ITEM 7J NHS Fife Clinical Governance Committee. 13 February NHS Fife Clinical Governance Report October December 2012 Q3 report summary

Transcription

1 ITEM 7J NHS Fife Clinical Governance Committee 13 February 2013 NHS Fife Clinical Governance Report October December 2012 Q3 report summary 1. Situation This report is a review of patient feedback received during the October December 2012 quarter. The focus of the report is on feedback received that is clinical in nature or may impact on patient safety and wellbeing. It also provides information about cases considered/concluded by the Scottish Public Services Ombudsman during the quarter and any Fatal Accident Inquiries determined. 2. Background NHS Fife has an ongoing commitment to providing safe, effective and person centred care. Feedback and complaints provide a valuable source of information for identifying areas of good practice and also areas for improvement. Learning is a critical element of an organisation committed to doing the right thing for the people using its services and for the staff who provide that service. 3. Assessment 3.1 Overall activity for this period Operational Division 84,243 New and Review Out Patients Attendances 1,995 Elective In Patient Admissions 7,603 Emergency In Patient Admissions 6,041 Day case Admissions (other than maternity and neonatal) 3,216 Maternity and Neonatal Admissions (In patient and day case) Community Hospitals 2,943 New Out patients Seen 9,573 Review Out patients Seen 17 Day Case Admissions 347 Emergency In Patient Admissions 412 Elective In Patient Admissions Total activity = 204,390 compared to 118,819 in the previous quarter A total of 501 thank you s were received during the quarter and donations to the sum of 87,431.38

2 3.2 Complaints received The graphs below provide comparable data in relation to the numbers of complaints received, breakdown by local delivery units and general themes. Formal Complaints January February March April May June July August September October November December Of the 96 formal complaints received in the quarter (107 in previous quarter), 21 were upheld, 23 partially upheld and 23 not upheld. 29 remain open. Formal complaints by Delivery Units April December April-June2010 July-Sept 2010 Oct-Dec 2012 Oct-Dec 2010 Jan-Mar 2011 April-June 2011 July-Sept 2011 Oct-Dec 2011 Jan-Mar 2012 April-June2012 July-Sept 2012 Operational Division Dunfermline & West Fife CHP Glenrothes & North East Fife CHP Kirkcaldy & Levenmouth CHP NHS Fife Board The above graph identifies that the majority of complaints sit within the Operational Division. Further analysis of that information identifies that the majority of complaints remain within the 2

3 Emergency Care Directorate. A more detailed breakdown is provided to the Strategic Management Team on a six monthly basis. Complaints by Issue Type 1 October December 2011 Complaints by Issue Type 1 October December Delays In/At 9 Environment/Domestic 26 Procedural Issues 5 Staff 56 Transport Delays In/At 4 Environment/Domestic 29 5 Procedural Issues 5 Staff 59 Transport Treatment 54 Waiting Times Treatment 58 Waiting Times 15 The above graphs compare year on year for the time period, the issue types arising from complaints. Clinical treatment, staff attitude and environmental factors being the most common themes. The Committee should note that one single complaint may generate multiple issues. 3.3 Key issues from complaints received During the quarter there was an increase in the number of complaints within Maternity Services. Commonly these complaints have featured a combination of clinical treatment, staff attitude and communication issues. The Management Team are aware and reviewing the situation within Maternity Services. Wound care featured in a number of complaints during the quarter with one case in particular identifying the need for clear guidance for staff in relation to wound closure and the availability of wound care products. NHS Fife is involved in a range of initiatives at national and local level to promote best standards in wound care and to share that across the Board area. Discharge Planning also featured in the quarter with a number of complaints raising concern about the planning process which lacked involvement and support. Many of these complaints identified expectations beyond the scope of what is routinely provided, identifying a need for staff to manage expectations and for public education. 3

4 4. SCOTTISH PUBLIC SERVICES OMBUDSMAN (SPSO) Cases investigated reaching conclusion and reported There were no published reports during the quarter. Cases reaching determination Five cases reached determination during the quarter, three of which were complaints against GP Practices and one against the CHP with the remaining case relating to the Operational Division. The first complaint raised concern that a GP did not provide reasonable care or treatment to a patient between July and October The patient attended the GP on a number of occasions in relation to symptoms of pain and bleeding and the GP diagnosed haemorrhoids. A subsequent visit to the Practice resulted in the patient seeing a different doctor who made a referral to hospital where the patient was diagnosed with colorectal cancer. The Ombudsman sought independent advice which suggested that treatment had been appropriate. A referral to hospital had been made following a second visit to the GP Practice and the Adviser could find no reason for the GP to expedite the request. The SPO did not uphold the complaint, concluding that treatment was reasonable. A further complaint about a GP practice raised the issue of a GP unreasonably refusing to undertake a non emergency home visit. In responding to the complaint the GP provided an explanation in relation to the criteria used to determine home visits and differentiated between emergency and chronic requirements. The SPSO s Advisor did not uphold the complaint; however noted that the patient had not directly been involved in the discussions and asked the GP to consider this, should a similar situation arise in the future. A final complaint about a GP Practice raised concern that the Practice unreasonably failed to make a referral to physiotherapy and neurology and that the complaint response unreasonably contained inaccuracies. The SPSO concluded that the general care and treatment of the patient by the Practice was reasonable; however there was a delay in sending a neurology referral. The Practice did go on to make an urgent referral when there was a change in the patient s condition and on that basis the failure to make the referral sooner did not have any significant impact on the patient s care and treatment. The Practice did apologise during the complaints process and identified steps to prevent a similar problem occurring. The SPSO asked the Practice to provide a specific written apology for the failure to send the referral letter which was duly carried out. One case reached conclusion which concerned Kirkcaldy and Levenmouth CHP. The complaints investigated were that there was a failure to involve the family in the assessment of the patient s care needs and care plans over a number of years, which included the use of inaccurate and incomplete documentation (not upheld). The failure to inform the family of the Appeals Procedure for NHS Funded Continuing Care (upheld) and the failure to action complaints in accordance with the NHS Complaints Procedure (upheld). The case was a complex case concerning a patient with chronic advanced dementia dating back several years. A number of processes were in play at any one time which made dealing with the complaint difficult. The SPSO s Adviser considered the assessment process which included an 4

5 independent opinion, in view of the difficulties encountered. The SPSO concluded that the assessment of the patient had been reasonable with good supporting evidence of the assessment process. The SPSO upheld the complaint about informing the family about the Appeals Process, noting the extensive correspondence with the family and reference to this at various times throughout a protracted process. The SPSO upheld the complaint stating that he information should have been contained in the final response. They had no recommendation to make. With regards the final complaint, the SPSO highlighted significant delays in dealing with complaints made in June 2011 and August 2011 which had been identified as part of NHS Fife s own investigation process. As an apology and explanation had been offered the SPSO had no further recommendations to make. The final complaint concerned the Operational Division and raised a number of issues including: a delay in investigating, diagnosing and treating a patient, delays in obtaining scans and follow up, appropriateness of discussions in relation to Do Not Resuscitate Status, inadequacies in personal care and pain relief provided and lack of palliative care, inadequate bed availability, delay in providing access to records and inadequate complaint handling. The Ombudsman upheld all of the complaints with the exception of the bed availability complaint and made a number of recommendations, following which an action plan was developed. The implementation of that action plan is discussed at the Operational Division Committee. 5. Fatal Accident Inquiries There were no Fatal Accident determinations issued in the reporting quarter. 6. Recommendations from this report 6.1 The Committee is asked to note the content of the report. 6.2 The Committee is asked to note the key clinical issues raised during the quarter and actions taken, and to identify any additional actions that may be required. Anne Buchanan Nurse Director Louise Ewing Patient Relations Manager 5