Agenda No.
(Complaints, Litigation, Incidents, Coroners)
CLIC Report
Quarter 1
2015/16
Giles Thorpe, Deputy Director of Clinical Governance
Alison Kelly, Head of Litigation
Karen Berry, Quality Governance & Complaints Manager
Content Contributors: Martin Rutter, Risk & Clinical Incident Systems Administrator; Anne
Rutland, Patient Safety Manager
Data source: Ulysses Safeguard; Clinical Governance & Risk Team; Complaints Team; Legal Team
1
CONTENTS
Page No.
1.
Introduction
3
Background
3
Reporting
3
Serious Incidents
3
High Level Complaints
4
Complaints
4
Claims
4
Inquests
4
Demonstrable link between Complaints, Litigation, Clinical
4
Governance and Risk
Corporate Reporting Framework
5
Ensuring Board Assurance
5
2.
Safe
6
3.
Effective
14
4.
Caring
18
5.
Responsive
20
6.
Well Led
27
2
1. INTRODUCTION
This report provides details of Complaints, Litigation, Incidents and Coronial cases
(CLIC) from 1st April to 30th June 2015. The report draws from the figures, themes
and trends and identifies data that can inform learning and influence actions to
address the issues raised. The report should be cascaded to all staff via divisional
and corporate meetings and is available to the public via the Trust’s website.
The report is presented to the Divisions, who are required to demonstrate how
learning from these data is used to make improvements to enhance patient
experience and patient safety. The CLIC report is presented to the Trust Board via
the Risk and Compliance Group and assured at the Trust’s Quality and Patient
Safety Committee. It is also shared with external bodies as evidence of learning.
An aggregated approach to the analysis of CLIC and the evidence that any learning
from this report is disseminated Trust-wide will provide external stakeholders with
assurance that the safety and a positive experience for our patients, their advocates,
staff and visitors will be further enhanced.
Each quarter the CLIC Report will bring together the themes and trends of high level
complaints, reported incidents that have occurred over the past quarter, identified
Serious Incidents (SIs), action plans developed following complaints upheld by the
Parliamentary Health Service Ombudsman (PHSO), recommendations from claims
closures and actions requested by Her Majesty’s Coroner. These identify evidence
of follow-up, action, improvements and monitoring, where shortcomings in patient
care have contributed to compromised patient safety.
BACKGROUND
Data is sourced from the Trust’s Risk Management Database, Ulysses (Safeguard).
This is a relational database which facilitates recording of incidents, complaints and
claims and enables reports to be extracted by division, department and/or issue type
Incident reporting is web-enabled which means that reports are made via an online
report accessible on the Trust’s intranet.
REPORTING
The data in this report are aligned with the five key questions that the Care Quality
Commission (CQC) ask as part of its new comprehensive inspection process to
assess whether the organisation meets the required fundamental standards of care,
as outlined in the Health and Social Care Act. The five key areas cover whether the
Trust’s services are: Safe, Effective, Caring, Responsive and Well-Led.
SERIOUS INCIDENTS
A Serious Incident is an incident which has caused serious harm or had the potential
to cause serious harm and/or gives rise to lack of confidence in the Trust’s ability to
deliver safe and effective care in line with the Serious Incident Framework as set by
NHS England. Incidents considered to be serious incidence (in accordance with the
Trust’s Serious Incident Management Policy and Procedure) are also reportable to
the Clinical Commissioning Group, NHS England, the CQC and Monitor. All serious
incidents are subject to rigorous internal investigation and a 60 day report is
mandated, which represents the findings following the investigation and includes
recommendations, lessons learned and an action plan which is monitored both by the
CCG and through the Trust’s internal governance mechanisms.
3
HIGH LEVEL COMPLAINTS
All contacts with the Complaints Team are assessed on receipt to identify the
appropriate level of investigation to be pursued. The Ulysses (Safeguard) system is
reviewed to identify if a complaint is associated with an incident or serious incident.
High level complaints recorded will be of those received from professional
organisations and serious incident. To note all complaints are of equal
importance.
If the concerns contain an indication that harm has been caused as a consequence
of shortcomings in care, then in line with Trust policy, the issue is discussed with the
Clinical Governance and Risk Department for consideration as to whether a Serious
Incident Investigation should be undertaken.
It is important to note that complaints are not usually received at the time of the event
and in general terms it is necessary to reflect on a broader time span to identify
trends and themes, together with actions and subsequent monitoring.
CLAIMS
Notification, investigation and completion of the legal process can take a
considerable period of time. However, it is important to ensure that any evolving
trend is identified, together with assurance on actions from claims closure risk
recommendations are monitored.
INQUESTS
Inquests held where no criticism of care provided is expressed by the Coroner during
the conclusion are an indication of ‘safe’ care.
Actions in the form of a Coroner’s formal Prevention of Future Death (PFD) report
demonstrate a potential failing in the provision of ‘safe’ care.
DEMONSTRABLE LINK BETWEEN COMPLAINTS, LITIGATION, CLINICAL
GOVERNANCE AND RISK
The process for data identification of high level complaints and/or Serious Incidents is
demonstrated below:-
INQUEST
CLAIM
SERIOUS
INCIDENT
COMPLAINT
4
CORPORATE REPORTING FRAMEWORK
Weekly Reporting
Incidents
Divisional
Governance
ordinators/HoNQs/DDCG/DoN
Serious
Incidents
Execs/DoN/MD
Complaints
Divisional Complaint
Leads/HoNQs/DoN
DoN
Claims/
Inquests
Co-
Monthly/Bi-monthly/Quarterly
Reporting
Risk & Compliance Group
Patient Safety Group
Senior Management Group
Quality and Patient Safety Committee
Trust Board
Risk & Compliance Group
Patient Safety Group
Senior Management Group
Quality and Patient Safety Committee
Trust Board
Patient Safety and Experience Group
Risk and Compliance Group/
Patient Safety Group
ENSURING BOARD ASSURANCE
In order to provide Board Assurance, the Clinical Governance and Risk Department
and the Complaints and Litigation Teams will request evidence of compliance when
action plans are completed. This will demonstrate that lessons have been learnt and
changes in practice is embedded.
Future plans will include recommendations to be added to the Ulysses system and
evidence and actions tracked and reports formulated from this system.
5
2. SAFE
Clinical
Support
Services
Medicine
Surgical
Services
Women &
Children
Corporate
Serious Incidents declared
Serious Incidents closed with
action plans
CNST claims closed with
recommendations
Third party liability claims
closed with recommendations
PHSO Cases Upheld/Partially
Upheld with action plans
PHSO Cases Upheld/Partially
Upheld with action plans and
financial redress
Inquests held
Inquests held with actions
Inquests held with Prevention
of Future Death (PFD) Reports
Complaints received
High Level Complaints from
professional organisations or
serious incidents.
Cardiothoracic
Services
Quarter 1 Apr - Jun 2015
(Quarter 4 2014/15)
Acute Medicine
“By safe, we mean that people are protected from abuse and avoidable harm”.
4(3)
1(7)
1(3)
19(7)
7(11)
4(3)
2(2)
0(4)
3(2)
0(1)
16(10)
7(12)
3(2)
0(0)
1 (3)
0 (0)
1 (0)
0 (0)
5 (2)
1 (0)
n/a
0 (0)
0 (0)
0 (0)
0 (0)
0 (1)
0 (1)
2(0)
0 (0)
0 (0)
0 (0)
4(0)
0 (0)
0 (0)
n/a
0 (0)
0 (0)
0 (0)
0 (1)
1 (0)
0 (0)
n/a
2 (0)
0 (0)
0 (0)
1 (1)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
1 (1)
0 (0)
0 (0)
1 (2)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
n/a
n/a
1(0)
34 (27)
3 (5)
10 (8)
2 (2)
15 (8)
3 (0)
44 (44)
6 (3)
35 (21)
4 (2)
16 (22)
1 (0)
8 (13)
2(1)
Further information is available from the Clinical Governance & Risk
Department, Complaints or Legal Teams
6
COMPLAINTS
When complaints are received they are assessed by the Complaints Team, in
conjunction with the PALS service to identify the appropriate level of investigation to
be pursued. If there is an indication that harm has been caused as a consequence of
shortcomings in care the Ulysses (Safeguard) Risk Management system will be
scrutinised to identify if there are any current incidents or serious incidents relating to
the complaint. The Quality Governance and Complaints manager will then link with
the incident or serious incident process and oversee the process to ensure that a
robust joint response is provided to minimise any poor experience to the patient
and/or family.
In Quarter 1, 21 complaints were assessed on receipt as “high” level compared to 3
complaints in Quarter 4. 10 of those 21 were from MPs’. There has been an increase
of high level complaints due to identifying the specific criteria that make the complaint
high level.
CATEGORIES/THEMES
The Top 5 categories in Quarter 1, equating to 75% of the total complaints received,
are shown below with comparisons to Quarters 1, 2, 3 & 4.
Top 5 Category Types - Quarter 1
60
54
48
50
40
35
30
30
29
28
23
20
15
10 10
31
26
Qtr 2 2014/15
24
Qtr 3 2014/15
18
12
14
11
10
15
11
9
Qtr 4 2014/15
Qtr 1 2015/16
0
Attitude
Communication
Medical Care/
Treatment
Medical
Judgement/
Diagnosis
Nursing
Care/Treatment
The top categories in Quarter 1 showed reductions/increases (from Quarter 4) as
follows:• Attitude: ↓20%
• Communication: ↑ 110%
• Medical care/treatment: ↑37%
• Medical judgement/diagnosis: ↑70%
• Nursing care/treatment: ↑67%
The increases in many of these categories may relate to the category groups on the
Trust Ulysses system being by refined. For example in Communication, Dementia
and DNACPR have been added to reflect the issues raised in complaints.
In order to address the issue of increased complaints relate to communication the
team delivered a ‘Message of the Week’ in April to highlight the responsibility of all
7
staff to be aware of the lasting impression they make on patients, relatives, visitors
and other members of staff.
Complaint themes and patient experience was presented at the Governance
symposium in June.
The new complaints policy invites complainants to attend an initial meeting to provide
foresight to clinicians about the impact of their actions on patients and relatives.
The top 5 categories in Quarter 1 are broken down into Divisions as follows:-
Division
Medical
Medical
Nursing
Attitude Communication Care/treatment Judgement/diagnosis Care/treatment
Acute Medicine Division
3
1
16
6
3
Cardiothoracic Division
0
1
3
1
0
Clinical Support Services Division
0
2
5
1
1
Estates And Facilities Division
0
1
0
0
0
General Medicine Division
3
6
9
8
5
QIPS Division
1
3
0
0
0
Surgical Services Division
3
8
10
7
2
Women & Children Division
2
1
6
0
4
Corporate
1
4
0
0
0
8
INCIDENTS
Total Incidents Reported with Grading of Actual Impact
Q1 2015/16
1200
1000
800
No-Low Harm
600
Mod-Sev Harm
400
Total
200
0
Apr-15
May-15
Jun-15
The number of moderate to catastrophic harm Incidents is evidenced as 1.8
percent of all incidents reported. This is reflective of the latest national figures
showing the Trust is now ranked 13th out of 140 of all non-specialist Trusts for
incidents reported, compared with 2012 when it was the second worst
performing in all medium acute Trusts. The figures relate to April to
September 2014 and are compiled by the NHS National Reporting and
Learning System. More importantly, the breakdown of incidents resulting in
harm is better than the national average for the first time with more near miss
incidents reported than most other Trusts.
All incidents continue to be reviewed by the Clinical Governance and Risk
Department to ensure accuracy, identifying the potential for a Serious
Incident.
SERIOUS INCIDENTS
Trust declared Serious Incidents Quarter 1 2015/16
18
16
14
12
10
8
6
4
2
0
Apr-15
May-15
Jun-15
9
The number of Serious Incidents has increased slightly in June (16 up from 9 in
May), however May did show a low number of SI’s declared and it should be noted
that 4 of the SI’s declared in June were incidents occurring in May which required
more extensive investigations prior to review.
The percentage of SIs in relation to all incidents reported can be evidenced below for
Quarter 1:
Number of
Percentage
Number of
Internal
of II’s per
Serious
Investigations
total
Incidents
(formerly
incidents
Level 0 SI’s)
Percentage
of SIs per
total
incidents
Calendar
Month
Number
of Total
incidents
April 2015
985
3
0.30%
13
1.32%
May 2015
986
5
0.50%
9
0.91%
June 2015
1001
3
0.10%
16
1.60%
Serious Incidents
SI's by Division Quarter 1 2015/16
9
8
7
6
5
4
3
2
1
0
Apr-15
May-15
Jun-15
Divisional distribution is evidenced above. The Divisions which show the highest
numbers of SIs are those with the largest clinical areas, and the greatest number of
clinical procedures being undertaken. The distribution of SI’s is also reflective of the
number of incidents reported per Division which shows General Medicine as the
largest reporter
Serious Incidents are graded accordingly to the relevant Ulysses Cause Group as
evidenced below. This allows for consistency when grouping Serious Incidents to
identify whether there are any specific trends that are of potential concern that may
require additional Trust-wide input.
10
10
9
8
7
6
5
4
3
2
1
0
SI's by Cause Group
Q1 2015/16
Apr-15
May-15
Jun-15
Tissue Viability SIs (Hospital Acquired Grade 3 Pressure Ulcers), are the highest
reported Serious Incidents in Quarter 1. The Harm Free Evaluation Group meets on
a weekly basis and both Falls and Pressure Ulcers are discussed in order to
determine avoidability and lessons learned. This meeting is attended by the CCG for
collaborative agreement. The bespoke Root Cause Analysis combined with bespoke
IO training for Pressure Ulcers and Falls RCA’s has allowed for rapid decisionmaking and evidences immediate actions taken to mitigate risk, where required,
whilst also ensuring that reports are completed in a consistent and robust manner.
Avoidable Hospital Acquired Grade 3 Pressure Ulcers continue to reduce and this is
reflective of the shared learning and immediate action process of the Harm Free
Group.
As part of the Trust’s commitment to improving the quality of care delivery, patient
experience and staff learning, the Clinical Risk and Governance Team are
undertaking visits to ward and clinical areas to provide assurance that lessons
learned from Serious Incidents are embedded in all areas or identify gaps in
knowledge.
11
Internal Incidents
Following changes to the Serious Incident Framework (March 2015), Serious
Incidents are no longer reported as Level 0, 1 or 2. Grading has been removed as
NHS England found that incidents were often graded without clear rationale and
possibly lead to incidents being managed and reviewed in an inconsistent and
disproportionate manner.
Under the new framework serious incidents are not defined by grade - all
incidents meeting the threshold of a serious incident must be investigated and
reviewed according to principles set out in the Framework. The Trust continues
to investigate some incidents as Internal Investigations which incorporates a 7
day report which evidences a robust investigation, and an action plan which
results in immediate learning. The 7 day report is also shared with the
commissioners.
Internal Investigations YTD by Division
5
Acute Medicine
Corporate
4
CTC
3
General Medicine
CSS
2
Surgical Services
1
Women & Children
0
Internal Investigations by Cause Group 2015/16
10
9
8
7
6
5
4
3
2
1
0
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
12
The top two cause groups for Internal Incidents in Quarter 1 are Clinical Assessment
and Review and Treatment or Procedure. This is reflective of the SI’s reported
following exclusion of Tissue Viability and Slips, Trips and Falls.
In assuring that there is open and honest communication with external stakeholders,
all Internal Investigation 7-day reports are shared with the Clinical Commissioning
Group for information purposes.
This informs all relevant parties that sufficient scrutiny is paid to those incidents that
could potentially identify precursors to harmful sentinel events.
All of the Internal Incidents are categorised in the same manner as the SIs which
allows for comparative analysis.
13
3. EFFECTIVE
“By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence”.
FE
COMPLAINTS
There was an 16.5% increase with 162 new complaints received in Quarter 1
2015/16 compared to 139 in Quarter 4 2014/15.
Complaints - 2015/16
250
200
150
100
50
0
Qtr 2 2014/15
Qtr 3 2014/15
Qtr 4 2014/15
Qtr 1 2015/16
Complaints by Division - 2015/16
70
60
50
45
384037
41
40
30
Qtr 2
2014/15
59
33
2323
34
28
21 21
20
11
10
37
15
8 6
10
Qtr 3
2014/15
33
25
13
Qtr 4
2014/15
17
7
5
13
10 8
Qtr 1
2015/16
0
Acute
Medicine
CTC
Integrated
General
Core Services Medicine
Surgical
Services
Women &
Childrens
Other/
Corporate
The graph above evidences an increase in 5 divisions with a reduction in complaints
for Women and Children’s Services and Corporate.
14
Complaints acknowledged within 3 working days with Complaint Management
Plan/Consent request and required outcomes
Complaint Acknowledged within 3 working days
100%
80%
60%
40%
20%
0%
Qtr2 (14/15)
Qtr3 (14/15)
Qtr4 (14/15)
Acknowledged in target
Qtr1 (15/16)
Target
LITIGATION
A total of 38 Clinical Negligence Claims (Letters of Claim and Letters Before Action)
were received between 1st April to 31st June 2015. (16 of which were part of the
Group Action against the Trust) This represents a 59% increase on the number
received in Quarter 4, 2014/15 (24).
CNST Claims received
(by Division)
20
15
Qtr1 15/16
Qtr4 14/15
10
Qtr3 14/15
5
Qtr2 14/15
0
Total claims received does not include claims where no allegation has yet been
made
15
** For clarity, Obstetrics relates to Obstetrics alone, whilst Obstetric /… relates to Obstetrics
and Gynaecology. Orthopaedic relates to Orthopaedic Surgery
The above graph is reproduced from the NHS Litigation Authority extranet data. It will
be included in future reports to provide an illustration of improving and/or declining
trends.
INCIDENTS
Total Incidents Reported with Grading of Actual Impact
Q1 2015/16
1200
1000
800
No-Low Hard
600
Mod-Sev Harm
400
Total
200
0
Apr-15
May-15
Jun-15
The number of moderate to catastrophic harm Incidents is evidenced as 1.8
percent of all incidents reported.
Incidents are categorised into 26 different cause groups. Thematic analysis of
incidents is identified in the table and graph below which shows the ten cause groups
with the highest number of incidents reported each quarter.
16
Cause Group
Qtr1
Tissue Viability
479
73%
Slips/Trips/Falls (Patient)
368
Admission, Discharge &
Transfer
267
Documentation &
Appointments
291
Medication
256
Maternity
255
Equipment & Medical Devices
92
Clinical Assess & Review (Inc.
Test/Scan/Specimen)
130
Treatment Or Procedure
154
Safeguarding
65
Qtr2
Qtr3
Qtr4
TOTALS
Comments
Total number of incidents reported is
reflective of Grades 1-4 and inclusive of
those admitted to hospital with pressure
ulcers. Percentage of incidents reported
where pressure ulcers are reported on
admission in red.
12 (3.2%) of these incidents were
declared as serious incidents.
98% of these incidents reported as a
Grade 0, no harm/near miss. Common
themes include out of hours transfers and
delays in transferring patients out of
critical care
Mainly incidents of no harm to patients,
incidents related to EMR/EPR, clinic overruns and incomplete documentation.
98% of the incidents reported were near
miss/no harm. The majority of the
incidents reported were administration,
prescription and dispensing errors and
Medication Matrix’s are completed for
reflection, learning and sharing.
Incidents reported reflect a large
proportion (98%) as near miss, no/minor
harm. One incident reported as causing
harm is being investigated as a Serious
Incident.
Reported across Divisions with little
impact on patient care and delivery.
5 of these incidents reported have
resulted in the incidents being
investigated as Serious Incidents (3) and
Internal Investigations (2)
4 incidents reported in this cause group
have been identified as Serious Incidents,
1 as an Internal Investigation.
Safeguarding incidents have increased
slightly month on month. The majority of
the incidents are raised in respect to
external allegations and shows an
increased awareness by staff to escalate
concerns.
17
SERIOUS INCIDENTS
Compliance against the standard for notifying the CCG and NHS England of Serious
Incidents was sustained at 100% in Quarter 1.
Compliance with 2-Day Notification of STEIS to CCG
by Quarter, 2015/16
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
Qtr 1
Qtr 2
Qtr 3
Qtr 4
18
4. CARING
“By caring, we mean that staff involve and treat people with compassion,
kindness, dignity and respect”.
COMPLAINTS
As part of the ongoing quality improvement work further analysis will be undertaken
to identify those concerns/questions that may not fall into the category of formal
complaint, to ensure that they are addressed at a local level, led by the Clinical
Divisions to ensure that responses are provided by the most appropriate staff, using
the best route, in a manner that is most suited to the patient and/or relative.
In addition complainant will be offered by telephone an initial face to face meeting to
address their concerns. This will be arranged at a location of their choice and a time
that is convenient for them, providing assurance that this is done in a timely fashion.
SERIOUS INCIDENTS
Duty of Candour
The table below shows adherence to the contractual requirement to ensure that
patients and/or relatives are informed when a patient safety incident that has
potentially caused moderate or severe harm, or death. The legislation Duty of
Candour requirements commenced in November 2014.
Compliance for Verbal Duty of Candour 2015/16
102%
100%
98%
96%
% Compliance
94%
% Target
92%
90%
88%
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
During the Quarter 1 there have been some occasions in which it has not been
appropriate to have verbal conversations and send letters to patients to inform them
of the potential of a serious incident occurring whilst under the care of the hospital.
Such decisions are taken when there is an opportunity to ensure that sometimes
difficult conversations are held face to face and with appropriate support in place to
support any distress that may occur. Any potential breaches to the standard are
discussed with the Clinical Commissioning Group who make a final determination of
whether a breach has occurred. In all cases in Quarter 1 it was agreed that no
breach had occurred and that the decisions that the Trust made in delaying the
standard approach for Duty of Candour were in the best interests of the patient and
showed a caring and compassionate approach. In ensuring that the Trust focusses
on the patient, where it has been deemed more appropriate, a delay in undertaking
Duty of Candour has occurred by only a few days, so that it minimises any potential
distress to a patient and/or their family,
19
5. RESPONSIVE
“By responsive, we mean that services are organised so that they meet people’s
needs”.
COMPLAINTS
Divisional adherence to agreed target dates
The following graph represents the number of complaint responses that have been
sent out from the Trust within the target date agreed with the complainant (including
agreed extensions where additional investigation has been required during the
process).
The Trust target is set at 90% compliance. It should be noted that some delays
attributed to Divisions were contributed to by delays in other parts of the process,
including corporate response times.
The Complaints Team will be reviewing the current management process in order to
improve response times, and to ensure that Divisions are provided with the
appropriate support, whilst allowing for greater responsibility of the management of
the process. This will be supported through the development of the Ulysses
Safeguard Customer Services module.
Reopened complaints
The Trust experienced an 83% increase in reopened complaints with 33 reopened in
Quarter 1 2015/16 (18 in Quarter 4 2014/15). 15 of those 33 will in future not be
counted as reopened cases as they have requested a meeting following response
letter and this is stage two of the complaints process.
20
Re-opened Complaints
by Division
25
20
15
10
Qtr2 14/15
5
Qtr3 14/15
0
Qtr4 14/15
Qtr 1 15/16
Upheld//Not Upheld complaints
Quarter 1 has shown a reduction in upheld complaints across the Trust.
Complaints Upheld
Qtr 2 14/15
Division
Qtr 3 14/15
Qtr 4 14/15
Qtr 1 15/16
Sent
Upheld
Sent
Upheld
Sent
Upheld
Sent
Upheld
Acute Medicine
Cardiothoracic
Services
Integrated Core
Services
Medicine
38
14
11
1
34
4
16
1
19
11
5
3
26
8
10
1
17
8
23
12
17
14
15
4
48
20
32
12
40
20
47
20
Surgical Services
60
21
38
10
40
14
24
9
Women & Childrens
Corporate/Other
32
2
11
0
26
9
16
5
17
14
8
3
22
6
11
1
Upheld complaints Q1 2015-16 by category type
16
14
12
10
8
6
4
2
0
14
7
7
4
2
1
2
5
3
1
1
2
2
2
1
1
1
21
SERIOUS INCIDENTS
Reports to the CCG
Compliance with RCA report sent within 30 working days
120%
100%
80%
% Compliance
60%
% Target
40%
20%
0%
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
N.B. as from 01/05/2015 the 30-Day target for the RCA Report changes to a 40-day target
The compliance with 30 day draft received within the Clinical Governance and Risk
Department has dropped slightly in quarter 1. Changes to the NHS England Serious
Incident Framework took effect from the 1st of May 2015 as agreed by the CCG. The
standard is now that the draft RCA is received at day 40 and sent to the
Commissioners by day 60. Additional work is required by Divisions to identify
reasons for the failure to adhere to the standard. Whilst this is an internal target,
failure to provide a draft report within 30 (40) days can, and as has been evidenced
previously, impact upon the ability of sufficient quality assurance prior to sending
externally within the 45 (60) working day target.
The redesigned RCA tool for Pressure Ulcers and Falls has been successful in
driving forward speedier completion of the RCA as well as provision of shared
learning across the Divisions. Bespoke Pressure Ulcer and Falls RCA Training has
commenced for ward-based senior staff as investigating officers for pressure ulcers
and falls specifically to enhance this process.
Compliance with RCA report sent within 30 working days
Comparison between April 2014 & April 2015
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2015 -2016
2014 - 2015
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
22
Report to CCG
Compliance with RCA report sent within 45 working days
120%
100%
80%
%
Complian
ce
60%
40%
20%
0%
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
N.B. as from 01/05/2015 the 45-Day target for the RCA Report changes to a 60-day target
Compliance against the 45 day target to submit reports to the CCG has not met the
expected standard and this is reflective of the late submissions of draft reports at day
30.
There still remains further work within Divisions to ensure that satisfactory completion
and amendment of SI reports reaches the 100% mandated target.
100 day action plan to CCG
Compliance with Action Plans Closed by CCG
within 100 working days - 2015/16
150%
100%
% Compliance
50%
% Target
0%
Apr-15
100%
Jun-15
Aug-15
Compliance comparison between Action Plans Closed by
the CCG
in 2014/15 & 2015/16
80%
60%
2015 -2016
2014 - 2015
40%
20%
0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
23
Compliance with the 100 day closure of actions plans against the externally
mandated target has not met the agreed standard. Further training is planned with
the Divisions to ensure that action plan leads are provided with the requisite
resources to work with action point leads to collate information in a timely fashion for
submission to the CCG. Internal policy changes have been cascaded to ensure the
draft Action Plan is presented simultaneously with the RCA for all Serious Incidents.
Divisions have been advised that closer scrutiny of the recommendations made
within the SI Reports at Divisional and Corporate Governance level should be made
to ensure the recommendations are Specific, Measurable, Achievable and Realistic
(SMART) in order to evidence real change through action plans.
Action Plan Compliance
(%)
Qtr 1
Acute Medicine
0%
Corporate
n/a
CTC
61%
General Medicine
61%
CSS
50%
Surgical Services
67%
Womens & Children
100%
Internal Investigations – 7 day report Compliance
Compliance with 7-Day Reports for Internal Investigations 2015/16
120%
100%
80%
60%
Compliance
Target
40%
20%
0%
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
There has been a reduction in compliance in quarter 1. There are currently 2
outstanding reports and Divisions responsible have been asked to ensure a more
robust process in ensuring compliance against the standard. The Trust will continue
to investigate incidents within the 7 day report framework to ensure lessons are
learned and immediate actions are taken. Compliance will continue to be monitored
at Divisional level and the 7 day reports will be shared with the CCG for information
and assurance of good governance practice.
24
INCIDENTS
Compliance with 20-Day Incident Closure target,
by Quarter 2015/16
102%
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
Qtr 1 - 15/16
Qtr 2 - 15/16
Qtr 3 - 15/16
Qtr 4 - 15/16
Acute
120%
CTC
General Med
CSS
Surgical
W&C
Monthly Compliance with 20-Day Closure of Incidents - by
Division, 2015/16
100%
Acute
80%
CTC
General Med
60%
CSS
40%
Surgical
W&C
20%
Corp/Other
0%
Apr-15
May-15
Jun-15
The above shows Trust level and Divisional level compliance against the standard to
close incidents within 20 working days of reporting. Divisional responsibility to
ensure closure of these incidents is managed through monthly performance reporting
frameworks, where actions to resolve any gaps is identified and monitored.
INQUESTS
Further to the closure of two inquests, where no criticism of the Trust was made,
meetings have been held with bereaved families to provide a better understanding of
the clinical management of their loved ones.
25
6. WELL LED
“By well led, we mean that the leadership, management and governance of the
organisation assure the delivery of high quality person-centred care, support
learning and innovation, and promote an open and fair culture”.
DIVISIONAL LEADERSHIP
It is important to monitor the effectiveness of Divisional actions and determination to
improve patient safety and experience by being well led.
This is done through escalation of exceptions through Patient Safety, Risk and
Compliance and Patient Experience Groups, with any concerns raised at Senior
Management Group. This falls in line with the Trust’s Risk Management and
Integrated Governance Frameworks.
COMPLAINTS MANAGEMENT
RECOMMENDATIONS/ACTIONS
Actions identified during complaint investigation relating to “upheld” complaints are
added to the shared drive and the evidence of action populated by Divisions. The
Complaints QID will shortly be replaced and a report on recommendations/actions
will be sourced from the Ulysses database.
In Quarter 1, 56 complaints were upheld and Ulysses has recorded 40
recommendations in the graph below
Each upheld complaint requires actions for learning, these will be tracked and
evidenced on the Ulysses system and themed with serious incident. This forms part
of the quality improvement work underway for 2015/16.
Recommendations from Upheld Complaints Quarter 1 2015/16
7
6
5
4
Acute Medicine Division
3
Women & Children Division
2
Clinical Support Services Division
1
General Medicine Division
0
Surgical Services Division
Cardiothoracic Division
26
LITIGATION MANAGEMENT
A total of 17 recommendations were made following closed claims in Quarter 1, as
follows:Recommendation Type
Acute
Medicine
CTC
Integrated
Core
Services
Medicine
Surgical
Services
Action Plan
1
1
Audit Required
1
1
Medical Training
1
Procedure change
1
Record Keeping Medical
Risk Assessment
Women &
Childrens
Corporate
/ Other
Total
2
1
3
1
2
1
2
1
1
1
Staff Training - Medical
1
2
Staff Training – Nurse &
Midwifery
1
2
5
1
1
Of the 17 recommendations issues in Quarter 1 an example of a recommendation
that has been completed and closed is as follows. The action taken is detailed below;
Directorate
CTC
Recommendation
Ensure systems in place to continue
awareness of warnings about the use
of Chlorhexidine.
Action
New practice in place.
Absorbent towels placed
under patient during use of
Chlorhexidine. Once skin has
dried these towels are
removed and a further sheet
put in place.
INCIDENT/SERIOUS INCIDENT MANAGEMENT
Thematic Review of Recommendations by Quarter, 2015/16
30
20
10
0
Quarter 1
Quarter 2
New protocol design
Medical training
Imaging protocol review
Trust Policy development
Communication systems improvement
Audit/review of practice
Quarter 3
Quarter 4
Nurse training
Protocol/guideline update
Documentation improvement
Non-clinical staff training
Operational capacity development
27
As part of gaining a better understanding in relation to the kind of recommendations
that occur following Serious Incident investigation, an analysis is undertaken monthly
to consider quarterly comparative data. Training recommendations are the most
common theme throughout each quarter with common areas identified as falls and
pressure ulcer prevention and recognition and escalation of the deteriorating patient.
This is also reflective of the top cause groups for serious incidents.
Further analysis of the lessons learned and recommendations has commenced to
identify where improvements are evident and areas for focus require greater support.
This is evidenced below as the beginning of comparative analysis of SIs and
Complaints to determine whether there is a correlation between the issues arising
from patient safety incidents and those where poor patient experience occurs.
It is evidence that there is a consistent requirement for ongoing training of staff, with
an improvement in communication systems when complaints and SIs are identified.
This analysis will continue to develop in the coming year.
Recommendation Themes, SI's &
Complaints - Quarter 1
30
25
20
15
10
5
0
Incidents
Complaints
TRAINING – INCIDENT MANAGEMENT
Incident Reporting and Risk Assessment Mandatory Training
Mandatory training for all staff was commenced in March 2014, with a planned
trajectory for 80% compliance in September 2014. At 30th June 2015 compliance
was at 51% which is down from 61% in quarter 4 (2014/15).
This is being addressed with the individual Divisions and departments concerned as
part of the Trust’s Performance Management Framework.
Root Cause Analysis Training
Since internal training commenced in March 2013 (in house training since July 2014)
these sessions have trained 222 staff with the requisite skills and knowledge to
undertake Root Cause Analyses for Serious Untoward Incidents.
28
Divisional numbers of staff trained are identified below. Additional training sessions
are planned throughout 2015/2016 to increase the number of staff with the requisite
knowledge and skills to act as lead Investigating Officers for Serious Incidents.
The training will also aid in the investigation of standard incidents, complaints
investigations and the provision of accurate statements for other requirements. All
training is provided in-house by the Trust’s Patient Safety Managers and Quality
Governance and Complaints Manager. Further bespoke training has commenced
for 2015/2016 to support specific departments throughout the Trust, including
pressure ulcer and falls and 22 IO’s have been trained.
0
TRAINING – COMPLAINTS MANAGEMENT
Training is a fundamental requirement for developing and maintaining high standards
and this applies equally to dealing with, and responding to, complaints as to any
other aspect of service provision.
The Divisional Heads of Nursing & Quality and staff who are responsible for
investigation of complaints, must be supported and trained in investigation techniques
and root cause analysis, communication and customer care, which are fundamental
requirements for developing and maintaining high standard responses to complaints.
Any member of staff nominated by the Divisions to undertake complaint investigation,
commensurate with their level of responsibility, must either have undertaken Root
Cause Analysis training or the Trust’s online complaint training.
All new staff entering the Trust will receive information about the Complaints Policy
with a focus on local resolution and complaint management as part of their local
induction programmes. This will be monitored via Education and Training Department
reports.
Records of Complaints E-Learning Training completed is provided to the Quality
Governance and Complaints Manager by the Education and Training Department.
In Quarter 1 of 2015/16, 31 staff undertook the training (35 in Quarter 4).
Complaints E-Learning Module Trained Staff
(by Division)
Year-End position
by Division 2014/15
20
50
1845
1640
35
14
30
1225
1020
815
10
65
40
2
0
2015/16 Qtr 1
2014/15 Qtr 42
2014/15 Qtr 3
2014/15 Qtr 24
29