Public Trust Board Meeting 22 November 2011 Title Lessons Learned Report Paper Ref 12 PURPOSE (X) Information Strategic Aim Business Plan Objective Approval Decision X 1.2, 3 Assurance X Discussion Purpose of the paper The purpose of the paper is to highlight learning identified through the investigation of issues, themes and trends and the actions that are being taken or have been completed as a result. Recommendation It is recommended that the Board considers the steps that have been taken to identify lessons learned and supports the actions that have been taken or are being taken as a result. Author Hester Rowell, Head of Quality and Patient Experience Accountable Director: Steve Page, Executive Director of Standards and Compliance RISK ASSESSMENT Yes No Changes to the Corporate Risk Register and/or Board Assurance Framework Resource Implications Legal implications X X X CQC Registration Outcome(s) ASSURANCE/COMPLIANCE Auditors Local Evaluation NHSLA Risk Management Standards for Ambulance Trusts 16 4.1, 4.2 5 1
1. PURPOSE 1.1 The purpose of the paper is to highlight learning identified through the investigation of issues, themes and trends and the actions that are being taken or have been completed as a result. 2. INTRODUCTION 2.1 This report brings together information from the following sources: Incidents Serious Untoward Incidents Complaints and Concerns Clinical Incident Reviews Patient Experience Reports Reports by External Regulators. 2.2 The report covers the period 1 August 2011 to 30 September. 2.3 The following sources are also part of the systems for lessons learned, however there have been no issues highlighted or recommendations received during the period. Rule 43 Letters Safeguarding Serious Case Reviews. 2.4 It highlights learning identified through the investigation of issues, themes and trends and the actions that are being taken or have been completed as a result. 2.5 The report particularly highlights where common themes are identified across more than one source. 3. INCIDENTS 3.1 The table below shows the numbers of new incidents reported each month. Table 1: New Incidents Reported New Incidents Reported Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ops - A&E 166 212 193 209 172 260 A&R 64 85 62 55 107 61 PTS 51 56 66 52 61 59 OTHER 172 186 187 156 176 161 TOTALS 453 539 508 472 516 541 2
3.2 The other category primarily relates to incidents linked to fleet and estates and includes: road traffic collisions, vehicle damage and buildings damage. 3.3 The fleet department has appointed an accident reduction manager to oversee a programme of work to reduce the Trust s vehicle accident rate. Progress against initial priorities include: A draft driving policy has been put out for internal consultation Accident figures have been analysed, highlighting that a high number relate to reversing incidents. A reversing campaign is being developed to promote good practice. Opportunities have been identified for closer work between the fleet and legal departments. 3.4 The operational incidents have been further analysed to identify: Medication-related incidents Patient-related incidents Staff-related incidents. Table 2: Patient-Related Incidents Patient Related Incidents Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ops - A&E 13 19 22 24 23 24 A&R 0 2 1 0 4 0 PTS 27 23 27 27 27 28 OTHER 3 3 1 0 2 1 TOTALS 43 47 51 51 56 53 Table 3: Staff-Related Incidents Staff Related Incidents Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ops - A&E 44 71 64 83 59 75 A&R 3 2 4 4 5 0 PTS 14 20 27 11 14 14 OTHER 9 8 8 8 3 5 TOTALS 70 101 103 106 81 94 3.5 Two ongoing themes from incident reports are: equipment being damaged whilst being transported in blue equipment bags (in particular, several incidents were reported of damaged oxygen masks) 3
staff reporting injuries sustained as a result of carrying the blue equipment bags. 3.6 YAS has commissioned Loughborough University to work on a project to address these two issues. The project is looking at the design and contents of the blue bags used by staff working on double-man ambulances and the equipment used by rapid responders. The aim is to develop the design can be developed to reduce the risk of injury to staff and to best protect its contents. The project teams for these pieces of work have been identified and have met to review the current blue bag and identify key requirements for its replacement. 3.7 Injuries to staff have also been reported from transporting patients to vehicles on carry chairs. Investigations into these incidents highlighted problems using the chairs in situations including: steep staircases and where staff were taller/shorter than average. A project is underway, led by the risk and safety team to assess the current chairs and make recommendations for improvement. This will include engagement with staff and patients. Letters and notices were sent to patient representatives and staff in October to ask for people willing to participate in the project. It is anticipated that the first trials will start in January 2011 (depending on winter pressures). 3.8 Full project implementation plans, completion dates and key milestones are currently being agreed. Table 4: Medication-Related Incidents Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar North Yorkshire CBU 2 0 4 1 3 4 East Riding of Yorkshire CBU 1 3 0 1 1 0 Leeds & Wakefield CBU 21 25 14 5 8 41 Bradford, Calderdale & Kirklees CBU 9 9 8 14 8 14 South Yorkshire CBU 0 1 4 1 1 3 TOTALS 33 38 30 22 21 62 3.9 All medication-related incidents are reviewed by the Trust s Medicines Management Committee. The most significant numbers of incidents relate to the usage and storage of controlled drugs and are in line with previously identified themes of: Stock control Damage to drug packaging. 3.10 An action plan is in place, led by the Medicines Management Committee to embed policies and procedures locally and internal spot checks are being made through the Trust s Inspection for Improvement programme. 4
3.11 Due to a number of reports of diazepam stock control issues the Medicine s Management Committee is considering whether to manage this drug as a controlled drug. Table 5: Serious-Untoward Incidents SUI Incidents Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ops - A&E 0 1 0 1 1 1 A&R 0 0 0 0 1 0 PTS 0 0 0 0 0 0 OTHER 0 0 0 0 0 1 TOTALS 0 1 0 1 2 2 3.12 The four SUIs reported in this period relate to: i) Defibrillator failure ii) Delayed response due to dispatch error iii) Cannulation incident iv) CAD system failure. 3.13 The investigations for cases 1, 2 and 4 are ongoing. Case 3 has been closed as the investigation found that the clinical care provided by ambulance staff was appropriate and in accordance with clinical guidelines. 3.14 Action plans from the two SUIs reported in May and July continue to be tracked through the Risk and Safety team and are due to be completed by 30 November and 31 December respectively. Lessons will be reported in the next Board Lessons Learned Report. 3.15 A number of lessons have been learned from a previous SUI (currently awaiting a coroner s hearing) relating to a patient travelling with a voluntary car service (VCS) driver. These include: VCS drivers should be first aid trained (currently over 90% complete) VCS drivers should carry first aid bags and know the process for restocking (complete) A process should be in place for deep cleaning VCS vehicles (this is documented in the Occupational Exposure Policy) VCS drivers should understand Trust policy (information about the relevant policies and procedures are included in the VCS handbook) 5
4. COMPLAINTS AND CONCERNS Table 6: Complaints and Concerns ACCIDENT AND EMERGENCY 2011/12 APR MAY JUN JUL AUG SEP Attitude and/or Conduct 14 9 3 11 8 2 Aspects of Clinical Care 15 18 18 15 16 21 Driving and Sirens 5 1 10 5 0 9 Other 2 4 3 0 4 1 TOTALS 36 32 34 31 28 33 ACCESS AND RESPONSE 2011/12 APR MAY JUN JUL AUG SEP Attitude and/or Conduct 0 0 1 2 1 2 Response 16 17 18 20 25 23 Call Management 5 3 1 3 2 1 Other 0 0 0 0 0 0 TOTALS 21 20 20 25 28 26 A&E Activity 56159 55970 55160 57247 54907 55520 Complaints v Activity (%) 0.06% 0.06% 0.06% 0.05% 0.05% 0.06% PATIENT TRANSPORT SERVICES 2011/12 APR MAY JUN JUL AUG SEP Attitude and/or Conduct 4 6 5 2 7 4 Aspects of Clinical Care 4 3 8 3 3 4 Driving and Sirens 2 1 1 3 1 1 Response 52 65 72 79 62 40 Call Management 2 1 0 0 5 3 Other 0 0 0 1 0 1 Service to service 12 56 68 75 119 101 TOTALS 76 132 154 163 197 154 PTS Activity 77918 83549 88048 76083 78765 78850 Complaints v Activity (%) 0.10% 0.16% 0.17% 0.21% 0.25% 0.20% YAS TOTALS 2011/12 APR MAY JUN JUL AUG SEP Attitude and/or Conduct 18 15 9 15 16 8 Aspects of Clinical Care 19 21 26 18 19 25 Driving and Sirens 7 2 11 8 1 10 Response 68 82 90 99 87 63 Call Management 7 4 1 3 7 4 Other 2 4 3 1 4 2 Other areas of YAS 0 2 1 0 0 1 TOTALS 121 130 141 144 134 113 4.1 Lessons learned from complaints and concerns in this period are as follows: 6
Driving 4.2 A number of the complaints and concerns reported in the tables above as driving/sirens-related were cases where members of the public reported feeling intimidated by the driving of ambulance staff. To address this, in addition to the work being led by the new YAS accident reduction manager (see section 2 incidents), a reminder was put out to all staff from the Trust s chief driving tutor reminding them about good driving practice and the consequences should individuals be found to have shown undue aggression towards other drivers. Communication between YAS staff and patients/carers 4.3 A theme noted in this period was complaints/concerns arising as a results of a communications breakdown between YAS staff and patients/carers. More specifically, investigations into the complaints/concerns identified that the crew members had correctly followed procedures but that the patient/carers had not understood what was happening and why, which led to a poor experience. In a small number of cases patients/carers reported dissatisfaction with crew members language or attitude. To address this issue at a Trust level a communications element has been built into the specification for the YAS clinical skills and clinical leadership programmes (currently being commissioned). PTS Service-to-Service complaints 4.4 The significant rise in the number of service-to-service complaints between April and September 2011 corresponds to the introduction and rollout of the new system for logging and responding. 4.5 The figures show that the most common reason for service-to-service complaints are late pick up of patients for their inward journeys or late collection of patients from hospital to return home after their appointments. 4.6 The PTS team have identified that vehicles off the road (VORs) are a significant cause of delays. A meeting was held between the PTS locality managers and the Head of Fleet to discuss the issues. As a result it was agreed that the Fleet department would provide more advance notice of scheduled services to PTS vehicles and the VOR key performance indicator for PTS would be checked and the figures updated to ensure accurate monitoring. 5. CLINICAL CASE REVIEWS 5.1 YAS s clinical case review (CCR) process is followed when incidents highlighted through other channels (e.g. via the incident reporting process or complaints process) contain a clinical element. Clinicians can also self-refer for the process. 7
Each CCR panel is chaired by a senior clinical manager (or above) and comprises a full review and discussion of the clinical care provided to the patient concerned compared to YAS procedure and national clinical guidelines. 5.2 Nine CCRs have taken place in this period. Controlled Drugs 5.3 Following on from the theme highlighted in the September Board Lessons Learned report regarding adherence to procedures for managing controlled drugs, a further CCR was carried out into a similar incident in July 2011. This identified the need for a system to monitor drug-related incidents at an individual level. 5.4 Two CCRs related to clinicians management of patients suffering traumatic injuries. This is a previously noted theme and a programme of trauma training is underway. The first priority is to train staff to use new equipment for management of trauma patients. This will be followed up by further training as part of the clinical update days planned for early 2012. Communication between YAS staff and patients/carers 5.5 One CCR identified the issue reported in section 6 (complaints and concerns) relating to staff communication. 6. PATIENT EXPERIENCE 6.1 YAS s patient experience programme includes routine methods to capture and monitor data about patient experience through surveys and comments cards; more in-depth methods to look at the experiences of specific serviceuser groups; and systems to capture feedback from patient groups such as Local Involvement Networks. Patient appreciation 6.2 The clearest theme from all sources is that patients greatly appreciate the service they receive from YAS. The most frequent comment in the patient surveys is that people wish to express their gratitude and thanks for the care and reassurance of the staff members who attended them in an emergency or transported them to a planned appointment. Staff attitude 6.3 A much smaller number of service-users expressed dissatisfaction with the attitude of staff. This was a theme across A&E, A&R and PTS. Narrative comments suggest that a small number of staff members are expressing opinions/judgements about the appropriateness of the 999 call or use of the service. 8
Hospital discharge procedures 6.4 Three patient groups (from North Yorkshire, Kirklees and East Riding of Yorkshire) have raised issues regarding vulnerable patients and hospital discharge. These relate to the handover of care from the hospital to YAS and whether systems are in place to make sure that the ambulance staff have all the necessary information relating to that patient to ensure their safety. The YAS Safeguarding Committee is aware of these issues and is working with PTS colleagues to look at possible solutions. 7. REPORTS BY EXTERNAL BODIES Listening and Learning: the Ombudsman s review of complaint handling by the NHS in England 2010-11 7.1 This Health Service Ombudsman s second annual report on the complaint handling performance of the NHS in England. In particular it focuses on the achievement of NHS organisations against the commitments in the NHS Constitution to acknowledge mistakes, apologise, explain what went wrong and put things right. 7.2 This report highlights the following themes in relation to complaints about NHS services: Poor communication Dissatisfaction with clinical care Staff attitude Waiting times for access to services. 7.3 The most common interventions were: Apologies Putting things right Demonstration that lessons had been learned. 7.4 Of the sixteen patients who appealed to the Ombudsman, only one case was upheld. This related to poor communication by clinicians when they left a patient at home rather than transporting them to hospital. 7.5 Issues arising from this report and implications for YAS policy, practice and staff training will be considered at the next Patient Experience Group meeting. 8. NEXT STEPS 8.1 The YAS standards and compliance team continues to develop the Trust s approach to learning lessons. This work includes the following aspects: Developing culture to encourage reporting and reinforce a positive attitude to investigations with a focus on learning and not blame; Developing policy and procedure to increase focus on learning lessons and agreeing/monitoring improvement actions; 9
Improving sources of information to provide a stronger basis for identification of themes, trends and issues; Developing Board and departmental dashboard reporting to provide greater insight and assurance. 9. RECOMMENDATIONS 9.1 It is recommended that the Board considers the steps that have been taken to identify lessons learned and supports the actions that have been taken or are being taken as a result. 10