Affiliated Teaching Hospital
BOARD OF DIRECTORS:
AGENDA ITEM:
SUBJECT:
RESPONSIBLE DIRECTOR:
AUTHOR:
PREVIOUSLY CONSIDERED BY:
28 FEBRUARY 2014
10.2
OPEN SIRIS/INQUESTS/PHSO COMPLAINTS
Ms Clare Culpin
Director of Nursing & Quality
Mrs Sarah Thomas, Complaints & Claims Manager
Mrs Clare Beattie, Quality & Compliance Manager
Quality Governance Steering Group receive regular
reports relating to SIRIs and quarterly summary
reports which include updates on Inquests and
PHSO cases
EXECUTIVE SUMMARY:
SIRIs: The SIRI database provides details of current open SIRIs and the progress in the compilation
of the investigation and final report which is submitted to the Commissioners.
INQUESTS: 39 open inquests. In 15 cases, the Trust has provided a medical report on the last
admission or episode of treatment for patients who died outside of the Hospital. Such cases include
suicides, patients found dead at home or pronounced dead on arrival to the A&E department. Six
cases relate to patients with industrial disease whereby the Coroner is obliged to hold an inquest.
Seven cases are shown in bold and have been assessed as Medium or High risk and six of these
cases have been subject to SIRI or Internal Investigation. These cases may result in the Trust being
criticised by the Coroner, the family (via the media) or in the Trust receiving a “prevention of future
deaths” (PFD) report. All Medium and High risk Inquests have been reviewed by the Medical Director
and Director of Nursing & Quality.
PHSO: 8 current open complaints, four of which have been upheld. One complaint has not been
upheld and of the remaining three complaints, the Trust expects two of these to be upheld. The final
case has been discussed with the PHSO and as a result, the Trust expects this will not be upheld.
Please note the content
ACTION REQUIRED BY THE BOARD
OF DIRECTORS
Adverse publicity and financial implication in the event of
RISK TO THE TRUST (include reference
EQUALITY & DIVERSITY
compensation being recommended from the PHSO,
criticism from HM Coroner, adverse media at conclusion of
inquest and potential prevention of future deaths report
N/A
LEGAL IMPLICATIONS
Potential for complaints/inquests to be pursued as litigation
WORKFORCE ISSUES:
N/A
to BAF or Corporate Risk Register)
(including training and education implications)
FINANCIAL IMPLICATIONS:
Specify No/Yes (Detailed within the report).
COMMUNICATION/CONSULTATION
ISSUES
(including patient and public involvement)
STRATEGIC OBJECTIVE:
(specify trust strategic objective)
In the event that the PHSO recommends the Trust pay
compensation, there currently is no upper limit on the value
of this payment
Overview of PHSO shared with Patient Experience Steering
Group via the Trust’s Quarterly Patient Experience Report.
SIRI & Inquest overview provided via Quarterly Patient
Safety Report.
Has a reputation for safety and quality care.
Treats all people with dignity and compassion
People choose to come to and recommend to others
Chairman: Graham Foster
Chief Executive: Fiona Wise
Briefing
Meeting
Date
CMT
Description
Harm
Grading
Medicine
G3 PTD MAU/discharge
lounge
Major
18/02/2014
Surgery
G3 PTD ITU
Major
18/02/2014
Medicine
Fractured Back
Major
14/02/2014
Surgery
Grade 3 Pressure Tissue
Damage Deene B Ward
Major
13/03/2014
Medicine
Fractured scapula and ribs
Major
05/02/2014
Medicine
Delayed diagnosis of
stroke
Surgery
G3 PTD, Barnwell B
Major
28/01/2014
Surgery
Fracture NOF Deene B
Major
28/01/2014
Surgery
Potential failure to rescue
Surgery
G3 PTD BBW - Pop
Major
23/01/2014
Medicine
ED child head injury
Major
17/01/2014
Medicine
Fractured NOF HCP Ward
Major
07/01/2014
Medicine
G3 PTD Oakley
Major
30/12/2013
No Harm 28/01/2014
Catastrop
23/01/2014
hic
Director
Lead
Director of
Nursing
Director of
Nursing
Director of
Nursing
Director of
Nursing
Director of
Nursing
Director of
Nursing
Director of
Nursing
Director of
Nursing
Medical
Director
Director of
Nursing
Director of
Nursing
Director of
Nursing
Director of
Nursing
Director's
Due Date
10/04/2014
10/04/2014
29/03/2014
28/03/2014
27/03/2014
13/03/2014
13/03/2014
13/03/2014
06/03/2014
06/03/2014
07/03/2014
19/02/2014
10/2/2014
Directorate
Detail
MED
Patient deceased at home
MED
Patient deceased on arrival in A&E
MED
Patient deceased despite A&E treatment
MED
Patient deceased on arrival in A&E
SURG
Death following treatment for fracture
SURG
Death post surgery (≥ 24 hrs)
WOMCHI
Death post natal (community) - INQUEST SET FOR 16/17 APRIL 2014
MED
Suicide - INQUEST HEARD - ACCIDENTAL DEATH
MED
Industrial disease - INQUEST DATE 27/2/14
MED
Head injury on arrival in A&E
MED
Industrial disease
MED
Head injury on arrival in A&E - INQUEST SET FOR 13/3/14
MED
Suicide
MED
Death in hospital following fall at home
MED
Patient deceased on arrival in A&E
MED
Industrial disease INQUEST HEARD 6/2/14 - NO KGH WITNESSES, AWAITING CONCLUSION
MED
Head injury on arrival in A&E - INQUEST POSTPONED PENDING CRIMINAL INVESTIGATION
MED
Suicide
MED
Industrial disease
MED
Patient deceased on arrival in A&E - INQUEST POSTPONED AWAITING TRUST INVESTIGATION
REPORT
MED
Suicide
MED
Fall at home INQUEST HEARD 30/1/14 - NO KGH WITNESSES, AWAITING CONCLUSION
SURG
Died post discharge to other healthcare provider - INQUEST SET FOR 20/2/14 - TWO KGH WITNESSES
MED
Death in hospital- collapse at home - INQUEST HEARD 13/2/14, NO KGH WITNESSES - AWAITING
CONCLUSION
MED
Patient deceased on arrival in A&E - INQUEST SET 27/2/14 - NO WITNESS CONFIRMATION
MED
Death post-RTA - INQUEST POSTPONED - TRUST LEGALLY REPRESENTED
MED
Death in hospital following overdose - INQUEST SET 13/3/14 - NO WITNESS CONFIRMATION
MED
Death in hospital due to alcohol toxicity - INQUEST SET FOR 6/3/14 - NO WITNESS CONFIRMATION
Directorate
MED
MED
MED
MED
Detail
Death in hospital following fall - INQUEST SET FOR 13/3/14 - NO WITNESS CONFIRMATION
Industrial disease INQUEST SET 20/3/14 - NO WITNESS CONFIRMATION
Baby deceased on arrival at A&E - INQUEST SET 3/4/14
Industrial Disease INQUEST SET 17/4/14 - NO WITNESS CONFIRMATION
MED
Death in hospital following fall at home
MED
Patient died following fall at other healthcare provider INQUEST SET FOR 27/3/14 - NO WITNESS
CONFIRMATION
MED
Patient died at home day after discharge - INQUEST SET FOR 17/4/14
MED
Suicide
MED
Death in hospital following fall at care home - INQUEST SET FOR 17/7/14
MED
MED
Baby deceased on arrival at A&E
Patient deceased on arrival in A&E
Current PHSO complaints
Date
Complaint first
received at
KGH
Date
Complaint
Closed
Nature of Complaint
26/04/2012
25/07/2012
Complaint regarding the care of the patient who was on Maple
Ward/Urology team
04/12/2012
15/02/2013
04/12/2012
01/07/2013
03/01/2013
CMT
Date of
Investigation
Referral to
Carried out by KGH
PHSO
current status
RAG rating
Green – action completed
Upheld/Not Upheld Amber – action in progress
Red – not actioned
Women &
Children
Local Investigation
by CMT
14/09/2012
Final report issued
Upheld
G
Value of compensation payments since April 2013:
£28,500
Medicine &
Surgery
Local investigation
by CMT.
22/04/2013
Further questions to be answered
Awaiting decision
G
Number of complaints not upheld since April 2013:
6
Patient's husband unhappy that A&E did not undertake thorough
investigations for a bowel obstruction.
Medicine
Local investigation
by CMT
11/09/2013
Final report issued
Upheld
G
15/04/2013
Patient feels that she was not given the correct treatment when she came
into A&E. This is a cross complaint with the PCT concerning Nenedoc.
Medicine/ PCT
Local investigation
by CMT.
16/09/2013
Final report issued
Upheld
G
11/01/2013
14/06/2013
Patient's niece is complaining about the attitude, manner and behaviour of a
specific member of staff on Harrowden C Ward.
Medicine
Local investigation
by CMT.
03/10/2013
Final report issued
Not Upheld
G
15/02/2013
14/05/2013
The patient's daughter is complaining about how her mother's health
declined after she was moved from one ward to another.
Medicine
Local investigation
by CMT.
08/10/2013
Draft report upheld issues. Trust
reverted with comments,
recommendations to be amended
in final report
Upheld
G
14/08/2013
20/06/2013
Patient's wife feels that the care and treatment provided to her Husband
when he came into A&E was not acceptable.
Medicine
Local investigation
by CMT.
22/10/2013
Currently under investigation
Decision awaited
G
-
-
Unhappy with circumcision operation in 2010
Surgery
Informal
31/10/2013
Currently under investigation
Decision awaited
G
Patient's son is making a complaint regarding his mothers' treatment whilst
she was in A & E and Barnwell C.