Trust Board papers November 2012 - Barking Havering and ...

10. Serious Incidents Reported
Incidents which meet the NHS London SI reporting criteria are declared as they occur /
are detected. Because they are reported retrospectively, the information below details
incidents that either occurred within September 2012 or were reported in September
2012. There will be overlap and repetition between information provided each month
for this report.
Full summaries and details are to be found on the STEIS system (references numbers
provided).
Summary:
STEIS
number
Site
22405 QH
23880 QH
Issue
controlled
drugs
potentially
missing
NNU
admission /
transfer to
UCLH
Incident
date
Date of
declaration
MDT /
panel
reviews
10/09/12 10/09/12 10/09/12
23/09/12 25/09/12
27/09/2012
2/10/12
Comment
At routine controlled drug check on
morning of 10/9/12 it was found
that the controlled drug book had
been altered (pages removed) and
potentially some controlled drugs
were missing
congenital pneumonia / no
contributory care or service
delivery problems identified at
panel
11. Caesarean Deliveries including Elective Activity
When a decision is made to perform an emergency LSCS, the timing for this is dictated by the
acuity of each case which is graded from 1-4.
Grade 1
Caesarean section is considered as urgent and has an immediate threat to the life of the
woman and foetus. To be performed within 30 minutes.
At BHRUT hospitals, 54% of the audited grade 1 C/S were performed within 30 minutes.
Delays were due to:
• Increased BMI impacting on the procedure
• Difficulty in sitting the spinal
• Delay due to anaesthetic issues.
Mat 2 October 2012 (2).doc
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Compiled by C Frisby 12.07.2012
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