Board of Directors Meeting Report 27 May 2015 Agenda item 51/15 Title Complaints Annual Report 1 April 2014 to 31 March 2015 Sponsoring Director Authors Purpose Cheryl Schwarz Acting Chief Nurse Denise Townsend - Associate Director Governance Laura Mansfield Head of Patient Experience Monitor's annual reporting guidance requires NHS Foundation Trusts to compile an annual complaints report which is subsequently approved by the Board of Directors and displayed on the Trust website. Monitor then require evidence, in terms of the date the Board approved the document, be submitted as part of the annual report process. As per Monitor s requirements, the annual complaints report meets the recommendations under regulation 18 of the Local Authority Social Services and the NHS Complaints Regulations (2009). Previously considered at Executive Summary This paper provides information on complaints, PALS, claims and inquests received between 1 April 2014 and 31 March 2015. The report also provides information concerning compliments the Trust received, as well as information on organisational learning from closed cases. The data collated between 1 April 2014 and 31 March 2015 shows that the Trust received a total of 927 complaints, 3271 PALS contacts, 79 claims, 2060 compliments/positive feedback, 106 comment cards, and was involved in 64 inquests. Date Reviewed by Execs. 14 th May 2015 Related Trust Objective Patient Focus keep getting better Related Risk Legal implications / regulatory requirements BAF Risk 2 Patient safety, experience & outcomes compromised Good governance demands that organisations demonstrate learning from complaints, claims, inquests etc. Learning from 1
Action required by the Committee complaints and claims is also part of Monitors Quality Governance Framework. Learning from complaints, PALS, claims and Inquests is integral to promoting and providing an improved service for patients. As far as can be considered this paper has no detrimental impact for the 9 protected characteristics under the Equality Act 2010 The Board is asked to approve this report and receive assurance. 2
Complaints Annual Report 1 April 2014 31 March 2015 1. Overview: During the period 1 April 2014 and 31 March 2015 the Trust received a total of 927 complaints, 3271 PALS contacts, 79 claims, 2060 compliments/positive feedback, 106 comment cards (not including thank you cards), and was involved in 64 inquests. 2. Complaints: During year 2014/15, the Trust received a total 927 written complaints of which 778 have been closed by year end. During the last year we sought to obtain as much feedback (positive and negative) as possible from patients about their experience. We promoted feedback through the friends and family test, Patient s Association questionnaires, Patient Opinion, mystery shopper, comment cards, NHS choices and Twitter. We respond to all feedback when contact details are provided and when patients have concerns we always provide them with details of our complaints team should they wish to take any issues forward. We are pleased to report that we are receiving more feedback than ever before, much of which is very positive. We also identify when service users have unresolved issues and log these as complaints in order to ensure they are investigated and resolved; and this has contributed to the increase in the number of complaints received in the last year. Figure 1a: Complaints received over the last 5 years Although there has been an increase in the number of complaints received into the Trust when compared to hospital episodes during 2014/15 the level of complaints received equates to 0.09% of attendances, which is the same proportion of attendances as in the previous year Section 4 provides further information in respect of the key performance indicators for written complaints. 3
Table 1b: Total number of Complaints by Directorate (2013/14 figures in brackets) TCCA MSK D&T W&C Surgery Medicine A&E Other April 0 (1) 13(14) 6 (6) 10(5) 22(13) 19 (19) 9 (5) 10 (6) May 2 (1) 14(11) 8 (5) 5 (7) 17(10) 18 (16) 13 (11) 5 (4) June 1 (0) 11(9) 9 (3) 10 (9) 9 (14) 10 (13) 19 (7) 12 (4) July 0 (2) 11(13) 6 (4) 12(13) 24(14) 23 (17) 7 (7) 12 (4) August 1 (0) 11(4) 7 (9) 11 (9) 21(13) 14 (15) 10 (10) 11 (3) September 1 (0) 16(10) 4 (5) 13 (8) 29(12) 16 (15) 8 (10) 14 (1) October 0 (1) 11(17) 4 (7) 12 (8) 18(13) 19 (7) 8 (9) 13 (5) November 3 (0) 7 (9) 4 (9) 9 (6) 10(19) 22 (16) 6 (11) 9 (3) December 1 (2) 12(8) 3 (6) 11 (12) 16(21) 13 (11) 10 (11) 14 (0) January 1 (1) 9 (11) 6 (10) 8 (11) 14(21) 24 (28) 11 (11) 12 (3) February 0 (3) 26(18) 5 (8) 14 (6) 13(21) 11 (23) 9 (5) 21 (3) March 0 (0) 10(14) 3 (7) 11 (12) 28(21) 24 (15) 8 (18) 14 (2) 10 (11) 151 65 (79) 126 221 213 (195) 118 147 Total Complaints as a % of attendances 1.34% (1.5%) (138) 0.06% (0.06%) 0.09% (0.1%) (106) 0.09% (0.08%) (187) 0.08% (0.06%) 0.13% (0.1%) (115) 0.12% (0.1%) (38) N/A 3. PALS: During 2014/2015, the Trust received 3498 PALS contacts. Compared to hospital episodes in the same period this equates to contact at the rate of 0.34% of attendances. Section 5 provides further information in respect of the key performance indicators for PAL s issues. Figure 2a shows the total number of PALS contacts received over the last 5 years. We have seen a significant increase in the number of PALS contact in the last year by 67% and this is largely to do with a change to how they are recorded. In previous years not all enquiries were logged on to Datix, whereas now the PALS officers log every contact, ranging from simple queries such as arranging call backs to more in depth queries. The current figures show an accurate representation of the use of this service. It is important to note that PALS enquiries are not necessarily complaints, the majority of enquiries relate to advice and assistance, complaints are logged separately so they are not double counted. Should a PALS query arise which is actually a complaint this is counted as a complaint, PALS queries are not categorised as complaints on our Datix reporting system. The PALS officers continue to promote the service both within the Trust and out in the community. Better advertising and promotion of the service within the Trust has facilitated access to the service which has contributed to the increase in usage. 4
Figure 2a: PALS received during the last 5 years Table 2b: Total number of PALS contacts by Directorate (2013/14 figures in brackets) TCCA MSK D&T W&C Surgery Medicine A&E Other April 1 (0) 30 (21) 12 (12) 20 (6) 52 (39) 81 (30) 4 (8) 33 (24) May 0 (0) 30 (19) 23 (13) 23 (4) 79 (28) 80 (24) 5 (1) 57 (15) June 1 (1) 35 (15) 17 (10) 21 (14) 94 (33) 61 (26) 6 (3) 49 (6) July 0 (1) 34 (19) 16 (11) 16 (5) 97 (28) 59 (28) 12 (7) 65 (19) August 1 (0) 54 (18) 15 (17) 18 (14) 69 (35) 55 (25) 5 (6) 53 (15) September 0 (0) 47 (20) 26 (5) 7 (10) 92 (34) 48 (43) 5 (4) 53 (26) October 2 (0) 35 (23) 20 (14) 10 (7) 90 (38) 47 (23) 6 (6) 76 (36) November 0 (0) 35 (23) 22 (12) 18 (5) 98 (52) 41 (21) 12 (3) 73 (37) December 0 (0) 33 (42) 12 (9) 18 (8) 65 (51) 43 (31) 5 (7) 70 (33) January 2 (0) 54 (47) 14 (39) 12 (13) 63 (80) 38 (39) 6 (9) 63 (39) February 1 (0) 39 (33) 15 (29) 12 (18) 48 (57) 28 (33) 4 (12) 66 (45) March 0 (0) 38 (27) 11 (48) 15 (13) 68 (78) 68 (34) 5 (12) 98 (44) 464 203 190 915 756 Total 8 (2) PALS as a % of attendances 1% (0.3%) (304) 0.2% (0.13%) (217) 0.3% (0.3%) (115) 0.1% (0.08%) (552) 649 (328) 75 (78) 0.3% 0.4% 0.08% (0.2%) (0.21%) (0.09%) (339) N/A 5
The following graphs represent each Directorate with the number of complaints, PALS, compliments and claims received monthly in the last year (2014/15). Details of the number of Inquests received can be found in section 14. Its is noted that there are peaks of compliments received, this largely due to batches of compliments received into the team from wards, for example thank you cards, which may have accumulated from previous months. 6
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4. Key Performance Indicators (KPI s) for complaints: Table 3a compares our performance against the Key Performance Indicators for responding to written complaints over the last 4 years. Table 3a Compalints acknowledged within 3 working days Complaints responded to within the negotiated deadline 2014/2015 927 (100%) 778 (54.8% of those completed) Complaints reopened. 82 (10% of those completed) 2013/2014 883 (100%) 544 (62%) 90 (16%) 2012/2013 663 (100%) 465 (70%) 113 (17%) 2011/2012 736 (100%) 528 (72%) 152 (21%) Whilst there are no nationally set performance targets for complaints, the regulations state that all complaints should be acknowledged within 3 working days of receipt. As a Trust, we strive to achieve this 100% of the time either in writing (by letter or e-mail) or verbally (by phone). We have attained this standard for the last 4 years. The complaints team continue to work with the Directorates to increase compliance with the internal response target of 85%. This includes further monitoring of targets by the Directorates and feedback to each Directorate about their performance on a monthly basis including a RAG rating against the 85% internal compliance target. The complaints team meet with complaints lead in each Directorate on a monthly basis to monitor performance and offer assistance. Complaint incidence and compliance with response timescales are reported to the clinical director and discussed at the directorate performance meetings. As there is no nationally set performance target for the provision of a response, internally we set our own targets taking into account the complexity of complaint. When acknowledging the complaint we then set a timescale agreed with the complainant. As part of the complaint investigation process the complaints team rely on the clinical teams to respond in a timely fashion. Due to the significant pressures that the Trust has been under, clinical staff have been unable to meet all of the deadlines which has resulted in a delay in compliant responses being sent. Increased communication with the clinical services will be undertaken by the complaints team in order to help establish more realistic timescales for responses. In the event we are unable to meet the agreed deadline to respond to complainants we ensure that an update letter is sent before that deadline apologising for the delay, and wherever possible we provide a further timescale for the response to be sent. It has also been recognised through a review of the complaints team that there was a need to support to manage the increase in the workload. Therefore, the complaints department has recently taken on additional administration support to assist with booking complaint meetings and keeping complainants updated of the progress of their complaint. As a result of this support, an improvement to the service has been noted with overdue cases starting to be reduced. In addition to the above we have also developed a system for what we refer to as Rapid Response Complaints. These are queries or concerns that do not fall within scope of the 2009 Complaint Regulations, (which would require a full investigation), but they require more in depth and urgent assistance than the PALS service can offer. In the majority of 9
these cases we are able to pass the query directly to the Directorates to contact the complainant directly and resolve any issues before further problems or concerns occur. We began using this system in October 2014 and since then we have resolved 38 queries in this way which has helped us to deal with these matters much more quickly and provide an improved and more responsive service for our patients and service users. Given the increase in workload within the complaints department proposals are being developed to improve the efficiency of how complaints are managed with the aim of reducing response times and improving the complainant s experience of this service. These proposals are in line with the Patient Association Standards which are likely to be used as criteria for any future CQC inspections. It is pleasing to note that there has been a marked decrease in the number of complaints being reopened following the final response being sent, this has been gradually decreasing over the last four years. As can be seen in the chart below, currently only A&E and Theatres, Critical Care & Anaesthetics are achieving the internal response target, with variable performance in the other directorates. Compliance with responding to complaints within agreed deadline 5. Key Performance Indicators (KPI s) for contacts via PALS: The Trust recevied 3271 contacts via PALS during 2014/15. There is no statutory time limit in which a PALS enquiry must be completed, however, the expectation is that they should be resolved within 1 working day of the issue being raised. The majority of issues were resolved within this timeframe and that those that took longer were due to factors outside the control of the PALS team (e.g. key staff being away etc) and were responded to within a mutually agreed timscale. 6. Learning from complaints: The Trust is committed to learning from complaints and using feedback in developing service improvements and action plans are used to monitor the improvement actions identified following a complaint. 10
Many of the complaints received have required just an explanation with no further actions identified. Whilst these cases have not been upheld from a clinical point of view, we do acknowledge that there has in some cases been a failure in communication and this has been acknowledged in the complaint response and the members of staff involved fed back to. In order to address the communication theme identified in complaints, we have put in place some targetted customer care training sessions. We have already seen that this has had a postive impact in reucing complaints of this nature in the Women and Childrens Directorate. Over the coming year we will be working to improve the feedback loop in relation to complaints in conjunction with comments and compliments. The complaints team, with the assistance of the Patient Experience/Involvement team, will be working with the Directorates to ensure that actions are identified and the results communicated. This will then result in feedback to our service users in a You said, we did format. The Trust has recently subscribed to NHS Benchmarking Network which enables us to gather independent feedback from complainants following conclusion of their complaint. It is important to us is that the complainants feel that we have fully resolved their complaint. We are pleased to note that the results of the recent NHS Benchmarking report show the Trust is performing in the top quartile (of the Trusts participating in the benchmarking) in terms of resolving complaints. We do recognise that the number of participants to the survey is limited but the data collected is entirely independent and we believe it serves as a useful insight into how we are responding to complaints. The Trust also ranks in the top third of complainants who considered the complaint process to be on the whole a positive experience. The results evidence our recent issues with responding to complaints within the initial agreed timescale, however the results also show that other Trusts appear to be experiencing similar issues. Many complainants responding to the survey in relation to other Trusts considered that their complaint was not dealt with quickly enough. We are currently exploring ways to use this data and incorporate the feedback into our plans to improve the complaint investigation process. 11
7. Compliments/Positive feedback: In the last year, the Trust registered 2060 compliments/positive feedback. Of these 1866 were thank you cards sent to the wards and 194 were either received by letter/e-mail (88) or by comment card (106). Those registered by letter/comment card have been analysed for their themes which can be seen in the chart below. We are unable to do this for the cards as they often contain little specific information and can only be categorised as general thank you comments. The chart below shows a breakdown of those received in writing by subject: Themes from letters and comment cards received 2014/2015 180 160 140 120 100 80 60 40 20 0 8. Internet Feedback: During the last year, the Trust has been tracking and responding to feedback posted on sites such as NHS Choices and Patient Opinion. This is an important source of feedback for us and we respond to all comments left and feedback to departments. This is done either by responding to the comments directly via the website or posting advice and contact details on how to take the concern forward with the PALS or complaints teams if necessary. Comments are left from patients who have used hospital services and relate to the care and service provided. 70% of the comments posted have been positive. On the whole, the negative comments have related to waiting times and relevant departments have been provided with feedback. All comments are fed back to the teams involved in the same way other comments are. We have improved the way that we relay these comments to departments by having access to the comments on staffnet and emailing the managers to pass onto relevant staff. 12
9. Comment Cards: In addition to the 106 comment cards received and registered under compliments (see above), another 543 were received by the trust about a number of issues and breakdown to positive (483) and negative (60). These comments are distributed trust wide to enable more feedback to be shared and service improvements identified across the Trust. 10. Friends and Family (FFT): Since its implementation in 2013, the Trust has fully participated in surveying patients following their discharge. Patients who have been an inpatient, outpatient, daycase, A&E attendance or utilised our maternity services are asked if they would recommend our services. The response rate at the end of March 2015 now stands at 32.3% of attendances and 17.1% for A&E attendances. During the year we also volunteered to pilot an Easy read survey for patients with learning disablities which proved to be a success and we have continued to offer this survey to this group of patients. Our net promoter score, response rate for inpatients and A&E in 2014/15 can be found in Tables A and B. Maternity figures can be found in Table C. Annual Inpatient & A&E Friends and Family figures April 2014 March 2015 Table A 13
Table B Annual Maternity Friends and Family figures April 2014 March 2015 Table C 14
The system we are using (Envoy), gathers all responses and comments from patients feedback, including postcards, which are now entered manually onto the system, thus capturing all feedback in one place. Departments are encouraged to use the system to collate comments, look for particluar trends, and use as a feedback tool to make service improvements. Positive feedback is also promoted to help encourage and give recognition to staff, as a high number of positive comments relate to staff care and professionalism. We are promoting the display of You said, we did posters to show patients feedback we are receiving and the changes we make as a result of patient feedback. Ward are being provided with new standardised safety and qualtiy boards and a space has been designated to display response to patient feedback. 11. Themes: The following graphs show the main themes by Directorate that have emerged during 2014/2015. Included for comparison are the numbers of PALS, Compliments and complaints received in the same period TCC&A Theatres,Critical Care and Anaesthetics Directorate 100 90 80 70 60 50 40 30 20 10 0 3 1 1 1 3 1 1 8 89 Complaints: There were 11 complaints this year. This relates to 1.34% of their activity. We do acknowledge that this Directorate is involved with many more patients who are admitted under other Directorates. However the themes remain similar to last year with no specifc areas of concern noted. Actions taken include: Individual feedback for staff concerning attitude and aftercare advice given to patient (which patient deemed insufficient). Patient experience was shared with other members of staff at ward meeting. PALS: There were 8 PALS inquiries as follows: arrangements following death (1), attitude (1), communication (1), information (1) medical judgment (1) nursing care (1). There has been an increase in the number of compliments in this period: 89 compliments were recevied during 2014/15. 15
D&T Directorate Complaints : There were 65 complaints representing 0.09% of their activity this year. In this period there was a decrease in the number of PALS enquiries from last year and an over double the amount of compliments compared with 2013/2014. A key theme for complaints from 2013/2014 was attitudes, we are pleased to note this has decreased in the last year. Actions taken include: Individual feedback and additional training to staff regarding procedures for patients waiting in clinic, following an incident where a patient was left in a room unattended for an extended period of time. Several complaint responses sent contained bespoke action plans confirming actions taken or to take to prevent any of the same issues recurring for the patient/ complainant. PALS: 203 PALS were received; the main themes were information and assistance (63), communication (37) and appointment queries (16). 380 compliments were recevied during 2014/2015. Medicine Directorate (not including A&E) Complaints: There were 213 complaints representing 0.13% of their activity this year. No specific areas of concern have been identified within the themes. The number of complaints in relation to waiting times has halved since last year. Actions taken include: Clinic being remodelled to allow for more privacy. Review of property handling undertaken at ward level to avoid items going missing and how to communicate issues to patients and relatives. Working with junior medical staff to ensure attention to detail and accuracy within the records. 16
PALS: 649 PALS were received, 201 for information queries, 107 for communication issues, 44 for nursing/treatment and 41 relating to appointments. Compliments during this period have increased: 731 compliments were recevied during 2014/2015. Medicine Directorate (A&E only) Complaints: There were 118 complaints representing 0.12% of their activity this year. The key theme in complaints is medical care which are followed up as part of the complaint team s regular review with the governance lead for the Directorate. Actions taken include: In addition to the actions taken in the Directorate as a whole (above), A&E has improved the standard of cleaning in the emergency department. Ticketing system in A&E stopped due to negative patient feedback. PALS: 75 PALS were received, 16 were for general help and information, 14 were concerning medical judgment and 11 were nursing concerns. 500 450 400 350 300 250 200 150 100 50 0 MSK 10 21 11 20 12 464 295 Despite the increase in attendance over recent months the number of compliments has increased to almost double in the same period last year: 63 compliments were recevied during 2014/2015. MSK Directorate Complaints: There were 151 complaints representing 0.06% of their activity this year. Appointment issues are a key area for complaints which is addressed in the actions detailed below. Actions taken include: Improvements to clinic paperwork to avoid confusion and improve communication amongst staff. Alterations made to a care pathway to ensure treatment is not delayed. Joint call-centre for orthopaedic / rehabilitation 17
departments has been established to respond to incoming telephone calls. These improvements are aimed at reducing waiting times and to improve accessibility for outpatients. Individual work carried out with members of staff in different areas as a result of complaints. PALS: 464 PALS were received, 96 were general help, 67 were advice, 51 were for queries about appointments and 38 about cancellations. Compliments have increased in the last year: 295 compliments were recevied during 2014/2015. Surgical Directorate Complaints: There were 221 complaints representing 0.08% of their activity this year. Compliments have decreased compared with the same period last year, and PALS referrals have increased. Many of the complaints issues were related to appointment issues, in particular the Eye Unit. Improvements are in progress to address this as set out in the actions below. Actions taken include: Improved telephone service for patients calling the Ophthalmology service. Improved experience for visitors requesting to visit patients outside of normal visiting hours with extended and more flexible visiting hours. Do not disturb signage has been purchased for all clinic rooms to improve privacy and dignity Increase in the number of doctors and recruitment of new consultants in the eye unit. Changes made to the booking systems within Urology to ensure patients are informed of any cancellations. A new play area was installed in Ophthalmology to keep children occupied whilst waiting. Amendment to the Patient Administration System to improve how appointments are booked in a specific clinic. 18
PALS: 915 PALS enquiries were received, 225 were concerning cancellations, 137 were advice and information, 134 for appointments and 136 were about waiting times. 143 compliments were recevied during 2014/2015. W&C Directorate Complaints: There were 126 complaints representing 0.09% of their activity this year. PALS enquiries have increased. Nursing / midwifery care continues to be the subject of most complaints. In addition to the actions below this is being addressed with increased staffing and improvements to the staff structure. Actions taken include: Specific training to improve staff communication. Improved communication with patients and families receiving treatment in Neptune Ward. Replacement of Hysteroscopy information leaflet to reflect current practice. New system implemented to ensure all results are checked prior to mothers being discharged from maternity. In order to improve advice given to new parents around feeding issues a reluctant feeder s pathway flowchart has been added to the telephone triage folder on the unit for staff to use. This is an appendix to the Infant Feeding Guidelines which staff can access on the hospital s Intranet. PALS: 190 PALS were received, 36 were for general help and information, 25 for communication issues, 23 for cancellations and 22 in connection with appointments. Compliments have slightly decreased in this period compared with last year: 116 compliments were recevied during 2014/2015. 12. Status of Parliamentary & Health Service Ombudsman (PHSO) Cases: 18 cases were refered by patients to the PHSO, compared to 17 cases in 2013/14. 6 of the 18 cases remain open. In 10 of the 12 closed cases, no further action was required by the 19
Trust. In two of the closed cases the Trust was required to respond to reccomendations made and and put in place action plans which have all since been completed. 13. Cases with the Health Service Commissioner and/or Local Commissioner We do not currently have any cases with the Health Service Commissioner or Local Commissioner 14. Equality and Diversity Characteristics within Complaints Data is collected from the Trust Patient Administration System however, it only captures the following data regarding the age, gender and ethnicity of the patient around whom the complaint is made. If the complainant is not the patient, their charactersitics are not able to be recorded. Not all complaints involve the care of a patient, therefore this data is not captured below. Gender Male, 387 Female, 540 Age Age Total Complaints in Age Range (Percentage in Brackets) Percentage of Trust s Patients in Age Range Under 20 82 (9.9%) 14.5% 20 40 137 (16.6%) 18.9% 40 60 172 (20.9%) 21.6% 60 80 291 (35.3%) 31.9% Over 80 143 (17.3%) 13.1% 20
143 82 291 172 137 Under 20 20 40 40 60 60 80 Over 80 Ethnicity 900 800 700 600 500 400 300 200 100 0 836 1 10 1 2 4 2 4 2 1 1 26 During 2014/15 we had 1 complaint involving a patient with Learning Difficulties. We will are working to measure other protected characteristics in the future. 15. Litigation Claims During 2014/2015 the Trust reported 79 new Claims to the NHS Litigation Authority, it should be noted that not all claims relate to care or treatment in the current year. The 21
incident giving rise to the claim may span back a number of years, for example in the case of a claim relating to a child they have to the age of 21 to bring a claim against the Trust. The claims received can be categorised in the following three areas: Clinical negligence cases by Directorate Claims outcomes We have seen a slight decrease of 1.25% in the number of claims compared with 2013/2014. On average the Trust receives between 6-7 claims per month. 22
We have now started to record all data for potential claims, which we will be able to report on fully at year end 2015/2016. We have a robust system in place for investigation of potential claims to ensure we are able to act swiftly to any patient safety concerns and notify the risk team accordingly. NHSLA Reporting In line with NHSLA guidance the Trust ensures that all claims are reported to the NHSLA within 24 hours of receipt and 100% compliance has once again been achieved in the last year. 16. Inquests We had expected to see a decrease in the number of new Inquests opened by HM Coroner for Essex following the recent implementation of the new Coroner s Rules which were expected to reduce the number of Inquests opened by Coroner s nationally. Over the last year the Trust was involved in 64 Inquests which marks a 45% decrease compared with the previous year. In the year 2013/2014 the Trust was involved in 117 Inquests and this was due to HM Coroner for Essex dealing with a backlog of cases from previous years. Now the backlog of cases with the Coroner have been cleared, we are receiving on average 5 Inquest referrals a month. We are unable to benchmark this formally with other similar Trusts, however we will continue to monitor the rate of referral in order to identify any fluctuation in the number of cases referred. The Trust legal services team continues to attend every Inquest where Trust witnesses are attending. We do consider that attending in all cases offers invaluable insight to future risk management issues as well as serving as a further opportunity to identify any organisational learning required to improve our practices. Inquest Outcomes 2014/2015 Out of the 64 concluded Inquests last year, HM Coroner recorded 37 deaths by natural causes, 16 narrative conclusions, 1 death by industrial disease (not hospital related), 9 accidental deaths and 1 suicide. These outcomes are represented in the following pie chart. Inquest Outcomes 23
Regulation 28 Report to Prevent Future Deaths In the past year HM Coroner has drafted four Regulation 28 Reports to the Trust, also known as a Prevention of Future Death Report. This has replaced the old Rule 43 Report under the old rules. The new rules impose duty on the Coroner to consider making a report in every inquest case where there are any concerns about the care and treatment the Trust provides, even if those concerns did not cause death in the case. We have been advised by the Coroner that these reports are likely to be more commonly drafted as a tool to identify issues at Trusts and instigate improvements. All four cases involved inquests opened between 2012 and 2013, however as they formed part of a backlog of older cases with the Coroner they were not concluded until 2014. In each case the Trust responded to the Coroner s report within the necessary timescales and put in place action plans to address any service failures. Examples of learning/action taken from Regulation 28 Reports: Improvements to Trust s blood transfusion policy to ensure we have adequate staff to collect urgent blood for transfusion. Increased number of staff trained in blood collection to meet the needs of the service. Improved escalation policy for midwives to consultants in maternity More training provided to staff in Root Cause Analysis Training More in depth training delivered to staff on the safe use of bedrails Increased awareness of post fall neurological observations, embedded in policy and additional training. Review of labour inducing medication in patients with previous uterine injury. All cases were shared at Directorate governance meetings and much of this learning was also shared at our trust-wide Learning from Harm event which took place in the first week of September 2014. Key learning was also shared via our Risk Team s Weekly Incident Round up, Friday Round Up and staffnet. 17. Learning from Claims and Inquests We ensure that staff always receive feedback on cases they are involved in and we check compliance with action plans on every case. We have recently attended the NHSLA s Triannual Review to discuss the current system and suggest improvements to the support offered to us by the NHSLA. The Legal Team prepare claim update reports and meet with the Directorates regularly to discuss on-going claims and follow up action plans and learning. Examples of learning are set out below: Improvements made to the escalation plan for patients suspected to be suffering from torsion of ovarian cyst. 24
Additional training provided to improve record keeping, including times of referrals/ scan requests. Improvements made to the paediatric care pathway from A&E to the other Directorates. Addressed issues around stocking of equipment on paediatric resus trolley Purchased wet floor hazard signs that can be hung on a door warning of wet floor on the other side, to prevent falls. Changes made to VTE assessment of patients who transfer between wards to ensure they receive anticoagulant therapy if needed and prevent blood clots. Conclusion The Trust is committed to promoting patient feedback and learning from complaints, claims and inquests by utilising the whole range of feedback reported in this complaints annual report. We can demonstrate that learning is being shared and acted upon to improve patient experience and most importantly patient safety. 25