Annual Report on Complaints, PALS, incidents, claims Trust Board Meeting - Part 1 Item: 9.4 July 31 st 2013 Enclosure: M Purpose of the Report: To provide the Board with assurance around the processes to record and evaluate data received for complaints, PALS, incidents and claims over 2012/13, to highlight emerging themes and to outline next steps for improving reporting, triangulation and analysis in 2013/14. FOR: Information Assurance Discussion and input Decision/approval Duncan Burton, Sponsor (Executive Lead): Director of Nursing and Patient Experience and Jane Wilson, Medical Director Author: Deborah Lawrenson, Head of Corporate Affairs Jacky Bush, Head of Quality and Risk Assurance Clare Parker, Head of Complaints, PALS and Litigation Author Contact Details: Ext 2522 Financial/Resource Implications: Financial impact as a result of clinical negligent claims Risk Implications Link to Assurance Principal Risk 1 - Failure to maintain and Framework or Corporate Risk Register: improve quality of care Principal Risk 2 - Failure to maintain standards Legal / Regulatory / Reputational impact as a result of the impact Reputation Implications: on patients as a result of incidents and poor patient experience. Quality Governance Implications: Capabilities and Culture, Processes and Structure, and Measurement Link to Relevant CQC Standard: Outcomes: 4, 7, 9, 11, 14, 16 and 17 Link to Relevant Corporate Objective: Impact on Patients and Carers: Document Previously Considered By: Strategic Objective 1 - To deliver quality, patient centred healthcare services with an excellent reputation Strategic Objective 2. To deliver care by competent and caring staff working in effective and supportive teams who feel valued by the Trust Learning from Complaints, PALS, Incidents and Claims supports improvements in safety and patient experience. Executive Management Team 24 TH June, 2013 and 8 th July 2013
Recommendation & Action required by the Trust Board : The Board is asked to receive and comment upon the annual report for incidents, complaints, PALs and claims, to discuss planned next steps to improve reporting and triangulation of information in 2013/14 and to advise on further information or sources of assurance required in future reports to the Board.
Executive Summary This report provides the Board with an update on Incidents (including serious incidents), complaints, PALS, and claims during 2012/13, outlines general themes and actions taken and identifies priorities for 2013/14. During Q4 of 2012/13 the Trust replaced the Datix incident reporting system with Ulysses. There have been some issues with coding and in embedding the new system which has impacted on the Trust s ability to fully triangulate information. This report therefore is presented at a high level, outlining the information received by Risk Management Committee and Quality Assurance Committee throughout the year in order to identify what appear to be the emerging themes. Some comparisons have also been provided with data in previous financial years. As Ulysses embeds throughout 2013/14 and with improvements planned in analysing data, the quality of triangulation is expected to significantly improve. Incident reporting is key to delivering both staff and patient safety and enables the Trust to learn and prevent recurrence by improving or changing practice when necessary as such it was encouraging to see an increase in reporting of incidents of 4% overall and 8% in reported patient related incidents, in 2012/13, which demonstrated that the organisations reporting culture is maturing however further work is needed to increase levels of reporting to take the Trust out of the lower quartile on NRLS. The number of complaints received in 2012/13 fell in comparison with the previous year. This could be viewed as positive affirmation of improvement in services and experience however again it is important to ensure patients and their families are supported to raise issues and concerns. Following the Inpatient Survey results, focus will be given to improving the availability of information about raising concerns. Further emphasis is being given to this in the current financial year which may see an increase in the number of complaints received. The Surgical Assessment Unit (SAU) and the Delivery Unit experienced high volumes of incidents and complaints during the course of the year. Incidents and complaints were not about the same issues. Large numbers of recorded compliments have been received during the year, far exceeding the numbers of complaints. It is known that many more compliments are received than are formally recorded. Emerging themes have been identified in the report however it has become evident that further analytical support is needed to enable more effective triangulation of information. Consideration is being given as to how to address this issue through the organisation development review currently underway. Recommendations from national reviews such as the Francis Report and the Clywd/Hart Review of Hospital Complaints, which specifically asks for trend information to be provided to Boards as well as assessments of learning and service improvements as a result of complaints will be taken into account in planning the future approach to reporting to the Board and its sub committees in 2013/14. Recommendations - The Board is asked to receive and comment upon the annual report for incidents, complaints, PALS and claims, to discuss planned next steps to improve reporting and triangulation of information in 2013/14 and to advise on further information or sources of assurance required in future reports to the Board.
1. Background 1.1 In previous years the Board has received separate annual reports on Complaints, PALS and claims and Incidents. It was agreed to amalgamate the reports for 2012/13 and quarterly reports have been received at Risk Management Committee, which outlined performance and actions in place to address issues identified. The report provides further detail on each area, themes and actions taken forward. 1.2 During 2012/13 the Quality Assurance Committee received deep dive presentations on the following risk subjects: Royal Eye Unit Pressure Ulcers Management of medicine incidents C.difficile Patient Falls These presentations provided the Committee with an overview of the issues and assurance on actions being taken to reduce a recurrence of associated incidents. 2. Incidents 2.1 During Q4 of 2012/13 the Trust replaced the Datix incident reporting system with Ulysses. There have been some issues with coding and in embedding the new system which has impacted on the Trust s ability to fully triangulate information. As Ulysses embeds throughout 2013/14 and with improvements planned in analysing data, the quality of triangulation is expected to significantly improve. 2.2 The Trust has been promoting a strong reporting culture as high levels of reporting are recognised to improve patient safety, quality of care and the patient experience. There was an increase of 4% of reported incidents compared to 2011/12, a trend seen in previous years. The majority of incidents reported relate to patient care, in this category the increase in reporting was 8%. This is positive affirmation that the Trust has a strong reporting culture. 2.3 Patient safety incidents are categorised by levels of harm. This year the Trust reported separately severe harm caused by medication incidents and falls in the monthly Quality and Safety report to the Board. Incidents of harm or severe harm were very small. All seven severe harm incidents were investigated as serious incidents and reported to the Board in accordance with the trusts Serious Incidents Policy. Specific actions related to these incidents included: Implementation of National Early Warning Score (NEWS) Introduction of the Situation, Background, Assessment and Recommendation (SBAR) tool trust wide Review of Out of Hours/Hospital at Night teams Earlier recognition and treatment of pressure ulcers supported by better risk identification with risk assessment and treatment starting in A & E Documentation of skin changes on admission Audit of augmentin use with the trust. Antibiotic stewardship group to review its use in the antibiotic policy Chlorclean to be used daily on any wards with C.difficile cases Review of guidelines and policies More detail on serious incidents is covered in section 3.
2.4 During 2012/13 the National Reporting and Learning System (NRLS) reported 346 less incidents than the Trust submitted. They have acknowledged this error but it will not be retrospectively corrected. Even with the additional numbers the Trust is in the lowest quartile for reporting. Discussions have taken place with NRLS to ensure error does not arise again and focus will be given in 2013/14 to improve levels of reporting this will include training and development with the divisions to better understand how to report accurately and effectively. 2.5 Higher levels of reporting are to be encouraged to foster an open learning culture and therefore the Trust would expect to see levels of reporting rise. An incident task and finish group was set up under the Director of Nursing and Patient Experience with its first meeting taking place on June 18 th 2013. The group will be working with staff groups across the Trust to improve reporting and the use of the system. 2.6 The highest numbers of incidents (including serious incidents) were reported on the following issues in 2012/13, a summary of action taken under the following categories: Pressure ulcers o See section 3.2 for detail on actions taken Recognition and management of the deteriorating patient o See section 3.3 and 3.4 for detail on actions taken Patient identification failures o See section 3.5 for detail on actions taken Patient falls o New guidance and documentation for falls risk assessment and care planning issued o Deep dive at Quality Assurance Committee o Reinvigoration of the falls task and finish group o Alert equipment placed in wards to support intervention for patients at risk of falling o Work to ensure correct categorisation regarding Harm and No Harm o Recruitment of more Nursing staff this is an on-going action into the current financial year. Medication incidents o Work to ensure that medication incidents are correctly categorised regarding Harm and No Harm ; o Deep dive presentation at Quality Assurance Committee o Introduction of E-prescribing planned as part of the IT Strategy which will go live from the end of the year. Labour or delivery issues o Clinical guideline on third degree tears has been re-written to include changes to the clinic referral for postnatal follow up o Continuous recruitment of both midwives and support staff to reduce the use of bank and agency staff o Implementation of the midwifery manager on call out of hours o Improved training and education in the areas identified such as meconium aspiration and post-partum haemorrhage management
2.7 In Q4 of 2012/13 there was an increase in the number of incidents concerning lack of suitably skilled or trained staff. Further analysis is taking place in and effort to identify any correlation with other factors such as between the number of falls taking place on a particular ward, with the staffing levels or with the number of complaints received. There has been a significant drive to recruit more nursing staff during Q4 of 2012/13 and into the early part of 2013/14. Board reviews of the nursing establishment will take place twice a year from 2013/14 onwards. 3. Serious Incidents 3.1 The number of serious incidents reported in 2012/13 at 48, was slightly higher than the 45 reported in 2011/12 although it must be noted that previously reporting was done on a calendar rather than fiscal year basis. These figures reflect the comparison across fiscal years. 3.2 During 2012/13 there were 10 Pressure Ulcers and 14 maternity issues which represented the highest proportion of Serious Incidents with grade 3 pressure ulcers being the most frequent serious incidents in the year. Changes in practice to address the level of pressure ulcers included: Quality Accounts Priority (to reduce C.diff and falls) Earlier recognition and treatment of pressure ulcers Better risk identification Documentation of skin changes on admission Risk assessment and treatment starting in A & E Correct mattress usage Links to safeguarding Other key themes arising in serious incidents included failure to recognise seriously ill or deteriorating patients and failure then to escalate. Actions taken to address this issue included: Implementation of the National Early Warning Score (NEWS) Introduction of the Situation, Background, Assessment and Recommendation (SBAR) tool trust wide Review of out of hours and hospital at night teams Team development and removing cultural barriers to escalation 3.3 The Trust has joined NHS Quest which is a small collection of Foundation Trusts working together to address quality and safety issues. One of their initiatives in the coming year will be a focus on the deteriorating patient which the Trust is aiming to participate in. 3.4 The final key theme emerging from incidents in the year centred on issues with patient identification. Key actions taken to address these issues included: Re-enforcement of positive patient identification approaches throughout the patient journey (such as patient confirmation on consent forms) Resolution of CRS printing issues Inclusion of the issues on the Junior Doctor Patient Safety Training
4 Complaints 4.1 In 2012/13 there were 387 complaints. This was a reduction of 11% on 2011/12 which in turn was a reduction of 7% on the previous financial year. Whilst it is positive that complaints are reducing the Trust continues to focus on ensuring patients and their families are supported to raise issues and concerns which is key to supporting on-going improvement to patient care and the patient experience. 4.2 The top five themes from complaints received in 2012/13 were around: Issues with appointments particularly in the earlier part of the year Communication with patients and relatives Medical treatment Patient information Care or monitoring of the patient 4.3 A number of actions have taken place as a result of the complaints received during the course of the year. These included the following divisional specific actions: Issues with appointments particularly in the earlier part of the year o The Booking Teams were decentralised into specialties in October 2012. The teams are now based closer to the specialty staff which includes secretaries and consultants. o The centralised call centre was also decentralised and additional lines were added to reduce patient queuing upon one extension o Use of patient feedback to identify and influence changes to content of outpatient letters, communication operational policy and call centre reconfiguration. Communication with patients and relatives o Pathology is introducing a contemporaneous telephone messaging log. Consultants will be updating the log once they have completed the required. Any record where an action has not been recorded will be followed up by the secretary. Medical treatment o Following complaints about delay in administering the drugs for induction of labour, Maternity have introduced Propess which is a long acting Prostaglandin, which requires re-assessment after 24 hours, instead of six hour pessaries. In January 2013 further improvements were made with outpatient Propess being introduced, the enabled low risk women to be given Propess and allowed to return home, which has been favourably received by those patients involved. Patient information o To improve information given to patients around scar placement prior to surgery, the Surgical team have introduced a uniform approach to providing information to the patients at the time of booking the patient s surgery on the approach that will be taken during surgery. This has proven particularly helpful when care is shared between different consultants. Care or monitoring of the patient o Two hourly ward rounds ensure consistent quality of care, have now been introduced on the Surgical and Orthopaedic wards. However, work is still in progress to introduce these on the Medical wards.
4.4 The areas with the highest numbers of complaints during the year were typically areas with high levels of activity such as Outpatients, A & E and the Royal Eye Unit. During the course of the year an Outpatient improvement group, which included patient representation, was established to look at key issues and to plan work required to improve the patient experience. An update on this work was presented to the Board in June 2013 and will be taken forward in 2013/14. 5 PALS 5.1 Key areas of concern identified through the PALS service in 2012/13 were: Administration and clerical functions key issues were around back office secretarial and administration failures not completing administration tasks as promised. Concerns are escalated to Administrative Managers for the Specialities and to the Service Managers who review and resolve the individual issue at hand and consider how to minimise the likelihood of recurrence of the issues. Although individual issues are resolved effectively there is need for more systemic improvement particularly in areas where reduction in support services may be taking place. Communication Key issues were around inability to make contact, delay in responding and poor attitude of staff. Concerns are escalated to the Administrative Manager for practical resolution and to Service Managers for awareness of the issue. With regard to poor information being provided to relatives and patients these issues are generally resolved by the sisters on wards or junior doctors although in some cases escalation to matrons or consultants may be necessary. Waiting times key issues were concerns at being removed inappropriately from the waiting list, and that concerns were not being prioritised These issues would usually be resolved with either waiting list administration staff or with the consultant advising on clinical priority of the patient. In most cases there is not a system problem and generally issues have been around unhappiness with waiting times in clinics. These issues are escalated to the Outpatient Matron who takes action with the staff within the clinics, such as reminding them of the importance of constant updating to patients of delays, use of information boards. 5.2 The top locations of concerns raised through PALS were Administration/Secretarial areas i.e. back offices of all specialties, Outpatient Departments and Accident & Emergency followed by the Royal Eye Unit and Day Surgery Unit. It is not currently possible to reliably compare data year on year due to coding changes and staffing pressures however comparison on numbers is generally less valuable than comparison of trends.
6 Claims 6.1 With the changing culture nationally around litigation and with changes to legislation, the Trust has seen increased levels of general litigation in 2012/13 and the number of claims received was a third higher than in the previous year. This resulted in the Trust having a backlog of claims to deal with at the start of the year. During the course of the year 95 new cases were opened compared with 62 in 2011/12 and 42 in 2010/11. Efforts have been made to increase grip on claims management with additional administrative support provided. 6.2 At the end of the financial year 2012/13, there were 268 open cases being actively managed. This steep increase from 194 at the start of the year was as a result of a backlog of claims being registered onto the system and a rapid increase in new claims due to the impending Jackson Reforms*. It was identified that the Claims office was unable to manage the volume of claims and inquests and increased administrative support has been provided. There has been a proactive approach in targeting cases which have no merit or limitation issues, this has been helped by the migration of data from Datix to the new reporting system, Ulysses, as a result of which a number of solicitors have chosen to close and withdraw litigation, resulting in a reduction of open cases to the current level of 218 as of 12 th July 2013. (*Jackson Reforms is a planned change to the rules and regulations surrounding solicitor s charges before April 2013) 6.3 The majority of claims received by the Trust relate to maternity services, with issues including delay or failure to monitor appropriately, delay or failure to act on complications, unintended injury to patients and unexpected admissions to the Neo Natal Unit (NNU) and claims related to A & E around issues such as missed diagnosis on first presentation and delay or failure to monitor results appropriately. 6.4 It is important to note that claims often arise sometime after the actual event has taken place. This makes triangulation with other data difficult. Often claims have been subject to an SI investigation and therefore learning will have been disseminated as a result of that. Any new learning will be sent to the speciality lead who will share the information with junior doctors and learning will also be discussed at Morbidity and Mortality (M & M) meetings. 7 Rule 43s 7.1 A rule 43 is issued when evidence at an inquest gives rise to a concern that circumstances creating the risk of other deaths occurring in the future, and in the Coroner s opinion actions should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the Coroner may report the circumstances to a person who may have power to take such action. 7.2 In line with other Trusts, there is a significant sustained increase in the number of statements being requested by Coroners investigating deaths and of inquests now being held to investigate deaths. Most inquests are concluded with a finding of natural causes or an uncritical narrative verdict. Staff are prepared for giving evidence at an inquest, and supported when doing so, by the Head of Litigation, Complaints and PALS. Any adverse verdicts with critical findings are disseminated to the Executive Team where appropriate and to the Divisions involved. In most cases, any learning from the actual care around the time of the death will already have been identified and put in place, but
detailed feedback from the inquest hearing is passed to the Divisions and any additional learning identified. 7.3 During the last financial year two rule 43s were received by the Trust. These related to the handover of a patient to a mental health trust and the provision of an acute gastric bleed emergency endoscopy service. A 24 hour endoscopy service for GI bleeds is now in place. 8 Priorities for 2013/2014 8.1 Overall there has been an improving picture in terms of the level of understanding of the importance of reporting incidents and growing enthusiasm for the benefits of developing triangulated reported to better understand areas of concern, to improve the sharing of learning which in turn impacts positively on patient care and the patient experience. 8.2 The key priority for the current financial year is to improve analysis of the information obtained from complaints and incidents. Work will be undertaken to ensure that all sources of information are utilised to get a triangulated assessment of areas of concern. 8.3 All divisions monitor progress against actions from serious incidents with Trust wide progress being monitored at the Patient Safety Committee. It will be a priority to further embed this to ensure processes within the divisions are robust and actions are completed in a timely fashion. 8.4 It will also be a priority to fully utilise the Ulysses reporting system to improve rate of reporting, analysis and reports to divisions and to enable divisions to make best use of the local reporting available to them. 8.5 Lessons learnt from triangulation of Serious Incidents, incidents, complaints and claims will be built into training programmes and clinical governance meetings. Recommendations The Board is asked to receive and comment upon the annual report for incidents, complaints, PALs and claims, to discuss planned next steps to improve reporting and triangulation of information in 2013/14 and to advise on further information or sources of assurance required in future reports to the Board.