was fantastic both in the compassion she showed and level of commitment she gave to us. Ward F, Morriston Thank you to all the staff on Ward F for the friendly and professional way that they have allowed us to keep in touch with my uncle who has suffered a stroke. It has been a great comfort to all the family, near and far. Day Surgery, NPTH I was recently a patient in your day surgery unit at Neath Port Talbot Hospital, and I would like to thank you for the way I was treated. The care I received was excellent. The staff were fantastic. I just wanted to bring it to the Health Board s attention, as all too often we hear about the negative stories and not the positive. Thank you again. A&E, POWH I was treated for a head injury at POW A&E and I wanted to say thank you for the outstanding service and care I received. Your staff were all lovely and I was quickly put at ease, I couldn't have asked for a better service. Maternity, Singleton Hospital My daughter was born at Singleton Hospital delivery unit by emergency caesarean section. I felt the care I received by the staff at the hospital was truly exceptional, and allowed for the safe delivery of my daughter...the staff on the labour ward were excellent. The obstetric doctors and anaesthetist explained everything to us and helped us feel calm during what was a stressful situation...the care from our midwife on labour ward was truly outstanding. Even though we were in an emergency situation, she made sure that she had looked at our birth plan and that once baby was born and had been checked by the paediatricians, that we had skin to skin and that my partner got to cut the baby s cord...she went through breast feeding with us and made sure we were confident in looking after our newborn, as well as debriefing us on what had happened during the birth. We felt that the care 12
she gave us was over and above what we expected of our midwife...thank you for the safe birth of our daughter and making it such a happy experience. Children s Ward, POWH My son stayed on children s ward after his tonsils operation. Staff were fab with him I m really happy with the care he received. Thanks children s ward! Also thanks to the staff in theatre who were amazing when my child was drifting to sleep. A&E & Ward 4, POWH Last weekend, my mother had an emergency admission to A&E & then transferred to Ward 4 POWH. I would like to say a big thank you to all professionals involved, right from the ambulance services, Resus staff & Cardiology. My mother received first class treatment & was treated with patience, dignity & respect. The staff did everything to help her & we are filled with gratitude for staff saving her life... I was allowed to stay with my mother & assist with her care which helped a great deal. There have been a lot of negative comments made about the NHS, however, I can only commend the way the staff work under high pressure & keep positive & professional. Well Done POWH, and thank you so much. Ward J, Morriston Having recently undergone knee replacement surgery at Morriston Hospital, I am writing to express my thanks for the excellent care I received from ABM. From the time I attended my GP to ask if a knee replacement was needed, right through to having the operation was only ten months, and would have been 3 months shorter if I had been available for the first date offered for the operation. Staff in Ward J & Operating Theatre at Morriston Hospital including all the Ancillary Staff, Nurses, Physiotherapists, Occupational Therapists, Phlebotomists, Pharmacists and Anaesthetists looked after me in an a most efficient yet comforting manner and I have the highest regard for their people and professional skills. My thanks also to my GP for the speed of my referral and choice of Consultant who was everything one could have hoped for in a surgeon responsible for perhaps the most traumatic elective operation one could undergo. Well done ABM University Health Board and thanks again for an excellent service. 7. Ombudsman The Assistant Director of Nursing and Chief Executive have met with the new Ombudsman to outline the changes the Health Board has made and is continuing to make in relation to the complaints management process and managing Ombudsman cases. In order to significantly improve how we manage Ombudsman referrals and cases at all levels an experienced nurse with extensive governance experience started on the 1 st April 2014 as a Health Board Wide Ombudsman co-ordinator role. During 2013/2014 92 complaints were referred to the Ombudsman, 28 were put into investigation and 24 upheld or partially upheld. Two cases to date have been found to have serious failings and were reported under (section 16) of the Public Service 13
Ombudsman (Wales) Act (2005). The actions and lessons learned as a result are detailed below: Case 1 (Draft received in March 14 final report April 14) The first case relates to a section 16 & 17 of the Public Service Ombudsman (Wales) Act 2005. An action plan has been developed and an external review of governance and investigation procedures within Mental Health is being commissioned in order that the Health Board receives additional assurance in relation to these areas. Case 2 The second case relates to a complaint relating to the care of a patient in Morriston Hospital. The concerns were highlighted for the following areas: diagnosis and treatment in the Emergency Department, discharge, spinal surgery, ophthalmology input, manual handling assessment and personal care. S16 The third case relates to a complaint opened by the Ombudsman during 2012/2013 but the final report issued in 2013 /14. The concerns raised were in relation to the care of an elderly person following an emergency admission via Accident and Emergency Department at the Princess of Wales Hospital in July 2010. The Board has accepted that there were a number of failings during this attendance and that the care fell below the standard expected. The board will be addressing these with the department and the relevant members of staff involved. The Board has also clarified that there has been process improvements since the time of this patient s admission:- NEWS is in operation NICE 50 GUIDELINES are followed An improved cannulation process has been introduced The Emergency Department Handbook has been updated and available to all its staff member. 8. Internal Audit The Internal Audit Programme ensures an annual review of the Health Board s management of Concerns and Claims. The audit of Concerns was postponed until 2014/15 and the Claims Audit 2013/14 had a very limited scope to focus on the Welsh Risk Pool reimbursements rather than the claims process as a whole. The Welsh Risk Pool is funded by the Welsh Government by a top slicing arrangement. It is a risk-pooling scheme which reimburses member organisations (i.e. Local Health Boards and Trusts) for losses incurred as described in WHC 2000 (12). Claims for reimbursement must be made in accordance with the WRPS Reimbursement Procedure and will be considered by the WRP Services Advisory Board. All successful claims are subject to an excess of 25,000. The previous audit of this area achieved a Reasonable (Yellow) level of assurance. Noting that action is ongoing within the Health Board to address the wider learning of 14
lessons from concerns, the audit scope was limited to providing assurance on the accuracy of claims submitted to the Welsh Risk Pool for reimbursement. The Claims Audit, noting the limited scope above, provided a Green-level assurance rating, meaning that the Health Board can take substantial assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. There were no recommendations following the review. 9. NHS Redress Under the NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 arrangements, the Health Board is required to identify those complaints where the investigation finds that harm has been caused because of a breach of duty of care. In these cases, the Health Board is required to offer Redress to the person, which can comprise of: a written apology; a report on the action that has been taken, or will be taken, to prevent similar concerns arising; the giving of an explanation and the offer of financial compensation (up to a value of 25,000) and/or remedial treatment, on the proviso that the person will not seek to pursue the same through further civil proceedings. The potential benefits of implementing this process for the Health Board and for patients include the continual improvement of quality and safety of services and of patient experiences, a reduction in legal costs and a reduction in the time taken to settle cases to the satisfaction of all parties. During the year the Health Board identified 35 cases where there had been a breach of duty of care which may have resulted in harm. Due to the nature of the Redress process whilst these complaints will have had a response consideration of Redress was ongoing at the end of the year and will be resolved during 2014. The Health Board concluded 40 redress cases during 2013/14. 10. Claims Alongside those cases settled under the Redress process, the Health Board continues to receive new Clinical Negligence and Personal Injury Compensation Claims. During the year 239 Clinical Negligence Claims were received, which is an increase from the previous year when 178 were received. This increase was anticipated due to the Jackson Reforms which came into effect on 1 st April 2013. The Jackson Reforms are in part as a result of changes in legislation (Part 2 of the Legal Aid, Sentencing and Punishment of Offenders Act 2012. The reforms apply across civil litigation and one of the key changes relate to the no win no fee Conditional 15
Fee Arrangements (CFAs) which remain available in civil cases, but the additional costs involved (success fee and insurance premiums) are no longer payable by the losing side. It was expected that Solicitors would ensure any potential claims were covered by CFAs and/or insurance premiums in advance of the Jackson Reforms. The Health Board also received a total number of 84 Personal Injury Claims compared to 89 for the same period in the previous year. Some of the themes arising from Clinical Negligence and Personal Injury claims include: Slip/Trip/Falls (inside) and (outside) Manual Handling (object) Violence & Aggression patient to staff Delay in diagnosis and/or treatment Unintended injury during the course of an operation Possible delay or failure to monitor There are a total of 735 open claims on the Health Board s databases at the time of reporting. A total of 363 cases have been closed during 2013/14, compared to 91 cases during 2012/13. The closure may have arisen through settlement of the claim, successful defence or may have been withdrawn or inactive. 11. Inquests The Health Board provided evidence to a total of 106 inquests during 2013/14 compared to 69 during the same period of last year. During the period, Her Majesty s Coroners concluded that there were serious failings in two cases and issued a Rule 43 report for Case 1 and a Regulation 28 Report: Report to prevent further deaths for Case 2. A summary of those findings is presented below with details of the actions taken in response. Case 1 Relating to the death of a patient who had a fall whilst on the ward, sustaining a head injury, following which there was a failure to record neurological observations and failure to recognise any change in the patient s condition to that prior to the fall. The Health Board has taken action to improve the training of staff and to ensure observations are recorded by the implementation of the Transforming Care Scheme. In addition, the ward has implemented logging falls on the ward as well as reporting these through the incident reporting system. There is also now a Bay Handover on each shift that highlights each patient s needs. As part of the Transforming Care Scheme, visual management tools have been installed. These enable all nursing staff to easily identify which patients require high levels of care. In addition, following further investigations, it revealed that at the time of the incident general wards in the hospital were not routinely using the NICE guideline for head injury. Whilst ambulance crews, emergency department doctors and GPs are expected to be trained (as clinicians likely to see head injuries first hand) hospital general staff are 16
not amongst this list. As a result the Emergency Department provided training for general medical and nursing staff in the Princess of Wales Hospital. Case 2 Relating to the death of a patient who had an indwelling catheter that was not draining as much as it had been during his period of respite at a care home. There was a communication breakdown between the care home, district nurses and out of hours GP resulting in the patient not being seen by any clinical staff. There was no direct monitoring of his oral input and urinary output at the care home which would have provided evidence in support of a urinary tract infection. The patient did not have any clinical assessment of his condition for two days until his admission to hospital where he was diagnosed with sepsis from the urinary tract infection. The patient died in the evening following his admission. The Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, and Recommendation) for the switchboard staff at Princess of Wales Hospital to record out of hours requests for district nurses in greater detail. The GP out of hours has also raised awareness of the case and it has been agreed that handover of care should be made person to person and not via messages. During the period progress has been made in streamlining the inquest process and a member of the Patient Feedback Team from the Claims Section now attends the opening of inquests with the Aberdare Coroner. This process provides a clearer understanding on who is required to attend inquest hearings and the timescales for producing witness statements. The Health Board are also able to meet with the family and discuss any concerns relating to healthcare of the deceased and agree a way forward in terms of addressing the concerns. In addition, Inquest RAG rating criteria was developed towards the end of March 2014 and is now in use. This grading process assists in identifying high risk cases and results in early meetings with appropriate Executive Directors and Senior Managers. 12. Lessons Learned Putting Things Right provides the Health Board with opportunities for learning lessons from claims, complaints, and patient safety incidents. The aim is that these will lead to sustainable improvements to services. The following are just a small number of examples of some of the lessons learned from concerns arising during the past year: Concern summary Patient underwent orthopaedic surgery to right knee following which he suffered discomfort and it was identified that the screws used in fixation of the fracture were longer Lessons/Actions Surgeon involved has been written to formally to highlight the error in this case. Senior Orthopaedic Consultant has developed Learning Lessons education aimed at raising awareness to juniors through presentation at induction. 17
than appropriate. Presentation at Mortality and Morbidity Meeting to highlight the importance of correct screw length around joints Concern relating to: nutrition assessment/care plans. Some periods of inadequate wound management. Inconsistency in medication charts, resulting in periods of inadequate pain relief. No end of life pathway documentation was completed. Failure to respond in an appropriate timescales to patient relatives concerns. Failure to investigate in an appropriate timescale. Delay in Health Board s management of PVL1 MRSA All Wales Nutritional Pathway has been embedded in ALL surgical wards. All patients are assessed against the nutritional pathway and where appropriate monitored. Fluid balance charts are in place for ALL patients Regular checking and monitoring of patient pain relieve has been reinforced. Where failure is indentified a formal incident form is completed The national Skin Bundle has been introduced across ALL surgical wards. A review of Directorate Governance arrangements was undertaken in July 2011 subsequent to this complaint. All open Directorate complaints are reviewed on a weekly basis by Assistant General Manager - Lead for Governance Enhancing staff s awareness/updates of PVL Staplococcus Aureus Review of PVL Staplococcus Aureus management Pathways. Provide up to date Control of Infection advice and information to patient and family members with patient s consent to include explanation on the type of infection and any restrictions placed on the patient, including isolation needs Audit on Care Plans to ensure this takes place. Swab must be taken from patients if presenting with recurrent infection Audit established to ensure this occurs. Feedback given to the clinical teams involved in the care of patient. A summary of the learning points shared across Dermatology, Paediatricians and with the Emergency Department. 18
Management issues of a patient with viral meningio encephalitis (inflammation of brain and membranes) Awareness raising of the NEWS Policy has been undertaken, NEWS awareness training now forms part of medical induction and annual skills update training for nursing staff. Audit of processes for escalation of seriously ill patients. Audit of compliance with NEWS and rapid response policy. Health Board training on the sepsis screening tool delivered across the Locality. The learning which results from the investigation and management of Concerns, is shared both internally, and more widely with other organisations whenever appropriate, to support continuous improvement. 13. Next Steps - priorities for improvement The new processes, structures and arrangements for investigating and dealing with Concerns, Claims and Inquests in an effective way working closely with the patient experience staff as one new department Patient Feedback Team managed by the Assistant Director of Nursing and Patient Experience. The work will be developed and implemented in 2014/15. This detailed work will be undertaken across the next year to ensure improvements in the management of Concerns and Claims and that there is a robust and effective process to support learning and improvement across the Health Board. The findings of both external reviews commissioned by the Health Board and also by the Minister for Health & Social care shall be fully considered in development of priorities for improvement. The following are some of the areas of further work planned for next year: Full review and approval of the Putting Things Right Policy and Procedure. Improvements to accessibility of the concerns process for patients with sensory loss. Improvements to Concerns training for staff at all levels, via the development and roll-out of a training strategy and programme. Improved communications which highlight changes that have resulted from Concerns to be shared with staff across the Health Board, with the aim of improving learning from events. Implementation of Datix Web anticipated go live date of 1 st December 2014. 19