FOI Request
- Disclosure ID
- FOI/02388
- Request Date
- April 25, 2018
- Subject
- Serious Incidents
- Description
- 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?
- Please specify — for each year — how many of these serious incidents involved:
- death
- serious harm
- moderate harm
- low harm
- no harm
- For each death,
- state on which day it occurred and
- 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