Analysis of cases reviewed by the Clinical Risk Team at the State Claims Agency

SCA Analysis of cases reviewed by the Clinical Risk Team at the State Claims Agency Cases settled and resolved in 0 Anne Marie Oglesby

Contents Introduction... Breakdown of Closed Claims Outcomes... Incident Type of Settled cases resolved in 0... 3 Specialty of Settled Cases... 3 Surgical Subspecialty Cases... 4 Incident Type of Surgical Settled Cases... 4 Medicine Subspecialty Cases... 4 Incident Type by Specialty... 5 Settled cases reviewed by the Clinical Risk Team... 5 Incident type of the settled cases reviewed... 6 Top 5 incident types of the reviewed cases... 7 Contributory factors and root causes... 0 Conclusion... Figure : Breakdown of Closed Claims outcomes... Figure : Settled cases that were resolved in 0 by incident type (n=4)... 3 Figure 3: Specialty of settled cases resolved in 0 (n=4)... 3 Figure 4: Surgical settled cases by incident type... 4 Figure 5: Settled cases reviewed by the clinical risk team. (n=98)... 5 Figure 6: Incident type of the settled cases that were reviewed (n=98)... 6 Figure 7: Phase of care during which the adverse event occurred.... 6 Figure 8: Fatalities by incident type specific (n=98)...6 Figure 9: Year of occurrence of reviewed cases... 9 Figure 0: Top ten root causes identified... 9 Figure : Top ten contributory factors identified...0 Table : Surgical cases by subspecialty... 4 Table : Medicine cases by subspecialty... 4 Table 3: Settled cases top five specialties by incident type... 5 Table 4: Top 5 incident types of the reviewed cases and associated harm/injury to plaintiff... 7 Table 5: Harm/injury sustained as a result of the incident... 8 Page of

Settled cases resolved in 0 Introduction: Clinical Risk Advisors within the Clinical Indemnity Scheme at the State Claims Agency are responsible for conducting in-depth analysis on settled and closed claims known as Closed Claims Analysis. It is important to note that not all closed claims are a result of a submitted and processed claim, many closed claims are in fact pre-claims that have not evolved into a claim or have become statute barred, (which currently stands as two years for adults from knowledge of injury). Furthermore, a plaintiff may not proceed with a claim as they may receive advice from their legal team that the case is unlikely to succeed, or they may have received a satisfactory response to questions they may have had regarding the adverse event. Settled claims are a sub-set of closed claims and are those claims that were settled out of court. Valuable learning may be gleaned from review of these claims as these files may contain detailed expert reports and opinions which may be useful for sharing with the wider healthcare audience. It is important to note that the closed claims analysed for this report provide a snapshot profile of all claims closed for 0 rather than a representative sample. Figure gives a breakdown of the outcome of all claims closed in 0, with settled claims accounting for 54.6% of all closed claims, and cases that were classified as being either discontinued/statute barred or not pursued having a combined total of 30.6%. Breakdown of Closed Claims Outcomes for 0 Case settled Case discontinued Claim Statute Barred Case Intimated but not pursued Indemnity received Case for other insurer Apportionment Basis Lodgement/tender accepted Outside SCA Remit Case dismissed - no order as to costs Struck out for want of prosecution Case dismissed - costs to State Court Award None.7 0.9 0.7 0.7 0. 0. 0. 0. 0. 6.6 5.4 3.4 3.8 54.6 0.0 0.0 0.0 30.0 40.0 50.0 60.0 Settled Claims by Incident Type Figure : Outcome of claims resolved in 0 (n=44) While a total of 44 claims were closed between January st 0 and December 3 st 0, only 4 of these cases were considered settled therefore meeting the criteria for further analysis. These were claims that were closed, settled and administratively settled within 0. The top event types, Page of

accounting for 7.3% of the settled cases, are consistently within the four categories of diagnosis, peri operative/peri procedure, treatment and peri-natal (Figure ). Diagnosis incident Peri-operative / peri-procedure incident Treatment incident Peri-natal Other Slips/Trips/Falls Self-Harm Infection control incident Unplanned events Medication incident Blood transfusion incident Unexplained Injury/Unknown Cause Identification/Records/Documentation Incident Discharge incident Violence/Harrassment/Aggression/Abuse Inappropriate Behaviour Equipment/Device Incident Absconsion 5.8 4.6 3.7 3.3.5.5. 0.8 0.8 0.8 0.4 0.4 0.4 0.4 5.4 3.3 9.9 3.7 0 5 0 5 0 5 Settled Claims by Specialty Figure : Settled cases that were resolved in 0 by incident type (n=4) These cases occurred within the specialties outlined in Figure 3 Surgery Emergency Medicine Obstetrics Medicine Mental Health Radiology Gynaecology Paediatrics Allied Professional Services Other Haematology Community Health Services Anaesthesia 5.8 3.7.9.5... 0.4 0.4 7 4.9. 6.6 0 5 0 5 0 5 30 Figure 3: Specialty of settled cases resolved in 0 (n=4) As was the case in previous years, there is a familiar trend with regard to the top 5 specialties relating to settled cases, with one exception; the top specialities were Surgery, Emergency Medicine, Obstetrics and Medicine, however in 0 Mental Health replaced Gynaecology in the top 5. Page 3 of

Surgical Claims There were 64 surgical cases, of these 44% of these related to general surgery and 6.5% related to orthopaedic surgery. A complete breakdown by surgical specialty is presented in table. Specialty Frequency General Surgery 8 Orthopaedic Surgery 7 Gastro-intestinal Surgery 6 Urology 6 Breast Surgery Neurosurgery Plastic Surgery Vascular Surgery Total 64 Table : Surgical cases by subspecialty A breakdown of the surgical cases by incident type is presented in Figure 4. Peri operative/peri procedure is the most prolific type of event as one would expect for surgical cases. Peri-operative / peri-procedure incident Treatment incident Other Unplanned events Equipment/Device Incident 3 4 6 8 9 3 0 5 0 5 0 5 30 35 Figure 4: Surgical settled cases by incident type Medicine Claims Of the settled medicine cases that were resolved in 0, 44.4% were from General Medicine. A complete breakdown by subspecialty is presented in table. Specialty Frequency General Medicine 6 Medical Oncology 4 Cardiology 3 Infectious Diseases Nephrology Rehabilitation Medicine Dermatology Endocrinology Gastroenterology Geriatric Medicine Neurology Respiratory Medicine Rheumatology Total 36 Table : Medicine cases by subspecialty Page 4 of

Incident Type by Specialty It will come as no surprise, given its role in assessing the acute undifferentiated patient who present to Emergency Departments, the majority (56.8%) of diagnosis-related events occurred within the specialty of emergency medicine. Incident Type (gen) Emergency Medicine Medicine Mental Health Obstetrics Surgery Absconsion Blood transfusion Diagnosis 5 7 3 9 Discharge Equipment/Device Identification/Records/Documentation Inappropriate Behaviour Infection control 6 Medication Other 4 4 Peri-natal 3 Peri-operative / peri-procedure incident 7 4 3 Self-Harm 9 Slips/Trips/Falls 3 5 3 Treatment 5 5 8 Unexplained Injury/Unknown Cause Unplanned events Violence/Harrassment/Aggression/Abuse Total 5 36 4 4 64 Table 3: Settled cases top five specialties by incident type Settled Cases Reviewed by Clinical Risk Team As previously stated 4 settled cases were resolved in 0, with the clinical risk team completing closed claims analysis in 98 (40.7%) of the available cases. The data reflected in the remainder of this report relates to the analysis of these 98 cases. Surgery Obstetrics Medicine Emergency Medicine Mental Health Gynaecology Allied Professional Services Paediatrics Other Haematology Community Health Services 4. 9. 7.3 5.3 9.4 8.6 0 5 0 5 0 5 30 Figure 5: Settled cases reviewed by the clinical risk team. (n=98) Figure 5 represents the percentage of the settled cases that were reviewed by the clinical risk team by specialty. Page 5 of

Incident Type of Settled Cases Reviewed Peri-operative / peri-procedure incident Diagnosis incident Peri-natal Treatment incident Self-Harm Infection control incident Slips/Trips/Falls Other Medication incident Violence/Harrassment/Aggression/Abuse Unplanned events Inappropriate Behaviour Absconsion 6. 5. 4. 4.. 7.3.4 4.5 0 5 0 5 0 5 Figure 6: Incident type of settled cases that were reviewed (n=98). The type of incident related to the settled cases that were reviewed is presented in Figure 6. As can be seen, this trend is consistent with previous years particularly in relation to the top 5 incident types with the exception of Slips/Trips/Falls, which has now been replaced by Self-Harm. The phase of care that the event occurred in is presented in Figure 7. As can be seen 46% of the events occurred during a procedure (7.6%) or during care in the emergency department (8.4%). Procedure related A&E Ward care Intrapartum care Antenatal Care Not stated pre admission Neonatal Postnatal In-patient Not applicable Gynaecology Community Out-patient clinic Post Discharge 5. 4. 9. 8. 6.3 8.4 7.6 0 5 0 5 0 5 30 Figure 7: Phase of care during which the adverse event occurred Page 6 of

Top 5 Incident Types of Reviewed Cases As previously stated diagnosis, peri operative/peri procedure, treatment, peri-natal and self harm are the top 5 incident types related to the settled cases. Table 4 presents the patient outcome that was recorded for these 5 event types (n=98) Table 4: Top 5 incident types of the reviewed cases and associated harm/injury to plaintiff (n=98) Outcome Perioperative / periprocedure Diagnosis Perinatal Treatment Self- Harm Totals Birth Injury 0 0 0 0 Burn/Scald 0 0 0 0 Cerebral Palsy 0 0 3 0 0 3 Delay in Treatment 0 0 0 0 Dental Damage 0 0 0 0 Fatality 3 4 6 6 Fertility Impairment 3 0 0 0 0 3 Fracture 0 0 0 Haemorrhage 0 0 0 0 Infection 3 0 0 0 5 Infection (MRSA) 0 0 0 0 Infection (VRE) 0 0 0 0 Laceration 0 0 0 0 Nerve Damage 0 0 0 3 No apparent injury / reaction 0 0 0 Organ Damage 3 0 0 0 4 Other 0 0 0 0 Pain and suffering 4 4 0 0 Permanent Injury 5 0 0 9 Psychological/Psychiatric Injury 0 0 4 Serious deterioration in condition 0 0 4 Total 4 7 6 79 The types of permanent injury sustained by the plaintiffs in the cases reviewed included Nasal bone fragments united in the displaced position, Terminal illness due to failure to diagnose, Long term stiffness in joint likely to have been exacerbated by late diagnosis Scarring & slight indentation of nose following rhinoplasty. Fatality has been cited specifically as the outcome for the plaintiff in 3 of all cases reviewed as seen in Table 5, with of these occurring within the top 5 incident type as seen in Table 4 above. Page 7 of

Table 5: Harm/injury sustained as a result of the incident Outcome Frequency Percent Fatality 3 3.5 Pain & Suffering 3 3.3 Permanent Injury 0 0. Infection 7 7. Serious deterioration in condition 5 5. Organ Damage 4 4. Psychological/Psychiatric Injury 4 4. Cerebral Palsy 3 3. Fertility Impairment 3 3. Fracture 3 3. Laceration 3 3. Nerve Damage 3 3. Infection (C. Difficile) Infection (MRSA) No apparent injury / reaction Psychological Injury Birth Injury Burn/Scald Delay in Treatment Dental Damage Haemorrhage Infection (Hepatitis C) Infection (VRE) Other Replacement of catheter required Total 98 00 The fatalities in the cases reviewed resulted from a variety of contributory factors such as Delay in diagnosis metastatic liver disease Intracranial bleed following an instrumental birth Inadequate medical documentation and Duodenal perforation post cholecystectomy. Page 8 of

The following graph, Figure 8, provides additional information on these fatalities. Suicide within month of discharge Failure to Diagnose Unexpected Neonatal Death Stillbirth In-patient suicide Unintentional punct/laceration to organ Unexpected comps following op/proc Patient Fatality Patient absconsion - Harm Other Delay / Failure to treat - adv. outcome Choking Episode Birth injury incl instrument injury 3 4 4 0 0.5.5.5 3 3.5 4 Figure 8: Fatalities by incident type specific Year of Occurrence 30 5 4.5 0 0.4 5 0 5 0 9. 8. 8. 8. 8. 5. 4. 988 999 000 00 003 004 005 006 007 008 009 00 0 Year of Occurrence Figure 9: Year of occurrence of reviewed cases The year that the adverse event occurred is presented in Figure 9. The majority of the notifications for the reviewed cases were made via written correspondence, e.g. letter, email etc. STARSWeb was the method of notification in 50% of cases. This could be explained by the fact that STARSWeb was incrementally available during 004-009 to enterprises covered by the CIS, as well as the fact that a significant number of events come to light on foot of a solicitor s letter sent in to hospital management and, therefore, this is the organisation s first notification that an adverse event has taken place. Page 9 of

Contributory Factors and Root Causes Communication failure has been identified as the number one root cause as to why an adverse event occurred in 7.6% of the claims reviewed. Over 65% of the root causes identified related to communication, staff knowledge/skills/competency and the availability of protocols or guidelines. A breakdown of the top ten root causes identified is presented in Figure 0. Communications Failure Staff Knowledge/skills/competancy Availability of protocols/guidelines lack of supervision Staffing levels/skills mix Practitioner error Safety Culture issues Lack of effective leadership Failure to seek consent Resource issues Lack of effective ongoing training Admistrative/management support Not stated 5. 3. 6... 7.6 6.5 0 5 0 5 0 5 30 Figure 0: Top ten root causes identified There were 8 different contributory factor types influencing clinical practice identified in the cases that were reviewed. More than one factor contributing to the incident would have been present in the majority of the cases reviewed. The top 0 contributory factor types are provided in Figure. As can be seen, practitioner error accounts for 9.4%. Examples of this are practitioners working outside their scope of practice, inexperienced practitioners making diagnostic errors, prescribing or administering wrong medication etc. However, as 63.% of the reviewed cases related to diagnosis, peri operative/peri procedure and treatment type incidents, it is unsurprising that the top 0 factors identified relate to delays in recognising complications or delays in treatment. Practitioner Error Failure to Monitor Delay/failure in recognising complication Delay /Failure to treat Delay/Failure acting on formal result Competence/Skills/Knowledge Failure to seek consent Failure to provide adequate information Misdiagnosis Failure/Delay to perform tests 7. 6. 5. 5. 4. 3. 3. 9. 0. 9.4 0 5 0 5 0 Figure : Top ten contributory factors identified Page 0 of

Conclusion Overall, the findings are almost consistent with previous years with the top 5 event types leading to claims being Diagnosis, Peri operative/peri procedure, Treatment, Peri natal Self Harm Over 60% of settled cases involve the specialty of surgery, emergency medicine and medicine with over 46% associated with a clinical procedure or occurred during care managed by the emergency department. Of the settled cases reviewed, fatality and pain and suffering accounted for more that 36.8% of the harm/injury sustained. Over 65% of the root causes identified for those cases reviewed related to communication, staff, and policies/procedures/protocols. This highlights the importance of ongoing competency assurance programmes for health care professionals and the national roll out of track and triggers tools with definitive escalation policies such as the National Early Warning Scores. This national programme needs to include agreed early warning score systems for maternity and paediatric patients and structured communications tools such as ISBAR Identify, Situation, Background, Assessment and Recommendation which is a framework to simplify clinical communication in a variety of situations. There is also a need for more multidisciplinary policies, protocols and guidelines and technology assisted decision making tools. The clinical risk advisory service within the State Claims Agency will continue to incorporate the findings of this report in its work programmes to optimise patient safety through learning from incidents and claims. Page of