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FOI Request

Disclosure ID
FOI/02388
Request Date
April 25, 2018
Subject
Serious Incidents
Description
  1. How many Serious Incidents involving breaches of patient safety, as defined by the Serious Incident Framework, were recorded by your trust in a) each of the last five financial years (ie, 2012-13, 2013-14, 2015-16, 2016-17 and as much months of 2017-18 as you have available?
  2. Please specify — for each year — how many of these serious incidents involved:
    1. death
    2. serious harm
    3. moderate harm
    4. low harm
    5. no harm
  3. For each death,
    1. state on which day it occurred and
    2. briefly explain what led to the death.
Response

During the 2012/13 period, the Trust was transforming with the addition of Community Services and the Trust’s electronic Incident Reporting System was in its infancy. Therefore the numbers of StEIS reported Serious Incidents were relatively low, in comparison to later years, with the introduction of changes of the NHSE’s Serious Incident Framework and the increase in the Trust’s footprint of services within the Community.
There was a considerable increase in reporting Serious Incidents in 2014/15, which was due to the fact that Commissioners requested that we as an organisation report all stage 3 and 4 pressure ulcers on StEIS, including non-Trust acquired pressure ulcers. This was then stopped in agreement with Commissioners as it did not reflect a true picture of harm incidents attributable to the Trust. Stage 3 and 4 Pressure Ulcer incidents are now reported on StEIS if they have caused serious harm to the patient and were deemed to be avoidable and attributable to the Trust.
In 2015/16 the new NHSE SI Framework was published, which no longer had a definitive list of events/incidents that constituted a serious incident and organisations had to decide whether the potential for learning from an incident is so great, or the consequences to the patient so significant,
that it warrants using additional resources to mount a comprehensive response. Each incident must be considered on a case by case basis.
This in part is reflected in the gradual decrease in incidents reported as Serious Incidents year on year from the period 2015/16 to 2017/18, and which also reflects the Trust’s robust Quality Strategy to improve patient experience and reduce harm to patients.

Financial Year Serious Incidents

Total Number

Final level of harm Impact Date of Death Category of Incident (deaths)
2012-2013 15 Death – 4

Serious – 6

Moderate – 4

Low – 1

02/09/2012

12/11/2012

04/01/2013

26/01/2013

07/01/2013

26/04/2012

Suboptimal Care of a Deteriorating Patient

Unexpected Death

Unexpected Death

Patient Fall – Unexpected Death

Unexpected Death

Maternal Death

2013-2014 38 Death – 2

Serious – 11

Moderate – 17

Low – 7

Near Miss –  1

06/07/2013

24/08/2013

17/10/2013

24/02/2014

05/03/2014

10/03/2014

Patient Fall

Adult Medical Plan

Unexpected Death

Death Following A&E attendance

Sudden Death of Child

Unexpected Death

2014-2015 99 Death – 3

Serious – 18

Moderate – 59

Low – 12

Minor – 4

Near Miss – 3

24/01/2014

18/03/2014

29/03/2014

31/03/2014

02/04/2014

18/04/2014

27/04/2014

03/07/2014

17/07/2014

11/10/2014

01/12/2014

07/01/2015

12/02/2015

29/08/2014

09/02/2015

Death during procedure

Death during procedure

Patient Fall

Unexpected Death of Child

Unexpected Patient Death

Patient Death – Delay/Failure to Monitor

Unexpected Death

Unexpected Patient Death

Unexpected Patient Death

Unexpected Patient Death

Sub Optimal Care of a deteriorating patient

Patient Fall

Missed Opportunity – Failure to Rescue

Missed Fracture

Unexpected Death of Patient

2015-2016 64 Death – 3

Serious – 15

Moderate – 29

Low – 13

Minor – 2

Near Miss – 2

 

02/01/2015

22/03/2015

30/03/2015

13/04/2015

15/04/2015

19/04/2015

01/05/2015

06/05/2015

25/06/2015

26/07/2015

15/08/2015

05/09/2015

30/11/2015

15/01/2016

12/02/2016

13/02/2016

11/04/2015

Failure to Recognise

Unexpected Death of Patient

Unexpected Death of Patient

Failure to Rescue- Unexpected Death

Neonatal Death

Missed Opportunity – Failure to Rescue

Delayed Diagnosis

Patient Fall

Patient Fall

Unexpected Injury during procedure – cardiac

Failure to Rescue

Unexpected Patient Death-Post Elective Surgery

Delay/Failure to Monitor – Patient Death

Delay in Diagnosis/Failure to Rescue

Failure to Rescue

Unexpected Death  – CITU

Neonatal Death

2016-2017 57 Death – 3

Serious – 8

Moderate – 34

Low – 6

Minor – 1

Near Miss – 4

Ongoing – 1

27/02/2016

25/03/2016

06/06/2016

20/06/2016

04/07/2016

12/11/2016

15/11/2016

29/11/2016

07/12/2016

19/01/2017

14/02/2017

08/03/2017

Failure to Monitor

Unexpected Patient Death

Maternal Death

Missed Opportunity- Failure to Rescue

Unexpected Death

Unexpected/ Potentially avoidable Death

Treatment -Procedure/ Cardiology

Unexpected Patient Death/Complication of condition

Unexpected Patient Death – A&E car park

Missed Opportunity – Failure to Rescue

Missed Opportunity – Failure to Rescue

Patient Fall

2017-2018 to date 39 Death – 2

Serious – 2

Moderate – 21

Low – 6

Minor – 2

Near Miss – 1

Ongoing – 5

 

27/03/2017

30/03/2017

18/05/2017

28/05/2017

10/09/2017

16/10/2017

23/11/2017

27/11/2017

30/11/2017

02/01/2018

Sub-optimal care of the deteriorating patient

Apparent/actual/suspected self-inflicted harm

Surgical/invasive procedure

Surgical/invasive procedure

Patient Fall

Surgical/invasive procedure

Treatment delay

Sub-optimal care of the deteriorating patient Surgical/invasive procedure

Sub-optimal care of the deteriorating patient

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