Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
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10. Serious Incidents Reported<br />
Incidents which meet the NHS London SI reporting criteria are declared as they occur /<br />
are detected. Because they are reported retrospectively, the information below details<br />
incidents that either occurred within September <strong>2012</strong> or were reported in September<br />
<strong>2012</strong>. There will be overlap <strong>and</strong> repetition between information provided each month<br />
for this report.<br />
Full summaries <strong>and</strong> details are to be found on the STEIS system (references numbers<br />
provided).<br />
Summary:<br />
STEIS<br />
number<br />
Site<br />
22405 QH<br />
23880 QH<br />
Issue<br />
controlled<br />
drugs<br />
potentially<br />
missing<br />
NNU<br />
admission /<br />
transfer to<br />
UCLH<br />
Incident<br />
date<br />
Date of<br />
declaration<br />
MDT /<br />
panel<br />
reviews<br />
10/09/12 10/09/12 10/09/12<br />
23/09/12 25/09/12<br />
27/09/<strong>2012</strong><br />
2/10/12<br />
Comment<br />
At routine controlled drug check on<br />
morning of 10/9/12 it was found<br />
that the controlled drug book had<br />
been altered (pages removed) <strong>and</strong><br />
potentially some controlled drugs<br />
were missing<br />
congenital pneumonia / no<br />
contributory care or service<br />
delivery problems identified at<br />
panel<br />
11. Caesarean Deliveries including Elective Activity<br />
When a decision is made to perform an emergency LSCS, the timing for this is dictated by the<br />
acuity of each case which is graded from 1-4.<br />
Grade 1<br />
Caesarean section is considered as urgent <strong>and</strong> has an immediate threat to the life of the<br />
woman <strong>and</strong> foetus. To be performed within 30 minutes.<br />
At BHRUT hospitals, 54% of the audited grade 1 C/S were performed within 30 minutes.<br />
Delays were due to:<br />
• Increased BMI impacting on the procedure<br />
• Difficulty in sitting the spinal<br />
• Delay due to anaesthetic issues.<br />
Mat 2 October <strong>2012</strong> (2).doc<br />
Page 7 of 9<br />
Compiled by C Frisby 12.07.<strong>2012</strong><br />
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