Agenda and supporting papers - Plymouth Hospitals NHS Trust

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Annex 1 Item 8a SURGICAL ERROR • 4 Serious Incidents Reported (+ 3 surgical never events in March 2013 • Common themes identified during investigation: • Team working, culture and behaviour • Lack of standardised process • Surgical Safety Improvement Programme established • Accountable Lead: Greg Dix • Reporting to Safety & Quality Committee VENOUS THROMBOEMBOLISM • 2 Serious Incidents Reported • Common themes identified during investigation: • Failure to act on risk assessment • Failure to administer prescribed prophylaxis • VTE Improvement Workstream established • Accountable Lead: Alex Mayor • Reporting to Safe Care Group DELAYED DIAGNOSIS/FAILURE TO ACT ON DIAGNOSTIC RESULTS • 5 Serious Incidents Reported • Common themes identified during investigation: • Inadequate system to ensure results reviewed / acted on • Inadequate failsafe to highlight un‐reviewed reports • Radiology Improvement Workstream established • Accountable Lead: Peter Macnaughton • Reporting to Safe Care Group UNEXPECTED DEATH OF ADULT • 2 Serious Incidents Reported • Common themes identified during investigation: • None‐ remain under investigation • Completed RCAs to be reviewed by Safe Care Group to identify learning and required actions Confidential Information Leak, 1 Venous Thromboembolism, 2 Delayed diagnosis or failure to act on diagnostic results, 5 Unexpected death of adult, 2 Surgical Error (Retained foreign object or wrong site surgery), 4 Maternity Incident, 2 Ward Closure / Infection Control Incident, 10 Serious Patient Safety Incidents Summary Review of Reported SIRIs June 2012 – May 2013 Serious Incidents Reported by PHNT Other, 3 WARD CLOSURE/INFECTION CONTROL • 10 Serious Incidents Reported • Common themes identified during investigation: • • Improvement Workstream established: • Accountable Lead: Peter Jenks • Reporting to Infection Control Committee Unexpected death of child, 2 Inpatient fall, 3 Drug Incident (Insulin), 1 Follow Up Appointment Delay, 1 Hospital Acquired Pressure Ulcer (3/4), 28 INPATIENT FALLS • 3 Serious Incidents Reported • Common themes identified during investigation: • Failure to complete risk assessment • Failure to act on risk assessment • Safety Improvement workstream established • Accountable Lead: Kevin Marsh • Reporting to Nursing and Midwifery Board UNEXPECTED DEATH OF CHILD • 2 Serious Incident Reported • Investigation ongoing • Safe Care Group to review completed investigation report and identify learning and necessary actions HOSPITAL ACQUIRED PRESSURE ULCERS (3/4) • 28 Serious Incidents Reported • Common themes identified during investigation: • Failure to complete risk assessment • Failure to act on completed risk assessment • Safety Improvement Workstream established o Accountable Lead: Kevin Marsh o Reporting to Safe Care Group DRUG INCIDENT (INSULIN) • 1 Serious Incidents Reported • Common themes identified during investigation: • Failure to follow Hyperkalaemia treatment guidelines • Safe Use of Insulin Improvement Workstream established • Accountable Lead: Daniel Flanagan • Reporting to Safe Care Group FOLLOW UP APPOINTMENT DELAY • 1 Serious Incidents Reported (Ophthalmology) • Common themes identified during investigation: • Waiting lists not prioritised by clinical risk • Inadequate capacity to meet demand • Follow Up Backlog Improvement Workstream established • Accountable Lead: Paul McArdle • Reporting to Safety & Quality Committee
Annex 2 Item 8a Summary of Serious and Significant Complaints (June 2012 – May 2013) Serious and Significant Complaints by Sub‐type Adverse outcome of Operation/Surgery, 3 Weekend Discharge, 1 Aspects of Clinical treatment, 6 Clinical Review , 1 Communication to Patient/Relatives, 2 Conflicting Clinical Decisions, 1 Incorrect diagnosis (where no treatment), 7 Breakdown of Complaints by Grading Number of Serious Complaints = 11 Number of Significant Complaints = 24 Number of Significant Professional Complaints = 1 Breakdown of Complaints by Directorate Clinical Support Services = 2 Ophthalmology = 1 Emergency Services = 9 Medical Specialties = 3 Orthopaedics & Rheumatology = 2 General impoliteness/indiffer ence, 1 Clinical Review, 3 Pain Control, 1 Outpatient delay, 2 Inpatient Delays, 1 Incorrect Diagnosis, 1 Drug error/incident, 3 Slips, Trips and Falls, 2 Inappropriate Discharge, 1 Gastroenterology, Surgery and Renal = 10 Oncology & Blood Services = 1 Head & Neck Surgery = 2 Neurosciences = 2 Reproductive Health, Neonatal & Women's Services = 2 Children & Young People's Health = 1 Anaesthetics, Theatres & Pain = 1
Page 1 and 2: Trust Board Friday 5 July 2013, 9.0
Page 3 and 4: Members of Plymouth Hospitals NHS T
Page 5 and 6: Item 3 observer. The Chairman requi
Page 7 and 8: Item 3 Board oversight of contribut
Page 9 and 10: Item 3 the Board next month. • Th
Page 11 and 12: Item 3 been involved and there was
Page 13 and 14: Item 3 continuing to build. Mr Babe
Page 15 and 16: Item 3 to Norovirus, Professor Lewi
Page 17 and 18: Item 3 • Careful communication of
Page 19 and 20: Item 3 • Approved the writing off
Page 21 and 22: Updated: prior to July Board Item 4
Page 23 and 24: Updated: prior to July Board Item 4
Page 25 and 26: Item 8 Quality Impact Assessment Pa
Page 27 and 28: Item 8 3.2 Quarterly Summary Hospit
Page 29 and 30: Item 8 4.4 Monthly Proportion of Pa
Page 31 and 32: Item 8 Inpatient falls are currentl
Page 33 and 34: Item 8 REI signage PALS were contac
Page 35 and 36: Item 8 Complaints received listed b
Page 37 and 38: Item 8 The graphs below illustrate
Page 39 and 40: Item 8 5.5 Friends and Family Test
Page 41 and 42: Item 8 1. Pressure Ulcers (EoC) 2.
Page 43 and 44: Item 8 Observations The essence of
Page 45: Item 8a SUMMARY REPORT Trust Board
Page 49 and 50: Item 9 Key Recommendations The Trus
Page 51 and 52: Item 9 Effective Care (Section B2 o
Page 53 and 54: Item 9 Description 31 days from 'de
Page 55 and 56: Item 9 4.6 Non Elective Activity is
Page 57 and 58: Item 9 Summary of performance excep
Page 59 and 60: Item 9 Ensure that all patients adm
Page 61 and 62: Item 9 Forecast Significant progres
Page 63 and 64: Item 9 Update on previous actions C
Page 65 and 66: Contents EXECUTIVE SUMMARY D FINANC
Page 67 and 68: B1 Safe care Description Hospital S
Page 69 and 70: Response Rate Recommender Score B3
Page 71 and 72: B5 Other safety & quality metrics D
Page 73 and 74: C2 Non-Elective Activity Descriptio
Page 75 and 76: C4 Referral To Treatment (RTT) Desc
Page 77 and 78: C6 Other access & activity metrics
Page 79 and 80: D2 Cost improvement programme (CIP)
Page 81 and 82: D4 Cash Management Description Revi
Page 83 and 84: E1 Staffing numbers Description Est
Page 85 and 86: E3 Sickness absence PERFORMANCE IND
Page 87 and 88: Risk Rating F2 Monitor's Financial
Page 89 and 90: Item 10 DETAILED REPORT Trust Board
Page 91 and 92: Item 10 4. Key Issues for the Board
Page 93 and 94: Item 11 SUMMARY REPORT Trust Board
Page 95 and 96: Item 11 DETAILED REPORT Trust Board
Page 97 and 98:
Item 11 • Challenge in respect of
Page 99 and 100:
Item 11 Over the past two years, me
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Item 11 Getting it Right Charter An
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Item 11 Outcome of review with exte
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Item 11 Learning Disabilities Natio
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Item 11 Peer Review 2.5 Peer Review
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Item 12 Next Steps 1. Conversation
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Item 12 2. Board Inclusion Developm
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Item 12 EDS Grades and E & D Object
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Item 12 Plymouth Hospitals Trust -
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Item 12 3.6 The workforce is suppor
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Item 13 Key Recommendations The Tru
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Item 13 Telephone conversations.
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Item 13 19. The Medical Director ha
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Item 14 SUMMARY REPORT Trust Board
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Item 15 incident investigations to
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Item 15, Annex 1 3. Review of Actio
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Item 15, Annex 1 • Top three issu
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Item 15, Annex 1 The Chair asked SS
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Item 16 COMMITTEE MINUTES Finance,
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Item 16 pay and staffing, highlight
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Item 16 • PACS contract - likely
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Item 17 Terms and Conditions of Emp
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Item 17, Annex 1 29/2013 Minutes an
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Item 17, Annex 1 31/2013 Francis Re
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Item 18 SUMMARY REPORT Trust Board
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Item 18 Next Steps The Audit Commit
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Item 18, Annex 1 Matters arising 4/
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Item 18, Annex 1 time to embed and
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Item 18, Annex 1 Payroll & Expenses
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Item 18, Annex 1 The Committee note
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Item 18, Annex 1 Going Concern Revi
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Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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