Complaint Report to Trust Board for the Months April, May, June and July 2004

Item 4

Complaints, Litigation, Incident and PALS (CLIP) Report Quarter 2 – July to September 2008 Governance & Risk Management Department

Presented at CLIP Group: Wednesday 26th November 08

Contents:

1. Introduction - Overview Page 4 - Main Themes Page 4

2. Complaints - Complaints over the last 12 months Page 4 - Complaints by division Page 4 - Complaints by subject Page 5 - Complaints by subject and division Page 6 - Time taken to close complaints Page 6 - Divisional Compliance Page 6 - Activity data Page 7 - Healthcare Commission status Page 7

3. Claims - New claims received within Q2 Page 8 - Closed claims within Q2 Page 9

4. Incidents - Incidents over the last 12 months Page 10 - Total number of incidents by division Page 11 - Breakdown of incidents by type Page 11 - Top 10 reported incidents Trust wide Page 12 - Top 6 reported incidents per division Page 13 - Total number of incidents by consequence Page 17

5. PALS - Total number of reported concerns over 12 months Page 18 - Total number of reported concerns by division Page 18 - Top 6 reported concerns Trustwide Page 19 - Top Reported concerns by division Page 19

6. Organisational Learning

- Complaints Page 20 - Divisional Themes Page 23

Appendix 1 HCC Recommendations Page 34

Appendix 2 Maternity Trends Page 41 Page 2 of 53 Appendix 3 Maternity Newsletter Page 48

1. Introduction

The NHSLA Risk Management Standard 5: Learning from Experience requires all Trusts to have a coordinated approach for the management of risks identified through incidents, complaints and claims through a report including qualitative and quantitative analysis.

The Statistical Process Control (SPC) charts in the report will identify if there is a trend in a set number of figures. The chart takes the average (mean) from the first 6 months of numbers and then plots the mean line along the graph (the first 6 months may not be visible on the graph in the report). If the number per month then suddenly rises or falls and the total for each month is below or above the mean line for 6 consecutive months then the mean is adjusted to reflect this (hence a trend is identified).

Some of the graphs and tables make reference to the following abbreviations:

AMCD - Acute Medical Care CAN - Cancer Services CLIN - Clinical Support CLINI - Clinical Informatics CNMQ - Corporate FACIL - Facilities, Estates, Clinical Engineering and Fire Safety PACCES - Patient Access PLAN - Planning SURG - Surgery & Anaesthetics WACS - Women’s and Children Services WANS - Women’s and Neonatal Services

The report features incident severity graphs with the following severity gradings:

Negligible Minimal injury requiring no / minimal intervention or treatment.

Minor Minor injury or illness, requiring minor intervention

Moderate Moderate injury requiring professional intervention

Major Major injury leading to long-term incapacity/disability

Catastrophic Incident leading to death multiple permanent injuries or irreversible health effects

Serious Untoward Incident (SUI) An SUI is any major or catastrophic incident with the potential to cause serious harm and/or likely to attract public and media interest. This may be because it involves large numbers of patients, there is a question of poor clinical or management judgment, a service has failed or a patient has

of 53 died under unusual circumstances. In these instances the SUI is reported to the Strategic Health Authority.

This report is an analysis of Complaints, Litigation, Incidents and PALS reported in Q2 July – September 2008.

In many of the tables and graphs the results have been compared to the previous quarter Q1 April – June 2008.

Overview

Q4 April – June 08 Q2 July – September 08 Reporting Complaints 112 101 Decrease of11 Claims 709 617 Decrease of 92 Incidents 1705 1617 Decrease of 88 PALS 181 193 Increase of 12

Themes Identified Across Incidents, Complaints & PALS Q2 July – September ‘08

Incidents Complaints PALS 1. Fall on Level Ground Clinical Practice Communication/ Information to patients 2. Lack of suitably Attitude of Staff Appointments/Delayed/ trained /skilled staff Cancelled – OPD 3. Delay Appointments/Delayed/ Clinical Treatment Cancelled – Out patient 4. Fall from Height – Bed Appointments/Delayed/ Admissions/Discharge/Transfer or Chair Cancelled – in patient

Patient falls and lack of suitably trained staff were among the highest reported incidents and the high number of patient falls could be a consequence of the lack of staff.

Appointment problems feature high for both complaints and PALS

2. Complaints

Graph 1 SPC chart– Complaints over the last 12 months

of 53 Number of Complaints

70 Total

Mean 50 48 44 r 40 40 41 e 39 b

m 35 35 34 u 32 32 Upper N 30 30 Control 25 Limit 20 Low er 10 Control Limit 0 Oct Nov Dec Jan-08 Feb Mar April May June July Aug Sep

of 53 The average number of complaints is 40 per month however in the last 5 months this has fallen below the average.

Graph 2 – Total No of Complaints Received by Division

The only significant change in the number of complaints received during the quarter is a reduction in the number of surgical complaints, a reduction of 12

Total No of Com pliants Received by Division

50 45 40 35 30 25 Apr - June 20 July- Sept 15 10 5 0 AMCD CLIN CLINI CNMQ FACIL SURG WACS

Graph 3 – Top 6 Complaints by Subject

There has been a decrease in the number of complaints concerning admissions, appointments and waiting times, but as previously noted there has been an increase in the number of complaints about staff attitude.

Top 6 Com plaints by Subject

40 35 Apr-Jun 30 July-Sept 25 20 15 10 5 0 Clinical Admissions, Staff Attitude Facilities CommunicationNursing Care Practice Appointments & Waiting Times Table 4 - Top Complaints by Main Subject by Division

Recurrent themes occur in more than one Division. Clinical Practice and Communication/Staff Attitude are the subjects for complaints across the Trust.

Top Complaints by Subjects per Division Apr- June 08 July-Sept 08 Acute Medical Care Division Clinical Practice 13 12 Communication 3 7 Admissions/Appointments and Waiting Times 5 3 Staff Attitude 4 5 Clinical Support Staff Attitude 4 N/A Clinical Practice 4 1 Admissions/Appointments and Waiting Times N/a 2 Communication 2 1 Facilities, Estates, Clinical Engineering and Fire Safety Staff Attitude N/A 2 Facilities 7 3 Surgery & Anaesthesia Admissions, Appointments and Waiting Times 21 13 Clinical Practice 15 16 Staff Attitude 5 3 Communication 1 2 Womens and Children Services Clinical Practice 5 9 Communication 3 2 Staff Attitude 2 6

Table 5 - Time taken to close complaints

There has been an increase in both the acknowledgement rate and the response rate during the quarter.

Q1 Apr – June 08 Q2 July - Sept 08 No % No % Complaints received 112 N/A 101 N/A Acknowledged within 2 working days 102 91% 97 96% Total Closed within 25 working days 53 47% 62 61%

Table 6 - Compliance by Division

Division Q1 (%) Q2 (%) Acute Medical Care 59 68 Clinical Support Service 100 100 Facilities & Estates 71 80 Clinical Informatics N/A 50 Surgery & Anaesthesia 38 69 Women’s & Children’s 12 29 Corporate/Trust Wide N/A N/A

of 53 In Q2 the divisions closed the following complaints on time: AMCD 23; CLIN 4; Facil 4; Surg 24; WACS 6

It is pleasing to note that all the Divisions either maintained their performance or improved upon the previous quarters performance. Against this, they have also cleared some of the outstanding complaints although it is acknowledged that there is still much more to do. It is expected that all the outstanding complaints will be cleared by the end of November and that all responses will be investigated and responded to within the required response time (25 working days).

Table 7 - Activity Data

The following table shows the levels of patient activity within the Trust and how the number of complaints received compare in percentage terms. Data obtained from Which Doctor.

No of Complaints Q3 Q4 Q1 Q2 (07/08) (07/08) (08/09) (08/09) No of Complaints 158 150 134 137 (Informal/Enquiry & Formal) Finished Consultant Episodes 19,909 20,290 21,893 21,364 Inpatient (Percentage) (0.8%) (0.7%) (0.6%) (0.6%) A&E Attendances (Percentage) 29,647 29,164 31,301 30,124 (0.5%) (0.5%) (0.4%) (0.5%) Outpatient Attendances 71,444 70,236 84,000 81,668 (Percentage) (0.2%) (0.2%) (0.2%) (0.2%

Table 8 - Healthcare Commission (HCC) status

July - Sept Q2

Case Reference No Date recommendations Date Trust to Further Action received from HCC Respond to HCC Recommendations C200803_0411 16/07/08 18/08/08 Trust Responded (D3991) 15/08/08 – Action Plan detailed Appendix 1 C200803_0454 15/08/08 23/09/08 – 06/11/08 (Action plan (D3588) Extension provided detailed in Appendix 1) C200806_047 26/08/08 25/09/08 Trust responded (D3847) 08/10/08 (actions detailed in Appendix 1)

Under Investigation (detailed below)

Case Reference No Date Request received Date Trust Submitted Information to HCC by Trust from HCC C200806_0585 16/07/08 Complaints file and relevant medical records (D3793) supplied 01/08/08 – This was the second request following further local resolution C200808_0186 27/08/08 Complaints file and relevant medical records (D3892) sent 15/09/08 C200807_0592 28/08/08 Complaints file and relevant medical records (D3899) sent 13/10/08 following negotiation for further local resolution, which was declined by the complainant

of 53 Appendix 1 provides the details of follow-up actions implemented in response to Healthcare Commission recommendations following initial review of complaints.

3. Claims

The table shows the total number of claims made against the Trust from 1st July 08 – 30th September 08

Incident date Division Specialty Stage of Claim Description Total reserves 26/10/2007 AMCD RESP Letter of Claim Requesting compensation for stress during the period following his £10,000 stroke on October 26 2007 and unable to work. 16-May-2008 WACS GYN Letter of Claim Patient suffered burn on the left thigh related to a diathermy plate £5,000 attached whilst undergoing a procedure for TCRF (mid procedure). This was discovered mid procedure when the machine was alarming and not working properly.

15-Oct-2007 SURG GSUR Letter Before Claim for loss arising from a defect in her medical treatment from on £20,000 Action or around 15 October 2007 1-Sep-2005 SURG TRAU Letter of Claim Daughter convinced that poor standards of cleanliness at the £15,000 hospital resulted in her mother contracting a hospital infection, which ultimately caused her death. 26-Oct-1998 WACS OBSTER Letter Before Referred to delivery suite, staff surprised that DK felt as though she £1,100,000 Action was in labour. Staff realized about to give birth. Baby delivered but was taken to intensive care unit. Child has Cerebral Palsy and attend a special school

23-Oct-2007 SURG GSUR Letter of Claim Alleging a failure to arrange a date for an operation on his ankle and £5,000 negligence in dealing with his ruptured achillies tendon in a timely manner. After consulting his GP he contacted the Spire Hospital at Bushey and paid for private treatment. He is now requesting compensation. 26-Oct-2006 WACS OBSTER Letter Before Failure to manage patients labour appropriately resulting in a delay £1,150,000 Action in the delivery of Emily and the consequent injury to her. 15-May-2007 WACS GYN Letter Before Admitted for termination of 6 week pregnancy and insertion of coil. £5,000 Action Not given follow up advice. 39 July 2007, waters broke informed not pregnant. returned following day scan revealed 18 week pregnancy. Informed baby would not survive.

1-Apr-2007 WACS OBSTER Letter of Claim Failed to be followed up by hospital. At time of having stitches £5,000 Liability Denied removed told that there was an infection in the wound. 23-Sep-2005 SERVS BAPS Letter Before No specific allegations other than seen by Reconstructive Surgeon £8,000 Action at Mount Vernon Hospital 4-Feb-2008 AMCD EMERC Letter Before Alleging clinical negligence after he was admitted to A&E on the £10,000 Action 4.2.08 for treated for putative meningitis.

The total potential cost is £2,850,000

of 53 Table 2 - Claims Closed Within This Quarter Q2 (July - Sept 08)

Incident date Division Specialty Synopsis Outcome Total payments 11-Jun-2004 WANS MIDWIF Claim for damages arising from death of baby Payment before £99,339 proceedings served

1-Mar-2003 SURG TRAU Misdiagnosis failing to diagnose torn cartilage. Withdrawn £0 SURG GSUR Patient had operation in 2005, he has had ongoing problems Withdrawn £0 since and is still in pain.

Following a hernia operation in March 2005 the right side remained painful. He was operated on again in September 2005 for a recurrence of the right-sided hernia and then he had a pus/blood build up in the scar. 13-Mar-2005 WANS OBSTER Failure to closely monitor pregnancy and labour, baby showing Withdrawn £2,863 signs of Cerebral Palsy 28-Mar-2005 AMCD GENM Failure to check previous medical records or carry out relevant Payment out of £24,583 tests that would have identified low blood sodium count. More Court after appropriate treatment would have prevented deterioration. proceedings issued 23-Nov-2005 SURG BURNS Patient believes that his finger has become infected following Closed no further £0 operation to repair a Flexor Tendor injury as button put on top of contact finger to hold wires was left on finger for 3 months when he was advised that this should have been removed after 6 weeks.

8-Jan-2004 AMCD COTE Failure in all areas to appropriately care for and acknowledge risk Payment before £102,312 of pressure sores. Due to patients medical condition proceedings served

The total amount payable by the NHSLA of closed/settled claims during Q1 April - June 08 was £54,966 4. Incidents

The Trust reported 1617 incidents in Q2 July - September ‘08, the number reported has fallen by 5% from Q1 April - June ’08 which reported 1705 incidents. The reason for this could be attributed to a fall in the number of reported incidents or a delay in the processing of incidents on time.

The Risk Management Department has started to analyse the number of incidents reported by patient bed days used and spells.

The two tables below are calculated using patient safety incidents only over the last 12 months measured against bed days used and spells (the spell refer to the dominant consultant specialty from the patients admission to discharge).

Oct Nov Dec Jan-08 Feb Mar Apr May Jun Jul Aug Sept Bed days Used (all 21732 21348 20769 22241 20791 21799 19562 20744 20149 2061820023 19725 wards inc maternity) Patient Safety 386 383 357 376 291 314 336 358 401 427 357 327 Incidents Patient Safety Incidents per 100 bed 1.7 1.8 1.7 1.7 1.4 1.4 1.7 1.7 1.9 2.0 1.8 1.6 days

Oct Nov Dec Jan-08 Feb Mar Apr May Jun Jul Aug Sept Main Consultant Episodes within 6631 6584 5646 6395 6405 6321 6650 6508 6329 6430 6024 6325 Patient Spell Patient Safety 386 383 357 376 291 314 336 358 401 427 357 327 Incidents Patient Safety Incidents per 100 5.8 5.8 6.3 5.8 4.5 4.9 5.0 5.5 6.3 6.6 5.9 5.2 Spells

The information in these tables has been obtained from ‘Which Doctor’

The remaining incident charts below report on all incidents (clinical and non-clinical). A total of 6860 incidents have been reported over the past 12 months.

Graph 1 SPC - Number of incidents (by incident date) Oct ‘07 - Sept ‘08

of 53 Num ber of Incidents Total

1000 Mean

e 690 b 670 643

m 600 572 571 586 593 u 540 523 548 538 Upper

N 486 400 Control Lim it 200

0 Lower O c t N o v D e c J a n F e b M a r A p r M a y J u n J u l A u g S e p Control Lim it Date

The table shows that the average number of incidents reported has fallen from 620 to 560 per month since February 2008.

Graph 2 - Number of incidents by Division (by incident date)

Total No. of Incidents Reported by Divsion

400 Q1 (Apr-J un) Q2 (J ul-Sept 300

The table shows there has been a 11% decrease in the number of incidents reported by Women’s and Children’s Services compared with quarter 1.

Graph 3 - Breakdown of Incident Type (by incident date)

of 53 Types of Incidents Reported

Q1 (Apr-J un) 600 Q2 (J ul-Sept)

There has been a decrease in the number of infrastructure/environmental incidents this quarter compared to last quarter. The specific types of incidents which decreased were those related to Missing, inadequate or illegible healthcare records. The Risk Management and Governance department has discussed this decrease with Health Records and there is currently a back log in incident forms being entered onto Datix.

Graph 4 - Top 10 Reported Incidents by Trust wide (by incident date)

of 53 Top 10 Incidents Reported (Trust Wide)

100 Q1 Apr-Jun '08 80 Q2 Jul-Sept '08

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This graph identifies the highest reported incident by subject in Q2 (and compared to Q1), there have been no ‘Delay’ incidents (in terms of the time it takes for a transfer) during Q2. Where as this type of incident was within the top 10 for Q1.

There was an increase in the number of incidents relating to a lack of staff in Q2 compared with Q1. 23% of these incidents were reported by the division of surgery relating to the problems with the Nurse in Charge of ITU having to care for a patient, which contravenes best practice. Apart from ITU the area which reported the most number of incidents due to a lack of staff was Stuart ward. Two of the incidents for Stuart ward reported that the closure of Lancaster ward had a direct impact on the staffing problems as the ward now receives more dependent patients.

There was a high risk incident, relating to a lack of staff, reported by CCU. There were not enough staff available to attend to a Cardiac Console which was alarming.

Graph 5 - Top 6 Reported Incident Per Division (by incident date)

of 53 Acute Medical Care

Top 6 Reported Incidents - AMCD

Q1 (Apr-Jun '08) 60 Q2 (Jul - Sept '08)

0 Fall on level Fall from a Missing, Failure to act Physical Accident of Lack of ground height, bed inadequate on adverse abuse, some other Suitably or chair or illegible symptoms assault or type or Trained Staff healthcare violence cause record

The graph identifies the highest reported incidents by subject in Q2 (and compared to Q1.)

During Q2 65 incidents were entered due to a lack of suitably trained staff. This subject of incident did not appear within the top 6 for Q1.

Stuart ward (which cares for highly dependent patients) reported 43% of these incidents for quarter 2, as noted above it is thought that the closure of Lancaster ward was a reason for the high numbers of these incidents. On 30th July Lancaster ward had to be shut to admissions however this decision was revoked. After discussion with the matron the decision and a total of four beds had to be closed.

Another incident of particular note, was the patient areas on the ward not being able to be deep cleaned due to reduced staff numbers.

Surgery & Anaesthetics

of 53 Top 6 Reported Incidents - Surgery & Anaesthetics

40 Q1 (Apr-Jun '08) Q2 (Jul-Sept '08) 30

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l l a u l a n A c y y L r e i l a m c b r a i d i a t g t e M A L s r l F / c k a o o S f a n m h i e T s s F A o v / d a

This graph identifies the highest reported incidents by subject in Q2 (and compared to Q1). Lack of suitably trained / skilled staff and missing records has decreased since Q1. The decrease in both of these type of incidents was also noted in the Q1 report when the figures were compared with Q4.

Women’s and Children’s Services

Top 6 Reported Incidents - WAcs

100 90 80 70 60 Q1 (Apr - Jun '08) 50 Q2 (Jul-Sept '08) 40 30 20 10 0

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This graph identifies the highest reported incidents by subject in Q2 (and compared to Q1) a high proportion of incidents reported by WACs, were not given a specific subject code and were logged under ‘Other.’ On investigating these incidents, no specific trend can be identified (an additional report is attached in the appendix)

of 53 Clinical Support

Top 6 Re porte d Incide nts - Clinical Support

Quarter 1 (Apr-Jun '08) 15 Quarter 2 (Jul-Sept)

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This graph identifies the highest reported incidents by subject in Q2 (and compared to Q1).

12 incidents were logged under the subject, ‘Medicine Not Administered’, but only one occurred within the Clinical Support division. The majority of these incidents were simply reported by the division. Similarly, only two of the incidents logged under ‘Dose or Strength Wrong or Unclear’ occurred within the division. Work is being done to address this discrepancy and hence this graph will be more accurate in future reports.

Facilities, Estates, Clinical Engineering and Fire Safety

of 53 Top 6 Reported Incidents - Facilities, Estates, Clinical Egineering & Fire Safety

10 Quarter 1 (Apr-Jun '08) 8 Quarter 2 (Jul - Sept) 6

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The above graph identifies the highest reported incidents by subject in Q2 (and compared to Q1). The graph shows that there was a significant decrease in the number of incidents which were logged under ‘Transfer – Delay/Failure.’

Of the incidents under ‘Other Incident Related to Security, two related to areas not being secure and three related to areas having poor lighting.

Graph 6 - Total number of reported incidents by Initial Consequence

of 53 Incide nts Re ported by Initial Conse quence

500 Quarter 1 (Apr-Jun'08)

400 Quarter 2 (Jul - Sept '08)

0 Negligible Minor Moderate Major Catastrophic Serious Untow ard Incident

Although it is not clear in the graph the Trust reported one SUI during Q1 and no SUIs were reported during Q2.

Two SUI’s have occurred in Q3 (Oct – Dec 08)

1. Allegations made against an A&E Senior Sister that she was witnessed to have used inappropriate behaviour including verbal and physical abuse against two patients.

2. Work being undertaken to install new shower room on Delivery Suite, which involved having to drill through the floor to install new drainage pipes. At 11.15 whilst drilling the workmen inadvertently punctured a vacuum pipe and then an Oxygen pipe . This led to copious amounts of Oxygen being released into the room. Leading to a potential fire/explosive hazard.

Both are being fully investigated

5. PALS

of 53 The total number of reported PALS concerns from 1st July – 30th September 2008 was 193 compared to 181 in the previous quarter.

Number of PALS

Total 140

120 Mean 100 102

e 77 b 71 Upper

u 64 60 61 Control N 59 56 51 Lim it 45 48 40 Lower 20 Control Lim it 0 Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept

The chart identifies that the mean (average) number of reported PALS is 72 per month with peaks in July, October, February and September 08.

Graph 2 - Total Number Of Reported Concerns By Division

Total Num ber of Reported Concerns by Division

Apr - Jun 08 50 J ul - Sept 08

0 AMCD CLIN CLINI CNMQ FACIL PACCESS SURG WACS OTHER

Surgery received the highest number of concerns in July - September 08 with 85 (44% of the total concerns), AMCD received 48 (25%) both of which are slight decreases from the previous quarter.

Graph 3 - Top 6 Reported Concerns By Trustwide

of 53 Top 6 Reported Concerns Trustwide

140 Apr - Jun 08 Jul - Sept 08 120

0 A p p o i n t m e n t s - A d m i s s i o n s / C o m m u n i c a t i o n / C l i n i c a l T r e a t m e n t A p p o i n t m e n t s - S t a f f A t t i t u d e D e l a y e d / C a n c e l l e d - D i s c h a r g e / T r a n s f e r I n f o r m a t i o n t o P a t i e n t s D e l a y e d / C a n c e l l e d - O P D I P D

Each PALS concern has more than one subject of concern, hence there are more reported subjects of concerns. Only the top 6 are shown in the table.

Communication/information to patients was the highest reported concern with 115, Appointments – delayed/cancelled – OPD received 63 both were decreases from the previous quarter.

Graph 4 - Top Reported Concerns by Division

This table relates to the reported number of subjects raised in the concerns for the top three divisions. (Note that many PALS concerns have more than one subject)

The decrease in the number of concerns about communication/information to patients can be seen in both the division of Acute Medical Care, Surgery & Anaesthetics and Women’s and Children Services.

Top Concerns Reported by Division April – June 08 July – September 08 Acute Medical Care Division Communication/Information to Patients 47 38 Appointments - Delayed/Cancelled - OPD 20 21 Clinical Treatment 20 23 Surgery & Anaesthesia Communication/Information to Patients 91 49 Appointments - Delayed/Cancelled – IPD 32 19 Appointments - Delayed/Cancelled - OPD 36 31 Admissions/Discharge/Transfer 12 32 Women’s and Children Services Communication/Information to Patients 13 8 Appointments - Delayed/Cancelled - OPD 3 1 Appointments - Delayed/Cancelled – IPD 1 2

6. Organisational Learning

of 53 This section of the report will detail the learning and actions following Complaints, Litigation, Incidents and PALS by Division.

6.1 Complaints

6.1.1 Surgery & Anaesthetics - Complaints

D4371 Patient was not provided with information regarding fitness for surgery and GP had not informed them of this, following receipt of letter from hospital.

As a result of this, all such letters are now copied to the patient directly in order to ensure that patients are kept fully informed as to decisions regarding their fitness for surgery.

D4423 – Failure to provide prescription

In future necessary prescriptions will be arranged at least a week prior to patients’ admission.

6.1.2 Acute Medical Care – Complaints

D4438 – Complaint about bladder irrigation being provided in A&E and the insertion of three way catheters

All A&E nursing staff will have further training in treating urology cases and will be written to in the near future reminding them that bladder irrigation is not a procedure that needs to wait until the patient has gone to the ward

6.1.3 Women’s and Children’s Services - Complaints

D4364 - As a result of complaint The Consultant Midwife, whose remit is normality, will be working with the midwives on the Birth Centre to act as a role model and ensure the practice remains within the ethos of women centred care. The Birth Centre guidelines and protocols will be reviewed and updated.

D4492 – Complaint about the identification of an ectopic pregnancy

Whislt the Trust’s current policy is in accordance with National guidelines this does not mean that we cannot learn from the patient experience in order to improve the services are provided. Division has, through its risk management agenda, already embarked on a plan to review its current processes.

6.2 PALS

6.2.1 Acute Medical Care Division - PALS

 Within Medicine, 48 concerns have been received, a decrease from the previous Quarter. Out of the 121 themes identified within this Division 38 relate to communication and information to patients.

 Within Cardiology concerns raised included patients chasing up Outpatient appointment to discuss diagnostic results, GP requesting clarification of medication, patient chasing up appointment for diagnostic testing and family requesting meeting with Cardiology consultant to discuss patients care and treatment.

 In Care of the Elderly, concerns raised included patient families meeting Consultant to discuss patient care and treatment, patient requiring information regarding admission,

of 53 treatment and referral, visiting times, staff attitude of Nursing staff and patients querying clinical treatment of strokes.

 Concerns within Emergency Care include staff attitude and patients concerned about clinical treatment

6.2.2 Clinical Support Division - PALS

 Clinical Support Division received a total of 13 concerns, within Radiology Services concerns raised related to patient querying procedure for x-ray referral, patient chasing up urgent CT scan and MRI scan.

 Within Surgical Appliances, concerns raised included waiting times for surgical appliances and patient chasing up surgical appliances.

 Pathology Services concerns raised include hand hygiene and communication of phlebotomist and redecoration of Blood Clinic in St Albans City Hospital.

6.2.3 Patient Access - PALS

 Patient Access Services received a total of 19 concerns which is an increase, relating to immense difficulties in getting through to Appointments and the Appointments Department not always being manned on the Watford General Hospital site. This has also been a constant problem for Quarter 3 and continuously been raised with Division.

6.2.4 Facilities and Estates - PALS

 11 concerns were received within this Division, which is an increase from previous Quarter, relating to attitude of switchboard staff, lack of money change facilities in St Albans City Hospital, patients querying about wheelchair services, attitude of workmen and patients querying about telecommunication service on the Ward.

6.2.5 Surgery & Anaesthesia - PALS

 Surgery & Anaesthesia Division have received 85 concerns, which is an increase from the previous Quarter.

 Within Trauma and Orthopaedic, 27 concerns were received which is a significant decrease from the previous Quarter, the majority of concerns raised related patients being cancelled for surgery, patients chasing up Outpatient appointments and patients concerned about waiting times in the fracture clinic, and patients chasing up information relating to diagnostic tests and treatment to be sent to GP.

 Within General Surgery, 16 concerns were received including cancellation of surgery and patient chasing up post operative Outpatient appointment and patient chasing up results following biopsy.

 Urology identified concerns relating to patients treatment and care whilst patient was an inpatient and cancellation and delay of surgery and Outpatient appointments. Within Ophthalmology concerns relate to cancellation and delay of Inpatient surgery, clinic space in the Emergency Eye Clinic, waiting times and lost property. As a result the Emergency Eye Clinic have a dedicated room. Oral Maxio Facial had concerns relating patients chasing up surgery and delay and cancellation Outpatient appointments. Page 23 of 53 6.2.6 Women and Children Services - PALS

Within this Division 13 concerns were received. Within Obstetrics patient had concerns about delivery of her baby and patients requested Midwife to go through their maternity notes. Paediatric Services, concerns raised included cancellation of surgery, patient’s father requesting results sent to GP and parents requesting patient to be referred to a specialist hospital. Gynaecology Services concerns raised included patient chasing up date for surgery and patient chasing up Outpatient appointment.

of 53 6.3 Divisional Themes and Trends

6.3.1 Acute Medical Care Q2 July – September 2008

Number of Specialty Complaints Litigation Incidents PALS Themes Actions Lessons learnt Cardiology 3 (+1 38  Night shift unaware of equipment informal) location  Obtaining supplies/equipment Emergency 6 22  Following procedures; in transfers,  Ongoing training and in Care obtaining blood, following care plans response to incidents Sexual Health 0 5  Administering blood tests on time  Diagnosis from test result Care of the 6 163  Transfers at unsuitable times  Ongoing drug Elderly  Controlled drug management management training  Management of patients likely to fall  Staff given additional  Completing paperwork adequately training in response to before transfer or discharge incidents  Not following correct care plan of patients with particular needs  Implementation of treatment by night shift General 19 (+5 361  Management of violent and abusive  Isolation given higher Medicine and informal) patients priority in bed subspecialties  Management of patients likely to management, less of a abscond problem as numbers  Management of patients likely to fall have decreased  Allocation of pressure relief  Continued emphasis on mattresses infection control to staff,  Delayed isolation of MRSA patients escalating breaches  Staff uncomfortable with carrying out  Reemphasis on regular treatment/medication in care plan checks on equipment  Behaviour of staff that could  Staff followed up compromise infection control after procedures  Broken equipment/call bells  Completing paperwork adequately breached before transfer, discharge or prescription  Failed communication between medical staff  Confidentiality breaches through careless handling of patient information

6.3.2 Surgery and Anaesthetics Q2 July – September 2008

Number of Department Complaints Litigation Incidents PALS Themes Actions Lessons Learnt

Trauma & 19 1 82 2 Complaints – 18 week work reducing Orthopaedics delay/cancellation/waiting wait times. Work ongoing times re reducing on the day cancellations. Incidents – Falls/Cancellations/ Equipment issues/Pressure Ulcers Business Manager for Theatres leading a piece of work to audit theatre quality equipment and replacement of obsolete equipment. Urology 6 0 18 6 Complaints - There is ongoing work to Communications improve the systems and processes in the Incidents – Inappropriate admissions dept/ Admissions (to incorrect wards/placed on lists at wrong site etc) Anaesthetics 1 0 5 0 Incidents – complications Review of incident Clinical Director for Aneas of treatment, care delivery 026806 where spinal reviewed incident with block was placed in locum concerned, wrong leg resulting in a following this it was felt fall post operatively this incident was a one off and human error. Aneas advised to be more

of 53 Number of Department Complaints Litigation Incidents PALS Themes Actions Lessons Learnt

comprehensive in his checks in future.

ITU 0 0 55 0 Incidents – Nurse In On going work to Charge of unit taking increase the staffing patients./ Delayed establishment in both Discharges/Patients units. admitted with IABP’s and Work ongoing to assess no staff trained sufficiently The issue with Balloon the training needs to care for them pumps is a clinical risk associated with these and has been placed on devices and the nursing the risk register staff competencies. General Surgery 10 2 112 12 Complaints – Cancellations/Care There is ongoing work to Standards/Communications improve cancellation rates across the whole of Incidents – Privacy & Incidents – increased surgery. Dignity Issue, patients monitoring and reporting remaining in mixed bays of events linked to mixed longer than the bays Transfer policy reviewed recommended acceptable in light of recent incidents time. Transfer issues – Pressure Ulcers, and changes in service problems with transferring increased reporting by delivery. patients from SACH back staff and completion of to an acute site. Pressure RCAs for grade 3&4. Ulcers.

PALS – general enquiries relating to admissions ENT 3 0 9 1 Complaints – No theme Identified need to set up rolling replacement Incidents – Equipment, Incidents – Business programme for all much of the ENT cases in progress for equipment equipment is old and needs replacing ENT equipment replacing

Ophthalmology 5 0 2 3 Complaints – Presently advertising for There is ongoing work to Cancellation/Delays locum to help with work improve cancellation rates

load. Outsourcing some across the whole of outpatient work to cope surgery. with capacity

Oral Surgery 2 0 5 4 Complaints – Cancellation/Delays

Incidents – Health records unavailable for OPD

Admissions 1 0 0 0 Data too small to analyse

Breast Surgery 0 0 5 2 Incidents - No obvious theme

Pain Services 0 0 2 2 Data too small to analyse Consent form under review to incorporate explicit mention of infection risks Sterile Services 0 0 1 0 Data too small to analyse

Vascular Surgery 0 0 1 0 Data too small to analyse Whilst not a theme as  Local guidelines such, there was an in development incident where a patient  Medicare 128 underwent surgery and it solution now used was later revealed that as recommended they were ‘at risk’ of as effective vCJD, at this point the against Prion instruments had been disease processed. Trust wide  Pre-Op actions have been Assessment identified and meetings process amended taken place to identify to ask patients if actions to manage the they have ever same situation should it been told they are occur again. at risk.

of 53 6.3.3 Clinical Support (September and October 08)

Number of Department Complaints Litigation Incidents PALS Themes Actions Lessons Learnt

Outpatients 0 0 6 0 Majority of incidents relate (1 from to patient notes, which OPD) are not within OPD control and have asked for these to be reclassified.

Patient hit head on shelf. Doctors needle stick injury Staff slipped on wet floor.

PALS - Delay in # clinic HHGH. Service Mgr. Is reviewing all T&O templates – This is Orthopaedics Pathology 0 0 17 0 Complaints - 2 of 4 Complaints - Trying to Complaints - Perhaps (3 from Path) (1 from complaints recruit phlebotomists; need to review banding path) about long High turnover. Trying to etc of phlebotomists. waiting times for retrain staff. Difficult area. phlebotomy Incidents - difficult to get Incidents - External corporate support for zero Incidents - Incorrect errors have been tolerance. For internal labelling of escalated numerous problems reflects samples times to various trust pressure staff under to Samples arriving in committees. Internal process workloads that department late & no errors setting up training comes into lab in bulk. longer fit for testing and review programme. Pharmacy 0 0 9 . Medicine not . Followed up with Pharmacy and clinical (11 Pharm) administered (not Ward, located & governance working to transferred with transferred revise how medicine Patient) . Prescriber contacted incidents are coded- . Incorrect prescription . Redispensed including reporting them in (x2) . Dose changed: Ward terms of divisions/wards . Incorrect storage of & Pharmacists rather than clinical

of 53 Number of Department Complaints Litigation Incidents PALS Themes Actions Lessons Learnt medicine (x2) informed support/pharmacy when . Dose on Prescription . Redispensed and pharmacists pick up errors unclear/incorrect (x2) annotated on wards. None of these . Incorrect storage of prescription chart to incidents were pharmacy medicine on ward detail correct storage incidents . Incorrect in fridge administration of . Nurses informed not medicine with to administer incomplete medicines not signed prescription for by doctors PPAS 0 0 0 Radiology None as lead 0 8 1 Complaints from patients Discussed at Radiology Communication with other regarding the length of Board meeting – no Divisions about current Multiple time waiting for action on the part of waiting times essential – responses examinations – upon Radiology required now happening on a supplied to investigation Radiology regular basis. assist other had not received referrals divisions. Patients informed Images/results missing - upon investigation images on PACS – results on CRIS

Incidents Incorrect patient details on request forms.

SACH theatre overruns & additional lists with no radiographic cover requested. Surgical 0 0 0 1 Difficulty with patient CLIP is standing agenda Appliances getting appointment with item at monthly meetings. surgical appliances department Therapies: 0 0 0 Dietetics 0 0 0 OT 0 0 0 Incident at SACH where a

of 53 Number of Department Complaints Litigation Incidents PALS Themes Actions Lessons Learnt (1 by OT) patient discharged on a Sunday PM, prior to OT intervention being completed. The OT was unable to treat the patient on the Friday, due to recovery form surgery. It was documented in the notes by the OT they would review on Monday AM. Patient did require follow up by OT for the provision of toilet equipment, which enhanced their independence and on this occasion was not clinically essential. Physiotherapy 0 0 2 Family of an in-patient not Response made to We must not assume aware that Physio had complaint lead. At staff patients pass on taken place on the wards. meeting remind all staff information to their Not the central part of the that it is essential to families. As it is not complaint. advise families of patients always possible to see with memory problems families of our older that Physio has taken patients we must seek a Patient fainting incident. place. We shall look at way to communicate that producing something therapy has been done. written for the bedside and suggest that families ask to see the physio involved. Ongoing work SaLT 0 0 1 Intentional failure to follow SLT discussed with staff SLT will continue to Specialist advice member concerned the highlight non-compliance risks of not following as a risk. Continue to advice and what to do in document management in future to request/discuss medical notes, nursing patient review notes and continue use of ALERT sign above patient’s bed.

Outpatients 8  The ceiling light fitting fell down onto a patient, the patient wasn’t injured just surprised. Asked if they were ok said was fine  Late running clinic -  HON spoke to another Fire alarm (false patient involved in the alarm) set off. incident on the phone. Patients became They were adamant aggressive and that the Nurses had complained this was set the alarm off as set off by staff so they the Fire brigade had could go home early not attended the incident. I explained that a workman(? ESTATES) had inadvertently set the alarm off, phoned switchboard to prevent call out. The patient refused to believe me & we had to agree to differ  Theft from  Security alerted to the department fact that the thief had knowledge of 3 separate key pad codes in OPD

Pathology 15 3 PALS – ongoing issue PALS - More interviews PALS - Perhaps need to (9 Heidi) (0 around phlebotomy waits taking place to fill review banding etc of Heidi) vacancies. phlebotomists Incidents - Incorrect

of 53 Number of Department Complaints Litigation Incidents PALS Themes Actions Lessons Learnt labelling of samples and Incidents - external errors Incidents - really difficult Samples arriving in have been escalated to to get corporate support department late & no various trust committees. for zero tolerance. longer fit for testing Internal errors setting up For internal problems training and review reflects pressure staff Specimen spilt over path programme under to process support worker as top had workloads that comes into not been secured lab in bulk. properly.

Staff fall Pharmacy 1 (0 Heidi) 4 Complaint: This was not a formal Situation being monitored complaint- letter sent to in department Unprofessional conduct of CEO and Chief Pharmacy Staff member Pharmacist raising issues. Chief Pharmacist has followed up on issues with staff member and written to complainant. Incidents:  Followed up with Feedback with all staff  Wrong quantity of dispensary staff regarding importance of medicine dispensed following procedures for  Product ordered dispensary and at ward  Omitted medicine urgently & Pharmacist level for clinical services. caused by failure of informed of omission Clinical Services pharmacist to order Pharmacy Manager after seeing chart conducting spot checks  Prescribing doctor on wards  Medication notified. Staff asked prescribed to which to ensure all product patient had a known ingredients checked allergy before being dispensed.

. Incorrect dose of  Medicine re- medicine dispensed. dispensed when error noticed. Staff informed of their error

of 53 Number of Department Complaints Litigation Incidents PALS Themes Actions Lessons Learnt PPAS Radiology None as lead. None 6 Supplying the dates of Discussed at Radiology N/A Comments Imaging examinations to Board – no action supplied to aid responses. required on the part of assist Surgery Radiology. & Medicine and  Graffitti on walls and WACS trolley in U/S baby changing room in main x-ray  Staff behaviour  Wrong patient x- rayed  Contractor receiving item off lorry outside PMOK reception and metal object hit him in Left temple  Patient had allergic reaction to injection Surgical 2  Patient unhappy with  Spoke to patient  Reviewed procedures Appliances treatment received about experiences, with Orthotist. from Orthotist arranged a follow up  Patient unhappy with appointment with waiting time to see different orthotist to Orthotist review case. PALS followed up with patient – hopeful this will not turn formal. Comments from Orthotist received.  PALS spoke to patient, office contacted patient and arranged appointment. Therapies: Dietetics 2 (0 Heidi) Both complaints were Response sent through Highlighted the part of a wider the complaints team. importance of ensuring complaint around Staff advised to ensure patients are given contact

of 53 Number of Department Complaints Litigation Incidents PALS Themes Actions Lessons Learnt patient care during that patients on long-term details on discharge. admission. support whilst in-patient should be discharged with Patient expecting a departments contact community dietetic details so that they could follow up as condition contact the team if their deteriorated. Patient condition deteriorated. had been under dietetic care throughout the admission and required intensive nutrition support. Assessed prior to discharge where dietitian didn’t feel community follow up was necessary. Discharged on oral nutrition support under the care of GP.

Complaint regarding patient with poor Response sent through Highlighted the nutritional intake and the complaints team. importance of nursing development of grade Discussed future patient staff following instructions 4 pressure sore. care with the lead nurse. left by the dietitians

of 53 Appendix 1

Follow-up actions implemented in response to Healthcare Commission recommendations following initial review of complaints:

C200806_047

The Trust to consider implementing multidisciplinary guidelines for the management of PPH [primary and secondary], if not already undertaken.

The Trust now has a multidisciplinary protocol for the management of patients presenting with post partum haemorrhage.

Clinical Director for A&E had also provided instructions to The East of England Ambulance Service, in February 2008: "Further to our conversations, this is to confirm that all women with post partum haemorrhage, defined as vaginal bleeding in any woman, up to 6 weeks following delivery, should not be taken to Hemel Hempstead General Hospital. However, as stated previously, all other PV bleeding MAY be taken to Hemel Hempstead, as long as they are haemodynamically stable and normal."

It has also been agreed with the Divisional Manager for Womens’ Services that they are in agreement with the A&E policy of referring all women with post partum bleeding to them, and for the A&E department to send those that are haemodynamically stable (normal blood pressure and pulse) to the ward for them to assess there. The team will come down to A&E to assess any patient with vaginal bleeding, if she is haemodynamically unstable.

C200803_0411

Action Plan attached as separate document (see below)

C200803_0454

Action Plan attached as separate document (see below) C200803_0411 (D3991) – ACTION PLAN TO ADDRESS HEALTHCARE COMMISSION RECOMMENDATIONS

Recommendation Initial Action taken/or to be implemented by Responsibility Evidence Trust 1 The Trust should adopt A revised and updated Anticoagulation, A Policy Consultant Anaesthetist Policy enclosed assessment for VTE as its routine on Risk Assessment, Prophylaxis and Consultant Haematologist practice, in line with DOH Management of Venous Thromboembolism (Authors) Mandatory requirement (April (VTE), was ratified in June/July 2008. 2007) There is an ongoing programme of education that is being led by the Trust’s Thrombosis and Anticoagulant Group in order to ensure that all clinical and nursing staff are aware of the requirements. This will also be covered in the FYI and FY2 junior doctors training sessions, which covers all new intakes of junior doctors.

In addition, the Risk Assessment forms now form part of the clerking notes completed on admission. 2 Treating Consultant and their Audits to monitor The Trust should adopt the good teams compliance are ongoing. practice of routinely starting all Treatment protocols provided in the policy In addition, a Trust wide patients who are at high risk of document. audit to be undertaken in VTE on Thromboprophylaxis, with Sept/Oct 2008 in order to a low molecular weight, heparin determine compliance with preparation the risk assessment from and that appropriate treatment has been provided) Results to be made available to complainant January 2009.

3 The Trust should ensure that all This is normal practice within the Trust, for both Clinical Lead & Business Update to be provided new admissions are seen by a surgical and medical patients. This is a particular Manager for Urology October 2008 consultant within 24 hours of problem for Urology, given the structure of the Recommendation Initial Action taken/or to be implemented by Responsibility Evidence Trust admission service. This will be taken forward by the Clinical Lead on his return from annual leave to ensure that a Consultant sees all urology patients within 24 hours of admission. 4 The Trust should inform The Estates team have commissioned an external Estates Department / Modern Update to be provided in complainant how the standards of contractor to replace the shower tray with a new Matron/Ward Sister January 2009 hygiene are to be met and low-rise tray, complete with fixed glass shower monitored in the shower facilities screen and walk in access. Walls to be faced with on Flaunden ward Respatex panels rather than tiles. The existing toilet is to be replaced to allow ease of floor cleaning. Flooring to be replaced to provide a raised threshold at the door entry point to ensure any water spillage does not escape in the ward area. In the meantime, Medirest, the Trust’s cleaning provider, will continue to regularly check this area with the assistance of the nursing staff on the ward. 5 Trust Recommendation – In order to look more fully at the depth of Business Manager for Urology Update to be provided in Complaint to be reviewed at one investigation that should have taken place, the & Divisional Risk Lead for October 2008 of the Surgical Division’s Risk complaint will be reviewed in order to share Surgery Meeting learning across the Surgical Division 6 Trust Recommendation – Case to In order to ensure that the learning identified form Clinical Lead for Urology Update to be provided be reviewed at Urology Clinical this case is shared more widely, the case will be October 2008 Governance Meeting presented at the meeting to be held on 19th September 2008.

of 53 C200803_0454 (D3588) - Action Plan to Address Healthcare Commission Recommendations

Recommendation Action Taken Responsibility Time Frame

1 Medical staffing An additional on call Senior Clinical Lead for Acute August 2007 House Officer has been employed Medical Care Division and ongoing at weekends to cover the wards and provided back up to the House Officer. 2 Adequacy of medical Ensuring that there are staff of Clinical Lead for Acute In place and cover to manager the appropriate seniority and Medical Care Division ongoing workload experience and support from physician of the week 3 Proposed changes in Staffing levels will remain Clinical Lead for Acute March 2009 medical staffing unchanged until the opening of Medical Care Division the Acute Assessment Unit (AAU) when the combination of the two acute hospital departments will allow the medical division to run two medical teams, one focusing on AAU and A&E, whilst the other team will focus on the inpatients in the medical and elderly care wards. The teams will have junior doctors of all grades from House Office to Specialist Registrar in both clinical areas to deal with the relevant urgent problems 4 Escalation Policy Formal escalation policy to be Heads of Nursing, Divisional Ongoing developed in order to call for more Clinical Directors, Clinical senior help Governance Manager 5 Review Trust’s Policy has been reviewed in Complaints Manager. Complete Complaints policy in accordance with both the NHS accordance with Complaints Regulations and the

of 53 Standard C14 Department of Health’s Core Standard C14 6 Remind all staff of All users email to be issued to Director of Nursing and End of importance of staff attaching the Trust’s Guide Patientss Services November recognising a complaint, to Complaints and ensure details are passed immediately to the Complaints Department 7 Present case to CLIP Anonomised case study to be Complaints Manager Ongoing Group presented and discussed at next meeting in November

of 53 Page 41 of 53 Appendix 2

Maternity Incident Trend Analysis Quarter 2: July – September 2008

Mode Of Delivery

Chart 1

Mode Of Delivery Q2

70 60 50 40 2007 30 2008 20 10 0 Spontaneous Instrumental Elective Emergency

There was a slight decrease in the total number of deliveries from 1417 in 2007 to 1368 in 2008. The spontaneous delivery rate was 60% in 2008 compared to 58% in 2007, the overall caesarean section rate dropped from 30% in the second quarter of 2007 to 28% in the corresponding period in 2008.

Total Incidents Reported

Chart 2

348 350 332

200 167 Total 150 DatixWeb

0 Jul - Sept 07 Jul - Sept 08 There was a very slight increase in the total number of incidents reported in maternity. Of those incidents approximately 50% were reported via the Datix electronic incident reporting forms and the rest identified and entered by the risk team, this is the main reason why the actual number of incidents reported within maternity is high, with probably very few that’s should be reported from the trigger list not actually being done so. However, This does clearly identify that there are still issues with clinical staff actually identifying when they need to report incidents from the clinical trigger list and then doing so.

The trigger list has recently been updated and has been circulated to all clinical areas, with the changes being advertised via the maternity risk newsletter. Ward managers and band 7 midwives are also being asked to ensure that all staff are aware of the changes and that they encourage active reporting. The Datix system has also been updated to include the changes made to the trigger list.

Staff Group Reporting Chart 3

250 Jul - Sept 07 Jul - Sept 08 200

0 A M D M U dmin idwi octo ana nkno istra fe r ger wn tor

There continues to be very poor reporting by medical staff, with those incidents that are being reported being done so by Registrars. For Consultant and SHO levels of reporting are almost non-existent. All Doctors are made of aware of the Datix reporting system at their induction, no password is required to use the system, the only requirement is that a member of staff can access the Trust intranet homepage. It had previously

of 53 been agreed that Consultants should try and encourage junior staff to actively report incidents. Interestingly agency midwives are readily reporting incidents identified from the trigger list As mentioned before the Risk Team are responsible for identifying around 50% of all clinical incidents that occur.

Areas Where Incident Occurred

Chart 4

300 Apr - Jun 07 Apr - Jun 08 250

0 K D K V A A C O ath eliv nut icto BC nte om the erin ery sfo ria nat mu r e S rd al nity uite

Delivery Suite continues to dominate reporting, with low levels of reporting from the other areas. The ward managers have been asked to look at whether this is truly reflective of what is occurring or if it is simply down to poor reporting by staff in these areas.

Types of Incident

Chart 5

350 Jul - Sept 07 Jul - Sept 08 300 250 200 150 100 50 0 P S V E atie taff isito nvir nt S Inci r inc ome afet dent ide ntal y nt inci dent

The vast majority of incident forms continue to be related to patient safety. The number of environmental incidents has fallen because there have been less episodes of staff shortage reported since the use of agency staff was increased.

of 53 Classification Of Incidents

Chart 6

Jul - Sept 07 300 Jul - Sept 08 250

0 Negligible Minor Moderate Major SUI

The majority of incidents continue to fall into the ‘ negligible’ and ‘minor’ groups. The increase in the number of moderate incidents reported can probably be attributed in part to improved risk scoring. Within the moderate group were a number of post partum haemorrhages, as well as babies requiring admission to NICU following traumatic deliveries. Overall there was generally a wide variation of types of incidents classified as moderate.

Of the 3 major incidents one involved in a Guthrie that was not taken until the baby was 39 days old as a result of a breakdown in communication. It was considered as a potential serious untoward incident, but was down graded to a near miss once the baby had been found to have a normal result. As a result of this incident the inpatient matron is looking at how communication between the wards, NICU and community can be improved to prevent a reoccurrence of such an incident.

The other 2 major incidents were massive obstetric haemorrhages, the first resulted in a hysterectomy, and both women required admission to ITU

Maternity Trigger List

of 53 Chart 7

100 Jul - Sept 07 90 Jul - Sept 08 80 70 60 50 40 30 20 10 0 A A B C D E fa H H IT N In n p B r e q i e y U I f a g A a la u le lp s C a e a s y ip d te U n s r h m r t th < s to in e in e 7 e e s c ju t c C n tr to r ic @ ti /S t u m y o m 5 n e y m n in ta 's l

Chart 8 50 Jul - Sept 07 45 40 Jul - Sept 08 35 30 25 20 15 10 5 0 I T R P P R R L S T U H U e e P r e e o h r n D D a t H o t p n o a d r u la a t g u n i U r p in u l s a c n s e r s d fu g a t e e e e s n o d d d c r i o re t S u o D o s h c w t n y n e e o e d s d a r a r s t E t d b u t o rr b re s a c o re g ia r e e c h

From the 1st November a revised trigger list has been introduced with a number of significant changes that will affect reporting. Delays in delivery by emergency caesarean section once the decision has been made should reduce following introduction of classification of all caesarean sections. An incident form should only be triggered when there is: 1. Immediate threat to the life of the woman or fetus 2. Maternal or fetal compromise, which is not immediately Life- threatening. Other changes include only reporting second stage when it is longer than 4 hours instead of the previous stated 3 hours to bring in line with NICE guidance, unexpected IUGR or macrosomia, inutero transfers due to NICU being closed, postnatal readmissions and delay in transfer to Labour ward from Victoria when in established labour.

Specific Maternity Triggers

Chart 9

of 53 3rd/4th Tears Actual and Reported

50 48 46 Datix 44 Cmis 42 40 38 Jul - Sept 07 Jul - Sept 08

The number of 3rd and 4th degree tears has fallen in comparison to the same quarter in 2007. Reporting is still not automatically occurring in all cases with a number continuing to be identified and reported by the risk team. Some SPRs are still failing to use the correct proforma for documentation, even with the new notes coming into use, which contains the required proforma.

Chart 10

PPH > 1000mls

70 60 50 40 Datix 30 Cmis 20 10 0 Jul - Sept 07 Jul - Sept 08

The number of actual PPHs over 1000mls has fallen slightly in quarter 2 of 2008 compared to the same period in 2007. Reporting of these has generally been high, however, the risk team has reported many of these rather than clinical staff involved in the actual cases. The group of women where there is often a failure to report PPHs over 1 litre are often those undergoing elective caesarean sections. There is to be an ongoing audit looking at the PPHs with the Labour Ward Consultant leading this.

Blood Loss Volumes for PPHs

Chart 11

of 53 Jul - Sept 07 60 Jul - Sept 08 50

0 1000 > 1999 2000 > 2999 3000 > 3999 4000 +

The majority of PPHs are below 2000mls; many of this category were women delivered by caesarean sections. In the 3-4-litre group these involved women who had elective LSCS and both were known to have large fibroids.

The 2 cases that resulted in loss over 4 litres were primigravidas who had massive blood loss after spontaneous deliveries, the first needed a hysterectomy and the 2nd required a Rusch catheter to control bleeding, both women were admitted to ITU.

Both cases have been formally investigated, with an initial review by a critical incident review panel and then presented at Clinical Governance where learning points were discussed and actions agreed. One of these women requested a copy of the internal investigation, which they have now received following review by Claims and Litigation. Both women have lodged formal complaints about certain aspects of their care. In the case where communication between staff groups and the client was highlighted as a major issue this was presented to staff at the Clinical Governance meeting for discussion.

Chart 12

Shoulder Dystocia

0 Jul - Sept 07 Jul - Sept 08

There has been an increase in the number of reported cases of shoulder dystocia in this quarter. Of the 16 cases 3 babies required admission to NICU and 2 babies had Erbs Palsy post delivery. There has been a formal complaint received about the management of one of these cases around her antenatal management rather than the delivery, another complaint was made because NICU failed to diagnose a fractured humerus, again there was no complaint about the actual delivery.

of 53 Chart 13

Failed Instrumental

18 Jul - Sept 07 Jul - Sept 08

The number of failed or difficult instrumental deliveries in this quarter was 19 compared to 21 in corresponding period in 2007. As part of the CNST requirements there should be ongoing audit undertaken, this has been allocated to be presented in the January Clinical Governance meeting.

Jacqui Mallard Divisional Risk Lead November 2008

of 53 Appendix 3

WACS Maternity Risk Newsletter November 2008

Critical Incident Reporting The electronic reporting system has been in place for some time now and many are using it very effectively. However uptake is still very patchy at times and many trigger incidents are still not being reported on a regular basis. The clinical incident trigger list has now been reviewed and some changes made with some new additions:

 In-utero transfers when NICU are closed  Second stage of labour has now been changed from 3 to 4 hours to bring in line with NICE guidance  Delay in emergency caesarean section greater than 30 minutes for classifications 1or 2  Soft tissue injury at LSCS such as bladder or bowel  Unexpected IUGR or macrosomia  Unplanned term admissions to NICU, which means babies of diabetic mothers, can now be excluded.  Postnatal readmissions of mothers or babies  Delay in transfer from Victoria ward to Labour ward when women in established labour or needing urgent transfer for other reasons

All other triggers remain unchanged. Please could staff familiarise themselves with the new trigger lists which are being placed in all clinical areas

Classification of Caesarean Sections All caesarean sections should now be classified according when documenting in the notes or entering onto CMIS. The hand held notes have been changed to allow for this to be recorded, the classification is already on the CMIS system. Basically the classifications are as follows:

1. Immediate threat to the life of the woman or fetus 2. Maternal or fetal compromise, which is not immediately Life threatening 3. No maternal or fetal compromise but needs early delivery 4. Delivery timed to suit woman or staff.

For incident reporting purposes a form should be triggered for classifications 1 or 2 when there has been a delay greater than 30 minutes from decision to delivery.

Retained Swabs In the last year there have been there several cases involving retained swabs causing the women much physical and mental distress. What has be come clear is that there is a need for all staff involved in cases to ensure that swab/instrument counts are correct after completion of a procedure.

All staff are accountable and need to take the required actions to prevent these incidents reoccurring.

The patient hand held notes have now been altered so that 2 signatures are required to confirm that swab and needle counts are complete on operative procedure pages. If the patient is in theatre she must not be taken out until the missing swab (or instrument) is accounted for. If the swab cannot be found this must be escalated to the Consultant on call and further diagnostic investigations instigated.

Complaints - Communication Issues Recently there have been a number of complaints, which have been around communication, and attitude of staff towards women and their families but also towards other members of staff. This has been particularly highlighted recently in several complaints where care has involved emergency management. In the October Clinical Governance meeting 2 cases clearly highlighted these issues and the following recommendations were made:

 When a women says that she is not feeling well or raises concerns she must be respected and concerns taken seriously  During a emergency situation there should be someone allocated to looking after the woman and her partner ensuring that they understand what is happening, what is being done and why and offering reassurance and support throughout.  There is a need for the multi disciplinary team to work together as a ‘team’ in these emergency situations and communicate effectively. Staff must treat each other professionally and with respect and when there are conflicts about management not disagree in front of the woman or her family, take the discussions elsewhere.

In future there will be more discussion with all staff about both general and specific communication issues and how it can be improved. This will be done through feedback from complaints to individuals and groups as well as through orientation and induction ward meetings, clinical governance etc.

Early Pregnancy Information Sessions and booking directly with Midwife Nora Lucey Consultant Midwife Over recent months there have been many relevant documents from Department of Health including National Screening, Maternity Matters, the Healthcare Commission, NICE Antenatal and Intrapartum Guidelines. Within the documents they advise that women should be given information as early as possible, ideally by 6 weeks, and have their booking completed by 10-12 weeks. As you are probably aware NICE have also recommended an additional contact with a midwife in early pregnancy, prior to the booking appointment that we currently offer.

Within West Herts we have addressed this issue by introducing early pregnancy information sessions, or ‘speed booking’ at children’s centres in Hemel, St Albans and Watford. We have extra sessions at Watford maternity unit for women who do not live in our catchment area. Posters advertise these sessions to all women who are newly pregnant. They have been distributed to the GP’s surgeries and children’s centres and are shortly going out to pharmacies and community notice boards. Women can phone the number on the poster and will be given information about the early pregnancy session in their local area.

The venues have places for up to 10 women and their partners to attend and the information is presented using Power Point presentation with time for questions, refreshments are available ensuring a relaxed environment. The sessions have been arranged on different days and times. Each session last approximately 1 hour. Of course within the national agenda women still have the choice to book directly with midwife and/or via the GP.

Training The mandatory one stop day for 2009 are now in the process of being allocated to midwives and those staff due to attend early next year will receive their dates first to allow them to be incorporated into the off duty. For those midwives who have not completed K2000 or provided evidence of any CTG their managers are now being informed.

CTG Study Day Midwives and student midwives who have been allocated a place on the CTG study day should have received a letter by now confirming their place. Can you please ensure that we receive

of 53 payment before the actual study day. The day will run from 09.00 to approximately 16.30pm; certificates will be issued to staff that attend the complete day.

Infection Control The Trust has now had its unannounced visit by the Health Care Commission although formal feedback will not be received for a few weeks yet, generally it is felt that the visit went well and the Trust has made major improvements and overall is doing very well.

Transfusions

1) National Patient Safety Agency (NPSA) Competencies

It is a national requirement as inspected by ie. the NHSLA for level 2 all staff who undertake the following procedures should be assessed on the following:

 Obtaining a blood sample for the Blood Bank  Preparation, collection and administration of blood transfusions - staff (support workers and midwives) need to undertake part or all of this, depending upon their practice.

These assessments were launched in September 2007, with the agreed target for 50% trust staff to have completed these by November 2008 and the rest by November 2009. All these assessments must be witnessed. All Ward Managers and Matrons should be successfully assessed by the Transfusion Nurse Specialist (TNS) and then they can become Assessors for their own ward/unit. All staff have a personal responsibility to ensure they undertake these competencies. This process is to be repeated every 3 years.

To obtain the competency forms and information please access the intranet and go into Departments, then Pathology and Blood Transfusion. For further information, please contact the TNS on Pager no: 07659 107255, or X7659 at Watford or X3023 At Hemel.

The total number of staff who have undertaken these competencies will be circulated appropriately Trustwide according to the ward/unit. I believe very few midwives and support workers from maternity have participated in this process.

2) Blood sampling for the Blood Bank

This continues to present a huge problem for the trust. As proved previously apart from unsafe practice, much time and money is wasted when these errors occur. A strategy to reduce these errors was the introduction of a box halfway down the following new request forms asking staff who obtained the blood sample (the sampler) to print their name and job title:  Blood grouping/crossmatching/blood product issue  Antenatal investigations only  Post delivery blood grouping and FMH estimation For Obstetrics and Gynaecology blood samples received by the Blood Bank - An example in January 2008: At WGH there were 160 rejected blood samples, which was 20.4% of blood sample requests received. At HHGH there were 21 rejections, which was 5.7% of blood samples received. For GP blood samples, which are mostly taken by our trust midwives: At WGH there were 6 rejections which was 23.1% of blood sample errors. At HHGH there were 21 rejections, which was 5.7% of blood samples received.

Can all staff undertaking blood sampling for the Blood Bank please undertake the competency test as soon as possible. Some staff continue to participate in poor practice by pre-labeling blood tubes. Please ensure all staff blood sampling are well aware of the guidelines on blood sampling as highlighted in the Blood Transfusion Policy.

Donella Arnett

of 53 Blood Transfusion Nurse Specialist

Jacqui Mallard Divisional Risk Lead November 2008