Annual Report on Management of
Serious Incidents - 1 April 10 to 31 March 11
Wendy Lefort, Quality & Governance Manager, August 2011
Contents
1.
Introduction ............................................................................................................................1
2.
National Patient Safety Agency framework .............................................................................2
3.
SI management in 2010/11 ....................................................................................................2
4.
Analysis of SIs in 2010/11 ......................................................................................................4
5.
Never Events..........................................................................................................................5
6.
Providers reporting SIs ...........................................................................................................5
7.
Learning from SIs ...................................................................................................................6
8.
Dissemination of learning .......................................................................................................7
10. Summary................................................................................................................................8
11. Recommendations .................................................................................................................9
Appendix 1 – NPSA changes to SI grades .................................................................................... 10
Appendix 2 – Targets for NHSC/P SI monitoring system objectives .............................................. 10
Appendix 3 – Overall SI activity in 2010/11.................................................................................... 11
Appendix 4 – List of Never Events ................................................................................................. 13
Appendix 5 – SI analysis by provider ............................................................................................. 14
Appendix 6 – Examples of action taken by providers following SI investigation ............................. 21
Appendix 7 – Glossary .................................................................................................................. 22
1. Introduction
NHS Cambridgeshire (NHSC) and NHS Peterborough (NHSP) (the PCT) have a
responsibility for commissioning services that deliver safe and high quality healthcare
for the population of Cambridgeshire and Peterborough. As part of this role, the PCT
holds providers to account through a clinical quality review (CQR) process and other
governance mechanisms. Providers are required to provide evidence as assurance
that the trust is meeting the quality indicators set out in the contract with the PCT.
The reporting and investigation of Serious Incidents (SIs), and taking forward
improvements from learning from these incidents is a significant part of the quality
and patient safety agenda of each provider trust. Using investigation and learning
from SIs is a proven mechanism to drive improvement in patient care. Provider
organisations have both a statutory and a contractual duty to have robust incident
and SI management systems that allow open and thorough reporting, investigation
and learning.
The management of SIs includes not only identification, reporting and investigation of
each incident, but also implementation of any recommendations following
investigation, assurance that implementation has led to improvements in care,
dissemination of learning to prevent recurrence, and thematic review to drive
systemic change.
NHSC/P SI Annual Report 10/11
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August 2011
2. National Patient Safety Agency framework
The National Patient Safety Agency (NPSA) ‘National Framework for Reporting and
Learning from Serious Incidents Requiring Investigation’ came into force in April
2010. The framework formalised the SI management requirements and provided
national measurable indicators for timeliness of SI reporting. These are used as the
basis of the contract quality indicators between the PCT and provider. The framework
also clarified roles and responsibilities for SI management and redefined SI
definitions and grades. Further details of the new grading system are given in
Appendix 1. The PCT and its provider services have been working to this framework
throughout 2010/11.
3. SI management in 2010/11
As part of the commissioning role of monitoring quality and patient safety in
commissioned services, the PCT has responsibility to scrutinise the providers’
management of SIs.
This report summarises the SIs monitored by the PCT during 2010/11, giving
comparison with the previous year where appropriate.
At the start of 2010/11 the commissioner approach to monitoring provider SI
management was supportive, with providers allowed to develop their SI systems in
line with the NPSA framework, and timescales for reporting not rigorously enforced.
The PCT had a range of mechanisms in place to monitor the management of
provider SIs including:

Assessment of initial SI reports, updates on immediate action taken, final
investigation reports and action plan updates

Feedback on SI reports, including requirement for additional investigation

Follow-up on areas of concern. For example the NHSC Associate Medical
Directors carried out an audit of incident reporting at Papworth following concern
about the low number of SIs reported. This provided assurance that a
comprehensive system is in place to assess, review and reflect on incidents and
determine those which meet the definition of SIs.

Co-ordination of multiorganisational SIs, including review of individual
organisation investigations and oversight of combined report and cross-boundary
action plan implementation
At the start of 2011, the PCT’s holding to account approach to provider quality
indicators was significantly strengthened with the use of contract levers to address
poor performance. A review of SI timeliness and quality of reporting showed that the
supportive approach had not achieved the necessary outcomes. A more performance
based approach was introduced to be in line with the overall approach to quality
indicator monitoring.
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Procedures introduced include:

A regular flagging system to clarify outstanding reporting requirements to
providers

Increased PCT senior clinician and management involvement to ensure relevant
issues from SIs are escalated. Thus the importance of prompt and robust
investigation leading to improvements in care is modelled by the PCT and can be
promoted to providers with the aim of embedded in their culture.

A PCT cluster escalation policy which ensures any concerns regarding SIs and SI
management are escalated to the appropriate level and drive remedial action if
required

A regular PCT SI Quality Assurance meeting to involve both clinical and
operational staff, reviewing all new SIs, those awaiting closure and all SIs that
have been open for more than 6 months

Development of the SI database to include additional performance information
about timeliness of reporting and response to queries
The early results from the procedures put in place show some improvement in
timeliness of reporting, and has lead to an increase in SIs closed following
completion of action plans. The SHA positively recognise the improvements made to
date. Providers that have failed to show expected improvements are currently subject
to contract escalations.
The PCT is monitoring progress and have produced a range of metrics to measure
process. However, there is still concern about the outcome of SIs, with the quality of
final reports and action plans inconsistent, and a lack of thematic review to support
further learning. To address these gaps, further procedures are proposed, as follows:

Additional quality assurance for final report review to maximise learning from the
SI, and to identify any themes across other SIs. This will be supported by the SI
Quality Assurance meeting.

Requirement for more regular thematic review including areas of concern and
other issues raised at SI Quality Assurance meetings, CQRs and other sources

Triangulation of SI investigation and learning with any improvement plans in place
for providers. For example a Care Quality Commission concern about staffing
would prompt a more in-depth review of staffing issues in the SI investigation.

Review of outcome evidence, including clinical audit, to demonstrate whether
required improvements following an SI are being embedded at service level

Lowering of thresholds for SI reporting where there are significant concerns with
provider performance to ensure robust investigation of a wider range of incidents
that will inform the improvement plans of the provider
A set of outcomes for the PCT SI monitoring system has been agreed which will give
measurable evidence of the effectiveness of the changes put in place. These include:
 A reduction in delayed SI reporting which will result in prompter implementation of
actions from SI learning
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 A reduction in the number of SIs where the PCT has to ask additional questions
following review of initial and final reports and action plans, indicating more robust
reporting with provider ownership
 Following thematic review and learning from similar SIs, a reduction in SIs in
areas under review or a reduction in the common root causes in these SIs
Targets for these outcomes are given in Appendix 2.
4. Analysis of SIs in 2010/11
The significant changes in overall SI activity are summarised below. Further details
are given in Appendix 3. Please note that there are limited statistics available for
NHSP for 2010/11 due to different data collection systems and limited capacity.

There was a substantial reduction in SIs related to infection control (from 17 in
2009/10 to 3 in 2010/11 for NHSC). This is due to the effectiveness of
improvements in infection control systems in NHS providers leading to a reduction
in the incidence of MRSA and C difficle infections.

The last three months of the 2010/11 saw a significant increase in the reporting of
grade 3 and grade 4 pressure ulcers. This was due to work put in place by trusts
to stress the importance of reporting and investigating these incidents, highlighted
by national and local focus on pressure ulcers in quality indicators and initiatives.
A programme of work aimed to reduce the incidence of avoidable pressure ulcers
has started for 2011/12. This includes streamlined reporting systems using a
template designed together with providers, a county wider pressure ulcer group to
share learning across the health economy, and inclusion of pressure ulcer targets
in provider’s Commissioning for Quality and Innovation (CQUIN) frameworks.

The number of suicides / possible suicides increased from 16 in 2009/10 to 28 in
2011/12 (NHSC figures). The PCT have been working closely with the mental
health provider (Cambridge & Peterborough Foundation Trust (CPFT)) to address
the root causes identified for SIs relating to suicide. The quality of risk
assessments and care planning was highlighted as a theme in the NHSC review
of final reports relating to suicide. CPFT have put actions put in place as part of
the suicide prevention work to address these areas.
Actions taken to date by CPFT include:
o Use of a Global Trigger Tool to identify patients at risk
o Improvement of risk assessment training for all clinical staff
o Clinical audit of clinical risk assessment and evaluation of care plans for
inpatients
The trust has rolled out a refresher training programme for management of
depression, and established a joint Suicide Prevention Group linking with GPs to
ensure appropriate risk assessment at all stages.
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5. Never Events
The Department of Health defined a list of eight Never Events in 2010. These are
serious, largely preventable patient safety incidents that should not occur if the
available preventative measures have been implemented. This list was increased to
25 in April 2011. These are given in Appendix 4.
Never Events must always be reported as grade 2 SIs. They attract more in-depth
management and review, and providers will be rated as Red whilst they have an
investigation ongoing for any Never Event. There is also a financial penalty for the
provider.
There was one Never Event reported in NHSC and NHSP in 2010/11. This incident
has been investigated both internally and though external scrutiny, and the
recommendations of the investigation are being implemented. The CQR receives
regular updates to ensure the learning from this minimises the likelihood of
recurrence.
6. Providers reporting SIs
There are four main providers reporting SIs to NHSC. These are:

Two acute trusts, Cambridge University Hospital Foundation Trust (CUH) and
Hinchingbrooke Healthcare Trust (HHCT)

One mental health trust, Cambridgeshire & Peterborough Foundation Trust
(CPFT)

One community provider, Cambridge Community Services (CCS)
Other trusts that report SIs to NHSC include:

Out-of-hours service, Urgent Care Cambridge (UCC)

Papworth Hospital NHS Foundation Trust – Papworth is jointly commissioned by
NHSC and the East of England Specialised Commissioning Group (which
commissions specialised health services on behalf of all EoE PCTs). When an SI
occurs at Papworth, the route for reporting is determined by the service where the
incident occurred.

HMP Littlehey and HMP Whitemoor

EoE Ambulance NHS Trust - the trust reports SIs that relate to NHSC patients or
services

NHSC SIs - SIs that relate to independent contractors, or involve multiple
agencies, are reported and investigated by NHSC
Analysis of SIs reported by providers is given in Appendix 5.
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The following providers reported SIs to NHSP in 2010-2011:

One acute trust, Peterborough and Stamford Hospital Foundation trust (PSHFT))

One mental health trust, Cambridgeshire & Peterborough Foundation Trust
(CPFT)

One community provider, Peterborough Community Services (PCS)
Other trusts that report SIs to NHSP include:

Out-of-hours service, Peterborough

HMP Peterborough (Kalyx)

NHSP SIs - SIs that relate to independent contractors, or involve multiple
agencies, are reported and investigated by NHSP
7. Learning from SIs
The PCT reviews SI final reports to ensure all relevant aspects of the SI have been
investigated and recommendations follow from the investigation findings. This
process is being strengthened to challenge providers to consider further areas of
learning and how learning can be embedded.
Review of final reports in 2010/11 show investigations highlight the importance of
having clear policies and procedures, and training in place to support staff. Several
SIs raise the importance of good interaction and communication between staff, and
of ensuring staff are engaged and aware of their accountability in all areas of work.
The issue of poor documentation remains a significant contributing factor to many
SIs.
Provider resource issues and staffing levels were only identified as factors in a small
percentage of SIs. However, this will need careful monitoring as the NHS moves into
a period of significant financial pressures and greater levels of staff in transition as a
result of NHS reform.
The main root causes identified from SIs in 2011/12 are similar to those recorded in
2009/10. The PCT is working with providers to focus on systems that address these
generic causes. However, these root causes are likely to remain the main concerns,
as they reflect situations where systems were not used or did not support staff
adequately.
One of the most important aspects of SI management is ensuring prompt
implementation of any changes resulting from the SI investigation. The PCT monitors
the implementation of recommendations from SI investigations to ensure changes
are made to improve care. Some of the changes made by trusts resulting from
learning from SIs are given in Appendix 6. NHSC and NHSP will be working with
providers to address the next step of whether changes have led to improvement,
using clinical audit and other quality assurance processes. The timeliness of actions
will also be addressed to ensure that actions are implemented without inappropriate
delay.
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8. Dissemination of learning
NHSC and NHSP disseminate findings from SIs and thematic reviews across the
health economy where there is appropriate learning. This is done via:

Targeted newsletters, such as the Clinical Governance newsletter sent to all GPs,
dentists and optometrists

Learning events, such as the countywide SI meeting, or at specific groups such
as the Dental Audit meeting

Development of SI reporting requirements to include clinician leadership and
involvement of patients and families

Robust monitoring at CQRs between NHSC, NHSP and providers to ensure
compliance with a range of quality indicators, including SI management.

CQUIN and Quality Account negotiations to ensure improvement is rewarded
where needed and priorities for improvement take on board recent SI learning
Intelligence shared across the health economy at the SI learning meetings includes:

Clinical leaders throughout the NHS must advocate and lead the necessary
changes

There must be significant focus on procedures to support staff in exceptional
situations such as the swine-flu epidemic

Clarification of process where incidents result from poor practice/actions of
independent agencies

The need for a joined-up approach to ensure appropriate information is available
at each stage of the patient’s journey
To further strength the dissemination of learning, NHSC and NHSP will require
providers to provide a summary of learning from SIs that can be shared across the
health economy by the PCT, and to use their networks to disseminate learning widely
with their peer organisations.
9. Timeliness of SI reporting and investigation
The timeliness of SI reporting is an indicator of both level of clinical engagement,
ownership and leadership, and the capacity and capability of the trust in carrying out
root cause analysis. Prompt reporting and investigation leads to remedial action and
action for improvement being implemented as soon as possible. Lack of ownership
and poor engagement lowers commissioner confidence that provider organisations
have a robust culture in place to maintain resilience for quality and patient safety in
transition.
The table below shows that timeliness of final reports has improved slightly during
2010/12 but remains well below the targets set for reporting by the NPSA framework
and the NHSC/P SI procedure. All providers remain non-compliant with the
requirement for providers to complete grade 1 investigations within 9 weeks of
reporting, unless there are valid reasons for delay. The outcome of an investigation
may be delayed by police involvement or the need for an inquest. However lack of
capability and capacity will no longer be accepted as a valid reason for delay.
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Number of weeks taken for SI investigation
Weeks between date
#
of reporting and final
2010/11
report received
No. (%) of SIs
Within reporting timescales
9 or less weeks
23
20%
Outside reporting timescales
10 – 19
47
40%
20 – 29
25
21%
30 – 39
7
6%
40 – 49
5
4%
50 – 59
4
3%
More than 59
7
6%
Median (weeks)
Maximum (weeks)
16
128
2009/10
No. (%) of SIs
16
13%
19
25
14
16
16
14
16%
21%
12%
13%
13%
12%
30
138
The NPSA framework sets out timescales for reporting that cover not only final
reports, but also other deadlines as set out below. These timescales have been set
to allow providers time to complete full investigations, whilst ensuring immediate
remedial action is identified where necessary and improvements in care implemented
as soon as possible.
Type of Report
Required Timescales
Initial reports
Initial updates
2 working days from date of incident
7 working days from date SI received for level 1
3 working days for level 2 and Never Events
9 weeks from date SI received for grade 1
12 weeks for grade 2 / Never Event
4 weeks after last action on action plan
Final reports
Action plans
Because of the importance of learning from SIs in a timely way, the PCT have put in
place mechanisms to highlight and monitor any delay in reporting. Regular
performance information is addressed in the CQRs and contract penalties will be
used to hold to account providers who consistently miss the deadlines for SI
reporting.
10. Summary

The introduction of the NPSA framework for management of SIs in April 2010 has
lead to development of more robust systems in providers. This has been coupled
with increased monitoring by NHSC and NHSP to ensure timely reporting and
high quality final reports and action plans.

There was a substantial reduction in SIs related to infection control, reflecting the
effectiveness of improvements in infection control systems in NHS providers.

The last three months of the 2010/11 saw a significant increase in the reporting of
grade 3 and grade 4 pressure ulcers. This was due to work put in place by trusts
to stress the importance of reporting and investigating these incidents, highlighted
NHSC/P SI Annual Report 10/11
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August 2011
by national and local focus on pressure ulcers in quality indicators and initiatives.
Providers have targets to eliminate all avoidable pressure ulcers and this will be
monitored during 2011/12.

The number of suicides increased during 2011/12. The quality of risk
assessments and care planning was highlighted as a theme in the NHSC review
of final reports relating to suicide. CPFT have put actions put in place as part of
the suicide prevention work to address these areas.

The information available for analysis of SI management in 2010/11 was limited
by the data collected on the SI database at the beginning of the period. During
2010/11 the expectation for providers to have much more robust SI management
systems has necessitated a significant increase in data collected. This will be
available to measure both provider and commissioner performance during
2011/12.

A range of mechanisms has been put in place to strengthen the commissioner’s
role in monitoring SI management of providers. The effectiveness of these
systems will be measured against a set of objectives for the PCT. NHSC and
NHSP will continue to hold providers to account where they do not comply with
the NHSC/P SI procedure.
11. Recommendations
1. Embed the new mechanisms put in place by the PCT to monitor provider SI
management, and monitor their effectiveness using measurable objectives for the
NHSC/P SI monitoring systems:

Reduction in delayed SI reporting

Reduction in the number of SIs where the PCT has to ask additional questions
following review of initial and final reports and action plans

Reduction in pressure ulcers and suicide SIs, and SIs in other areas
highlighted by thematic review where overarching actions are put in place to
address systems problems in these areas
2. Strengthen the review of action plan monitoring, ensuring prompt implementation
of recommendations, and use of clinical audit and evaluation to ensure changes
have led to improvements.
3. Hold providers to account against the NHSC/P SI procedure for SI management,
using contract levers where necessary to ensure reporting organisations give
timely updates and final reports of the investigation into the SI, and follow up
recommendations and implement action plans in order to improve care.
4. Ensure the learning from SIs is disseminated widely and appropriately, both by
providers and the PCT. Providers will be required to provide a summary of
learning from SIs that can be shared across the health economy by the PCT, and
to use their networks to disseminate learning widely with their peer organisations.
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Appendix 1 – NPSA changes to SI grades
The NPSA framework sets out a revised grading system for SIs with grades 1 or 2
allocated to incidents. Grade 1 incidents require investigation using NPSA root cause
analysis (RCA). Grade 2 incidents require closer monitoring and involvement by the
PCT and/or NHS EoE (the local Strategic Health Authority (SHA)) and may require
an independent investigation to complete the RCA.
Providers must also notify the PCT about any incident where it is unclear initially if
the incident meets the definition of an SI. These notifications are given a grade 0.
This gives the provider the chance to investigate further and determine if the incident
does meet the definition of an SI. If not, the incident is downgraded and is not subject
to the robust investigation required for an SI. However, investigation will still take
place within the provider organisations as part of their incident reporting system.
Appendix 2 – Targets for NHSC/P SI monitoring system objectives
Objective
Reduction in delayed SI reporting
Type of
NPSA timescale
Target
report
Initial
2 working days from date of 80% of SIs reported to
reports
incident
timescale, or valid reason for
delay in reporting agreed
Initial
7 working days from date
80% of SIs reported to
updates
SI received for level 1
timescale, or valid reason for
3 working days for level 2
delay in reporting agreed
and Never Events
Final
9 weeks from date SI
50% of SIs reported to
reports
received for grade 1
timescale, or valid reason for
12 weeks for grade 2 /
delay in reporting agreed
Never Event
Action
4 weeks after last action on 75% of action plans completed
plans
action plan
to timescale, or valid reason for
delay in reporting agreed
Current
performance
Estimate 40%
(2010/11)
Estimate 40%
(2010/11)
20% (2010/11
NHSC)
NA
Objective
Reduction in number of SIs where the PCT has to ask additional questions
Target
Current performance Comments
2011/12 – 50% 26% (Jan – June 2012) This should increase initially as the PCT puts in
2012/13 – 20%
place a more robust peer review system for
reports
Objective
Reduction in number of Pressure ulcer and suicide SIs, and any other areas
highlighted by thematic review
Area
Target
Current performance
Pressure ulcers
35 (Jan – June 2012)
53 (Jan – June 2011)
Suicides
22 (April 2011 – Mar 2012)
28 (April 2010 – Mar 2011 NHSC)
Other targets will be set as appropriate following thematic review
Objective
Improvement in timeliness of review and feedback for final reports
Target
Current performance
Comment
95% Feedback within 20 days for all SIs
83% (Jan – June 2011)
NPSA target
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Appendix 3 – Overall SI activity in 2010/11
Number of SIs
The number of SIs monitored by NHSC between 1 April 2010 and 31 March 2011 is
given below. The changes to the monitoring of SIs has resulted in more detailed
information being available for 2010/11 than for 2009/10.
Status
2010/11
2009/10
SIs reported during period
110
SIs occurring in the period
(reported as at end July 2011)
122
SI investigations completed
during period
100
SI action plans completed
during the period - SI closed
47
Not recorded
101
Not recorded
SIs open at end of period
89
Not recorded
120
The number of SIs occurring is greater than those reported due mainly to the late
reporting of several pressure ulcer SIs. This delay is being addressed with the
provider in question.
Of the 101 SIs open at the end of 2010/11, 47 were being investigated. For the
remaining 54, recommendations have been approved and the trusts are
implementing the action plans.
The number of SIs monitored by NHSP between 1 April 2010 to 31 March 2011 is
given below.
Status
SIs reported during period
2010/11
2009/10
57
26
Month of reporting
The month of reporting for NHSC SIs is shown in the graph overleaf. This shows that
SI reporting reduced during the first part of the year, and then increased over the last
six months. Pressure ulcer reporting increased significantly in the first three months
of 2011, with the increase in other areas spread across the NPSA categories.
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August 2011
All NHSC SIs reported - 1 April 2010 to 31 March 2011
(with 2009/10 figures for comparison)
2009/10
2010/11
20
Number of SIs reported
15
10
5
0
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
SI categories
Each SIs is classified under one of the NPSA defined categories. The table below
shows the categories where 5 or more SIs were reported to NHSC in 2010/11, or
where there have been significant changes from 2009/10.
Category
2010/11
2009/10
Suicide / Possible Suicide
28
16
Clinical Assessment & Treatment
25
21
Pressure ulcer
9
0
Infection Control
3
17
Information
7
10
The number of NHSC SIs for each grade for 2010/11 are given below. The levels
from 2009/10 are also given although these are not directly comparable.
Grade
1
2
Total
2010/11
89
21
110
Level
1 and 2
3
Total
2009/10
54
35
89
As this was a new requirement under the NPSA framework, there was some variation
in interpretation between providers, with some trusts not reporting any grade 0 SIs
and another reporting 12, including 6 unexpected deaths and 4 missing persons. This
discrepancy has now been addressed and the requirements agreed with providers.
After review, 23 incidents reported as grade 0 during 2010/11 did not meet the
definition of a SI and these were downgraded, and are not included in the analysis for
this report. There were two grade 0 SIs awaiting assessment as at 31 March 2011.
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Appendix 4 – List of Never Events
Never events are defined as ‘serious, largely preventable patient safety incidents that
should not occur if the available preventative measures have been implemented by
healthcare providers’.
To be a “never event”, an incident must fulfil the following criteria;
 The incident has clear potential for or has caused severe harm/death.
 There is evidence of occurrence in the past (i.e. it is a known source of risk).
 There is existing national guidance and/or national safety recommendations on
how the event can be prevented and support for implementation.
 The event is largely preventable if the guidance is implemented.
 Occurrence can be easily defined, identified and continually measured.
The following list shows the events from the original list, and those that have been
added for 2011/12.
1. Wrong site surgery (existing)
2. Wrong implant/prosthesis (new)
3. Retained foreign object post-operation (existing)
4. Wrongly prepared high-risk injectable medication (new)
5. Maladministration of potassium-containing solutions (modified)
6. Wrong route administration of chemotherapy (existing)
7. Wrong route administration of oral/enteral treatment (new)
8. Intravenous administration of epidural medication (new)
9. Maladministration of Insulin (new)
10. Overdose of midazolam during conscious sedation (new)
11. Opioid overdose of an opioid-naïve patient (new)
12. Inappropriate administration of daily oral methotrexate (new)
13. Suicide using non-collapsible rails (existing)
14. Escape of a transferred prisoner (existing)
15. Falls from unrestricted windows (new)
16. Entrapment in bedrails (new)
17. Transfusion of ABO-incompatible blood components (new)
18. Transplantation of ABO or HLA-incompatible Organs (new)
19. Misplaced naso- or oro-gastric tubes (modified)
20. Wrong gas administered (new)
21. Failure to monitor and respond to oxygen saturation (new)
22. Air embolism (new)
23. Misidentification of patients (new)
24. Severe scalding of patients (new)
25. Maternal death due to post partum haemorrhage after elective Caesarean
section (modified)
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Appendix 5 – SI analysis by provider
NHS Cambridgeshire
The number of SIs by reporting organisation for 1 April 2010 to 31 March 2011 is
given below. This excludes any grade 0 SIs which are subsequently downgraded.
Organisation
SIs
reported
during
period
SIs
occurring
during
period
SI
investigations
completed
during period
SI action
plans
completed
during period
CUH
28
25
25
HHCT
17
19
CPFT
31
CCS
Open SIs as at 31 March 2011
SIs being
investigated
Action plans
being
implemented
13
15
13
22
7
4
17
30
29
9
10
21
13
27
5
5
9
1
UCC
4
4
4
0
0
4
Prisons
2
2
1
2
1
0
EoE
Ambulance
4
4
7
7
1
0
Papworth
1
3
1
0
0
1
NHSC
10
8
6
4
7
2
Total
110
122
100
47
47
54
The table shows a difference between the number of SIs reported and the number
occurring during 2010/11. There can be a significant delay in an incident occurring
and it being reported to the PCT. For example, there may be an inquest for a patient
who appears to have died of natural causes (which would not be reported as an SI).
The inquest may determine the death was not due to natural causes and an SI would
then be raised.
However, with the increase in pressure ulcers, some trusts have collected these SIs
and not sent in a timely manner. The database has been extended to allow recording
of acceptable delays, and providers will be held to account where the reason for
delay in reporting is not valid.
Further analysis of SIs reported in 2010/11 for NHSC’s major providers is given in the
following pages.
NHSC/P SI Annual Report 10/11
Page 14 of 23
August 2011
Cambridge University Hospitals NHS Foundation Trust
The categories of CUH SIs are shown below:
Category
Clinical Assessment & Treatment
Categories relating to patient care
Other
Number of SIs
12
11
5
There were no themes identified regarding the type or location of SIs reported by
CUH. SIs categorised as relating to Clinical Assessment & Treatment covered a
range of specialities within the Trust and the root causes included delay in escalation,
poor planning of care and treatment, and lack of communication and documentation.
The three pressure ulcers were all reported in the first quarter of 2011.
The monthly reporting pattern for CUH is given below.
CUH SIs reported - 1 April 2010 to 31 March 2011
7
6
Number of SIs reported
5
4
3
2
1
0
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Number of weeks taken for SI investigation
% final reports completed within 9 weeks or less
Median (weeks)
Maximum (weeks)
NHSC/P SI Annual Report 10/11
Page 15 of 23
30%
18
86
August 2011
Cambridgeshire Community Services
The categories of CCS SIs are shown below:
Category
Pressure ulcer
Categories relating to patient care
Other
Number of SIs
5
5
less than 5
Five pressure ulcer SIs were reported in the first quarter of 2011, following a
campaign to increase awareness of the requirement to report and investigate such
incidents.
CCS were part of the multi-disciplinary team reviewing the end-of-life pathway across
acute, primary and community care. The SI identified poor quality information
available for families and carers of terminally ill patients, and CCS is working with
other organisations to produce a more joined-up and accessible information pack.
CCS staff frequently visit nursing and residential homes to care for patients and may
identify SIs within these homes, particularly in relation to safeguarding of vulnerable
adults. Trust staff report these incidents and CCS have a role to ensure the home
takes action to address any safeguarding concerns.
The monthly reporting pattern for CCS is given below.
CCS SIs reported - 1 April 2010 to 31 March 2011
7
6
Number of SIs reported
5
4
3
2
1
0
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Number of weeks taken for SI investigation
% final reports completed within 9 weeks or less
Median (weeks)
Maximum (weeks)
NHSC/P SI Annual Report 10/11
Page 16 of 23
0%
15.5
30
August 2011
Cambridge and Peterborough NHS Foundation Trust
The categories of CPFT SIs are shown below:
Category
Suicide / possible suicide
Unexpected death
(subsequently downgraded from SI)
Other
Number of SIs
20
8
less than 5
The quality of risk assessments and care planning was highlighted as a theme in the
NHSC review of final reports relating to suicide. CPFT have put actions put in place
as part of the suicide prevention work to address these areas. CPFT also plan to
establish a joint Suicide Prevention Group linking with GPs to ensure appropriate risk
assessment at all stages.
CPFT used the grade 0 option for reporting 8 unexpected deaths during 2010/11.
These subsequently were determined to be from natural causes.
The monthly reporting pattern for CPFT is given below.
CPFT NHSC SIs reported - 1 April 2010 to 31 March 2011
7
6
Number of SIs reported
5
4
3
2
1
0
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Number of weeks taken for SI investigation
% final reports completed within 9 weeks or less
Median (weeks)
Maximum (weeks)
NHSC/P SI Annual Report 10/11
Page 17 of 23
0%
21
128
August 2011
Hinchingbrooke Healthcare NHS Trust
The categories of HHCT SIs are shown below:
Category
Number of SIs
Clinical Assessment & Treatment
9
Categories relating to patient care
6
Other
less than 5
HHCT had a number of SIs involving colorectal cancer surgery. NHSC requested
assurance that this did not show professional or systemic concern which may not
have been highlighted by individual reports. HHCT had already commissioned an
independent external review, the recommendations of which are being followed
through. HHCT carried out an audit of all colorectal operations that had been
completed over the past three years.
There were no other themes identified regarding the type or location of SIs reported
by HHCT. SIs categorised as relating to Clinical Assessment & Treatment cover a
range of specialities within the Trust and the root causes include issues with clinical
engagement, lack of awareness of guidelines, and lack of communication.
HHCT reported one Never Event during 2010/11 relating to a retained instrument.
The monthly reporting pattern for HHCT is given below.
HHCT SIs reported - 1 April 2010 to 31 March 2011
7
6
Number of SIs reported
5
4
3
2
1
0
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Number of weeks taken for SI investigation
% final reports completed within 9 weeks or less
Median (weeks)
Maximum (weeks)
NHSC/P SI Annual Report 10/11
Page 18 of 23
42%
12.5
27
August 2011
NHS Peterborough
The number of SIs by reporting organisation for 1 April 2010 to 31 March 2011 is
given below:
Organisation
Open SIs as at 1 April 2011
SIs being
Action plans
investigated
being
implemented
SIs
reported
during
period
SIs closed
during
period
PSHFT
12
3
17
2
PCS
7
3
13
3
CPFT
8
8
16
0
5
2
9
2
1
0
1
0
0
0
1
1
33
16
57
8
NHS
Peterborough
HMP
Peterborough
Specialist
Commissionin
g
Total
Intelligence from each provider has not been presented in this report. However, the
following process are now in place to ensure complete and robust information is
available for 2011/12:

Capacity for managing NHSP SIs has been identified in the Integrated Quality
and Governance team

The Integrated Quality and Governance team has worked with NHSP healthcare
organisations to clarify the requirements for provider SI management

SI reports are now sent to a dedicated NHSP in-box

Timeliness for processing of reports has improved as required

Clinical Quality forums cover provider SI management and review

The back log of incomplete investigations has been completed and cleared
Further detail of SIs reported to NHSP for each provider in 2010/11 is given in the
following pages.
NHSC/P SI Annual Report 10/11
Page 19 of 23
August 2011
Peterborough & Stamford Hospitals Foundation Trust
The number of SIs reported by PSHFT in 2010-11 has increased. Work to improve
reporting processes has been on-going with the hospital. PSHFT are seen by the
SHA as low reporters of SIs in the East of England. Provider reporting and monitoring
processes have been further developed to ensure that all incidents that meet the
serious incident definition are reported appropriately as SIs to NHSP. Work to
improve the timeliness of reporting and the completion of investigations will continue
with the provider and the implementation of learning through investigations and
reviews will be monitored through the clinical quality review process.
Cambridgeshire & Peterborough NHS Foundation Trust
There has been an increase in the number of reported suicides. The quality of risk
assessments and care planning was highlighted as a theme in the NHSP review of
final reports relating to suicide. CPFT have put actions in place as part of the suicide
prevention work which should address these areas, but monitoring of this will need to
continue. CPFT also plan to establish a joint Suicide Prevention Group linking with
GPs to ensure appropriate risk assessment at all stages. Outcomes from this group
will need to be reviewed quarterly to ensure it is fit for purpose.
Peterborough Community Services
There has been an increase in the number of SIs reported by PCS in 2010-11.
Serious incidents have been under-reported within community services in previous
years. The development of serious incident reporting processes within PCS,
increased awareness of the serious incident definition and an improvement in the
reporting culture has led to an increase of serious incident numbers. The
development of reporting processes achieved by PCS in 2010/11 will continue to be
monitored as services transfer to new providers in 2011/12. PCS are lower reporters
of Pressure Ulcer (PU) SIs than CCS, there may of course be several reasons for
this. It is essential that learning is collated to ensure that if treatment of vulnerable
patients in PCS results in development of less PU’s that best practice is shared in a
timely way across organisations.
HMP Peterborough
HMP Peterborough continue to engage with NHSP and the SI reporting processes,
reporting healthcare SIs when they occur. One serious incident has been reported
this year.
NHS Peterborough
The number of SIs reported by NHSP has increased this year. Work has been ongoing to improve awareness of SIs reporting by independent providers. There have
been a number of multi-agency investigations that have led to shared learning across
the health and social care economy and improvements to pathways of care.
NHSC/P SI Annual Report 10/11
Page 20 of 23
August 2011
Appendix 6 – Examples of action taken by providers following SI investigation
Training
 Retraining for ambulance clinicians in anaphylactic care.
 Introduction of formal human factors training for theatre staff, to compliment the
use of the World Health Organisation safe surgery checklist.
Documentation
 The VTE Risk Assessment Form amended to facilitate and prompt reassessment
after 24 hours, including a consideration by specialities to ensure it is sensitive to
particular requirements of the patient population.
 Joint development across primary and secondary care of clear, accessible
information for families and carers of terminally ill patients that covers all end of
life services.
Clinical responsibility
 All allied health professionals informed regarding their responsibility to document
in the patient records and inform the nurse in charge of any treatment regimes on
ward patients.
 Reminder in the staff bulletin of the importance of maintaining a professional
relationship with their patients at all times and to report any incidents at an early
stage.
Policy development
 Development of a standard operating procedure for communicating assessment
outcomes.
 Review of the current evidence base and risk/benefits of prophylactic antibiotic
use in specific care.
Pathway management
 Establishment of a community project group to review the role of medical staff
with the aim of embedding and collocating medical staff within their pathway team.
 Review of care pathway for mental health teams including identifying associated
care records documentation required.
NHSC/P SI Annual Report 10/11
Page 21 of 23
August 2011
Appendix 7 – Glossary
Being Open
Open communication of patient safety incidents that result in harm
or the death of a patient while receiving healthcare.
Carers
Family, friends or those who care for the patient. The patient has
consented to their being informed of their confidential information
and to their involvement in any decisions about their care.
Clinical
Governance
A framework through which NHS organisations are accountable
for continuously improving the quality of their services and
safeguarding high standards of care by creating an environment in
which excellence in clinical care will flourish.
Commissioning
organisation
An organisation with responsibility for buying services from
service providers in either the public, private or voluntary sectors.
Health economy All stakeholders that contribute to healthcare in a specified region.
Incident
An event or circumstance which could have resulted, or did result
in unnecessary damage, loss or harm such as physical or mental
injury to a patient, staff, visitors or members of the public.
Independent
contractors
GPs, dentist, optometrists and community pharmacists that
provide services as independent businesses contracted with the
commissioner.
Infection
control
Processes, policies and procedures used to minimize the risk of
spreading infections, especially in healthcare facilities.
Information
Governance
The structures, policies, procedures, processes and controls
implemented to manage information in such a way that it supports
the organisations regulatory, legal, risk, environmental and
operational requirements.
Never Events
Patient safety incidents that should not occur if the available
preventative measures have been implemented by healthcare
provider.
NHS-Funded
Healthcare
Healthcare that is partially or fully funded by the NHS, regardless
of the location.
NPSA
National Patient Safety Agency. An organisation that leads and
contributes to improved, safe patient care by informing, supporting
and influencing the health sector.
Patient pathway
The care and treatment received by the patient as seen from the
patient’s perspective rather than that given by individual health
care organisations
Provider
organisations
Organisations that NHSC and NHSP commission to provide
healthcare to its population. These organisations provide a wide
range of healthcare including acute, primary medical and dental,
ambulance, community and mental health services
NHSC/P SI Annual Report 10/11
Page 22 of 23
August 2011
Root cause
A cause which leads to an outcome or effect of interest.
Commonly, root cause is used to describe the depth in the causal
chain where an intervention could reasonably be implemented to
change performance and prevent an undesirable outcome.
Safeguarding
children and
vulnerable
adults
Ensuring that people live free from harm, abuse and neglect and,
in doing so, protecting their health, wellbeing and human rights.
Children, and adults in vulnerable situations, need to be
safeguarded. For children, safeguarding work focuses more on
care and development; for adults, on empowerment,
independence and choice.
Severe Harm
A patient safety incident that appears to have resulted in
permanent harm to one or more persons receiving care.
SI
Serious Incident - An incident that meets the definition set out by
the NPSA:
A serious incident requiring investigation is defined as an incident
that occurred in relation to NHS-funded services and care
resulting in:
 Unexpected or avoidable death of one or more patients, staff,
visitors or members of the public;
 Serious harm to one or more patients, staff, visitors or
members of the public or where the outcome requires lifesaving intervention, major surgical/medical intervention,
permanent harm or will shorten life expectancy, or result in
prolonged pain or psychological harm (this includes incidents
graded under the NPSA definition of severe harm);
 A scenario that prevents or threatens to prevent a provider
organisation’s ability to continue to deliver health care
services, for example, actual or potential loss of personal/
organisational information, damage to property, reputation or
the environment, or IT failure;
 Allegations of abuse;
 Adverse media coverage or public concern for the organisation
or the wider NHS;
 One of the core set of ‘Never Events’ as updated on an annual
basis
Strategic Health Strategic health authorities (SHA) manage the local NHS on
Authority
behalf of the secretary of state. Their responsibilities include
making sure local health services are of a high quality and are
performing well. The local SHA, EoE NHS, covers the east of
England.
Thematic review A review of related incidents to determine if there are common
root causes that should be addressed to prevent re-occurrence of
similar incidents.
Unexpected
Death
Where natural causes are not suspected. Local organisations
should investigate these to determine if the incident contributed to
the unexpected death
NHSC/P SI Annual Report 10/11
Page 23 of 23
August 2011