APPENDIX 2 Clinical Risk Management Report Quarter 4 2015/16
1. Introduction The Trust recognises that Clinical Risk Management must be fully embedded within the organisation through a clearly articulated structure and well led from board to ward. The Trust seeks assurance through a variety of methods that clinical services are safe, effective, responsive and caring. The Clinical Risk Management Report forms one component of this. The report will identify the following key clinical risk monitoring indicators and alongside the developing patient safety strategy will allow for a focus on the key clinical risk areas, driving forward quality improvements in patient safety. Reportable indicators for the purposes of the Clinical Risk Management Report are: Serious Incidents Significant Adverse Events Adverse Incidents Near Misses Complaints, Claims & Inquests This report presents the activity, identified risk issues and improvement actions taken in quarter 4 2015/16 in relation to reported serious incidents, significant incidents, adverse incident reports and near misses, claims and inquests. Complaints are reported in the Patient & Carer Experience report. The report has developed since its inception in quarter 1 with narrative detail, however it is continuing to develop data that is being used to drive the patient safety agenda and inform the patient safety strategy which will sit alongside this clinical risk report. The seven priority action areas will be reported against from Quarter 1 in the new 2016/17 Clinical Risk Report. Performance will be tracked against the previous year s data (where appropriate) and is split into performance at a corporate level and in the care group structure; with the aim of providing assurances in relation to the safety of services taken from the information derived from the systems and processes that have been established to report, monitor, improve and learn from clinical risk information. 2. Organisational Learning Key learning points are identified in this report. The quarterly Organisational Learning Performance Report provides greater detail in terms of the specific recommendations being made against clinical risk issues that have been investigated. 2
3. Serious Incidents Number of Serious Incidents from 2013/14 to Q4 2015/16 40 35 30 25 20 15 10 5 0 Admission / discharge Attempted / transfer suicide issues Death of patient Fire / fire alarm Illegal Acts 3.1 Serious incidents (SI) over the last 3 years Miscellane ous. Physical or MH Problems Missing Patients (inc attempted absconsion ) The graph above shows the comparison of SI s over the past 3 years. The number of incidents reaching SI status has reduced significantly since the introduction of the new SI framework and reporting mechanism from NHS England. If the deaths that met the significant event threshold were added to the deaths meeting serious incident threshold this would result in 35 patient deaths during 2015/16 compared with 38 deaths in previous years. Other Patient / Care problems Patient records - loss / destruction / damage / theft Pressure ulcer Sec urity incident self harm Violence & Slips / trips Agression / falls (physical) 2013/14 1 4 38 0 0 0 4 1 3 1 5 1 0 2 1 2014/15 4 2 38 1 1 0 1 2 1 0 10 0 1 0 1 2015/16 1 0 18 1 0 1 3 1 1 2 1 0 1 0 2 3
3.2 Quarterly data (2015/16) There were 7 new SI s agreed in Quarter 4. A summary of the nature of the incidents is given below. Death of Patient 1. Lady walking her dog along the river bank found a body. The deceased was confirmed as a patient who was receiving services from the Trust. 2. Patient's body was found in a derelict house. No cause of death identified at this time and circumstances of the death are currently unknown. 3. Following a welfare check being carried out at the patients supported living residence, the Patient was found unconscious. An ambulance and the police were called and they confirmed that the patient had died. 4. Patient was admitted to intensive care, where he received treatment, but his condition deteriorated and patient died. Fire / Fire Alarm 5. Fire was started in the unit by a patient. Incident resulted in a staff member needing hospital treatment. Missing Patient 6. The Trust was informed by the police that patient is reported as a missing person since leaving his home in his car on the 27.2.16. 7. Patient / Care Problem Patient transferred from acute care to a Community Hospital. Issues with the patient s assessment and treatment in the Community Hospital. Patient transferred back to acute services. 4
3.3 Comparison of Top 3 SI s for 2014/15 against 2015/16 (up to Q4) The table below shows that the main category of incident for a serious incident remains death of a patient. Pressure ulcers recorded as serious incidents have dramatically reduced over the year which demonstrates a significant improvement in care and treatment preventing deterioration to grade 3 or above. The pressure ulcer report is included in section 6.6 with analysis from the Tissue Viability Nurse. From Q1 in the new reporting year, the Tissue Viability Nurse will provide an independent Pressure Ulcer Report which will provide detailed analysis of all reported pressure ulcers and the improvements and changes to care provision that have brought about the reduction in pressure ulcers for patients under the sole care of Humber NHS Foundation Trust. 3.4 Patient Deaths The Trust has reviewed the procedure for reviewing and investigating all deaths in line with the recommendations made by Mazars for Southern Health. Staff are expected to report all deaths on DATIX and these will continue to be reviewed through the Clinical Risk Management Group (previously known as Organisational Risk Management Group). A number of processes are already in place within the Trust to review and investigate deaths reported for patients currently within or recently discharged from our care. The Trust Mortality Review Group undertakes in-depth reviews and analysis of all deaths. The review is currently underway and will make recommendations based on its findings. This Group is chaired by the Medical Director. 3.1 SI by Care Group These graphs give oversight of where SIs occur in relation to care groups and can help with future planning of investigation resources. 5
Children and Learning Disability Services have a low number of incidents that reach the serious incidents threshold due to the nature of the work and the safeguarding reporting mechanisms that are external to Humber NHS Foundation Trust. Any child deaths are overseen through the Child Death Overview Panel and are reported through the Safeguarding Report as either Serious Case Reviews or Lessons Learnt. Children s services actively participate in this process. There have been no child deaths in Quarter 4 receiving Humber services Community and Older People Services also have a low number of incidents that meet the serious incident threshold. There are a number of deaths that do not meet the criteria for investigation at SI level in relation to palliative and end of life care. Community Services end of life care has oversight from a regional End of Life Group. Humber is represented by the Nurse Consultant for Palliative Care. 6
Mental Health Services is the highest reporter of incidents that meet the Serious Incident threshold. The Trust is robust and transparent in the reporting of deaths where circumstances are unclear or lapses in care may be apparent. Under duty of candour all reports are shared with families and the Coroner where an inquest is undertaken. Where the Trust identifies that an internal investigation is not appropriate, external reviews will be requested. Specialist Services report a lower number of Sis than the Mental Health services. During the quarter HMP Wakefield reported 2 SI's (1 patient death and 1 patient care issue), the remainder were wards and teams which reported single SI s. HMP Wakefield contract ended 31.3.16 3.2 SI Investigation Reports There were 11 completed SI reports submitted to the Commissioners in Quarter Three 7
Of the 9 that have been marked by the CCG, all were judged as acceptable. (There is no longer any grading just acceptable and unacceptable). We are awaiting feedback on the remaining 3 reports. 3.3 Recommendations from Serious Incident Investigation Reports Quarter 4 Patient Death A patient was under the care of the Trust adult and older people s mental health services from June 2013. (SI 2015-31588) The patient had admissions to both adult and older adult inpatient services during 2015. He was discharged in September 2015 and seen on the day of discharge by his care coordinator. No significant risks were identified. Although appropriate plans and decision making were in place there was no evidence of adherence to formal section 117 procedure, in that no formal pre-discharge meeting was held under the terms of CPA/section 117. The patient s body was recovered from the River Ouse. A subsequent inquest has confirmed an outcome of suicide. No root cause was identified however the investigation identified the following learning points: Lessons Learned a) The assessment of pain and physical comorbidity is an essential element of older people s mental health services which is not embedded in practice. b) Referral pathways for psychological intervention are complex and not commonly understood. c) Adherence to standards of CPA and section 117 aftercare planning is not evident in this case. Patient Death The Hospital Mental Health Team assessed a patient who had taken an overdose. The patient was referred for secondary mental health assessment. The patient did not attend the appointment. The Trust was later informed via the Coroner that the patient had died. (SI 2015 34286) No root cause was identified however the investigation identified the following learning points: Lessons Learned a) Potential gap in cluster 4 provision between primary and secondary care. b) Need to improve communication between all providers and agencies involved in care pathway. Assault A patient detained under the Mental Health Act residing in the Humber Centre was being managed with a segregation and seclusion plan due to a long history of assaultive behaviour and incidents throughout his care history. (SI 2015-36359) The patient assaulted a staff member who required hospital treatment for facial injuries caused by a pen. Staff responded rapidly to the incident and the patient was restrained. No root cause was identified. The patient has since been transferred to high security. 8
Lessons Learned The interviews confirmed that staff involved with the incident demonstrated a working knowledge and understanding of policies and procedures. Staff prefer 1:1 debriefing sessions following traumatic incidents that group debriefs. Patient Transfer A patient was assessed in Scarborough Hospital and it was decided that an admission was required to Mental Health Services in Hull. As they neared the inpatient unit the patient became acutely agitated and tried to take control of the car. The car was damaged and the patient left the car. The staff provided support to the relative and apologised for the circumstances surrounding his relative s admission. (2015-37841) Root cause- inappropriate method of transferring the patient Lessons Learnt Clear guidance to be developed regarding assessment of patients presenting outside of Humber NHS Foundation Trust and how they are transported to Humber services based on risk assessment. Patient Absconsion A patient detained under the MHA was subsequently granted 2 hours unescorted leave and left the unit at 15.00 hours but never returned. The patient was discharged from the unit in absentia due to their Section 2 of the Mental Health Act 1983 expiring on the same day. (SI 2015-38367) No root cause identified. Lessons Learned Newly-qualified staff who are on Preceptorship should be supported by an experienced regular staff nurse when making significant clinical decisions. Patients with a past absconsion risk are likely to abscond again. 4. Significant Events Analysis (SEA) 4.1 SEA by Category Death of a patient may be deemed an SEA rather than SI if the circumstances and information from the briefing report indicates that there are no untoward circumstances on initial investigation. Conducting an SEA allows for investigation and should any issues arise that appear concerning the incident can be upgraded to an SI. It is noted that a number of deaths that may be requested for SEA investigation relate to individuals who may have been using addictive substances and died whilst receiving services from Humber NHS Foundation Trust and other providers. Work is ongoing to ensure investigations with partner organisations are robust. It is also key that whilst the nature of the individual deaths may not be untoward, the premature or unexpected nature of the death should be investigated to ensure that any learning or themes can be extracted in order to support wider learning. A piece of work is in progress, led by the Trusts appointed thematic reviewer to work with senior clinical staff to discuss the nature of incidents, support and interventions available to individuals who use substances whilst under the care of Humber NHS Foundation Trust; with the aim of assuring patients, carers and the board that this particularly vulnerable group are recognised within the investigation process. Reporting against this work group is expected in Quarter 1. 9
4.2 SEA by Care Group The information below can be split down into the following categories by care group. This information demonstrates that in line with serious incidents, the Mental Health Care Group manage and report a higher number of patient safety incidents. Significant Events are divided into two reporting styles; Comprehensive and Concise. Comprehensive SEs requires a timeline and analysis of the care provided. This is assigned to an incident that is not deemed an SI but where significant harm has occurred and the organisation wishes to learn lessons where possible. Concise SEs are allocated where a low level harm or near miss has occurred and the organisation believes that the team could learn through reflection on the event to minimise potential future harm or prevent the incident occurring again. Following a review of the current documentation, the Concise SE has been adapted to maximise the focus on reflective learning and reduce the administrative burden on clinical staff. These reports will be submitted back into the incident team and feature as a thematic review of all concise SEs rather than individual reports for the purposes of the clinical risk report. This allows consideration of wider team learning where appropriate. The comprehensive SE remains unchanged to ensure that the chronology and analysis is given full consideration. These will continue to appear individually within this report. 10
Community Services & Older Peoples Mental Health Care Group Q4 1. Patient on a community ward barricaded themselves in their room and caused superficial cuts to their arm. 2. Patient with dementia was 2 weeks post-op from fractured neck of femur. Patient was found to be dehydrated with hypernatraemia (high sodium ), acute kidney injury and low potassium. Children s and Learning Disability Care Group 1.Admission of a minor to adult in-patient unit on Section 2 of the Mental Health Act Specialist Services Care Group 1. Patient found at home deceased. 2. Patient found in bed with a ligature around his neck. Mental Health Services Care Group 1. Patient found deceased. 2. Patient and male friend injected heroin. Patient was later found by his friend unresponsive. An ambulance was called. Ambulance staff pronounced patient deceased. 3. Patient climbed over the garden wall and exited the unit. 4. Patient was found hanging. 5. Patient was reported in local press as a missing person on 09/02/16. On 18/02/16, staff informed via GP that patient had died. 6. At 21:00hrs, patient approached staff to inform that she had swallowed a battery, which she had taken from a clock on the unit. 7. Patient fatality. 11
4.3 SEAs Key Messages & Lessons Learnt- Overview Reference Number: SEA 2015-46 What Happened A fire occurred late evening within a bed room at 1 st floor level by deliberate ignition of clothing and bedding materials. The fire was extinguished by a member of staff and all patients were evacuated and accounted for as per the evacuation policy for the building. What was learnt Response to fire was good, all proceedures followed. Although patient has a long history of contact with services and presentation of self harm there was no indication of firestarting which would endanger the life and safety of others. Reference Number: SEA 2015-45 What Happened Patient was transferred to in-patient unit from a PICU environment on a Section 2. He was assessed by the Locum Psychiatrist the following day, made informal and discharged without appropriate follow up. What was learnt Staff nurses should feel confident to challenge medics, in a non-confrontational and professional manner. Nursing staff should initially raise concerns with Charge Nurse/ Deputy Charge Nurse and escalate to senior mangement if not available. Transfer summaries must be written and handed over to highlight areas of need, and also potential risk factors, including views from family/carers Reference Number: SEA 2015-44 What Happened The patient was under the care of the East Riding Partnership (ERP) Community Drug and Alcohol Team after being transferred from the ERP Specialist Drug Service. Subsequent liaison with the patient s Probation Officer and a police check on 5th December 2015 the patient was discovered deceased at their property. What was learnt Improved record keeping in terms of contact arrangements required. Agencies involved in the person care did not liaise or co-ordinate involvement. Reference Number: SEA 2015-42 What Happened In patient fall What was learnt There is no evidence the physiotherapist communicated verbally with the shift coordinator following an assessment, although there was written documentation regarding the outcome of the physiotherapy assessment. The care plan and the daily zonal engagement plan were not updated following the physiotherapist assessment. 12
Reference Number: SEA 2015-40 What Happened Patient took an overdose of paracetamol whilst on an in patient unit.the patient subsequently made a full recovery. What was learnt The formulation and input from psycholgy support enabled the team to change the way we work towards discharging complex patients. Reference Number: SEA 2015-38 What Happened The patient had a longstanding mental illness and had been known to local mental health services since 1993 with multiple episodes of care both as an in patient and out patient. Concerns were raised by the family to say they were unable to contact the patient. The police were contacted on 17 November 2015 who discovered the patient deceased. What was learnt There is an appreciation of the need to identify through the supervision process if a caseload is becoming hard to manage and identifying and reviewing any patients with whom there is difficulty engaging. Reference Number: SEA 2015-37 What Happened Patient found deceased lying on their back in the communal court yard of the block of flats, having sustained multiple injuries following taking recreational drugs. The death was reported to the Coroner. What was learnt Record keeping issues in terms of contemporaneous record keeping and clinical risk assessment. Reference Number: SEA 2015-35 What Happened The patient was detained on S37/41 MHA 1983, a low secure ward at the Humber Centre. They had a period of unescorted ground leave and failed to return. They have been found in Scotland and returned to the Humber Centre. What was learnt Controls regarding access to bus passes, cash cards etc. were not sufficient. Though this was an unusual situation, it is possible that other patients may travel to Scotland in the belief that the Mental Health Act 1983 may not apply. 5. Adverse Incidents Adverse incidents are reported through Datix and for the purposes of this report include all incidents. In relation to reporting incidents, it is encouraged within the organisation for staff to report all incidents and near misses. The information can be analysed and steps taken to reduce the opportunity for such incidents to reoccur or to track themes and develop patient 13
safety strategies with the clinical teams to either reduce the likelihood of occurrence or reduce the severity of such incidents. 5.1 Total Number of Adverse Incidents from April 2014 (recorded by quarter) Since the work in Quarter 1 to address the reduced reporting of incidents through Datix, the Trust has seen a sustained steady increase in incident reporting. This is a very positive position and demonstrates that staff understand the need to report incidents and near misses. Work was planned in Quarter 4 to undertake rapid improvement events to focus on the use of Datix in the high reporting areas listed below, however due to competing priorities this has not occurred across all the areas. Further plans are in preparation to review the use of DATIX in Quarter 1 and report back through the clinical risk report. Areas for review in Datix Reporting in Q1 are as follows: Violence and Aggression Self-Harm incidents Medication errors A review of Safer Staffing Datix reporting has taken place see section 5.5 The review work will give an opportunity for clinicians to influence how Datix is configured to report and collate data on these incident categories. It will also allow opportunity to explore training opportunities that staff require in order to correctly utilise DATIX and to understand how DATIX is being used in the organisation. The DATIX Senior Administrator is finalising a training package on the use of DATIX and plans are on track to facilitate DATIX training for interested individuals through a bookable system with the Learning and Development team. 5.2 Trust-wide by Severity of Harm In the graph below, the severity of harm reported remains consistent throughout Quarter 4 with the positive reporting of incidents with no harm and low harm. It is positive that incidents are not causing harm; this could indicate that staff interventions or other factors are preventing these in escalating to actual harms. Work needs to be undertaken to increase understanding of the actions, processes or interventions made to prevent patient harm will enable a sharing of good practice and potential for further improvement. 14
5.3 Trend Analysis The themes remain consistent in terms of the highest reported incidents in both 5.3 and 5.4. Violence and Aggression Pressure Ulcers Medication Errors The new Patient Safety Strategy identifies all 3 areas for priority action and initial progress is detailed in Section 6. 5.4 Top 10 Incident Categories over the past 3 years 15
Falls are noted to have increased in year-end reporting in year 15/16. There is opportunity to explore this patient harm through work that is commencing with the Improvement Academy. This will be reported on in more detail in Quarter 1. 5.1 Staffing Levels by Severity of Harm Reported staffing level shortages remained relatively consistent in Q4. Staffing is an area that is currently being scrutinised further within the Trust as a number of reports and information is collated. At the end of Quarter 4 a new Staffing Escalation Procedure was approved to ensure staff are aware how to manage and escalate shortages of staff on inpatient units. This procedure also provides clear guidance on how to report the severity of harm in Datix. The Trust notes that this will increase the reporting of harm levels, but will enable detailed, transparent information to be available that clearly describes the impact of not achieving agreed staffing levels. Humber NHS Foundation Trust is committed to open, honest reporting in order to understand the impact and required actions to provide high quality, safe patient care. 16
5.2 Severity of Adverse Incidents by Care Group This quarter has seen a significant rise in reporting by Children and Learning Disability Care Group, this will be further examined in the individual Care Group reports below. Community and Older Peoples services are the highest reporter of incidents within the Trust. However when viewed against severity of harm and SEAs and SI s this indicates that the Care Group is a strong reporter overall and not indicative of high risk/harms. Whitby services commenced provision from the Trust in March 2016, for the purposes of Quarter 4 and Quarter 1 going forwards, their data will be reported separately to enable oversight of the number, type and severity of incidents reported. This will allow the Care Group to focus on areas for improvement and development. This separate reporting will be reviewed in Q4 2016/17. Incident Types Reported by Whitby Community Services As can be seen above, one month data does not reveal any clear issues at this time. 17
Top 10 Incident Types Reported by Community and Older Peoples Mental Health As is expected The Community and Older People Care Group report the most pressure ulcers through Datix. Section 6 gives an indepth review of pressure ulcers. Top 10 Incident Types Reported by Mental Health Services Care Group The Mental Health Care Group continues to report in the incident area of violence and aggression and self-harm. In addition patients going missing increased significantly over Quarter 4, the majority of these incidents link to a male inpatient unit. During Quarter 4, due to review of the incidents, urgent upgrading works took place to fully replace the existing perimeter fencing and the incidents have subsequently reduced significantly Top 10 Incident Types Reported by Children s and Learning Disability Care Group 18
Children and Learning Disability services report highly in Violence and Aggression this quarter, the majority of these incidents have been related to one particular patient in a Learning disability unit with specific care needs due to their presentation and levels of challenging behaviour. A clear support plan is in place to help manage this patient. Oversight is given by the Clinical Care Group Director. Concerns for persons Datix have risen this quarter, this correlates with an increase in safeguarding referrals from CAMHS services and can be reviewed in the Annual Safeguarding Report which incorporates Quarter 4 data. Top 10 Incident Types Reported by Specialist Services Care Group As previously noted, the staffing level shortages for Specialist services are skewed this quarter with reception desk shortages. Self-harm and violence and aggression remain the most reported patient harms this quarter for specialist services. Top 10 Incident Types Reported by Corporate Services 19
The security incidents reported by Corporate services include 1 Information Governance incident and 5 lost ID badges/smart cards. 6. Pressure Ulcer Management Pressure ulcer prevention and management continues to be a national and local driver and will continue to be in the coming years with an aging population and with that the increasing risk of increased co-morbidities. This will result in an increased investment into Tissue Viability services to prevent an ever increasing risk of skin integrity breakdown due to pressure shear and other risk factors associated with skin breakdown. The previous report identified that the trust had piloted the SKINN bundle in the community setting. The pilot did not provide the desired outcomes as the tool as it is does not fit the community environment. This was fed back to the Trust and the Commissioners. The Commissioners are in agreement with this finding. The Tissue Viability Service has since revisited the SKINN bundle, we are currently looking at the feasibility of a revised version that maybe suitable for the community, although it would require significant investment and multi service buy in to make it work. Innovations Since the last report the TV service has provided the bases with laminated aide memoires on Accurate Pressure Ulcer Assessment. This supports the previous document for patients and carers on Preventing Pressure Ulcers. Other potential innovations for implementation are the introduction of a flag system for System One that would not allow the wound assessment to continue without the PU risk assessment being completed. The TV team are also looking at a new tool called React to Red, which might have a significant reduction in the risk of the ulcer deteriorating if detected early enough. The TV team have also collaborated on the production of a DVD for Care and Nursing homes with another NHS organisation and supported by industry. That should be available shortly. This should have a positive effect on providing accessible education and support as 20
it has been found that the homes have not logged on and used the on line modules previously provided. If utilised this should reduce the number of ulcers that are in shared care that we have only a degree of influence on. Process Change Over the last quarter there has been a significant process change in the way that we report and potentially investigate pressure ulcers. The new process for datix reporting remains the same, with a few amendments to the datix document. The change has occurred at the point of those ulcers that require a Root cause analysis. Previously this was undertaken by one specific person, which provided some excellent investigations. The weakness in the old process was the ownership of the root cause of the ulceration. The new process allows the Matron with the support of a local clinician to investigate the cause. This in itself has proved to improve practice by allowing the matron to see what the practice is really like. It also is in their interest to take ownership, as it is the clinician involved in providing the care, meaning that the actions will be acted on. The agreed timescale for the RCA is 4 weeks. The RCA is then sent to the Tissue Viability lead for comment and feedback. The RCA is then closed or escalated if appropriate. The new process has already had a positive outcome demonstrated by the positive feedback from the matrons who now feel more empowered as they are involved in the process. Ongoing work and innovation 1. Review, adapt and potentially adopt a version of the SKINN bundle if resources can be secured to support the process. 2. Introduce a version of the React to Red, to ensure that all patients that are at risk of skin breakdown have the appropriate assessments performed at the right time. 3. Develop a Pressure ulcer Pathway to support the PU policy. 4. Continue to support the new RCA process that will provide better preventative measures. 5. Develop a red flag system for S1 that will prevent the completion of part of the assessment unless the risk assessment has been undertaken. 6. Continue to provide education and training through supervision, TV modules ran x 6 per year. Bi-annual conferences within the organisation focussing on Pressure ulcer prevention and Safeguarding this year. 7. Include Safeguarding on the datix feedback, ensure that the duty of candour is completed and the risk of harm is correctly documented. 8. To attend national conferences to ensure that we are up to date with our care and intervention. To strive to become innvators. 6.1 Pressure Ulcer Recording The table below show the percentage of each Grade of PU against all PU acquired in that quarter with the percentage of acquired in our care against that specific grade. 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 Total No of Grade 1 PU 1 3 1 2 4 4 15 Percentage Total PUs 1% 2% 1% 1% 3% 3% 2% No. Acquired In Our Care 1 1 1 2 3 2 10 Percentage of Grade 1 100% 33% 100% 100% 75% 50% 67% 21
Acquired in Our care No of Grade 2 PU 101 133 113 113 85 80 625 Percentage Total PUs 65% 71% 61% 67% 58% 54% 63% No. Acquired In Our Care 56 56 60 61 37 40 310 Percentage of Grade 2 Acquired in Our Care 55% 42% 53% 55% 44% 50% 50% No of Grade 3 PU 42 27 23 23 14 19 148 Percentage Total PUs 27% 14% 12% 13% 10% 13% 15% No. Acquired In Our Care 19 10 15 13 7 9 73 Percentage of Grade 3 Acquired in Our Care 45% 37% 65% 56% 50% 47% 49% No of Grade 3+ PU 7 24 44 30 39 41 185 Percentage Total PUs 4% 13% 24% 18% 27% 28% 19% No. Acquired In Our Care 4 9 29 22 26 21 111 Percentage of Grade 3+ Acquired in our Care 57% 38% 66% 86% 67% 51% 60% No of Grade 4 PU 5 1 4 2 4 4 20 Percentage Total PUs 3% 1% 2% 2% 3% 3% 2% No. Acquired In Our Care 3 1 1 0 1 2 8 Percentage of Grade 4 Acquired in Our Care 60% 100% 25% 0% 25% 50% 40% Grade 2 pressure ulcers remain the most prevalent category of ulceration at 63%. There has been a continuing reduction in the grade 2 ulcers over documented 6 quarters. Norm = 101 in Q3 14/15 down to Norm = 80 in Q4 in 15/16. The number acquired in our care has also reduced over the same period. The reduction can be traced to the increased patient, carer and nurse awareness of the risk. There is also the increased organisational ownership of the pressure ulcer problem. Grade 3 Pressure ulcers have also significantly reduced over the eighteen month period, in excess of 50% from the start point of the table. This again is reflected in the number that were acquired in our care Norm = 7. There has been a slight increase in that number over the last quarter, however these ulcers have been unavoidable to Humber. Those ulcers that have been acquired in our care has dropped significantly from N= 19 in Q3 14/14 down to N= 9 in Q4 2016. The reduction in those acquired in our organisation should continue to show a downward trajectory based on the new investigation and ownership process. That should be reflected in coming quarters. This should also be enhanced by the continued trust investment in TV training with a focus on Pressure ulcer prevention. Grade 3+ which include those ulcers considered to be ungradeable and deep tissue injuries has stabilised over the last 4 quarters since the introduction of the grade 3+ category. This was introduced to make sure that those ulcers where not omitted from the RCA process. What is clear again is the significant reduction in the number of grade 3+ acquired in our care. 22
Grade 4 ulceration has again shown an overall stabilisation over the 6 quarters, with very low numbers per quarter reported. The last quarter however has shown two ulcers in total 6.2 Cumulative Pressure Ulcer reporting The table shows the general reduction in all grades of ulcer. There has been a slight variance between Grade 3 and Grade 3+ as staff have become more aware of the grading system through accessing Trust training. The grading system was introduced with the support of the commissioners. The data for grade 4 pressure ulcers remains positive within Q4 2016, as there has been only two reported grade 4 pressure ulcers that have developed in our care. Results of RCA s undertaken within the Neighbourhood Care Services The process for RCA investigation has changed significantly over the last quarter, giving greater ownership to the Matron and the local clinician. This has had a very positive outcome already as previously stated. There have been a total of 9 RCAs undertaken or in process at the time of the report for Q4. The RCAs to date have shown that all the ulcers have been unavoidable to Humber NHS Foundation Trust. However there have been significant lessons learnt which has resulted in some amendments to documentation etc. The actions have been identified, documented and have been presented to the teams and individuals by the Matrons as positive learning outcomes that are now managed in a timely way. The process has dramatically improved the ongoing management of pressure ulcers. 23
7. Near Misses 7.1 Trust wide Near Misses reported by quarter from April 2014 onwards Near miss reporting is remaining consistent through the year, with slight variance between 90-125 near misses reported each quarter. Medication errors remain the highest reported near miss over the year. Security incidents relate to the individuals who have left inpatient services without permission and are expected to reduce from Quarter 1 with improved security measures in one of the main units reporting missing patients. Patient Care and Patient information near misses are also highly reported as near misses, to fully understand this trend, During Quarter 1 a review of the previous year s incidents will be reviewed and reported on. 7.2 Near Misses reported by Care Group 2015/16 24
7.3 Near Misses key messages As work progresses within the patient safety strategy, Care Groups will be encouraged to review the near miss data and identify any key themes or new patterns of reporting to remove any potential hazards, processes or systems that are linked to near misses within the organisation. 8. Claims and Inquests Quarter 4 2015/2016 8.1 NEW CLAIMS in Quarter 4 (2015/16) 8.1.1 Clinical Negligence Claim Podiatry Allegation There was a delay in referring patient for amputation of his toe. Status Expert evidence is being sought prior to letter of response. Hull and East Yorkshire Hospitals Trust is also a defendant in this claim. SI, SEA completed or Complaint Received No. Initial clinical review suggests there were no concerns regarding the care provided by this Trust. 8.1.2 Request for support with inquest Mental Health, In-Patient Incident Patient died following self-ligature on in-patient unit. Status Inquest due 21 September 2016. Family represented. Article 2, Jury inquest SI, SEA completed or Complaint Received Internal SI completed (SI 2015-17021). The Trust has commissioned an external investigation. 8.1.3 Request for support with inquest Mental Health, In-Patients Incident Patient died on railway line after leaving in-patient unit. Status Inquest date still to be set. Solicitor s Letter has been received.. SI, SEA completed or Complaint Received Internal SI completed (SI 2015-23632) 8.1.4 Request for support with inquest Mental Health Incident Patient found deceased at home Status 25
Inquest due 01 June 2016. No solicitor letter has been received but the family has asked for an extension of limitation. SI, SEA completed or Complaint Received Internal SI completed (SI 2015-13068) 8.1.5 Employee Claim Mental Health In-Patient (Forensic) Incident Member of staff was injured after tripping on a protruding door stop. Status Claim lodged. SI, SEA completed or Complaint Received No 8.2 CLOSED CLAIMS in Quarter 4 (2015/16) 8.2.1 Request for support with inquest. CAMHS Incident Patient died after self-ligature at home. Outcome Narrative conclusion at inquest. NHSLA closed the file, not anticipating a claim. SI, SEA completed or Complaint Received No SI or SEA carried out. A complaint was received after the inquest had concluded. 9. Review of Clinical Risk Reporting for 2015/16 9.1 Internal Governance Arrangements The years reporting demonstrates a new governance and assurance reporting system for incidents, investigations and outcomes within Humber NHS Foundation Trust. Reporting of clinical risk over the year has improved with the development of a Clinical Risk Management Report. This collation and review of data has allowed oversight and scrutiny of the type of near miss or patient harm occurring within clinical services and enabled the development of a patient safety strategy to focus upon those harms that are most frequently experienced by our patients. There have been significant changes in the reporting and management of serious incidents over the year, with a move from an external team of Serious Incident Investigators to an internal Care Group process, overseen by the Chief Operating Officer and Care Group Directors. The change in the definition of Serious Incidents also brought about a review and new process for incidents that no longer met the SI threshold. The Trust introduced a new Significant Event Analysis process, which allowed either a comprehensive review, including a chronology of events or a concise review, which is a team reflection event. 26
Oversight of patient safety, incidents and safeguarding is structured in the Nursing and Quality Directorate, with an appointed Assistant Director of Nursing working to the Director. Within the current consultation on structures, a patient safety lead has been identified to support the patient safety strategy going forwards. These additional processes encourage the review of patient harms and consideration of lessons learnt and actions to be taken to reduce the severity of the harm or the incidence or recurrence. 9.2 National Context and Guidance During the winter of 2015, the sharing of the Mazars 1) report brought sharply into focus the oversight and scrutiny of investigations for people who had a diagnosis of a mental health or learning disability. The Trust has been committed to reviewing processes for investigating deaths in light of this report and will present a refreshed process to the Board. Critically, Humber NHS Foundation Trust has had a Mortality Review in place for the year led by the Head of Nursing. All deaths which are not expected are investigated as previously identified, in the case of Connor Sparrowhawk 2), who died unexpectedly in a bath in a NHS Trust. What is unclear at this time, is how the definition of expected death will be recognised nationally, it is well documented that people with serious mental illness and some people with learning disabilities have a reduced expected life span; however, this does not mean that their deaths should not be reviewed or investigated in the absence of any apparent incident. Death by Indifference 3) and Parity of Esteem 4) are issues that continue to headline in health care discussions and the Trust will remain watchful for changes in guidance and regulation. The Good Governance Institute in association with Datix 5) released a report in November 2015 highlighting that harm to patients arises mainly from failures in the health care systems, rather than wilful or negligent acts of individuals. Professor Berwick 6) in reviewing the NHS culture on patient safety noted that it still had some way to go in moving away from a punitive blame culture. This is a difficult transition when often organisations can feel under pressure to identify the issues and the public demand answers, system failures can be seen as an unwillingness to share specific details and take responsibility. The statutory duty of candour aims to move away from a defensive name and shame culture to one that acknowledges harm and works with patients and carers to identify the issues and look at ways to prevent or reduce the harm in future. The Trust has introduced a number of steps to ensure we capture when Duty of Candour has been undertaken and shared the requirements within teams. There is more work to do with clinicians to help them embed an understanding of the Duty of Candour, both the statutory duty and professional responsibility. 9.3 Patient Safety Priorities for 2016/17 As is clearly reflected in this report, the Trust needs to review the management of violence and aggression within its services. A new workgroup to review the Positive Proactive Care Guidance has been established and is focussing on current training methodologies and responses to aggression. A real commitment is focussed on reducing restrictive interventions but also positively reporting on these through the Clinical Risk Report. Self-harm, which includes the use of ligatures and cutting is growing nationally and particularly in the child and adolescent population. With the approval of the patient safety strategy, the opportunity to focus all Care Groups on this area of harm is vital. The Trust is keen to work with partners in this area and across the region. This will include focussing on 27
suicide and the Trusts Strategic Suicide Plan, led by the Medical Director. The Trust will need to address training for staff in compassionate and targeted individual responses to people who self-harm or who wish to take their own life. Reviewing the Year and all the serious incidents that have been investigated and reported, these 2 areas are a key concern for Humber NHS Foundation Trust. The Trust is also keen to ensure that patients and carers are invited to participate in these improvement plans. Clear links with the patient experience team are required. Oversight of the Datix incident reporting system remains with the Datix officer. In the previous structure co-ordination of the Investigations sat with a senior clinician, however this has been reviewed and will sit with the clinical systems assurance officer. The Senior clinician who previously oversaw investigations will be refocused to undertake regular thematic reviews and give greater insight and reflection across investigations to ensure the learning is taken across the Trust. These reports will feature in future clinical risk reports and will also lead to future staff learning events in the clinical teams. For the year forward, the patient safety and clinical risk management team are keen to develop the patient safety profile in the Trust and encourage all staff to think about patient safety and their contribution to reducing or preventing harm. Links with the Academic Health Sciences Network through the Improvement Academy for Yorkshire and Humber are now in place and the opportunity to work on Safety Huddles in clinical teams has been widely embraced by a number of teams. A development day is being held in May with the Improvement Academy to take this work forwards. The Clinical Risk Report will evolve for 2016/17 with the following changes: 1. Tissue viability will create its own independent risk report quarterly. 2. Patient deaths will be reported through the Mortality Review Group within this report as an enhanced reporting section for transparency. 3. Progress against each of the Patient Safety Priorities form the Patient Safety Strategy will be reported within this report. 4. Care Groups will provide commentary for their risk areas and any additional actions or work they are undertaking. 5. Focussed Reviews will be included when specific pieces of work have been undertaken to analyse incident or harm trends and make recommendations for improvement. References 1. Mazars. 2015. Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015. https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazarsrep.pdf 2. Verita. 2015. Independent review into issues that may have contributed to the preventable death of Connor Sparrowhawk. https://www.england.nhs.uk/wp-content/uploads/2015/10/indpndnt-rev-connorsparrowhawk.pdf 3. Mencap. 2007. Death by Indifference. https://www.mencap.org.uk/sites/default/files/documents/2008-03/dbireport.pdf 4. Centre for Mental Health. Parity of Esteem. Website. http://www.centreformentalhealth.org.uk/parity-of-esteem 28
5. Good Governance Institute. 2015. What every healthcare director needs to know about patient safety. www.good.governance.org.uk 6. Berwick. D. (2013) A promise to Learn, A commitment to Act. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/22670 3/Berwick_Report.pdf Report written and collated by: Salli Midgley: Assistant Director of Nursing for Patient Safety and Safeguarding Darren Hillerby: Clinical Systems Assurance Officer Simon Barrett: Tissue Viability Nurse 29
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