Serious Incident Report Public Board Meeting 26 November 2015 Presented for: Presented by: Author Previous Committees Governance Yvette Oade, Chief Medical Officer Craig Brigg, Director of Quality None Trust Goals The best for patient safety, quality and experience The best place to work A centre for excellence for research, education and innovation Seamless integrated care across organisational boundaries Financial sustainability Key points 1. This report includes a summary of new serious incidents, including two never events, that have been reported in September and October and the initial actions that have been taken to mitigate the risks. 2. There has been an increase in pressure ulcers and patient falls resulting in serious injury in the last two months. 3. The paper includes a summary of the completed investigations which have been submitted to the CCG in September and October 2015; it outlines the root cause(s) of the incidents and summarises the actions agreed to address the care and service delivery problems identified during the investigations. Information Information Information 1
1. SUMMARY This report summarises the serious incidents that have been reported to Commissioners at NHS Leeds West CCG in September and October 2015 with information about the initial actions taken to mitigate the associated risks. 2. BACKGROUND The Trust is committed to identifying, reporting and investigating serious incidents, and ensuring that learning is shared across the organisation and actions taken to reduce the risk of recurrence. The Trust seeks, where at all possible, to prevent the occurrence of serious incidents by taking a proactive approach to the reporting and management of risk, to ensure safe care is provided to patients, through the promotion of a positive reporting and investigation culture. A serious incident is defined as where a patient, member of staff or member of the public has suffered serious injury, major permanent harm, unexpected death or where there is a pattern of incidents or actions which have caused or are likely to cause significant concern. Patients are not always harmed as a result of a serious incident. Near misses may also constitute a serious incident where the contributory causes are serious and may have led to significant harm. These are reported and investigated in line with our Serious Incident Procedure to help us learn and take action to prevent patients, staff and members of the public from being harmed. The number of serious incidents reported by month to NHS Leeds West CCG, as the agreed responsible commissioners representing all of our CCGs, is included in figure 1. Fig 1: Total number of Serious Incidents reported by month 2.1 Pressure Ulcers The decision to include the development of category 3 pressure ulcers as serious incidents in addition to category 4 pressure ulcers is directly linked to our programme for improvement, which is focused on reducing the incidence of harm from more severe pressure ulcers. Like the category 4 pressure ulcers, category 3s are subject 2
to Root Cause Analysis investigation led by the responsible specialty team and the reports are reviewed by a central group. Figure 2 illustrates the number of Category 3 pressure ulcers reported since April 2014. Fig 2: Total number of Category 3 Pressure Ulcers In September 2015 there were five category 3 pressure ulcers reported to the CCG. There were two category 3 pressure ulcers reported in October 2015 as potential serious incidents, however these have not been reported to commissioners due to a change in the reporting procedure following publication of the revised serious incident framework by NHS England in April 2015, which recommended that the process for reporting category 3 pressure ulcers was reviewed locally to identity the most serious pressure ulcers that were considered to be avoidable and led to longerterm or permanent harm. The Trust has agreed with the commissioners that a category 3 pressure ulcer will be reported as a serious incident to the CCG where the Root Cause Analysis investigation concludes it could have been prevented and led to longer-term or permanent harm. The outcomes of the investigations of the two category 3 pressure ulcers that were reported in October 2015 as potential serious incidents are currently awaited. 2.2 Falls Falls resulting in serious injury, for example, a fractured hip or head injury requiring surgery also began to be reported to Commissioners at NHS Leeds West as Serious Incidents from January 2015. These incidents are subject to a detailed Root Cause Analysis investigation to help us identify the causes and to agree actions that we need to take to reduce risk. The process is led by both the specialty team and CSU and the reports are reviewed by a central group. The chart below shows the number of patient falls resulting in serious injury. It is disappointing to see that following a notable reduction in the last two months of quarter one and quarter two, there has been an increase in quarter three. Reducing the total number of patient falls within the Trust is also part of our improvement programme. Review of all falls related incidents across the Trust for the period January 2015 to October shows that there has been a 22% reduction in incidents demonstrating that the work we are undertaking is having a positive impact 3
on patient safety. The Trust s Corporate Nursing Team, Patient Safety and Quality Managers and clinical leads are working closely with the Clinical Service Units with a view to reducing the number of falls resulting in serious harm. Fig. 3: Total number of falls resulting in serious injury 3. New Incidents A total of twenty serious incidents were reported to Commissioners at NHS Leeds West CCG in September and October 2015; this number includes the potential category 3 pressure ulcers for October. These are currently being investigated and are summarised below together with details of the immediate actions taken. 3.1 Category 3 pressure ulcers In September 2015, five of the serious incidents reported were category 3 pressure ulcers. In October two category 3 pressure ulcers were reported to Risk Management but not declared to the CCG due to a change in the reporting procedure described in section 2.1. It is pleasing to note that no category 4 pressure ulcers were reported for the period being reviewed. It is 296 days since the Trust last reported an incident of development of a category 4 pressure ulcer received in our care. Reducing category 3 and category 4 pressure ulcers is a priority area for further improvement in 2015/2016, working in conjunction with our commissioners and partner organisations. This work is included in the Trust s Safety Improvement Plan. 3.2 Patient Falls In September 2015, three of the serious incidents reported were in relation to patient falls. In October 2015, five of the serious incidents reported were in relation to patient falls. A significant amount of work is currently being undertaken within the Trust to reduce the number of patient falls as a priority area in our quality improvement plan. 4
3.3 Neonatal Death In September a baby was born at term in a poor condition and was transferred to the neonatal unit where a diagnosis of Chronic Hypoxic-Ischemic Encephalopathy (HIE) was made (brain damage caused by a reduced supply of oxygen). Following a discussion with the parents, care was withdrawn and the baby sadly died the following day. Immediate Action Taken An immediate review established some potential issues relating to documentation and arrangements for the review of abnormal CTG tracings. There is no evidence at this stage to suggest that these issues would have changed the outcome for the baby. However, a decision has been made to conduct a Serious Incident Investigation as there may be an opportunity for learning to take place. 3.4 Patient Injury (Fractured Wrist) In October a patient was admitted to hospital and was being investigated for seizures, confusion and intermittently aggressive behaviour. The patient was receiving 1-1 supervision from an external security contractor that had been arranged to provide support to wards in our hospitals where this was required. Prior to the incident the patient became agitated and attempted to pull a television off the wall in his room. The contractor tried to stop the patient by pulling his hands away and during that time the contractor reportedly heard a click from the patient s right wrist. An x-ray revealed a fracture to the patient s right wrist. Immediate Action Taken The contractor was informed immediately and the individual employee is currently not working in the Trust pending the outcome of the investigation. Following the incident a plan was put in place to call upon the Trust security staff if the patient s behavior becomes unmanageable. The incident was reported to the Health and Safety Executive and the CQC have registered their interest in the outcome of the investigation. An immediate Root Cause Analysis investigation was carried out and a decision was subsequently made to conduct a Serious Incident Investigation. 3.5 Never Events It is extremely disappointing to report that two never events occurred in the Trust in October. A never event is a serious incident that has the potential to cause serious harm to a patient and is preventable if the checking procedures are in place and followed consistently. This means we have reported four never events since April 2015. To raise the awareness of all staff across the Trust, the Chief Executive has talked through these two never events and shared the individual patient stories at Team Brief. He has highlighted the impact that these avoidable incidents have on patients and the concerns they raise about patient safety. The details of the incidents are as follows: 5
3.5.1 Retained Swab In October a patient was admitted for a liver transplant. Post operatively the patient s recovery was delayed due to symptoms of fever. Sepsis, inflammatory response to an infection, was subsequently diagnosed. An abdominal CT scan was carried out which raised suspicion that a foreign object had been retained in the patient s abdomen. The patient was subsequently taken back to theatre and a surgical swab was removed. Immediate Action The incident was discussed with the patient and an apology was offered; the patient recovered well from the surgery and swab removal and discharged home without further complications. The incident was declared as a serious incident and never event and reported to NHS West Leeds CCG and the Trust Development Authority (TDA). A debrief meeting was held with the staff involved which identified issues in relation to the swab count and use of swab safe (containers for storing used swabs). The patient recovered well and has subsequently been discharged home. A detailed investigation is currently taking place. A new priority training package in conjunction with the Theatres Education team regarding accountable items has been developed and this will be delivered to all staff involved in the accountable items process. A communication was sent to all Clinical Directors, Heads of Nursing and General Managers by the Deputy Chief Medical Officer and Medical Director (Operations) to be shared with clinical staff involved in theatres work Including all surgical specialities, dentists, interventional radiologists, obstetricians & cardiologists. 3.5.2 Wrong Site Block (Never Event) In October a patient was being prepared for an open ankle fusion procedure on her left leg. She had consented to have a general anesthetic with a regional anesthetic block for post-operative pain relief. The operating department practitioner (ODP) accompanied the patient to the anesthetic room and the patient was prepared for the procedure. The ODP positioned the right leg to enable a nerve block to be performed. As the right leg was being held in position the ultrasound was repositioned and the anaesthetist performed the block to the right (incorrect) leg. As soon as the block was completed the ODP realised that the block was on the wrong side. A local anaesthetic block was performed on the correct side (left) and the operation was completed uneventfully. Immediate Action Taken The incident was discussed with the patient and an apology was offered. The incident was declared as a serious incident and never event and reported to NHS West Leeds CCG and the Trust Development Authority (TDA). A debrief meeting was held with the staff involved. An aid to ensure all anaesthetists stop and check before administration of a block has been placed on ultrasound machines in theatres and the procedure will be presented at the monthly clinical audit meeting. A detailed investigation has commenced. 6
4. COMPLETED INVESTIGATIONS There has been one Serious Investigation completed and submitted to the CCG during September and October. The incident is summarised below along with the details of the root cause and the action plan agreed to address the care and service delivery issues identified. Summary A patient was taken to the Emergency Department (ED) at St James s Hospital (SJUH) by ambulance after being found above a motorway bridge on the outskirts of central Leeds, contemplating a suicide attempt. Before a psychiatric assessment took place the patient left the ED and gained access to a high level fire exit on the SJUH site and either fell or let herself fall from the fire escape. The patient received extensive but not life threatening lower limb injuries. Root Cause The patient s risk of self-harm was not formally assessed and as a result of this the patient was able to leave ED and self-harm. The required level of observation and supervision was not provided. This was due to lack of clearly formalised or understood guidelines for staff in the department to follow. Learning Identified and actions taken The lesson learned through investigation of this incident is that psychiatric assessment for patients with known mental health problems should be prioritised. The following actions will be implemented to prevent recurrence of similar incidents in the future: ED together with Acute Liaison Psychiatry Service (ALPS) are to produce guidelines covering the initial mental health assessment/triage and referral pathway to ALPS; the simultaneous assessment and treatment of mental and physical health; the levels of observation required, focusing specifically on Mental Health Act guidance, persons trained in safe restraint and utilising security staff when required. ED together with ALPS to agree a formalised risk assessment tool for management of patients at risk of harm to self and others. ALPS and ED to determine competencies required by staff in ED when looking after patients with mental health symptoms. Identify appropriate locations with restricted access within EDs to facilitate assessment, observations and ongoing care of vulnerable patients. Risk assessment to identify and restrict access to high level access points at Leeds Teaching hospital by the Estates team to be completed and actions agreed where appropriate. 5. PUBLICATION UNDER THE FREEDOM OF INFORMATION ACT This paper is made available under the Freedom of Information Act 2000. 7
6. RECOMMENDATION Trust Board is asked to receive the serious incident report, note the new serious incidents that have been reported, including initial actions taken to mitigate risks and the closed investigations and the agreed actions. Dr Yvette Oade Chief Medical Officer November 2015 8