CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 1/1/213 to 31/12/213
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 31/12/213 4. Corporate Themes 97 31 2492 28 Corporate Theme Formal Complaint Informal Complaint Incidents Clinical Negligence Claims Other 19 131 955 3 Admission/Discharge/Transfer 14 41 318 Communication & Attitude 47 55 136 Diagnosis 16 9 76 4 Equipment 4 58 Health Records 2 2 86 Inadequate Care /Treatment 64 7 115 21 Page 3 of 22
CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) Infection Control 46 Manual Handling 8 Medication Errors 8 5 147 Patient Falls 176 Pressure Ulcers 1 87 Staff/Visitor Accident 64 Staffing 1 117 Violence & Aggression 2 1 13 Page 4 of 22
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
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 285 166 513 5 Admission/Discharge/Transfer 125 112 94 1 Communication & Attitude 67 57 56 Diagnosis 44 4 12 Equipment 2 21 15 1 Health Records 41 35 12 Inadequate Care /Treatment 5 66 83 Infection Control 4 9 33 Manual Handling 5 1 2 Medication Errors 59 24 72 Patient Falls 7 24 145 Pressure Ulcers 1 1 76 Staff/Visitor Accident 23 14 19 3 Staffing 6 17 37 1 Violence & Aggression 15 13 75 2 6. 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
6.2 Incidents by Category & Actual Harm 1 23 45 - Moderate No Minor Major Death Near Harm Miss - Near Miss 1 - No Harm 2 - Minor 3 - Moderate 4 - Major 5 - Death Other Admission 6 41 8 1 Attitude 3 7 2 2 Blood/fluid Administration 1 1 6 2 Breach In Policy/procedure 13 53 9 1 Burns/Scalds 4 C-Difficile 1 2 Clinical Care/assessment/treat 13 47 23 2 Collision Between Vehicles 1 2 Communication 23 86 12 Consent 1 1 1 Contact With Dangerous Part Of 1 Contact With Hazardous Substan 2 2 Cuts & Abrasions 2 Data Protection - Security Bre 8 27 1 1 Diagnosis 29 3 1 1 Discharge 1 32 9 2 Discriminatory Abuse 2 Environment 1 1 1 Equipment 9 36 9 1 Fire Or False Alarm 1 1 Fraud 1 Health Records 15 67 5 Hit By Falling/moving Object 2 7 2 Hit By Moving Vehicle 1 Impact With Stationary Object 1 3 Infection Control 4 3 8 1 Investigations 52 33 7 1 1 Lost Property 13 2 Manual Handling 8 1 Medical Emergencies & Cardiac 1 5 4 5 1 Medication Error 29 91 24 2 1 Needles And Sharps 2 4 11 2 Non-Compliance 5 29 13 1 Operative Procedures 2 15 2 1 Patient Fall 7 13 6 2 4 Pregnancy & Birth (Managed) 5 98 55 Pregnancy/birth 1 1 2 Page 7 of 22
Pressure Ulcers 1 7 67 1 2 Radiation (Patients & Public) 21 6 3 1 Referrals 5 11 3 3 Security Breach - Physical Sec 2 2 1 Security Related Incidents 2 14 1 Slips/trips/falls (Staff And V 2 5 17 3 Specimen Handling 5 13 2 Staffing 19 84 11 2 Theft 2 Transfer 1 112 11 3 Unauthorised Access To It Syst 2 Unexpected Death 2 7 1 Vandalism 2 Violence/aggression 13 48 31 9 1 Wounds 4 14 359 7 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
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 474 176 158 147 136 121 116 12 94 87 85 56 55 53 48 43 37 34 31 27 22 2 19 16 2 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 & 11 12 13 14 15 16 17 18 19 11 111 112 113 114 115 116 117 118 119 12 121 122 123 124 125 126 127 128 129 13 131 132 133 134 135 136 137 138 139 14 141 142 143 144 145 146 147 148 149 15 151 152 6.3 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
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.
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
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
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.
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.
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)
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
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.
8.3 Informal Complaints by Ward/Department
9. Clinical Negligence Claims Category Total Clinical Care/assessment/treat 21 Consent 1 Diagnosis 4 Pregnancy/Birth 2 9.2 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.
9.3 Clinical Negligence Claims by Specialty
2. 9.4 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 213-14- 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
Page22 of 22