Investigation Template Please read Incident Investigation Protocol before initiating this investigation This can be found on the NHS Lothian intranet under Healthcare/A-Z/Risk Management Incident Investigation Protocol This template should be used for investigation of all Significant Adverse Events (SAE) resulting in major harm or death and for RIDDOR reportable incidents. Please save the template securely on your NHS shared drive as you work through the investigation. Once completed, update the document control details (within the footer) and attach the latest version into the relevant Datix incident as Draft. Please note also that there must be no person- identifiable information in this report instead please say patient A, ward B, doctor C etc throughout. Summary incident description and outcome Datix ID No: 282914 Deceased patient was discovered to be lying on her side, instead of her back, on the tray inside the mortuary cooling facilities. Consequently the fluids had pooled into the side of the deceased s face. The deceased s face was extremely discoloured. Mortuary staff felt she was unsuitable for viewing. Time period of investigation: Description of Investigation Reported to Start Finish Robert Aitken Stuart Laidlaw 11/11/15 8/2/16 Claire Smith Aris Tyrothoulakis Incident date: 10/11/2015 Incident type: Major Location of incident: Mortuary RIE Actual effect on patient/staff/ Deceased patient wrongly positioned and in the incorrect fridge please specify: compartment. Scope and level of investigation Internal investigation within Organisation led by the senior nursing team in liaison with Facilities Management and Bereavement Manager Written statement request Interviews with relevant staff Review of policies Datix completion. Adherence to Severe Adverse Event policy Involvement and support of patient and relatives in response to incident 11/11/15 - Mortuary staff alerted their manager, Alison Anderson. Datix completed by Mortuary technician. DATIX pathology managers. Mortuary manager contacted Bereavement Coordinator, as felt family should be told as they may wish to view. Bereavement Manager then escalated this to General Manager who telephoned deceased s daughter. Family extremely upset but pleased to be informed. 12/11/2015 - daughter and son asked to come and view deceased. Arranged for meeting with Bereavement Manager and General Manager for 6pm. Daughter and son viewed deceased in RIE mortuary. Daughter requested visit to look at the fridge space, this was facilitated by AND and mortuary manager 23/12/15 Detection of incident (who, when & how) Mortuary technician discovered incident the next morning, 11/11/2015 when carrying out her usual checks on deceased patients admitted to mortuary overnight. Alerted and escalated to the line manager Chronology of incident/ events (dates & times of key events/ actions, use separate sheet if required) Timeline 10/11/2015 23.30hrs transferred to mortuary facilities by portering staff. File Name: 282914 SAERApr1620 Version: 3 Date: February 2014 Produced By: NHS Lothian Author: Page: 1 of 6 Review Date/ Status:
11/11/2015 09.00hrs deceased patient discovered to be lying on her side. Reported to mortuary manager Datix completed. 11.30hrs - Mortuary manager contacted Bereavement coordinator to help escalate this as family would need to be told about incident. 15.30hrs family were contacted by General Manager and incident explained. 12/11/2015- Family requested to come to hospital to view deceased patient. 18.00hrs Family viewed with General Manager and Bereavement Manager in attendance Care and service delivery problems that led to the incident Contributory factors Contributory Factors Guidance Patient factors - This was a sudden and unexpected death. Patient was obese and due to her illness had a grossly extended abdomen. Individual (staff) factors - Porters lack of awareness of what equipment to use for a safe lateral transfer Communication factors - Lack of appropriate communication re deceased patient was bariatric. Task / technology factors Equipment and Education issues Work environment factors - Pat-slide and glide sheet were not always available. Equipment - Concealment trolley was not in full working order. Pat-slide and glide sheet should have been available Education and training Training sessions have been put in place for Cofely porters. See action plan Organisational factors Moving and Handling procedures for deceased bariatric patients have been revised. See action plan. Key issues Poor communication between the ward staff and portering supervisor that the deceased was bariatric and may have required different equipment and more staff to transfer safely. Porters were not using correct techniques for safe lateral transfer. Porters did not use appropriate equipment, glide sheet and pat-slide. Concealment trolley was in a state of disrepair. Consequences for the family. Lessons learned Manual handling guidelines for bariatric patients were not followed as per current guidelines. Manual handling guidelines for carrying out lateral transfer were not followed. Communication between ward/dept staff and portering supervisor whether there are any manual handling issues in particular with weight, shape and position has room for improvement. Robust and consistent information is required in both NHS Lothian s guidelines and Cofely s Guidelines. Understand the consequences for family and all the staff involved in the incident. More education is required in particular around manual handling procedures and necessary equipment required. Recommendations Moving and handling guidelines for deceased bariatric patients need revised and updated. Cofely s Procedure for the transfer of deceased patient needs revised and updated. Robust plan for implementation of updated guidelines and procedures. Concealment trolley replaced and a more suitable one sourced and used on a trial basis initially. Mortuary exploring alternative cooling facilities for bariatric patients. Education for porters on moving and handling procedures, mortuary services and bereavement service. Produced By: NHS Lothian Author: Page 2 of 6 Review Date/ Status:
Education sessions need expanded to cover WGH and SJH. Clear and concise pathway for escalating a mortuary issue to nursing directorate if necessary. Improvement plan Moving and Handling guidelines for deceased bariatric patients are currently being updated and will be submitted for approval at the next Clinical policy and documentation group on 29 th March 2016. Deceased Patient Procedure (Last Offices) updated re deceased bariatric patients. Revised guidelines and procedures must have a robust implementation plan to reach all staff. Alternative style of concealment trolley needs to be explored. Moving and handling, mortuary, bereavement service and porters to jointly source what is available and the plan is to trial some different styles of trolley. Education sessions currently being delivered to porters by Moving and Handling, mortuary services and bereavement service should be expanded to cover WGH and SJH sites. Arrangements for shared learning where, when & by whom TBC once all guidance has been updated and signed off by the Clinical Policy and Documentation Group Author: SL/RA/KM Date: 8/2/16 For SAE, the incident must not be closed on Datix until this report has completed the formal governance approval process. This will be done at the end of the process by Clinical Governance and Risk Management Support staff. This can be found on the NHS Lothian intranet under Healthcare/A-Z/Risk Management SAE Sign-off process SIGNED OFF BY (IF SIGNIFICANT ADVERSE EVENT) CH(C)P Director/ General Manager/ UHD Director of Operations Signed: Date: 06/04/16 Signed: J McNulty, AND Date: 21/2/2015 Divisional Nurse/ Medical Director/ CH(C)P Clinical Director/ Chief Nurse Brian Cook 08/04/2016 Sarah Ballard Smith 07/04/2016 FINAL APPROVAL Medical Director Signed: David Farquharson Date: 13/04/2016 Nurse Director Signed: Alex McMahon Date: 13/04/2016 Please ensure that the Improvement Plan Summary on the following page is completed. Produced By: NHS Lothian Author: Page 3 of 6 Review Date/ Status:
Improvement Plan Summary Document Datix No 282914 Contributory Factors Moving and handling guidelines for deceased bariatric patients in our care required updating Communicatio n re deceased bariatric patients between all the involved staff needs a more robust process Issues linked to contributing factors Current guidelines were not being followed due to specialist equipment and lack of staff awareness No robust system in place to document/prompt/remin d staff of their responsibility in communicating this information to porters, mortuary staff or funeral directors. Actions to Address Factors New guidelines currently being revised and will go the next Clinical Policy and Documentatio n Group for approval Pilot notification form for deceased patients is currently being trialled. Cofely supervisors ask if there are any moving and handling issues requiring a further risk assessment. Level of Recommendatio n (Individual,, Directorate, Organisation) Organisation Organisation By Whom By When Moving and Handling 29/03/201 6 Bereavement Service Cofely Supervisors Ward staff 29/03/201 6 Resource Requirement s Evidence of Completio n Completio n Sign-off Complete Complete Produced By: NHS Lothian Author: Page: 4 of 6 Review Date/ Status:
Concealment trolley not in full working order. Mechanism for raising or lowering the trolley was not working. Clips to secure mortuary tray were broken Pat-slide and glide sheets not always readily available. During transfer the trolley could not be raised or lowered to facilitate safe lateral transfer. Tray could move during transfer as not secured on top of the concealment trolley No used as unavailable Trolley has been replaced with one in full working order however; it is not fully compatible with fridge trays. Trial of other concealment trolleys is planned. Ward staff need to be reminded they are to be made available prior to transfer. Cofely Moving and handling Mortuary manager Ward Staff Cofely Mortuary By when? 30 th May 2016 January 2016 Ongoing Completed Education and training must be updated and provided to porters on all sites Current practice was outdated and unsafe A back up supply of glide sheets will be made available from Cofely and mortuary. Education sessions for all portering staff currently being run to update staff mortuary/bereaveme nt team & manual handling January 2016 Completed Produced By: NHS Lothian Author: Page: 5 of 6 Review Date/ Status:
on process and expectations when caring for deceased patients as well as manual handling and equipment updates. Recommend this is expanded to WGH and SJH. Produced By: NHS Lothian Author: Page: 6 of 6 Review Date/ Status: