CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 01/10/2013 to 31/12/2013

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 01/10/2013 to 31/12/2013"

Transcription

1 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 1/1/213 to 31/12/213

2

3 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 1. Introduction On a quarterly basis, aggregation of Complaints, Litigation, Incidents, PALS and Safeguarding referrals reported on our Risk Management System (Safeguard), is completed to determine the corporate themes and key issues. The purpose of this paper is to report the Quarter 3 213/14 position on aggregated CLIPS, identify themes and action being taken and to recommend any further remedial work that may be required. 2. Executive Summary As in previous quarters, the categories of adverse event most likely to arise across all CLIPS are those involving diagnosis and inadequate care/treatment. The latter show a trend associated with delays in treatment, capacity and transfer arrangements. As in the previous quarter, there are trends across most CLIPS in Accident and Emergency, Trauma and Orthopaedics and General Surgery. Pressure Ulcers categorised as severity 2, or 3 have increased compared to the previous quarter. There were 2 category 4 pressure ulcers reported during Q3 compared with 4 pressure ulcers in Q2. Wounds, patient falls and medication error related incidents are the most frequently reported incidents. Falls reporting levels remain constant, with the majority of incidents occurring in MLTC. However, the overall numbers have increased by 5% in Q3 compared to Q2. 6 incidents caused moderate - major harm. There have been 37 Serious Incidents reported compared with the previous quarter when there were 36 reported. One National Never Event (insulin related) was reported during Q3. There was one complaint alleging major harm which has been caused by inadequate treatment compared with 1 in the previous quarter. There have been no new claims with the potential for resulting in a significant compensation award. A range of improvement work-streams continue to be implemented, particularly in relation to pressure ulcers, falls, documentation, nutritional care, intravenous fluids and fluid balance. 3. CLIP Totals Total numbers of New Formal Complaints, Clinical Negligence Claims, Incidents and Informal Complaints Date Range Formal Complaints Informal Complaints Incidents Clinical Negligence From 1/1/213 to 31/12/ Corporate Themes Corporate Theme Formal Complaint Informal Complaint Incidents Clinical Negligence Claims Other Admission/Discharge/Transfer Communication & Attitude Diagnosis Equipment 4 58 Health Records Inadequate Care /Treatment Page 3 of 22

4 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) Infection Control 46 Manual Handling 8 Medication Errors Patient Falls 176 Pressure Ulcers 1 87 Staff/Visitor Accident 64 Staffing Violence & Aggression Page 4 of 22

5 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) During Q3 213/14, the trend picture was similar to Q2 213/14 with themes across all CLIPS including: - Diagnosis issues - Inadequate Care/Treatment - Communication failure - Admission/Discharge and Transfer The category of adverse event most likely to arise across all CLIPS is inadequate care/treatment. During Q3 there were 268 issues reported compared to 358 in Q2, equating to a 25% reduction. There are a range of issues arising from CLIPS involving inadequate care and treatment Inadequate nursing or medical care Delay in providing care or treatment Diagnosis issues continue to feature in all CLIPS, however during Q3 there has been a decrease of 18% within incident reporting. There has been a generalised reduction in most categories across all CLIPs during Q3, however there has been a increase in both complaints and incident reporting relating to Medication Errors. The following table details the Corporate themes by Division. It should be noted that these figures are influenced by the higher levels of incident reporting in MLTC and WCCSS. Further discussion is contained in the sections on individual CLIPS. Page 5 of 22

6 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 5. Corporate Themes by Division Womens, Childrens and Clinical Support Services Surgery Medicine and Long Term Conditions Estates and Facilities Other Admission/Discharge/Transfer Communication & Attitude Diagnosis Equipment Health Records Inadequate Care /Treatment Infection Control Manual Handling Medication Errors Patient Falls Pressure Ulcers Staff/Visitor Accident Staffing Violence & Aggression Incident by Category Type Total Clinical Incident 232 Maternity Managed Event 159 Violence & Aggression 13 Non Clinical Incident 96 Report An Accident/Near Miss A 85 Security Incidents - Security 17 Page 6 of 22

7 6.2 Incidents by Category & Actual Harm Moderate No Minor Major Death Near Harm Miss - Near Miss 1 - No Harm 2 - Minor 3 - Moderate 4 - Major 5 - Death Other Admission Attitude Blood/fluid Administration Breach In Policy/procedure Burns/Scalds 4 C-Difficile 1 2 Clinical Care/assessment/treat Collision Between Vehicles 1 2 Communication Consent Contact With Dangerous Part Of 1 Contact With Hazardous Substan 2 2 Cuts & Abrasions 2 Data Protection - Security Bre Diagnosis Discharge Discriminatory Abuse 2 Environment Equipment Fire Or False Alarm 1 1 Fraud 1 Health Records Hit By Falling/moving Object Hit By Moving Vehicle 1 Impact With Stationary Object 1 3 Infection Control Investigations Lost Property 13 2 Manual Handling 8 1 Medical Emergencies & Cardiac Medication Error Needles And Sharps Non-Compliance Operative Procedures Patient Fall Pregnancy & Birth (Managed) Pregnancy/birth Page 7 of 22

8 Pressure Ulcers Radiation (Patients & Public) Referrals Security Breach - Physical Sec Security Related Incidents Slips/trips/falls (Staff And V Specimen Handling Staffing Theft 2 Transfer Unauthorised Access To It Syst 2 Unexpected Death Vandalism 2 Violence/aggression Wounds Most frequently reported incidents include Admission/Discharge/Transfer Falls Staffing Communication Incidents causing moderate to catastrophic harm during Q3 involve: Pressure ulcers Pressure ulcer incidence is monitored closely across the organisation and remedial action progress considered in a monthly report to the Board. Incidence of category 2 pressure ulcers has increased from 49 in Q2 213/14 to 67 in Q3. The more serious ulcers are developing in lower numbers in hospital, overall the numbers are similar to previous quarters. It should be noted that this report includes category 1 pressure ulcers which are not included in the monthly performance and quality reports. During Q3, these totals have significantly decreased from 18 incidents reported in Q2 to 7 incidents reported in Q3 (61% reduction). Patient Falls Patient falls incidence is subject to close monitoring across the organisation, with remedial action considered by the Board on a monthly basis. During Q3 there was a slight increase (5%) in the total number of falls reported compared to Q2, however falls causing moderate or major actual harm increased by 5%. (6 incidents reported in Q3 compared to 3 incidents in Q2) Staffing issues Staffing issues continue to be most frequently reported by Delivery Suite (21 incidents reported). During Q3, 13 incidents were reported as causing minor or moderate harm, compared with 2 reported in Q2. The Director of Nursing has presented a report on nurse staffing requirements to the Trust Board. Admission, discharge and transfer Admission - delays in providing a bed for specifically the surgical speciality Discharge - delays in receiving medication and non-timely completion of electronic dicharges Transfer - Theatres reported an increased number of incidents relating to lack of post-operative surgical beds. Unexpected death There were 1 incidents relating to unexpected deaths. 7 cases were obstetric incidents and have been investigated through the Perinatal Mortality and Morbidity forum. 1 case was a child death following withdrawal of treatment. 2 adult death cases were reported and were the subjects of local root cause analysis investigations. Neither of these patients' died as a result of the incident. Page 8 of 22

9 Wounds Patient Medication Transfer Communication Staffing Violence/aggression Investigations Health Pressure Clinical Breach Admission Equipment Discharge Non-Compliance Infection Data Diagnosis Radiation Slips/trips/falls Referrals Operative Specimen Blood/fluid Needles Medical Lost Attitude Environment Unexpected Manual Security Burns/Scalds Impact Pregnancy/birth C-Difficile Collision Consent Cuts Discriminatory Fire Theft Unauthorised Vandalism Contact Fraud Hit By Or Property & Protection Falling/moving Moving Records Handling Abrasions False With Emergencies Control Related And Breach Between Ulcers Procedures (Patients Policy/procedure Administration & Error Death Stationary Dangerous Sharps Hazardous Birth Alarm Access Vehicle Abuse (Staff - Incidents Security Physical Vehicles & And To & It Wounds Patient Medication Transfer Communication Staffing Violence/aggression Investigations Health Pressure Clinical Breach Admission Equipment Discharge Non-Compliance Infection Data Diagnosis Radiation Slips/trips/falls Referrals Operative Specimen Blood/fluid Needles Medical Lost Attitude Environment Unexpected Manual Security Burns/Scalds Impact Pregnancy/birth C-Difficile Collision Consent Cuts Discriminatory Fire Theft Unauthorised Vandalism Contact Fraud Hit By Or Property Protection & Falling/moving Moving Records Handling Abrasions False With Control Breach And Related Between Ulcers (Patients & Error Death Sharps Birth Alarm (Staff - Wounds Patient Medication Transfer Communicati Staffing Violence/aggr Investigations Health Pressure Clinical Breach Admission Equipment Discharge Non-Complia Infection Data Diagnosis Radiation Slips/trips/falls Referrals Operative Specimen Blood/fluid Needles Medical Lost Attitude Environment Unexpected Manual Security Burns/Scalds Impact Pregnancy/bir C-Difficile Collision Consent Cuts Discriminatory Fire Theft Unauthorised Vandalism Contact Fraud Hit By Or Property & Moving False Fall With And & Incidents by Division and Category (Top Ten) 6.4 Incidents by Actual Harm and Division By Division, incidents have occurred in the following proportions: Division Q3 (213/14) Q2 (213/14) Q1 (213/14) MLTC 46% 43% 49% WCCSS 31% 31% 28% SURGERY 21% 25% 21% COMMERCIAL.4%.6%.2% CORPORATE.7%.4%.7% Historically, MLTC has consistently reported the highest number of incidents each month, equating to approximately half of all incidents, however during this quarter there has been a slight increase from 43% in Q2 to 46% in Q3. Surgery incident reporting has decreased this quarter, whilst WCCSS remains at a constant reporting level of 31%. Work will be required to understand low levels of reporting in Surgery. The Division reporting incidents that are causing the most harm to patients is MLTC, this being influenced by the incidence of pressure ulcers, falls and other wounds. Other than these incidents: - Falls are more frequently reported in MLTC - Staffing issues are reported more frequently in WCCSS and MLTC - Equipment issues more frequently reported in WCCSS and surgery - Medication errors were most frequently reported in MLTC

10 6.5 Incidents by Ward/Department -As in previous quarters, Ward 27 (Delivery Suite) continues to report the most incidents. This is mainly attributable to the numbers of incidents reported where an unavoidable complication of pregnancy occurred, but was managed according to protocol or guidance. Delivery Suite also report high numbers of staffing issues. - Patient's Own Home incidents have increased this quarter with approximately 72% of incidents being attributed to wounds predominantly identified on admission to hospital. - Accident & Emergency most frequently report clinical care, treatment and assessment incidents, a continuing trend for the third quarter. - Theatres continue to report transfer delay incidents at increased levels. - Ward 5/6 has increased reporting levels relating to inappropriate transfers. - Ward 16 continue to report wounds, falls and violence and aggression incidents. - Ward 3 has increased reporting levels relating to wounds, falls and pressure ulcers. - Ward 12 continue to report wounds, falls and medication errors. - Ward 21 feature in the top 1 this quarter due to increased reporting of neonatal readmissions within 28 days. 5% of the department incidents refer to this trend. WCCSS have been asked to review. - Imaging department continues to feature with 35% of incidents attibuted to near miss and radiation issues.

11 6.6 Serious Incidents 37 incidents were reported as Serious Incidents to the SHA in Q3, a slight increase on Q2 when 36 incidents were reported. These include: Pressure Ulcers 14 cases were reported which is a decrease compared to the last quarter when 17 cases were reported. Findings from root cause analyses are presented by individual team leaders/senior sisters to the Pressure Ulcer Steering Group and themes used to inform improvement work. Infection Control: 2 incidents were reported. Falls 4 cases were reported during Q3, remaining at a constant level as previously reported in Q2. Findings from root cause analyses are considered collectively by the Falls Prevention Steering Group and themes used to inform improvement work. In addition, there is an ongoing programme of weekly audits being carried out in order to gain further insight and new improvement initiatives involving falls prevention education, wider availability of low rise beds and increased 'sitter' provision have now been implemented. Delayed Diagnosis 5 cases have been reported, 3 cases were radiology related whilst the remaining 2 cases were delayed diagnosis of cancer. A review of Imaging Services in relation to Serious Incidents has been completed and presented to the Executive Committee. Obstetric Cases 6 obstetric cases were reported - 2 intra-uterine deaths, 1 unexpected admission to Neonatal Unit, 1 unexpected neonatal death, 1 intra-partum death and 1 maternal admission to ITU. Information Governance Breach 1 incident was reported relating to sensitive correspondence about a staff member being inadvertently sent to the wrong address. Insulin related 2 cases were reported, (1 case classified as a Never Event). A Trust wide initiative on improving inpatient diabetes management (insulin related) is in progress. Fluid balance monitoring 1 case was reported relating to inadequate monitoring. Medication Errors 2 cases related to the delayed administration of antibiotics

12 7. Complaints Type Totals Appointments 7 Attitude 8 Clinical Care/assessment/treat 65 Communication 37 Diagnosis 16 Discharge 9 Environment 4 Food/beverages 2 Health Records 2 Information 3 Medication Error 8 Pressure Ulcers 1 Privacy/dignity 2 Referrals 2 Staffing 4 Transfer 2 Violence/aggression 2

13 There were 11 letters of complaint received in Q3 (including 1 conversion from informal to formal, with 183 themes arising. The departments most frequently involved were: Accident and Emergency Trauma & Orthopaedics General Surgery Clinical Care/assessment and treatment continues to be the most frequently themes in formal complaints, however there has been a decrease from 85 themes in Q2 to 66 themes in Q3. Complaints involving clinical care, assessment and treatment are most commonly being received in relation to care given in Accident and Emergency Trauma & Orthopaedics. General Surgery Lessons Learned: - Standard operating procedure to be developed to ensure children are accompanied by parents when returning from theatre. - Standard operating procedure to be developed for properly transferring between wards. - Competency based training for District Nurses on long term conditions. - Review and reinforcement of NICE guidance on tuberculosis in paediatrics. - Feedback to staff in Trauma & Orthopaedics regarding communication and attitude. - Revised discharge planning documentation. - Improved service for provision of tongue tie surgery. Patient Relations Team Developments - During October 213, we hosted the National Complaints Managers Group Conference, where the findings of the recent Clywd/Hart review into NHS Complaints were presented. - Also during October 213, we organised a "Learning from Patient Experiences" conference which was well attended from staff across the Trust. The conference was attended by the Health Minister, Dr Daniel Poulter MP and delegates included staff from the George Eliott Hospital, who were keen to see how Complaints are dealt with at Walsall. The conference delegates listened to a number of patient experiences both positive and poor and had the opportunity to contribute to developing preventative action plans. Patients' were involved directly in the workshops and listened to the feedback from staff on what could have been done differently. Due to the success, requests have been made to hold smaller sessions with staff involving the patient in the development of the action plan. - The team have provided data to the Lorenzo project team in order to monitor the effects of the new system to enable staff to respond more quickly to concerns and complaints, particularly in areas such as Access.

14 7.2 Formal Complaints by Category and Division During Q3 Divisional formal complaints were received: Q3 (213/14) Q2 (213/14) WCCSS: 12% 13% Surgery: 39% 4% MLTC : 46% 44% Compared to Q2, there is a slight increase in MLTC and decrease in WCCSS and Surgery Table 7.3 provides a breakdown of the top 1 areas receiving the most complaints. The Divisional Quality Teams review all complaints to identify action required against themes within theses areas.

15 7.3 Formal Complaints by Ward/Department 7.4 Formal Complaint Response Times Response to complaint times has not reached the agreed standard of 7% within 3 days. During Q3, 31% of complaint reponses were sent out within the timescale, compared to 46% in Q2. The number of overdue complaints remains relatively stable with the total number of complaints overdue currently standing at 19. MLTC have no overdue complaints and are consistently working well with the Patient Relations Team to identify Investigating Officers quickly and respond to concerns. Investigating Officer training has been delivered recently to MLTC Senior Sisters and the Division has been the first to trial responding to complaints as a direct letter to the complainant. Further investigation training is to be delivered during February 214 to WCCS and Surgery Divisions. A review of the complaints management process in Surgery is being carried out to determine the reason for ongoing non-compliance. 7.5 Serious Complaints There were 22 moderately severe, and 1 major complaint received in Q3, compared with 33 severe, major and catastrophic in Q2. There is a risk of a clinical negligence claim arising from 2 complaints (assessment based on initial letter)

16 8. Informal Complaints Type Total Admission 5 Appointments 18 Attitude 21 Clinical Care/assessment/treat 74 Communication 34 Diagnosis 9 Discharge 17 Environment 3 Equipment 4 Health Records 2 Information 24 Lost Property 2 Medication Error 5 Patient Transport 1 Referrals 5 Staffing 1 Transfer 2 Violence/aggression 1

17 8.2 Informal Complaints by Category and Division 73 concerns related to clinical care, assessment and treatment in Q3, a significant decrease from 13 in Q2. Attitude related concerns have decreased slightly compared to the previous quarter. There has been a slight increase in concerns being raised about appointments, 18 in Q3 compared to 12 in Q2. Trauma and Orthopaedics and Access are the departments receiving the highest number of concerns, mainly concerned with clinical care, assessment and treatment. Surgery and MLTC continue to see higher numbers of concerns being raised around clinical care, assessment and treatment and attitude. Table 8.3 provides a breakdown of individual areas receiving the most informal complaints. The Divisional Quality Teams review all issues to identify action required against themes within theses areas.

18 8.3 Informal Complaints by Ward/Department

19 9. Clinical Negligence Claims Category Total Clinical Care/assessment/treat 21 Consent 1 Diagnosis 4 Pregnancy/Birth Clinical Negligence Claims by Category and Division There are currently 237 active clinical negligence claims files. 11of these have been referred to the NHSLA and of this group, 75 are being handled by Trust solicitors. Where a claim has been referred to the NHSLA, the case has progressed to a Formal Letter of Claim or proceedings have been issued. During Q3, 27 new claims were received. Of those received in Q3, there are 2 common themes, consistent with previous periods, quality of clinical treatment provided and diagnosis. In Q3, the specialties receiving most claims are Surgery, Obstetrics & Gynaecology and Trauma and Orthopaedics. Claims related to Accident and Emergency increased to 4 claims during Q3 compared to 2 claims in Q2. All claims are assessed as to their merit as soon as they are received and the Divisional Quality teams are provided with reports on activity.

20 9.3 Clinical Negligence Claims by Specialty

21 Serious Claims There have been no new claims received with the potential for resulting in a significant compensation award. 9.5 Closed Claims 41 claims closed during Q3: 5 claims closed with no compensation awarded/withdrawn - these claims closed due to lack of merit 34 claims closed due to inactivity 2 claims closed with compensation: 1 related to surgical error 1 related to inadequate care post surgery The Quality and Safety Committee has been kept abreast with the outcome of closed claims and the action taken to address risk issues via the Board Performance and Quality Report. 1 Safeguarding 78 safeguarding concerns were raised during quarter 3 and related predominately to vulnerability and neglect. The Trust received 6 external alerts in relation to the following categories of abuse - Institutional (1), Neglect/omission of care (4) andphysical abuse (1) Institutional abuse - 1 Hospital concern in relation to allegation that patients not toileted as insufficient staff available- concern in relation to privacy and dignity- unsubstantiated Neglect- 2 Hospital concerns in relation to transfer of care. Omission of information as part of a transfer process, (1 substantiated concern and 1 un-substantiated). 2 concerns in relation to deterioration of an existing pressure ulcerunsubstantiated. 2 incidences were reported by Tissue viability in relation to development of category 3 pressure ulcer within the hospital. These have been subjected to a root cause analysis. Physical abuse - 1 Hospital concern in relation to a patient who disclosed that he had been 'hit' by a nurse. This is subject to an internal investigation and police investigation. Other incidences - A relative was seen hitting her mom on the ward- this was reported to and managed by the police. A patient had disclosed sexual abuse early in her admission and this was reported. Staff observed patient being subjected to inappropriate touching by relative on the hospital ward. The later episode has been reported as a Serious Incident and RCA has been scheduled Other activity - Requirement also to submit trust safeguarding adults training data to sub group on a quarterly basis. MLCC leads co-ordinating data submission- reporting on level 1 awareness and recognition. Corporate update now includes safeguarding adult component. Trust supported domestic homicide reviews- early actions identified are in relation to the awareness of staff in A&E around domestic abuse. Awareness Training has been sourced via the domestic abuse forum who will attend the department to do local awareness briefing sessions. Leaflets have been distributed to A&E, public areas, and ward areas. 1 key messages have been developed and published within Chief Executive update as a guide for staff. Under the mental capacity act any adult who lacks capacity to make decisions around medical treatment and change of accommodation should be supported by an IMCA if they have no one representing their views. The current provider for the Trust since April 213 is Voicability. A concern has been received in relation to a patient who had an IMCA appointed but they were not consulted in relation to the decision around having a PEG inserted. The concern relates not to the decision but to the process. A response has been submitted by the consultant. MLCC have been requested to provide opportunity for Voicability staff to attend the Trust to promote the service. Learning disabilities- A quarterly report has been developed which allow monitoring of activity and achievement towards key performance indicators. The indicators are in response to Six lives action plan Whilst the report is for the black country partnership, the indicators relate specifically to acute care: no of referrals, no if inappropriate referrals, delay in discharge, Complaints and compliments. The proposal for CQUIN 214/15 is in relation to having a 'flagging 'system which identifies clients with a learning disability. The black country partnership has requested a meeting with informatics to progress this further. This 'flag' is an essential part of the 6 lives action plan in that identification of clients with a learning disability and adults with autism can ensure access to the acute learning disabilities liaison nurse and the ability for staff to make reasonable adjustments. CCG have requested completion of a self-assessment tool in relation to PREVENT to seek assurance from provider organisations on the implementation of this government policy NHS Standard Contract Prevent delivery for each provider organisation is now included within the NHS Standard Contract for 213/14 within Service Conditions paragraph 32. Trust lead facilitating plans for awareness raising within the Page21 of 22

22 Page22 of 22

CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 01/07/2013 to 30/09/2013

CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 01/07/2013 to 30/09/2013 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 1/7/213 to 3/9/213 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 1. Introduction On a quarterly basis,

More information

CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 01/01/2015 to 31/03/2015

CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 01/01/2015 to 31/03/2015 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 01/01/2015 to 31/03/2015 1. Introduction CLIPS Report (Complaints, Litigation, Incidents, PALS and On a quarterly basis, aggregation

More information

Safety Improvement Plan. Phao Hewitson Head of Clinical Governance

Safety Improvement Plan. Phao Hewitson Head of Clinical Governance Meeting Trust Board Date 29 th January 2015 ENC No 8 Title of Paper Lead Director Author Sign up to Safety Safety Improvement Plan Amir Khan Medical Director Phao Hewitson Head of Clinical Governance PURPOSE

More information

Annual Report on Complaints, PALS, incidents, claims

Annual Report on Complaints, PALS, incidents, claims Annual Report on Complaints, PALS, incidents, claims Trust Board Meeting - Part 1 Item: 9.4 July 31 st 2013 Enclosure: M Purpose of the Report: To provide the Board with assurance around the processes

More information

Complaints Annual Report 2011/2012

Complaints Annual Report 2011/2012 Complaints Annual Report 2011/2012 This report incorporates complaints handling for Basingstoke and North Hampshire NHS Foundation Trust and Winchester and Eastleigh Healthcare Trust for the period 1 April

More information

Trust Board 8 May 2014

Trust Board 8 May 2014 Trust Board 8 May 2014 Title of the Paper: Quarter 4 (1 st January 2014 31 st March 2014) CLIPS Report Agenda item: 205/17 Author: Jackie Ardley, Interim Chief Nurse Trust Objective: 1) Achieving continuous

More information

REPORT TO THE TRUST BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 24 FEBRUARY 2015

REPORT TO THE TRUST BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 24 FEBRUARY 2015 Enc L REPORT TO THE TRUST BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 24 FEBRUARY 21 INTEGRATED GOVERNANCE REPORT Trust objectives supported by this paper To provide healthcare of the highest standard

More information

PALS & Complaints Annual Report 2013 2014

PALS & Complaints Annual Report 2013 2014 PALS & Complaints Annual Report 2013 2014 This report provides a summary of patient complaints received in 2013/14. It includes details of numbers of complaints received during the year, performance in

More information

Data Quality Rating BAF Ref Impact on BAF Risk Rating

Data Quality Rating BAF Ref Impact on BAF Risk Rating Board of Directors (Public) Item 6.4 Subject: Annual Review of Complaints Process Date of meeting: 28 th April, 2015 Prepared by: Lisa Gurrell Patient and family support Manager Presented by: Sue Pemberton

More information

Project title. The true cost of Clinical Negligence? Rachel Brown. Date Month 2014 17 November 2015. Slater and Gordon Limited 2014

Project title. The true cost of Clinical Negligence? Rachel Brown. Date Month 2014 17 November 2015. Slater and Gordon Limited 2014 Project title The true cost of Clinical Negligence? Date Month 2014 17 November 2015 Rachel Brown 1 The true cost of clinical negligence? To a patient: pain, suffering, loss of amenity. Loss of life, independence,

More information

DATE APPROVED: DATE EFFECTIVE: Date of Approval. REFERENCE NO. MOH/04 PAGE: 1 of 7

DATE APPROVED: DATE EFFECTIVE: Date of Approval. REFERENCE NO. MOH/04 PAGE: 1 of 7 SOURCE: Ministry of Health DATE APPROVED: DATE EFFECTIVE: Date of Approval REPLACESPOLICY DATED: 1 POLICY TITLE: Incident/Accident Reporting REFERENCE NO. MOH/04 PAGE: 1 of 7 REVISION DATE(s): Ministry

More information

Departmental Solicitors Office

Departmental Solicitors Office 323-037f-001 One should not try to deduce solely from the classifications used whether or not there was an absence of care or whether lessons can be learned which would materially have affected what happened.

More information

Patient Complaints Annual Report 2012 2013

Patient Complaints Annual Report 2012 2013 Patient Complaints Annual Report 2012 2013 Executive Summary This report provides a summary of patient complaints received in 2012/13. It includes details of numbers of complaints received during the year,

More information

Contents. Appendices. 1. Complaints Relating to Commissioned Services Page 15

Contents. Appendices. 1. Complaints Relating to Commissioned Services Page 15 COMPLAINTS POLICY 1 Contents 1. Introduction Page 3 2. Purpose Page 3 3. Principles Page 4 4. Scope Page 4 5. Exclusions Page 5 6. Responsibilities Page 5 7. Complaints Management Process: Local Resolution

More information

Table of Contents Page Figures/Tables:

Table of Contents Page Figures/Tables: NTMA Clinical Adverse Events Notified to the State Claims Agency under the terms of the Clinical Indemnity Scheme. Incidents occurring between 1/1/212 and 31/12/212 Final Report. National Report Anne Marie

More information

NHS England Complaints Policy

NHS England Complaints Policy NHS England Complaints Policy 1 2 NHS England Complaints Policy NHS England Policy and Corporate Procedures Version number: 1.1 First published: September 2014 Prepared by: Kerry Thompson, Senior Customer

More information

PALS, Complaints, Claims and Incidents Annual Report 2013-14

PALS, Complaints, Claims and Incidents Annual Report 2013-14 PALS, Complaints, Claims and Incidents Annual Report 2013-14 Trust Board Item: 10.7 30 th July 2014 Enclosure: U Purpose of the Report: To provide the Trust Board with assurance around the processes to

More information

H ORGANISATIONAL LEARNING REPORT 2011/12 ITEM NO 7

H ORGANISATIONAL LEARNING REPORT 2011/12 ITEM NO 7 H ORGANISATIONAL LEARNING REPORT 2011/12 ITEM NO 7 Discussion X Report written by: Julie Hargreaves, Interim Head of Quality Governance Purpose of the report: To provide the Committee with a summary of

More information

Complaints Annual Report 2014-15. Author: Sarah Housham, Senior Complaints and PALS Officer

Complaints Annual Report 2014-15. Author: Sarah Housham, Senior Complaints and PALS Officer Complaints Annual Report 2014-15 Author: Sarah Housham, Senior Complaints and PALS Officer 1 Rnoh Complaints Annual Report 2014 / 2015 Complaints Handling & the Principles of Remedy Introduction Complaints

More information

Incident reporting procedure

Incident reporting procedure Incident reporting procedure Number: THCCGCG0045 Version: V0d1 Executive Summary All incidents must be reported. This should be done as soon as practicable after the incident has been identified to ensure

More information

Process for reporting and learning from serious incidents requiring investigation

Process for reporting and learning from serious incidents requiring investigation Process for reporting and learning from serious incidents requiring investigation Date: 9 March 2012 NHS South of England Process for reporting and learning from serious incidents requiring investigation

More information

Learning when things go wrong. Marg Way Director, Clinical Governance Alfred Health, Melbourne

Learning when things go wrong. Marg Way Director, Clinical Governance Alfred Health, Melbourne Learning when things go wrong Marg Way Director, Clinical Governance Alfred Health, Melbourne Safety and Quality Management in hospitals Things have changed a lot over the last 10 years.. HOSPITAL catastrophes

More information

Analysis of cases reviewed by the Clinical Risk Team at the State Claims Agency

Analysis of cases reviewed by the Clinical Risk Team at the State Claims Agency SCA Analysis of cases reviewed by the Clinical Risk Team at the State Claims Agency Cases settled and resolved in 0 Anne Marie Oglesby Contents Introduction... Breakdown of Closed Claims Outcomes... Incident

More information

Report submitted to: Trust Board Wednesday 25 th July 2012. Martin Emery, Head of Patient Experience Denise Flowers, AD Clinical Governance

Report submitted to: Trust Board Wednesday 25 th July 2012. Martin Emery, Head of Patient Experience Denise Flowers, AD Clinical Governance Southend University Hospital NHS Foundation Trust Board of Directors Meeting Report Agenda item 3/1 Agenda item 3/1 Report submitted to: Trust Board Wednesday 5 th July 1 Title: Complaints Quarter 1 report

More information

Sarah Bloomfield - Director of Nursing & Quality. Jackie Harrison - Head of PALS & Complaints

Sarah Bloomfield - Director of Nursing & Quality. Jackie Harrison - Head of PALS & Complaints Reporting to: Trust Board, February 2015 Enclosure 8 Title Q3 Complaints & PALS Report October - December 2014 Sponsoring Director Author(s) Sarah Bloomfield - Director of Nursing & Quality Jackie Harrison

More information

The State Hospital s Board for Scotland

The State Hospital s Board for Scotland The State Hospital s Board for Scotland PATIENT & CARER FEEDBACK Procedure for Feedback; Comments, Concerns, Compliments and Complaints (Incorporating the NHS Can I Help you Guidance) Policy Reference

More information

Claims Management Policy

Claims Management Policy Claims Management Policy April 2015 Author: Responsibility: Janet Young, Governance & Risk Manager All Staff should adhere to this policy Effective Date: April 2015 Review Date: April 2017 Reviewing/Endorsing

More information

Policies, Procedures, Guidelines and Protocols

Policies, Procedures, Guidelines and Protocols Policies, Procedures, Guidelines and Protocols Document Details Title Complaints and Compliments Policy Trust Ref No 1353-29025 Local Ref (optional) N/A Main points the document This policy and procedure

More information

Jill Watts, Group Chief Executive

Jill Watts, Group Chief Executive Group Chief Executive s Statement I am pleased to welcome you to our Quality Accounts 2016. Our 2016 Quality Accounts provide a transparent picture of BMI Healthcare s performance over the period covered

More information

About the Trust. What you can expect: Single sex accommodation

About the Trust. What you can expect: Single sex accommodation About the Trust The Royal Berkshire NHS Foundation Trust is one of the largest general hospital trusts in the country. We provide acute medical and surgical services to Reading, Wokingham and West Berkshire

More information

A Review of the NHSLA Incident Reporting and Management and Learning from Experience Standards. Assessment Outcomes. April 2003 - March 2004

A Review of the NHSLA Incident Reporting and Management and Learning from Experience Standards. Assessment Outcomes. April 2003 - March 2004 A Review of the NHSLA Incident Reporting and Management and Learning from Experience Standards Assessment Outcomes April 2003 - March 2004 September 2004 1 Background The NHS Litigation Authority (NHSLA)

More information

TRUST BOARD PUBLIC SEPTEMBER 2015 Agenda Item Number: 169/15 Enclosure Number: (9) Subject: Complaints, PALS and Plaudits Annual Report 2014/15

TRUST BOARD PUBLIC SEPTEMBER 2015 Agenda Item Number: 169/15 Enclosure Number: (9) Subject: Complaints, PALS and Plaudits Annual Report 2014/15 TRUST BOARD PUBLIC SEPTEMBER 2015 Agenda Item Number: 169/15 Enclosure Number: (9) Subject: Complaints, PALS and Plaudits Annual Report 2014/15 Prepared by: Presented by: Purpose of paper Why is this paper

More information

COUNCIL OF GOVERNORS 23 rd June 2014

COUNCIL OF GOVERNORS 23 rd June 2014 Paper 7.2 COUNCIL OF GOVERNORS 23 rd June 2014 TITLE EXECUTIVE SUMMARY The Council is asked to: Submitted by: Complaints procedure Driven by the national context of changes in expectation, scrutiny and

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Warrington Hospital Lovely Lane, Warrington, WA5 1QG Tel: 01925635911

More information

Open and Honest Care in your Local Hospital

Open and Honest Care in your Local Hospital Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement Programme aims to support organisations to become more transparent and consistent in publishing safety, experience

More information

MANAGEMENT OF COMPLAINTS, CONCERNS, COMMENTS AND COMPLIMENTS POLICY. Documentation Control

MANAGEMENT OF COMPLAINTS, CONCERNS, COMMENTS AND COMPLIMENTS POLICY. Documentation Control MANAGEMENT OF COMPLAINTS, CONCERNS, COMMENTS AND COMPLIMENTS POLICY Documentation Control Reference GG/CM/002 Date approved Approving Body Trust Board Implementation date Supersedes Patient and Carer Feedback

More information

Quality and Safety Report Quarter 2 13/14 Clinical Governance Manager Q2 - July - Sept 2013

Quality and Safety Report Quarter 2 13/14 Clinical Governance Manager Q2 - July - Sept 2013 Quality and Safety Report Quarter 2 13/14 Clinical Governance Manager Q2 - July - Sept 2013 Q21314 Quality and Safety Report - Public Quality and Safety Report Q2 July September 2013 1.0 Patient Safety

More information

Integrated Performance Report

Integrated Performance Report Integrated Performance Report M03 June 2015 Presented by: Angela Stevenson (Deputy Chief Operating Officer) Des Holden (Medical Director) Fiona Alsop (Chief Nurse) Paul Simpson (Chief Financial Officer)

More information

Lessons Learned paper Q1 and Q2 2014/15

Lessons Learned paper Q1 and Q2 2014/15 MEETING TITLE Trust Board Meeting in Public TITLE of PAPER STRATEGIC OBJECTIVE PURPOSE OF THE PAPER Bi-Annual Significant Events & Lessons Learned paper Q1 and Q2 2014/15 MEETING DATE 26/01/2015 PAPER

More information

EXECUTIVE SUMMARY FRONT SHEET

EXECUTIVE SUMMARY FRONT SHEET EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Quality and Safety Forum Date: 09.07.2015 Title: Monthly Board Report- Publication of Nursing and Midwifery Staffing Levels June 2015 Exception Report

More information

MID STAFFORDSHIRE NHS FOUNDATION TRUST

MID STAFFORDSHIRE NHS FOUNDATION TRUST MID STAFFORDSHIRE NHS FOUNDATION TRUST Report to: Report of: Joint Health Scrutiny Accountability Session Antony Sumara Chief Executive Date: 20 April 2011 Subject: Mid Staffordshire NHS Foundation Trust

More information

Quality and Engagement Sub Committee

Quality and Engagement Sub Committee Quality and Engagement Sub Committee 12 June 2012 Corporate Risk Register and Risk Management Strategy Executive Summary As part of authorisation, Blackpool Clinical Commissioning Group (CCG) must identify

More information

Review of compliance. Redcar and Cleveland PCT Redcar Primary Care Hospital. North East. Region: West Dyke Road Redcar TS10 4NW.

Review of compliance. Redcar and Cleveland PCT Redcar Primary Care Hospital. North East. Region: West Dyke Road Redcar TS10 4NW. Review of compliance Redcar and Cleveland PCT Redcar Primary Care Hospital Region: Location address: Type of service: Regulated activities provided: Type of review: Date of site visit (where applicable):

More information

Risk Management and Patient Safety Evolution and Progress

Risk Management and Patient Safety Evolution and Progress Risk Management and Patient Safety Evolution and Progress Madrid February 2005 Charles Vincent Professor of Clinical Safety Research Department of Surgical Oncology & Technology Imperial College London

More information

POLICY FOR HANDLING OF CLINICAL NEGLIGENCE CLAIMS

POLICY FOR HANDLING OF CLINICAL NEGLIGENCE CLAIMS POLICY FOR HANDLING OF CLINICAL NEGLIGENCE CLAIMS Date Comments Approved by Oct 07 Updated in line with NHSLA Standards Michaela Morris, Dir. Of Nursing & Operations Oct 09 General update and review. TEC

More information

CONTROLLED DOCUMENT. Number: Version Number: 4. On: 25 July 2013 Review Date: June 2016 Distribution: Essential Reading for: Information for:

CONTROLLED DOCUMENT. Number: Version Number: 4. On: 25 July 2013 Review Date: June 2016 Distribution: Essential Reading for: Information for: CONTROLLED DOCUMENT Risk Management Strategy and Policy CATEGORY: CLASSIFICATION: PURPOSE: Controlled Number: Document Version Number: 4 Controlled Sponsor: Controlled Lead: Approved By: Document Document

More information

Complaints Handling Policy Incorporating Complaints, Concerns and Compliments Version 5.0

Complaints Handling Policy Incorporating Complaints, Concerns and Compliments Version 5.0 Complaints Handling Policy Incorporating Complaints, Concerns and Compliments Version 5.0 Purpose: For use by: This document is compliant with /supports compliance with: To advise and inform hospital staff

More information

Review of compliance. Mid Staffordshire NHS Foundation Trust Stafford Hospital. West Midlands. Region:

Review of compliance. Mid Staffordshire NHS Foundation Trust Stafford Hospital. West Midlands. Region: Review of compliance Mid Staffordshire NHS Foundation Trust Stafford Hospital Region: Location address: Type of service: Regulated activities provided: Type of review: West Midlands Mid Staffordshire NHS

More information

Ethics and Patient Rights (EPR)

Ethics and Patient Rights (EPR) Ethics and Patient Rights (EPR) Standard EPR.1 [Verification of credentials of professional staff] The organization has an effective process for gathering, verifying, and evaluating the credentials (e.g.

More information

St George s Healthcare NHS Trust: the next decade. Quality Improvement Strategy 2012 2017

St George s Healthcare NHS Trust: the next decade. Quality Improvement Strategy 2012 2017 the next decade Quality Improvement Strategy 2012 2017 November 2012 Contents Contents Introduction Quality Matters 3 Internal drivers for change Our vision, mission and values 5 Our vision for St George

More information

CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Report of: CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Paper prepared by: Date of paper: June 2012 Director of Patient Services/Chief Nurse Deputy Director of Nursing (Quality) Subject:

More information

NHS Constitution Patient & Public Quarter 4 report 2011/12

NHS Constitution Patient & Public Quarter 4 report 2011/12 NHS Constitution Patient & Public Quarter 4 report 2011/12 1 Executive Summary The NHS Constitution was first published on 21 st January 2009. One of the primary aims of the Constitution is to set out

More information

Policy for the Reporting and Management of Incidents and Near Misses

Policy for the Reporting and Management of Incidents and Near Misses IMPORTANT NOTE: This policy is under review. It will be incorporated into a single Incident Management Policy - CORP/RISK 13 v.3 which will also reflect NHS England s Serious Incident Framework published

More information

Hip replacements: Getting it right first time

Hip replacements: Getting it right first time Report by the Comptroller and Auditor General NHS Executive Hip replacements: Getting it right first time Ordered by the House of Commons to be printed 17 April 2000 LONDON: The Stationery Office 0.00

More information

CLAIMS MANAGEMENT & INVESTIGATION POLICY. Clinical Negligence, Personal Injury & Property Claims. 3.0 Corporate. 3.2 Trustwide Management

CLAIMS MANAGEMENT & INVESTIGATION POLICY. Clinical Negligence, Personal Injury & Property Claims. 3.0 Corporate. 3.2 Trustwide Management CLAIMS MANAGEMENT & INVESTIGATION POLICY Clinical Negligence, Personal Injury & Property Claims SharePoint Location Non-Clinical Policies and Guidelines SharePoint Index Directory 3.0 Corporate Sub Area

More information

The NHS complaints procedure (England only) August 2009

The NHS complaints procedure (England only) August 2009 The NHS complaints procedure (England only) August 2009 Introduction This document has been produce to provide LMCs, practices and GPs with guidance on the requirements of the NHS complaints system, including

More information

Governing Body 13 November 2013

Governing Body 13 November 2013 Paper 07 Governing Body 13 November 2013 Overview of complaints and handling processes Paper Author Lead Executive FOI status Michaela Maloney, Interim Head of Communication and Engagement Brendan Ward,

More information

Risk Management Strategy

Risk Management Strategy Authors Name & Title: Joan Matthews Risk Manager, Hazel Holmes Director of Nursing Scope: Trust Wide Classification: Non Clinical Strategy Replaces:, v3.1 To be read in conjunction with the following documents:

More information

Being Open Policy P033. Version Date Revision Description Editor Status

Being Open Policy P033. Version Date Revision Description Editor Status Document Information Board Library Reference Document Author Assured By Review Cycle P033 Head of Risk & Compliance Quality & Healthcare Governance 3 Years Note: This document is electronically controlled.

More information

POLICY & PROCEDURE FOR THE MANAGEMENT OF SERIOUS INCIDENTS

POLICY & PROCEDURE FOR THE MANAGEMENT OF SERIOUS INCIDENTS POLICY & PROCEDURE FOR THE MANAGEMENT OF SERIOUS INCIDENTS APPROVED BY: South Gloucestershire Clinical Commissioning Group Quality and Governance Committee DATE August 2015 Date of Issue: August 2015 Version

More information

He then needs to work closely with the Quality Management Director or Leader and the Risk Manager to monitor the provision of patient care.

He then needs to work closely with the Quality Management Director or Leader and the Risk Manager to monitor the provision of patient care. Chapter II Introduction The Director has a major role in the effort to provide high quality medical care with a high degree of clinical safety. He is ultimately responsible for the professional conduct

More information

Complaints Policy and Procedure. Contents. Title: Number: Version: 1.0

Complaints Policy and Procedure. Contents. Title: Number: Version: 1.0 Title: Complaints Policy and Procedure Number: Version: 1.0 Contents 1 Purpose and scope... 2 2 Responsibilities... 2 3 Policy Statement: Aims and Objectives... 4 4 Definition of a complaint... 4 5 Procedure...

More information

NOTICE OF PRIVACY PRACTICES. The University of North Carolina at Chapel Hill. UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates

NOTICE OF PRIVACY PRACTICES. The University of North Carolina at Chapel Hill. UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates NOTICE OF PRIVACY PRACTICES The University of North Carolina at Chapel Hill UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

More information

Policy for Safeguarding Adults from Abuse

Policy for Safeguarding Adults from Abuse Policy for Safeguarding Adults from Abuse ID # 2008 Line 67 Author Brenda Rance Author s Job Title Named Nurse, Safeguarding Adults Division Corporate Nursing & Patient Services Department Corporate Nursing

More information

Complaints Policy. Controlled Document Number: Version Number: 6 Controlled Document Sponsor: Controlled Document Lead: Approved By:

Complaints Policy. Controlled Document Number: Version Number: 6 Controlled Document Sponsor: Controlled Document Lead: Approved By: Complaints Policy CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Version Number: 6 Controlled Document Sponsor: Controlled Document Lead: Approved By: Policy Governance

More information

Trust Board Meeting: Wednesday 10 September 2014 TB2014.106

Trust Board Meeting: Wednesday 10 September 2014 TB2014.106 Trust Board Meeting: Wednesday 0 September 204 Title 203/4 Annual Health and Safety Report Status For information Board Lead(s) Mr Mark Trumper - Director for Development and the Estate Key purpose Strategy

More information

Policy and Procedure for Claims Management

Policy and Procedure for Claims Management Policy and Procedure for Claims Management RESPONSIBLE DIRECTOR: COMMUNICATIONS, PUBLIC ENGAGEMENT AND HUMAN RESOURCES EFFECTIVE FROM: 08/07/10 REVIEW DATE: 01/04/11 To be read in conjunction with: Complaints

More information

Clinical Governance Development Committee October 2007 Dr Foster RTM Alerts Progress Report

Clinical Governance Development Committee October 2007 Dr Foster RTM Alerts Progress Report Clinical Governance Development Committee October 2007 Dr Foster RTM Alerts Progress Report 1. Background Information 1.1. Initial review of the tool in November 2006, and subsequent queries in January

More information

Welcome to our Clinical Negligence Service

Welcome to our Clinical Negligence Service CLINICAL NEGLIGENCE Welcome to our Clinical Negligence Service What is Clinical Negligence? This is proving that the standard of care received from a health care professional fell below that of a reasonably

More information

INCIDENT POLICY Page 1 of 13 November 2015

INCIDENT POLICY Page 1 of 13 November 2015 Page 1 of 13 Policy Applies To All Mercy Hospital Staff Credentialed Medical Specialists and Allied Health Personnel are required to indicate understanding of the incident policy via the credentialing

More information

Risk Management Strategy

Risk Management Strategy Risk Management Strategy A Summary for Patients & Visitors This leaflet has been designed to provide information on the Trust s Risk Management Strategy and how we involve patients and the public in reducing

More information

Report to: Trust Board Agenda item: 10. Date of Meeting: 9 March 2011. South West Acute Hospital Learning Disability (LD) review.

Report to: Trust Board Agenda item: 10. Date of Meeting: 9 March 2011. South West Acute Hospital Learning Disability (LD) review. Report to: Trust Board Agenda item: 10. Date of Meeting: 9 March 2011 Title of Report: Status: Board Sponsor: Author: Appendices South West Acute Hospital Learning Disability (LD) review. For information

More information

Complaints Annual Report

Complaints Annual Report Complaints Annual Report 1 st April 31 st March 2011 Date: May 2011 Prepared by: Martin Emery, Head of Patient Experience Sue Hardy, Director of Nursing 1 1. Introduction This report provides information

More information

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST Appendix A PERFORMANCE MANAGEMENT FRAMEWORK Corporate Performance Document PATIENT EXPERIENCE CSF 1: Measure and exceed patient expectations, improving the

More information

Complaints Annual Report 2013/14

Complaints Annual Report 2013/14 Complaints Annual Report 2013/14 1. INTRODUCTION This is the complaints annual report for Hampshire Hospitals NHS Foundation Trust (HHFT) for the period 1 April 2013 to 31 March 2014. Hampshire Hospitals

More information

NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic. Safe staffing for nursing in adult inpatient wards in acute hospitals overview bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed

More information

The NHS complaints procedure (England only): guidance for primary care

The NHS complaints procedure (England only): guidance for primary care The NHS complaints procedure (England only): guidance for primary care August 2015 Introduction This document provides LMCs (local medical committees), practices and GPs with guidance on the requirements

More information

JOB DESCRIPTION. Information Governance Manager

JOB DESCRIPTION. Information Governance Manager JOB DESCRIPTION POST TITLE: Information Governance Manager DIRECTORATE: ACCOUNTABLE TO: BAND: LOCATION: CSS Head of Information Governance 8a CSS Job Purpose The Information Governance Manager will ensure

More information

NHS outcomes framework and CCG outcomes indicators: Data availability table

NHS outcomes framework and CCG outcomes indicators: Data availability table NHS outcomes framework and CCG outcomes indicators: Data availability table December 2012 NHS OF objectives Preventing people from dying prematurely DOMAIN 1: preventing people from dying prematurely Potential

More information

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST MAIN BOARD - JANUARY 2015 LEGAL SERVICES REPORT 1 Executive Summary 1.1 The Legal Services Report for Gloucestershire Hospitals NHS Foundation Trust is submitted

More information

DNV Healthcare Maternity Quality and Risk Forum

DNV Healthcare Maternity Quality and Risk Forum DNV Healthcare Maternity Quality and Risk Forum Alison Bartholomew Director of Business Development, Baby Lifeline Training Ltd December 2013 - London Ensuring the healthiest outcome possible from pregnancy

More information

The purpose of this report is to provide an update on the progress of the development of business continuity plans in the Trust

The purpose of this report is to provide an update on the progress of the development of business continuity plans in the Trust Meeting / Committee: Board of Directors Meeting Date: 31 July 2012 This paper is for: (Only 1 column to be marked with as appropriate) Action/Decision Assurance Information Title: Business Continuity Update

More information

AVOIDING UNPLANNED ADMISSIONS ENHANCED SERVICE: PROACTIVE CASE FINDING AND CARE REVIEW FOR VULNERABLE PEOPLE GUIDANCE AND AUDIT REQUIREMENTS

AVOIDING UNPLANNED ADMISSIONS ENHANCED SERVICE: PROACTIVE CASE FINDING AND CARE REVIEW FOR VULNERABLE PEOPLE GUIDANCE AND AUDIT REQUIREMENTS April 2014 AVOIDING UNPLANNED ADMISSIONS ENHANCED SERVICE: PROACTIVE CASE FINDING AND CARE REVIEW FOR VULNERABLE PEOPLE GUIDANCE AND AUDIT REQUIREMENTS A programme of action for general practice and clinical

More information

Berkshire West Clinical Commissioning Groups

Berkshire West Clinical Commissioning Groups Berkshire West Clinical Commissioning Groups Corporate Policy 1 (CP1) CCG Policy for the Handling of Complaints Version: 1 Ratified by: Date ratified: April 2013 Name of originator/author: Name of responsible

More information

Board of Directors Meeting Report 27 May 2015. Agenda item 51/15

Board of Directors Meeting Report 27 May 2015. Agenda item 51/15 Board of Directors Meeting Report 27 May 2015 Agenda item 51/15 Title Complaints Annual Report 1 April 2014 to 31 March 2015 Sponsoring Director Authors Purpose Cheryl Schwarz Acting Chief Nurse Denise

More information

Agenda Item 8.12 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST. The Director of Corporate Services Carole Self

Agenda Item 8.12 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST. The Director of Corporate Services Carole Self CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Report of: Paper prepared by: The Director of Corporate Services Carole Self Head of Legal Services Michelle Lindup Date of paper: May 2014

More information

Clinical Indemnity Scheme

Clinical Indemnity Scheme Clinical Indemnity Scheme Obstetric Forum Farmleigh 11 th February 2014 Obstetric Litigation The Role of the Clinical Indemnity Scheme Ita Guilfoyle Solicitor/Clinical Claims Manager Clinical Indemnity

More information

Chesterfield Royal Hospital NHS Foundation Trust THE ADVICE CENTRE AND COMPLAINTS POLICY

Chesterfield Royal Hospital NHS Foundation Trust THE ADVICE CENTRE AND COMPLAINTS POLICY Chesterfield Royal Hospital NHS Foundation Trust THE ADVICE CENTRE AND COMPLAINTS POLICY 1. INTRODUCTION 1.1 The aim of the Advice Centre is to support the Trust s Service Experience Strategy by providing

More information

Pauline Jones, Director of Nursing. Approve Adopt Receive for information. No Score. Carbon Reduction. Management Board

Pauline Jones, Director of Nursing. Approve Adopt Receive for information. No Score. Carbon Reduction. Management Board Trust Board Part 1 Agenda Item 14. Date: 27 March 2013 Title of Report Legal Services Annual Report 2011/12 Purpose of the report and the key issues for consideration/decision The Board is asked to review

More information

SCDCCLD0319 Promote healthy living for children and families

SCDCCLD0319 Promote healthy living for children and families Overview This standard identifies the requirements when promoting healthy living for children, young people and families. This includes working with families to help them identify healthy living options,

More information

Serious Case Review. Elm View Nursing Home

Serious Case Review. Elm View Nursing Home Serious Case Review Elm View Nursing Home 1 Introduction... 4-7 About the nursing home and its residents... 4 The serious case review... 4-7 The questions the review asks... 5 The areas the review looks

More information

Details about this location

Details about this location Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Prince George Duke of Kent Court Shepherds Green, Chislehurst,

More information

SOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST CORPORATE POLICY AND PROCEDURE NO.14 CLAIMS MANAGEMENT

SOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST CORPORATE POLICY AND PROCEDURE NO.14 CLAIMS MANAGEMENT SOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST CORPORATE POLICY AND PROCEDURE NO.14 CLAIMS MANAGEMENT DOCUMENT INFORMATION Author: Jill Hall Corporate Secretary This document replaces: SCAS Claims

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Vision MH - Cornerstone House Barnet Lane, Elstree, WD6 3QU

More information

Discussion Assurance Approval Regulatory requirement Mark relevant box X X X

Discussion Assurance Approval Regulatory requirement Mark relevant box X X X Report to: Public Board of Directors Date of Meeting: 26 th February 2014 Report Title: Integrated Governance Dashboards January 2014 Status: For information Discussion Assurance Approval Regulatory requirement

More information

Open and Honest Care in your Local Hospital

Open and Honest Care in your Local Hospital Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support organisations to become more transparent and consistent in publishing safety, experience

More information

Improving Services for Patients with Learning Difficulties. Jennifer Robinson, Lead Nurse Older People and Vulnerable adults

Improving Services for Patients with Learning Difficulties. Jennifer Robinson, Lead Nurse Older People and Vulnerable adults ENC 5 Meeting Trust Board Date 18 th December 2014 Title of Paper Lead Director Author Improving Services for Patients with Learning Difficulties Kathryn Halford, Director of Nursing Jennifer Robinson,

More information

ADVERSE INCIDENT REPORT FORM (AI-1)

ADVERSE INCIDENT REPORT FORM (AI-1) REF NO: ADVERSE INCIDENT REPORT FORM (AI-1) This form should be used to report any incident/accident or potential incident (i.e. a near miss ) which has caused loss, harm or damage, or has the potential

More information

Patient safety and nutrition and hydration in the elderly

Patient safety and nutrition and hydration in the elderly Patient safety and nutrition and hydration in the elderly Caroline Lecko May 2013 2013 The Health Foundation The scale of the problem The scale of avoidable harm associated with the provision of nutrition

More information

Clinical Audit Procedure for NHS-LA and CNST Casenote Audit

Clinical Audit Procedure for NHS-LA and CNST Casenote Audit Clinical Audit Procedure for NHS-LA and CNST Casenote Audit NHS Litigation Authority (NHS-LA) Risk Management Standards for Acute Trusts Pilot Clinical Negligence Scheme for Trusts (CNST) Maternity Clinical

More information