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

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1 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 available in the UK The paper supports the achievement of all Trust Objectives through the underpinning strategy of ensuring that the Trust has an appropriately trained and supported workforce ensuring that the facilities and equipment used by the Trust are of high quality ensuring that robust arrangements are in place to ensure financial stability ensuring that the Trust is well governed and works effectively in partnership Purpose of the paper To present to the Trust Board of Directors activity related to Quality Assurance and Risk Management. Summary of key points The Trust is continuing to maintain a robust reporting culture. The top 3 categories of incidents remain consistent as abusive disruptive behaviour, medication errors and incidents relating to patient information. Compliance with national standards in relation to complaint management continues to improve. Board Action required The Board is asked to review the report and indicate any actions required. Author: Executive Sponsor: Angela Wendzicha, Head of Legal and Governance John Reid, Director of Nursing and Clinical Operations FOR ASSURANCE 1

2 Sheffield Children s NHS Foundation Trust Integrated Governance Report Angela Wendzicha, Solicitor Head of Legal & Governance 1 April January 21 2

3 Contents 1. Executive Summary 4 2. All Reported Incidents 3. Clinical Risk Clinical Incident Statistics Root Cause Analysis Investigations (not determined as Serious Incidents) 3.3 Serious Incident Investigations 3.4 Complaints 3. Litigation and Inquests Non Clinical Risk Health and Safety Related Incidents Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Incidents Security Related Incidents 14. Trust Risk Register NPSA Alerts 1 7. Freedom of Information Requests 1 8. Safeguarding 1 9. Regulatory Compliance 1. Audit and Effectiveness 16. Patient Led Assessments of the Care Environment (PLACE) 17. Information Governance 17 3

4 1. EXECUTIVE SUMMARY The following report illustrates the activity from April 214 January 21 and is based on the data held on the Legal and Governance database as at 2 February 21. Updates since the previous report presented in December 214 are highlighted in bold. The Trust continues to demonstrate a robust reporting culture with a total of 3332 incidents reported during April 214 January 21. The majority of the incidents reported have a consequence graded as negligible which required no or minimal intervention. The three top categories of reported incidents relate to: Abusive, violent, disruptive or self harming behaviour these incidents mainly occur at the Becton Centre. Medication errors Patient information The Trust has identified a total of 8 (1 identified during December/January) incidents that have been subject to Root Cause Analysis Investigations and a total of incidents that have been reported externally as Serious Incidents. The Trust has not been involved in any incidents that fall under the category of never events. A total of 22 (4 during December/January) health and safety related incidents were reported with slips, trips and falls, sharps related incidents and moving and handling incidents being the most reported incidents. The Trust reported 8 incidents to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations during the reporting period. A total of 148 (22 during December/January) security related incidents were reported with the majority relating to abusive, violent or disruptive behaviour. During the reporting period a total of letters have been sent to parents outlining the behaviour that is expected of them. No behaviour letters were required during December/January. A total of 93 (18 during December/January) formal complaints have been received by the Trust during the reporting period. A review and change in practice relating to the management of complaints has seen an increase in compliance with national standards, in particular during the period October-December 214. Litigation continues to remain active within the Trust with a total of 2 open potential claims against the Trust. A total of 26 new risks were added to the risk register with 24 risks being closed. A total of 284 new requests for information under the Freedom of Information Act 2 were received with 172 being closed. A total of 39 requests for copies of medical records were received during the reporting period. Action plans relating to assessments made by the Care Quality Commission remain ongoing. Activity remains constant within the Quality Department. The Head of Legal and Governance is currently working with the Quality Standards Manager to highlight changes in practice as a result of audit and this is expected to be included in reports going forward. 4

5 2. ALL REPORTED INCIDENTS The data contained within this report illustrates the information held on the Legal & Governance Department database on Monday 2 nd February 21. It should be noted that for each of the graphics illustrating the number of incidents reported there is a consistent decrease in numbers due to the fact that not all incidents had been received in the Legal and Governance Department by the reporting deadline. It is anticipated that the introduction of on line reporting will improve real time reporting. 2.1 All Incidents by Type All incidents by Type April January Data Confidentiality Security Health & Safety Patient Safety 8 Figure 1 A total of 3332 incidents have been reported during the period April 214 to January 21. Figure 1 above demonstrates that as with previous years and months the highest number of incidents reported related to Patient Safety. Figure 2 below shows the monthly totals since the beginning of the financial year with a comparison for totals reported from previous financial years.

6 Patient Safety Health & Safety Security Data Confidentiality Total Totals 29/ / / / / /21 April May June July August September October November December January February March Total Figure 2 6

7 3. CLINICAL RISK 3.1 Clinical Incident Statistics All incidents classed as Patient Safety are reported to the National Reporting and Learning System (NRLS) on a monthly basis by the Legal & Governance Department. The next National Performance Report is due for publication on 8 April 21 and will report on activity during the period 1 April September 214. Figure 3 below illustrates the patient safety related incidents reported during the period April 214 to January 21 by NRLS category All Reported Clinical Incidents Patient Safety by NRLS Category Financial Loss Anaesthesia Unplanned/Unexpected readmission into Hospital Diagnosis Failed/Delayed IRMER Regulation Issues Data Confidentiality Security Unexpected Death Clinical Assessment Implementation of care, or on-going monitoring/review Accident that may result in personal injury Medical Device/Equipment Treatment, Procedure Consent, Confidentiality or Communication Infrastructue, Resources Access, Appointment, Admission, Transfer or Discharge Patient Information Medication Figure Top 3 NRLS Incident Categories reported Figure 4 below illustrates the highest categories of patient safety related incidents reported during the period April January 21 namely abusive, violent or disruptive behaviour, medication related incidents and those relating to patient information.. 7

8 9 Top 3 NRLS Categories reported Abusive, Violent, Disruptive or Selfharming Behaviour Medication Patient Information 6 Figure Abusive, Violent, disruptive or Self-harming Behaviour Incidents A total of 87 incidents were reported relating to Abusive, Violent, Disruptive or Self-harming Behaviour during the period April 214 to January 21, of these, 6 occurred on the Becton site. Lessons Learned Escalating behaviour within client groups results in a review and update of the individual risk assessment and if appropriate transfer to alternative specialist units. Close liaison between Becton and the Legal and Governance Department has resulted in the incident form being amended to ensure additional details are captured during incidents relating to restraint. In order to support staff at Becton, a series of policies have been introduced during December 214 and January 21 providing clear procedures for staff in relation to day to day situations. These include the Seclusion Policy, Searching Policy, Missing Persons policy and the Reducing Restrictive Interventions Policy. The aforementioned polices are being supported by specific training sessions for staff Medication Incidents As a result of medication incidents, changes in practice have been introduced as follows: Worksheets have been reformatted relating to Cidofovir due to a number of incidents whereby the incorrect dose and concentration during the preparation stage occurred. All oral chemotherapy must be prescribed using the chemcare prescribing system 8

9 The introduction of ward based Medicine Management Technicians and an increase in the number of ward Nurse Educators have been instrumental in the implementation of action plans from previous investigations which has resulted in a lack of repetition of those incidents. The Medicines Management Group has been re-launched and now meets on a monthly basis and has a multi-disciplinary attendance. During December 214 and January 21 the group has considered the role of the Trust Medication Safety Officer in line with National Guidance in addition to reviewing a number medication related Safety Alerts. Medication Incidents by Division or Service MEDicine Figure April May June July August September October November December January Surgery & Critical Care Community & WAMH Pharmacy, Diagnostics & Genetics External to SCH 9

10 3 2 2 Top 3 Medication incidents by NRLS Category Administration from a clinical area Error during the prescription process Error during dispensing from Pharmacy Figure Patient Information Incidents During the reporting period April 214 to January 21, a total of 31 incidents related to patient information. The majority of these incidents relate to misfiled records and incidents whereby pages have been inappropriately put into overfull records. All such incidents are reported to and discussed at the Clinical Records Committee in addition to the Information Governance Committee. It is expected that the introduction of the Electronic Document Management System will reduce these incidents Consequence of Clinical Incidents Figure 7 below illustrates that the majority of reported incidents (2,943 in total) received an agreed consequence of (1) on a scale of 1- indicating severity. These required no or minimal intervention or treatment. A total of 319 incidents were graded as (2) that resulted in minor intervention or minor delay to the administration of medication. One incident was graded as () because the patient had an unexpected death. This has been the subject of a Serious Incident Investigation in addition to an Inquest held in January 21. In her Determinations and Findings, the Coroner concluded that the precise mechanism of what caused the death remains unknown.

11 3 3 Patient Safety incidents by Agreed Consequence Negligible 2. Minor 3. Moderate 1 4. Major. Catastrophic April May June July August September October November December January Figure Root Cause Analysis Investigations Figure 8 below illustrates the Root Cause Analysis Investigations carried out from April 214 to January 21. No & Reference Date of Incident Description Date to ERMC 1. IR //14 Orthopaedic fixator device March 21 programming error 2. IR //14 Fractured femur found at the point of therapy February IR136 16/9/14 Aggressive patient admission to February21 AAU and delayed transfer to CAMHS 4. IR1323 2/8/14 Resuscitation trolley drug expiry check not carried out February21. IR /8/14 Patient delayed in ED prior to February21 transfer to Leeds Teaching Hospitals Trust 6. IR482 7/6/14 Incorrect Midazolam infusion in Theatres November IR //14 Baby tooth extracted in error February21 8. IR74 /4/14 Interruption to Flow Cytometry May 214 service Figure 8 A review of the internal process for completion of investigations has been undertaken by the Head of Legal and Governance in conjunction with the Risk Manager which will result in an improvement in the reporting timescales.

12 3.3 Serious Incident Investigations Figure 9 below details the Serious Incidents declared new during the reporting period. No & Reference Date of Incident/Date Reported 1.214/128 July-September 213/ //214 Reporting deadline (2 working days) met Y/N No Description Safeguarding allegations at Becton 2.214/386 23//214/26//214 No Grade 3 Pressure sore 3.214/ //214/27//214 No Unexpected death 4.214/ /7/214/2/7/214 Yes Unexpected death in theatres.214/34367 August 2- September 214/ 21//214 Figure 9 No Incorrect sweat test results 3.4 Complaints Number of complaints received Number acknowledged within 3 working days Number of final responses completed within 2 working days Number of complaints referred to the Ombudsman Number upheld by the Ombudsman 93 (+2 verbal no further action and 2 retracted) Figure 67 (72%) 2 (6%) 2 New Complaint Acknowledged within 3 working days Final response within 2 working days Compliant not upheld Complaint partially upheld Complaint upheld Quarter Quarter Quarter (one remains in progress) Quarter All ongoing Figure The predominant themes in complaints relate to issues around communication across all clinical teams in addition to clinical treatment decisions.

13 A full review of the internal complaint process has been completed by the Head of Legal and Governance which has resulted in a significant improvement in complaint acknowledgement and response times. 3. Litigation and Inquests 3..1 Open Claims The Trust currently has 2 open potential claims with new claims received during December 214 and January 21. A total of 6 potential claims were closed with no case to answer Inquests During the reporting period the Trust has been involved in a total of Inquests, all of which resulted in short narrative conclusions. 4. NON-CLINICAL RISK 4.1 Health and Safety Related Incidents H&S Incidents by Category IRMER Lifting accident Injury from physical or mental strain Other personal accident Exposure to electricity, harmful substance Needlestick injury Slips, Trips & Falls Other Abuse, aggesive or selfharming behaviour Environmental Matters Figure: A total of 22 Health and Safety categorised incidents for the period April 214 to January 21 were reported. Slip, trip and falls and needdlestick incidents show the greater incidence rate by type for the period. The above table includes all reported Health and safety incidents including those categoriesed as environmental matters, and under the category of other. 13

14 4.2 RIDDOR During the reporting period April 214 to January 21 there were 8 ( 3 during December 214 and January 21) RIDDOR Reportable Incidents (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Incidents). All incidents have been reported to the Health and Safety Executive (HSE) via the web portal. The trend relates to slips and each incident has been investigated and preventative measures reviewed. 4.3 Security Related Incidents A total of 148 security related incidents were reported during April 214 and January 21 with 63 relating to abusive or disruptive behaviour. A total of behaviour letters have been sent to parents who displayed abusive and aggressive behaviour. Security by Category Related to Personal Property Related to Premises, lan or real estate Figure Security - Other Abuse, violent, disruptive or self harming behaviour Access, Admission Personal Accident Related to equipment. TRUST RISK REGISTER During the reporting period April 214 to January 21 a total of 26 new risks were opened and a total of 24 risks were closed. Risks Opened Patient Safety Financial H&S Security Total Risks Closed Patient Safety Financial H&S Security Total

15 6. NPSA ALERTS During the period April 214 to January 21 a total of 1 safety alerts have been received with 84 being assessed as not applicable to the Trust. A total of 28 have been assessed as relevant to the Trust with 22 closed within the deadline and 1 overdue. The overdue alert relates to safer spinal epidural and is outwith the control of the Trust. 7. FREEDOM OF INFORMATION The Freedom of Information Act 2 gives the public a general right of access to information held by public authorities in relation to their activities. The Trust has an obligation under the Act to provide the information requested promptly and no later than 2 working days after the date of receipt of the request. The Legal and Governance Department acquired responsibility for the management of requests under the Freedom of Information in March 214 from the IT Department. A full review of the processes and internal procedures has taken place. During the period April 214 to January 21 the Trust received a total of 284 new requests with 172 requests being closed. 8. SAFEGUARDING 8.1 Training statistics The Trust overall compliance for safeguarding training at January 21 was 87% as follows: Level 1: 92% Level 2: 92% Level 3: 82% 8.2 Safeguarding case reviews The Trust currently is participating in the following multi agency reviews: Serious Case Reviews: 4 Case Reviews: 2 Domestic Homicide Reviews: 1 9. REGULATORY COMPLIANCE 9.1 CQC Intelligent Monitoring The December 214 CQC Intelligent Monitoring Report for the Trust is shown below: One risk has been identified relating to staff appraisals and actions are underway to address this. 1

16 9.2 CQC Action Plans Main site The Trust main site was inspected by the CQC during 7-9 May 214 resulting in an action plan with initiatives being undertaken by the Executives and Divisional leads. The action plan is monitored via the Trust Executive Group and the Risk and Audit Committee. The action plan was reported to the Public Board in January. 9.3 CQC Action Plans Becton site Three unannounced inspections have been carried out on Emerald Lodge (November 213), Sapphire Lodge (February 214) and Ruby Lodge (February 214). The inspections were limited to the compliance with the Mental Health Act Action plans are currently in progress.. AUDIT AND EFFECTIVENESS.1 Commissioned Priority Programme The Trust currently has 18 commissioned audits registered within the priority programme for 214/21..2 Clinical Audit and Service Evaluation Projects The following table illustrates the Projects registered by Division from 1 April 214 to January 21. Division Level 1 Level 2 Level 3 Level 4 Total MEDicine Surgery & CC Pharmacy & Diagnostics CWAMH Research 1 1 Corporate/Trust wide Total Key to levels: Level 1 Trust external priority projects (commissioned, CQC, CQUINNS) Level 2 Trust priority NHSLA, Complaints Level 3 National or Accreditation projects Level 4 Division/Speciality projects, clinician interest 16

17 .3 NICE Guidance Technology Appraisals (TA) A total of 328 Technology Appraisals have been released during the reporting period. Public Health Guidance (PHG) A total of 6 Public Health Guidance received during the reporting period with 23 not applicable to the Trust. Quality Standards A total of 7 Quality Standards received with 4 not applicable to the Trust. The Head of Legal and Governance is currently working with the Quality Manager to review any changes in practice as a result of the above.. PATIENT LED ASSESSMENTS OF THE CARE ENVIRONMENT (PLACE) PLACE are self assessment of a range of non-clinical services which contribute to the environment in which healthcare is delivered in both the NHS and independent healthcare sector in England. The table below illustrates the recent assessments carried out. Assessment PLACE Scores by Site vs the National Average National Average SCH Main Site Becton Ryegate Cleanliness 97.2% 99.81% 99.73% % Food and Hydration 88.79% 89.3% 94.21% NA Privacy, Dignity and Wellbeing 87.73% 79.31% 9.23% 78.41% Condition, Appearance and Maintenance 91.97% 94.9% 97.97% 98.7%. INFORMATION GOVERNANCE Evidence continues to be collated in preparation for submission for compliance with the Information Governance Toolkit by end March 21. The submission is expected to show that the Trust is compliant with the tool kit standards. The ongoing action plans are monitored via the Information Governance Committee and Clinical Governance Committee. 17