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

Transcription

1 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 1/7/213 to 3/9/213

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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 2 213/14 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. In addition, Imaging services also features across incidents and informal complaints, although unlike Q1, there are no new claims. The notable increase in complaints received relating to AMU in the previous quarters has persisted into Q2. Pressure Ulcers categorised as severity 2, or 3 have been identified in lower numbers compared to the previous quarter. However, there were 4 category 4 pressure ulcers compared with 3 and 2 in the respective 2 previous quarters. Wounds, transfer and equipment related incidents are the most frequently reported incident. The increase is due mainly to incident reports being made of staff being unable to obtain falls prevention equipment of low rise beds and alarms. Falls continue to be reported in high numbers, occurring most frequently in MLTC. However, the overall numbers continue to reduce, with an 18% decrease from the last quarter. There was one fall resulting in catastrophic harm. There have been 36 Serious Incidents reported compared with the previous quarter when there were 28. There were no National Never Events. There was one complaints alleging major harm has been caused by inadequate treatment compared with 5 in the previous quarter. There has been one new claim 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 1/7/213 to 3/9/ Corporate Themes Corporate Theme Formal Complaint Informal Complaint Incidents Clinical Negligence Claims Other Admission/Discharge/Transfer Communication & Attitude Diagnosis Equipment Health Records Page 3 of 21

4 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) Inadequate Care /Treatment Infection Control 66 Manual Handling 9 Medication Errors Patient Falls Pressure Ulcers 82 Staff/Visitor Accident 68 Staffing Violence & Aggression Page 4 of 21

5 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) During Q2 213/14, the trend picture was similar to Q1 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 Q2 there were 34 issues reported compared to 317 in Q1. 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 Inadequate vital signs monitoring. Diagnosis issues continue to feature in all CLIPS, however whilst there has been a notable increase of 5% within incident reporting, there has been a similar percentage reduction for diagnosis related claims during this Q2. There has been an increase in complaints and incidents involving: - Admission, Discharge and Transfer - Staffing 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 21

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 3 6 Medication Errors Patient Falls Pressure Ulcers 3 79 Staff/Visitor Accident Staffing Violence & Aggression Incident by Category Type Total Clinical Incident 216 Maternity Managed Event 22 Violence & Aggression 15 Non Clinical Incident 133 Report An Accident/Near Miss A 94 Security Incidents - Security 1 Page 6 of 21

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 Admission Antimicrobial 1 Attitude Blood/fluid Administration Breach In Policy/procedure Burns/Scalds 4 C-Difficile Clinical Care/assessment/treat Communication Consent 3 Contact With Hazardous Substan 2 1 Cuts & Abrasions 6 Data Protection - Security Bre Diagnosis Discharge Discriminatory Abuse 2 1 Environment Equipment Fire Or False Alarm 1 1 Food Stuff Contamination 1 Fraud 1 Health Records Hit By Falling/moving Object 1 9 Impact With Stationary Object Infection Control Investigations Lost Property Manual Handling Medical Emergencies & Cardiac Medication Error Needles And Sharps Non-Compliance Operative Procedures Patient Fall Pregnancy & Birth (Managed) Pregnancy/birth 1 3 Pressure Ulcers Radiation (Patients & Public) Page 7 of 21

8 Referrals Security Breach - Physical Sec Security Related Incidents 1 Slips/trips/falls (Staff And V Specimen Handling Staffing Theft Transfer Unauthorised Access To It Syst 2 1 Unauthorised Access To Pt Reco 1 Unexpected Death Vandalism 2 Violence/aggression Wounds Most frequently reported incidents include Admission/Discharge/Transfer Falls Staffing Equipment Communication Incidents causing moderate to catastrophic harm are more likely to involve: Inadequate patient care/treatment The most frequently reported incident in this category relates predominately to capacity and transfer of care between wards. These incidents continue to be monitored by the Divisions. Pressure ulcers Pressure ulcer incidence is monitored closely across the organisation and remedial action progress considered in a monthly report to the Board. Last quarter, incidence of category 2 pressure ulcers showed a significant improvement, from 66 in Q1 213/14 to 49 in Q2. The more serious ulcers are developing in lower numbers in hospital, overall the numbers are similar. It should be noted that this report includes category 1 pressure ulcers which are not included in the monthly performance and quality reports. During Q1, these incidents decreased from 42 in Q1 to 18 in Q2 (57% 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. Last quarter, there was a significant improvement in the total number of falls reported (2% reduction on Q1), in addition falls causing actual harm decreased by 5%. Staffing issues Staffing issues are most frequently reported by Delivery Suite. 2 incidents were reported as causing minor or moderate harm, compared with 17 in the previous quarter. Admission, discharge and transfer Admission - delays in providing a bed for specifically surgical and gynaecological specialities 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 7 incidents relating to unexpected deaths. 6 cases were obstetric incidents and have been investigated through the Perinatal Mortality and Morbidity forum. The remaining case was an adult death which has undergone a Serious Incident Investigation. Page 8 of 21

9 Wounds Transfer Staffing Patient Violence/aggression Communication Clinical Equipment Medication Health Pressure Breach Investigations Infection Admission Discharge Data Non-Compliance Diagnosis Slips/trips/falls Operative Referrals Needles Specimen Blood/fluid Lost Attitude Radiation Environment Impact Hit Unexpected C-Difficile Manual Theft Medical Cuts Burns/Scalds Pregnancy/birth Consent Contact Discriminatory Fire Vandalism Antimicrobial Food Fraud Security Unauthorised By Or Property & Protection Stuff Falling/moving Records Handling Abrasions False Emergencies With Control Related And Breach Ulcers Procedures (Patients Policy/procedure Contamination Administration & Error Death Stationary Sharps Hazardous Birth Alarm Access Abuse (Staff - Incidents Security Physical & And To & It Wounds Transfer Staffing Patient Violence/aggression Communication Clinical Equipment Medication Health Pressure Breach Investigations Infection Admission Discharge Data Non-Compliance Diagnosis Slips/trips/falls Operative Referrals Needles Specimen Blood/fluid Lost Attitude Radiation Environment Impact Hit Unexpected C-Difficile Manual Theft Medical Cuts Burns/Scalds Pregnancy/birth Consent Contact Discriminatory Fire Vandalism Antimicrobial Food Fraud Security Unauthorised By Or Property Protection & Stuff Falling/moving Records Handling Abrasions False With Control Breach And Related Ulcers (Patients & Error Death Sharps Birth Alarm (Staff - Wounds Transfer Staffing Patient Violence/aggr Communicati Clinical Equipment Medication Health Pressure Breach Investigations Infection Admission Discharge Data Non-Complia Diagnosis Slips/trips/falls Operative Referrals Needles Specimen Blood/fluid Lost Attitude Radiation Environment Impact Hit Unexpected C-Difficile Manual Theft Medical Cuts Burns/Scalds Pregnancy/bir Consent Contact Discriminatory Fire Vandalism Antimicrobial Food Fraud Security Unauthorised By Or Property & Stuff 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 Q2 (213/14) Q1 (213/14) MLTC 43% 49% WCCSS 31% 28% SURGERY 25% 21% COMMERCIAL.6%.2% CORPORATE.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 reduction from 49% to 43%. Surgery incident reporting has increased steadily over the previous 2 quarters, following successful promotional campaigns. 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 MLTC 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. - Theatres continue to report transfer incidents at increased levels relating to lack of beds for patients' recovering from surgical procedures. - Accident & Emergency most frequently report clinical care, treatment and assessment incidents, a continuing trend from Q1. - Patient's Own Home incidents have increased this quarter with approximate 5% of incidents being attributed to wounds identified on admission to hospital. - Imaging department continues to feature in the top 1 for the third quarter with increased reporting in relation to patients' delays for investigative procedures due to lack of portering staff. - Ward 3 has increased reporting levels relating to patient falls and decolonisation issues. - Ward 12 trend predominantly relates to lack of low rise beds. - Ward 16 continue to report wounds, falls and equipment incidents. - Ward 15 reports patient falls and equipment related issues. - Ward 14 main trends are wounds and patient falls.

11 6.6 Serious Incidents 36 incidents were reported as Serious Incidents to the SHA in Q2. These include: Pressure Ulcers 17 cases were reported which is a significant increase compared to the last quarter when 11 cases were reported. Findings from root cause analyses are considered collectively by the Pressure Ulcer Steering Group and themes used to inform improvement work. Infection control incident 3 incidents were reported. Falls 4 cases were reported compared with 3 cases in the previous quarter. 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 3 cases have been reported relating to a misidentification of patient during CT scanning procedure, 2 cases of failure to diagnose thrombo-embolisms. Obstetric cases 3 obstetric cases were reported - 2 intra-uterine deaths and1 unexpected admission to Neonatal Unit Safeguarding 1 case of accessing maternity service using alias identification details. Unexpected Deaths 2 unexpected deaths have been reported- 1 child death following a triage delay within the A&E department and 1 adult death within the Community - awaiting post-mortem results Information Governance 1 incident was reported involving a member of staff who inadvertently mislaid documentation relating to children's health visiting. Failure in follow-up 2 cases were reported, 1 relating to failure to follow-up within Dermatology speciality and 1 failure to follow protocol during inpatient admission.

12 7. Complaints Type Totals Access 1 Admission 4 Appointments 13 Attitude 16 Clinical Care/assessment/treat 88 Communication 29 Diagnosis 14 Discharge 16 Discriminatory Abuse 1 Environment 6 Equipment 1 Food/beverages 1 Health Records 5 Information 7 Lost Property 2 Medication Error 6 Patient Transport 1 Privacy/dignity 4 Referrals 1 Staffing 3 Transfer 1

13 There were 98 letters of complaint received in Q2 (plus 11 conversions from informal to formal, with 215 themes arising. This is a 23% increase on Q1. The departments most frequently involved were: Accident and Emergency Trauma & Orthopaedics Acute Medical Unit (AMU) There has been an increase in complaints related to maternity care. The most frequently occurring themes in formal complaints continue to concern clinical care/assessment and treatment, with an increase from 61 to 85 themes within the complaint letters. Complaints involving clinical care, assessment and treatment are most commonly being received in relation to care given in Accident and Emergency Surgical specialties particularly Trauma & Orthopaedics Specific focus of the complaints was around: Clinical care, assessment and treatment Appointments Lessons Learned MLTC Induction of junior doctors in A&E to include management of hip pain Leaflet to be given to patients/carers to help with communication regarding Swift Discharge Suite when patients are "stepped up" from A & E. Lead nurse for the Swift Discharge Suite to investigate how "step up" transfer of care is recorded on FUSION in liaison with the surgical/medical teams. Surgery To monitor what student nurses are saying to the patients to ensure that information is not conflicting or misguiding. To highlight risks of remaining un-catheterised effectively to patients if they decline to be catheterised; this is especially relevant when staff are sure this is what is needed for the patient to maintain their safety. To ensure that wards have a bladder scan present on the ward. WCCSS Delivery Suite Team will be having a multi-disciplinary team meeting as a direct result of the complaint to look at the events of care to see if we can do things differently for patients, especially around the issues of communication. Discuss with individual midwife the importance of explaining findings and potential outcomes to patients. Also discuss communication with regards to using appropriate terminology so patient's understand Midwives to report all unusual side effects from epidurals to the anaesthetists. Patient Relations Team Developments Complaints Conference held involving patient stories and investigating officer training. Dr Daniel Poulter MP also participated Engagement with the local patient relations network Staff training has started including the Leadership Academy Foundation Programme. Officers are attending patient forums more widely

14 7.2 Formal Complaints by Category and Division Divisionally, formal complaints are received: WCCSS: 13% Surgery: 4% MLTC : 44% Compared to Q1, there is a proportionate increase in Surgery and decrease in WCCSS and MLTC 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, remaining at 46% in Q2. Further initiatives have been implemented to address the failure to meet the standard: The Heads of Nursing are trialling new system where a first draft of the complaint response is compiled as part of their investigation The Heads of Nursing are ensuring availability for early meetings with complainants where it looks like this would resolve the issues quickly (every Thursday) A third member of the complaints team is now drafting formal complaint responses. Allocation of the patient relations team to response drafting is being spread between the backlog and newer complaints 7.5 Serious Complaints There were 33+ moderately severe and major complaints received in Q2, compared with 46 and 5 respectively in the previous quarter. There is a risk of a clinical negligence claim arising from 2 complaints (assessment based on initial letter)

16 8. Informal Complaints Type Total Access 3 Admission 9 Appointments 12 Attitude 26 Clinical Care/assessment/treat 1 Communication 43 Diagnosis 1 Discharge 17 Discriminatory Abuse 1 Environment 3 Equipment 4 Food/beverages 3 Health Records 7 Information 29 Lost Property 1 Medication Error 4 Patient Transport 1 Privacy/dignity 2 Referrals 7 Staffing 1 Transfer 1 Violence/aggression 1

17 8.2 Informal Complaints by Category and Division 13 concerns related to clinical care, assessment and treatment in Q1, a slight decrease from 113 in the previous quarter. Attitude related concerns are being raised in similar numbers to the previous quarter. There has been a 3% reduction in concerns being raised about appointments, redusing form 147 to 12, but still higher than Q4 212/13 (71). Trauma and Orthopaedics, Easi-book and Access are receiving concerns in high numbers. Accident and Emergency receive the most informal complaints, mainly concerned with clinical care, assessment and treatment, followed by Trauma and Orthopaedics, with the most common themes emerging from issues around appointments. Surgery and MLTC continue to see higher numbers of concerns being raised around clinical care, assessment and treatment compared with previous quarters. These are most being received in the highest numbers in relation to: Trauma and Orthopaedics Accident and Emergency Imaging 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 17 Diagnosis 5 Patient Fall 1 Pregnancy/Birth Clinical Negligence Claims by Category and Division There are currently 25 active clinical negligence claims files. 148 of these have been referred to the NHSLA and of this group, 36 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 Q2, 25 new claims were received. Of those received in Q2, there are 2 common themes, consistent with previous periods, quality of clinical treatment provided and diagnosis. In Q2, the specialties receiving most claims are Surgery, Obstetrics & Gynaecology and Trauma and Orthopaedics. Claims related to Accident and Emergency dropped to 2 from 3 last 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.

20 9.3 Clinical Negligence Claims by Specialty

21 Serious Claims There has been 1 new obstetric claim with the potential for resulting in a significant compensation award. No specific allegations have yet been made. 9.5 Closed Claims 33 claims closed during Q2: 25 closed with no compensation awarded - these claims closed due to lack of merit. 8 closed with compensation: 2 related to diagnosis 4 related to inadequate care 1 related to consent to treatment 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. There are no trends arising from the claims closed in Q4 with regard to specialty or department. 1 Safeguarding 26. Page21 of 21