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

Transcription

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

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3 1. Introduction CLIPS Report (Complaints, Litigation, Incidents, PALS and 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 /15 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 inadequate care and diagnosis. This quarter, there are recurrent trends across all CLIPS in Accident and Emergency and Trauma & Orthopaedics. Pressure Ulcers categorised as severity 2, or 3 have increased compared to the previous quarter. There was 1 category 4 pressure ulcer reported during Q4 which is a decrease compared to Q3 when 2 pressure ulcers were reported. As per previous quarters, wounds, patient falls, staffing and medication errors continue to be the most frequently reported incidents. Falls reporting levels have remained constant with the majority of incidents occurring in MLTC. There were 245 falls in Q4, the exact same number was reported in Q3. There was 1 serious fall causing major harm. There has been a significant increase in the number of Serious Incidents reported, 36 incidents were reported in Q4 compared to 23 incidents which were reported in Q3. There were no Never Events in Q4. The number of formal complaints decreased during this quarter, notably the number of moderately severe allegations has decreased from 63 in Q3 to 33 in Q4, however a further 32 complaints have yet to have their final gradings applied. There were 3 complaints alleging major harm, the same number were recevied in the previous quarter. There were no complaints alleging catastrophic harm. 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. New workstreams for improving care for deteriorating patients and insulin management commenced at the end of this quarter. Lessons learned from actual harm incidents include: When medications are not adminstered to patient a prompt handover is required to ensure delayed medication rather than a complete omission. A notification should be sent to the referring clinician who is responsible for informing staff of any patients at high risk of falls. All Midwifery Led Unit attendances and patient drug charts to be entered and scanned onto BADGER system prior to being filed in the hospital records. Lessons learned from serious incidents: Ensure that the ITU bleep protocol is followed and accurate recording undertaken when clinicians swap shifts. Robust system to be implemented for assessment and evidencing of patients' capacity for refusal of treatment. Staff to ensure any abnormal radiology relating to child safeguarding is formally reported by a Consultant Radiologist. Copy of resuscitation sheet to be placed in the maternal records alert to be used by ambulance crew in obstetric emergency situations en-route to alert the maternity teams in preparation for incoming emergency. Page 3 of 24

4 CLIPS Report (Complaints, Litigation, Incidents, PALS and 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 Claims From 01/01/2015 to 31/03/ Corporate Themes Corporate Theme Formal Complaint Informal Complaint Incidents Clinical Negligence Claims Other Access 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 Page 4 of 24

5 CLIPS Report (Complaints, Litigation, Incidents, PALS and During Q4 2014/15, the trend picture was similar to the previous two quarters with themes across all CLIPS including: - Inadequate Care/Treatment - Diagnosis The category of adverse event most likely to arise across all CLIPS continues to be inadequate care/treatment, however during Q4 there was a 13% decrease in this category issues were reported compared to 388 in Q3. Notably 79% of claims received during the quarter were attributed to inadequate care/treatment. 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 Access was added as new corporate for Q4 and had the highest number of themes reported across all CLIPS (excluding claims). Appointment related issues have been incorporated into this theme. 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 24

6 CLIPS Report (Complaints, Litigation, Incidents, PALS and 5. Corporate Themes by Division Womens, Childrens and Clinical Support Services Surgery Medicine and Long Term Conditions Estates and Facilities Other Access 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 6.1 Type of Incident Type Total Clinical Incident 2476 Maternity Managed Event 216 Violence & Aggression 123 Non Clinical Incident 117 Report An Accident/Near Miss A 76 Security Incidents - Security 7 Page 6 of 24

7 6.2 Incidents by Category & Actual Harm Moderate No Minor Major Death Near Harm Miss 0 - Near Miss 1 - No Harm 2 - Minor 3 - Moderate 4 - Major 5 - Death Total Other Administration Admission Antimicrobial Appointments Attitude Blood/fluid Administration Breach In Policy/procedure Burns/Scalds Clinical Care/assessment/treatment Collision Between Vehicles Communication Consent Contact With Hazardous Substance Cuts & Abrasions Data Protection - Security Breach Death Diagnosis Discharge Discriminatory Abuse Environment Equipment Fraud Health Records Hit By Falling/moving Object Homecare Incident Reporting Impact With Stationary Object Infection Control Investigations IT / Patient Information System Lost Property Manual Handling Medical Emergencies & Cardiac Arrest Medication Error Needles And Sharps Page 7 of 24

8 Non-Compliance Nutrition Operative Procedures Patient Fall Pregnancy & Birth (Managed) Pregnancy/birth Pressure Ulcers Radiation (Patients & Public) Referrals Security Breach - Physical Security Security Related Incidents Slips/trips/falls (Staff And Visitors Only) Specimen Handling Staffing Theft Transfer Unauthorised Access To It Systems Vandalism Violence/aggression Wounds Page 8 of 24

9 Most frequently reported incidents include Wounds Falls Staffing Medication Errors There was 1 death reported during Q4 (a patient fall which was also investigated as a Serious Incident). Incidents causing moderate to catastrophic harm are more likely to 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 84 in Q3 to 89 in Q4. The more serious ulcers are developing in lower numbers in hospital, therefore overall the numbers remain constant. It should be noted that this report includes category 1 pressure ulcers which are not included in the monthly performance and quality reports. Patient Falls Patient falls incidence continue to be closely monitored across the organisation, with remedial action considered by the Board on a monthly basis. The reporting level for Q4 is the exact same number as Q3 - equating to 245 falls across the organisation. Falls causing moderate or major actual harm have increased slightly to 5 falls in Q4 compared to 4 falls in Q3. Clinical care/assessment incidents have decreased for the third consecutive quarter from 11incidents in Q3 to 7 incidents in Q4. Wounds - Reporting levels for moderate harm wounds has decreased by 14% during Q4. Lessons learned: When medications are not adminstered to patient a prompt handover is required to ensure delayed medication rather than a complete omission. A notification should be sent to the referring clinician who is responsible for informing staff of any patients at high risk of falls. All Midwifery Led Unit attendances and patient drug charts to be entered and scanned onto BADGER system prior to being filed in the hospital records. Page 9 of 24

10 Wounds Patient Staffing Medication Health Infection Violence/aggression Pressure Appointments Administration Equipment Clinical Communication Breach Transfer Non-Compliance Discharge Investigations Environment Admission Referrals Needles Operative Blood/fluid Lost Data Specimen Diagnosis Medical Radiation Attitude Slips/trips/falls IT Nutrition Hit Consent Death Impact Manual Burns/Scalds Cuts Homecare Contact Theft Collision Security Unauthorised Antimicrobial Discriminatory Fraud Pregnancy/birth Vandalism / By Patient Property & Protection Falling/moving Records Handling Abrasions Emergencies With Control Related And Breach Between Ulcers Procedures (Patients Policy/procedure Incident Administration Information & Error Stationary Sharps Hazardous Birth Access Abuse (Staff - Incidents Security Physical Vehicles & And To & It Wounds Patient Staffing Medication Health Infection Violence/aggression Pressure Appointments Administration Equipment Clinical Communication Breach Transfer Non-Compliance Discharge Investigations Environment Admission Referrals Needles Operative Blood/fluid Lost Data Specimen Diagnosis Medical Radiation Attitude Slips/trips/falls IT Nutrition Hit Consent Death Impact Manual Burns/Scalds Cuts Homecare Contact Theft Collision Security Unauthorised Antimicrobial Discriminatory Fraud Pregnancy/birth Vandalism / By Patient Property Protection & Records Handling Abrasions Fall With Control Breach And Related Between Ulcers (Patients Incident & Error Sharps Birth Abuse (Staff - Wounds Patient Staffing Medication Health Infection Violence/aggr Pressure Appointments Administration Equipment Clinical Communicati Breach Transfer Non-Complia Discharge Investigations Environment Admission Referrals Needles Operative Blood/fluid Lost Data Specimen Diagnosis Medical Radiation Attitude Slips/trips/falls IT Nutrition Hit Consent Death Impact Manual Burns/Scalds Cuts Homecare Contact Theft Collision Security Unauthorised Antimicrobial Discriminatory Fraud Pregnancy/bir Vandalism / By Patient Property & 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 (4) (4) (3) (2) (1) (4) Commercial 0% 0% 0% 0% 0% Corporate 0% 1% 0% 1% 0% WCCSS (3) 30% 28% 30% 30% 30% Surgery 25% 23% 24% 26% 22% MLTC (2) 45% 48% 46% 43% 47% MLTC continues to report the highest number of incidents each quarter, however there has been a slight reduction for this division compared to Q3, whilst still being influenced by high reporting levels of pressure ulcers, falls and other wounds. In contrast, (1) WCCS and MLTC division both have a generalised 2% increased reporting level compared to the previous quarter. Other than these incidents: - Staffing issues are reported more frequently in WCCSS and MLTC - continue to be monitored and escalated and a recruitment (4) exercise is in progress. - Medication errors were most frequently reported in MLTC - Incidents involving care and treatment occurred across all Divisions, but more frequently in MLTC - Infection Control incidents were predominantly reported by MLTC and Surgery. - Health Records related incidents were reported in high numbers by Surgery and WCCS.

11 6.5 Incidents by Ward/Department - The top ten reporting areas remain fairly similar to Q3, with Ward 27 (Delivery Suite) continuing 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 (50 reported during Q4 compared to 27 reported in Q3). Three new wards namely, Ward 10, Ophthalmology and Ward 29 feature this quarter and historically have not been in the top ten. - Patient's Own Home incidents have decreased during Q4, however approximately 75% of incidents reported against this location being attributed to wounds. - Accident & Emergency consistently report clinical care/treatment/assessment and wounds identified on admission incidents. Violence and aggression incidents in A&E have increased to 14% as per Q3 when 12% were reported, although there is generalised reduction for this category across the Trust. - Ward 15 reports patient falls (33% during Q4), violence & aggression and wounds. - Ward 10 reporting trends are wounds, infection control issues and patient falls. - Ward 4 predominantly reports patient falls and wounds, however there has been a notable increase in medicaton errors during Q4. - Ward 16 continues to report wounds, patient falls and violence & aggression. - Ophthalmology - main reporting theme is Health Records (58%) and appointment related issues. - Ward 29 reported patient falls (31%) and wounds. - Ward 3 consistently report patient falls (58%) and wounds

12 6.6 Serious Incidents 36 incidents were reported as Serious Incidents to the SHA during Q4 (2014/15), a significant increase compared to Q3 when 23 incidents were reported. Categories of Serious Incidents reported include: - Pressure Ulcers 10 cases were reported which is an increase compared to the last quarter when 9 cases were reported. Findings from root cause analyses are continue to be monitored by the Pressure Ulcer Steering Group and themes used to inform improvement work. Further work will be carried out during Q4 2014/15 to strengthen processes around governance and share lessons learned. - Infection control incidents: There were 7 incident relating to ward closures during Q4 (6 were due to Norovirus and 1case of Norwegian scabies) and 1 case of MRSA. This is a significant increase compared to 1 infection control incident reported in Q3. - Obstetric cases 4 obstetric cases were reported - (1 unexpected admission to Neonatal Unit and 3 intra-uterine deaths) hour breaches 2 breaches affecting the transfer of patients - Patient Falls 4 patients sustained injuries (3 fractured necks of femur and 1 subdural haematoma) - Delayed Diagnosis 4 cases of delayed diagnosis (1 fractured neck of femur, 1 cancer, 1 spinal cord compression and 1 cerebral aneurysm) - VTE 1 VTE related case - Sub-optimal care of the deteriorating patient 1 patient was affected by sub-optimal care. - Delayed treatment 1 patient was affected by a delayed OPD appointment. - Information Governance 2 Information Governance related Lessons learned from Serious Incidents include: Ensure that the ITU bleep protocol is followed and accurate recording undertaken when clinicians swap shifts. Robust system to be implemented for assessment and evidencing of patients' capacity for refusal of treatment. Staff to ensure any abnormal radiology relating to child safeguarding is formally reported by a Consultant Radiologist. Copy of resuscitation sheet to be placed in the maternal records alert to be used by ambulance crew in obstetric emergency situations en-route to alert the maternity teams in preparation for incoming emergency.

13 7. Complaints 7.1 Formal Complaints by Category Type Totals Admission 2 Appointments 6 Attitude 9 Clinical Care/assessment/treatment 54 Communication 15 Diagnosis 6 Discharge 4 Equipment 2 Information 1 Medication Error 2 Staffing 3

14 There were 82 letters of complaint received in Q4, with 105 themes arising. The departments most frequently involved were:. Trauma & Orthopaedics Accident and Emergency Ward 5/6. Gynaecology Clinical care/assessment and treatment continues to be the most frequently reported theme in formal complaints (54 themes), however there has been decreased reporting compared to last quarter (75 themes). Complaints involving clinical care, assessment and treatment are most commonly being received in relation to care given in Accident and Emergency Trauma & Orthopaedics Specific focus of the complaints was around general treatment care and supervision/suitability of treatment. Lessons Learned - Issues raised following a complaint will be discussed at relevant MDT to raise staff awareness identify training and development needs. - Complaints are shared with nursing teams for educational purposes and discussed at relevant Care Groups. - A&E staff will make electronic referrals to District Nursing teams to ensure patients' receive their appropriate and timely visits. - Patient transfer form to be developed to ensure consistent and updated information is passed to the relevant people when patients' are transferred or discharged to Nursing Homes. Patient Relations Team Developments: Team continue to meet the 30 working day response time. Now that this is being achieved regularly the team are working to ensure that Divisions are providing us with the appropriate quality paperwork to include Quality Assurance checklist and Action Plan. In the last quarter Patient Relations delivered Complaints Handling training to the FYI and FY2 doctor's. The format utilised a patient story with the patient attending themselves to share their experience and participate in the lessons learned discussion. Training was also delivered to the Therapies team for Planned Care and the newly employed nurses. This is in addition to the regular customer care slot at Trust induction. 10,000 Pt Relations Leaflets have now been delivered which will ensure full access to information across all wards and clinical areas - these have started to be rolled out. The next phase will include role out to GP surgeries and community sites. In addition a small number of National Complaints leaflets have been received published by the DoH. These leaflets are intended for patient bedsides and we are in discussion with the Patient Experience Group as to how best to implement this. The team have introduced a complaints handling quality assurance checklist which is currently being used to audit against a set of standards monitoring compliance with the recent complaints matters CQC audit and the PHSO user led vision for complaints handling. We were audited by the Information Governance and the Corporate Project Manager against the CQC Complaints Matters standards. The audit it demonstrated that the Patient Relations Team have robust systems and processes in place but are reliant on divisions providing updates and sending all relevant documentation in order for it to be saved on the Safeguard database. It is essential that completed complaint responses are returned to the PRT with all relevant statements, the quality assurance checklist and final risk rating.

15 7.2 Formal Complaints by Category and Division By Division, complaints have occurred in the following proportions: (4) Division (4) (3) (2) (1) (4) WCCSS 25% 23% 18% 20% 11% Surgery (3) 29% 37% 46% 35% 39% MLTC 45% 39% 36% 42% 48% Compared (2) to Q3, there has been a continued increase in the number of formal complaints attributed to the MLTC and WCCS Divisions for the third consecutive quarter, in contrast the Surgery Division has decreased for the third quarter. Table 7.3 provides a breakdown of the top 10 areas receiving the most complaints The Divisional (1) Quality Teams review all complaints to identify action required against themes within theses areas (4)

16 7.3 Formal Complaints by Ward/Department 7.4 Formal Complaint Response Times Response to complaint times has now reached the agreed standard of 70% within 30 days. During Q4, an average of 89% of complaint responses were sent out within the timescale, a significant improvement compared to 65% in Q3. The number of overdue complants has significantly decreased during Q Serious Complaints The number of serious complaints received during Q4 has remained fairly constant compared with Q3, however there were 33 moderately severe and 3 major complaints received compared with 63 moderately severe and 3 major in Q3. (32 complaints have not yet been graded/completed). There were no catastrophic complaints received in Q4. There is a risk of a clinical negligence claim arising from?? complaints (assessment based on initial letter)

17 8. Informal Complaints 8.1 Informal Complaints by Category Type Access 2 Admission 1 Total Appointments 266 Attitude 18 Clinical Care/assessment/treatment 117 Communication 66 Diagnosis 1 Discharge 18 Environment 2 Equipment 3 Food/beverages 2 Health Records 10 Information 47 Lost Property 1 Medication Error 2 Patient Transport 1 Privacy/dignity 1 Referrals 10 Staffing 3 Transfer 2 Violence/aggression 1

18 8.2 Informal Complaints by Category and Division The number of themes relating to informal concerns has continued to decrease during Q4-573 themes were reported compared to 605 in Q3. Appointment related themes have decreased steadily from 281 in Q3 to 263 in Q4. Clinical care/ assessment and treatment themes have remained at a similar reporting level as per Q3. As per previous quarters, Access and Trauma and Orthopaedics continue to be the departments receiving the highest number of concerns (20% received during Q4, compared to 19% in Q3), appointment related issues being the predominant trend. 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 these areas.

19 8.3 Informal Complaints by Ward/Department

20 9. Clinical Negligence Claims 9.1 Clinical Negligence Claims by Category Category Total Clinical Care/assessment/treat 22 Diagnosis 5 Patient Fall Clinical Negligence Claims by Category and Division There are currently 329 active clinical negligence claims files. 11 claims have been referred to the NHSLA during Q4 and of this group, 11 claims 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 Q4, 27 new claims were received and common themes are consistent with previous periods, quality of clinical treatment provided and diagnosis. During Q4 there has been an overall reduction in the reporting levels across the four main specialties Obstetrics, Trauma & Orthopaedics, Urology and A&E compared to the previous quarter. 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.

21 9.3 Clinical Negligence Claims by Specialty

22 Duty of Candour The statutory Duty of Candour (Regulation 20 of the Health and Social Care Act) was enacted in October Regulation 20 requires that NHS organisations ensure service users are fully informed where death or moderate/severe harm has occurred as a result of Notifiable Safety Incident. The Duty of Candour is also part of NHS organisations CQC registration requirement and has been included in The Standard NHS Contract since In addition, professional registration will include mandatory compliance with Duty of Candour. Incidents Considered for Duty of Candour During Q4 2014/15, a total of 62 incidents were formally considered to determine whether Duty of Candour applied. Of these incidents, 11 cases have been assessed as requiring Duty of Candour 5 patients have had face to face disclosure with the clinicians and received a letter of confirmation and are being invited to hear about the investigation findings 1 patient has had a face to face disclosure with the RCA findings included in discussions 1 patient has been invited to discuss RCA findings 1 patient is due to attend clinic for a face to face disclosure 1 patient - waiting for clinician evidence of face to face disclosure in clinic 1 patient has had a face to face disclosure but did not want to be given a letter at the time. The palliative care team are supporting this patient and will inform when the patient is ready to receive feedback on the RCA findings and actions 1 next of kin has had a face to face disclosure, letter to be sent when address obtained Of these incidents, 46 were assessed as not having caused moderate or severe harm or death: 24 caused minor harm 9 caused no harm 6 unavoidable pressure ulcers 4 unavoidable falls 1 unavoidable placental abruption 1 was attributable to another organisation 1 was a poor patient experience Of the remainder, 5 cases are still being considered: 2 ward closures due to norovirus outbreak 1 patient where histology is awaited 2 late reports of VTE 9.4 Serious Claims No claims have been received with the potential for resulting in a significant compensation award 9.5 Closed Claims 30 claims closed during Q4: 21 closed with no compensation awarded - these claims closed due to lack of merit or inactivity 9 closed with compensation: 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. 10 Key Learning from Clinical Audit National COPD outcome BTS results - COPD Care Bundle - internal / local review Outcome of the mortality review - Poor use of bundles was noted within this second review If the bundles are present, most are completed incorrectly, particularly for COPD. The checklists used by the AMU ward doctors on the morning ward rounds have led to some improvement in the rate of bundle completion. The recommendations from the audit were: The awareness of bundles needs to be increased, particularly amongst clerking doctors. All doctors should be encouraged to complete the care bundles, particularly during post takes as it requires little time to fill in and ensures implementation of the correct management plan for patients. Ensure that the use of bundles is covered in the routine induction of medical staff. Doctors completing the bundles should ensure that for each action point completed, the time is documented and signed Encourage the doctor completing the EDS to also enter the date and time of discharge on the bundles. Continue to use the AMU ward round checklist as this has led to some improvement in the use of bundles. Include a section at the end of the clerking sheet which reminds the clinician to complete the bundle and place the sticker on the indicated page. Small sample size in this audit? worthwhile re-auditing in December when there are likely to be more CAP and COPD admissions. Histology Audit Page 22 of 24

23 The audit concluded that 25 forms were received with errors from the Gynaecology outpatient department, all work received from GOPD was missing at least specimen location.11 requests from GOPD were also missing the requesting consultant, which equates to 44% of work from GOPD missing consultant information. The team were asked to ensure all request forms were completed correctly and highlighted to the team the mandatory fields noted on the request forms. National Paediatric Diabetes audit Good compliance was noted Walsall continues to be in line with national outcomes NBOCAP The next data submission deadline will be 6th February This will be the final deadline for audit data to be linked to HES data and death data. The Audit team will carry out the linkage to HES and ONS and in February/March, data validation meetings have been arranged to ensure validated data is submitted. Ceiling of Care Audit: The audit concluded that the ceiling of care is not documented in the majority of patients thus not complaining with the NCEPOD status, for patients where there is a decision relating to ceiling of care this is usually documented by the SpR or Consultant and were identifiable. The DNAR forms are only completed appropriately in 21% of patients which is in breach of resuscitation council guidance. A further finding highlighted the need for an improvement in documentation of communication with patients and families regarding decisions in the management of the patients care. DNAR Audit The audit noted that overall compliance with the DNAR form completion provides adequate assurance; however areas requiring improvement were the documentation pertaining to names of the MDT team involved with the decision and summary of the communication with patients. A further finding noted that 76% of patients with DNAR form had a PAR score of greater than or equal to 7 indicating a correlation between suggested indications for DNAR form and having a DNAR form in place. The audit noted the same recommendations as the ceiling of care audit, and agreed to merge the two action plans to standardise practice. An audit on the NICE guideline for Upper GI FastTrack referrals The audit noted that 67% of referrals met the NICE criteria. In total 19 patients had an upper GI cancer, these all met NICE guidance highlighting a pick up rate of 7.6%. It was noted that this also reflects the previous audit conducted. It was agreed to escalate the findings to DQT for recommendations and action as capacity and demand is being compromised and a risk being added to the risk register as there is currently a back log for OPD cancer waits. End of Life Care Audit Identified improvement in practice had been noted areas of good compliance were noted to be Education, prescriptions management particularly the protocol and the privacy and dignity. Areas noted for learning were 9-5 support was not available for the EOL patient - this has now been amended and addressed as part of the action plan following the audit Information given to patients who are noted to have reached EOL stages - this is in progress following the audit, information leaflets are currently being drafted Bereavement feedback / discussions - this is in progress by way of formal feedback, a business case has been developed for bereavement officers and facilities have been identified at the front end of the hospital Documentation of assessment of spiritual needs / beliefs - policy changed to allow Chaplin's to document discussions within the patients' health records 13% of the case notes did not identify any impending death which links to the ceiling of care audit and the DNAR audit all triangulate to the conclusion that although EOL documentation has improved there is still room for improvement amongst all staff within the organisation. A re audit/snapshot progress review was completed in December 2014 that highlighted the documentation of spiritual needs for those who have not been reviewed by the palliative team remains inconsistent. An action plan was developed and is currently in progress, update to be shared at joint audit session in May Safeguarding Total of 75 alerts received for Quarter 4. Concerns in relation to neglect, vulnerability and physical abuse. This total included 1 report of domestic abuse disclosure. Of the 75 referrals received, 15 referrals received externally in relation to concerns around acute care. *10 referrals relate to concerns around transfer of care / discharge arrangements *3 concerns in relation to hospital developed pressure ulcers *1 concern in relation to care delivery within ward area *1 concern in relation to alleged poor assessment in A&E 3 of the concerns received in this quarter relate to adults with a learning disability. 10 applications for deprivation of liberties safeguarding submitted during this quarter from the hospital. This is a decrease from the 11 requests submitted in the last quarter. CCG Performance framework-in relation to safeguarding adults for inclusion in next year's contract.the data in relation to safeguarding adults, DOLS, Mental capacity and PREVENT training in addition to number of alerts and referrels of persons in position of Trust.This data will be submitted in a scorecard at the agreed frequencies. Safeguarding adults flag with fusion operational at present- informatics scheduling a series of checks to ensure Page 23 of 24

24 effective and consistent. Learning disabilities learning events being scheduled for 2015/2016 for staff whicvh will be supported by service users and adults with a learning disability. Restrictive practice interventions- One of the recommendations within the guidence is for effective governance arrangements in relation to reporting when restraint is used. Recording and Reporting- the trust must publish an annual report which includes details of training, the number of interventions, any injuries that resulted and on going strategies.this is available on the Safeguard system and will activated and promoted across the organisation. The section addresses most of the information that is required Page 24 of 24