1) Please tell me separately for 2022/23 and 2023/24 the number of deaths for which a case record review or investigation has been carried out leading to the conclusion that they were more likely than not to have been due to problems in the care provided to the patient.
2022/23 – <5
2023/24 - 13
2) Please provide me with a brief overview of the FIRST FIVE incidents (in 2023/24 preferably or from 2022/23 if the former is not yet available) identified in question 1 (i.e. cases of deaths that were more likely than not caused by problems in care), withholding any identifying information that would run into a Section 40 exemption.
Incident 1
Diagnosis issue
Incident 2
Communication failure affected care
Incident 3
Issue regarding discharge
Incident 4
Delayed medication
Incident 5
Unplanned return to theatre
3) Finally, can you please summarise what the Trust learnt and what actions have been taken as a result of these five cases highlighted in question 2?
Incident 1:
Action taken following investigation:
· Case shown at departmental meeting for shared learning. No specific actions required.
· No systemic or process issues identified requiring action.
Incident 2:
Actions taken following investigation:
· The Medicine and Emergency Care Division reviewed the Emergency Care Pathway, along with the associated systems, processes and guidelines in place for managing patients presenting with headaches to aid clinicians when determining if the headache is classified as primary or secondary, and whether onward referral to Neurosurgical Services is necessary.
· Radiology to seek clarification from referrer before rejecting requests.
Incident 3
Actions taken following investigation:
· The Medicine and Emergency Care Division to ensure compliance of completion of Silver Trauma and Primary Survey screening within the Emergency Department
· Review whether Cerner needs to have an alert included for completion of Silver Trauma / Primary Survey, to remind Emergency Department staff about the importance of documenting a discharge decision and undertake an audit to review compliance with discharge documentation standards.
Incident 4
Action taken following investigation:
· The Anticoagulant service to ensure that the Peri-Procedural Management of Patients on Oral Anticoagulants, Antiplatelets and Low Molecular Weight Heparin, Version 2 is accessible to all staff across the Trust.
· The Endoscopy department and the Anticoagulant service to review the Trust wide policies to ensure they are relevant for endoscopy procedures and can be used in conjunction with the British Society of Gastroenterology guidelines to provide a standardised approach for the management of patients on anticoagulants who require invasive procedures in endoscopy.
· The Endoscopy service to ensure that patients who are identified as being on an Anticoagulant medicine are referred to the Anticoagulant team when they are booked for a procedure. Monitoring should be put in place to ensure that the process is being followed.
· The Endoscopy service to consider the development of a patient information leaflet for patients who take Anticoagulant medication and undergoing elective procedures to provide advice on when medication should be stopped and restarted and who to contact for advice.
· The Endoscopy service to review the organisation of procedure lists to take account of the number and complexity of patients on the list.
· The Endoscopy service to implement a standardised process for the clinician review of lists to minimise where possible the impact to patient care due to the complexity and timing of procedures.
Incident 5
Actions taken following investigation:
· Additional staff training regarding inputting fluid balance charts and assessing fluid input / output. The Trust has also organised a series of 1:1 eCoaching sessions for any clinical staff to book on who require further support.
· A tablet or computer on wheels to be used at patients’ bedsides when undertaking patient examinations and / or reviewing notes to ensure staff see patient observations in real time, identify trends within patient care and notice patient deterioration.
· The Trust has adopted the national ‘Martha's Rule’ (called ‘Call for Concern’). The initiative was implemented on 26 March 2024 and gives patients, families, carers and colleagues round-the-clock access to an urgent review from an independent team if they are worried a patient’s condition has deteriorated.
