Meeting: Trust Board meeting in public
Date: 30 July 2015
Report Title: Quality Digest – Integrated Complaints and Serious Incidents Report – May and
June 2015
Agenda Item: TB/15-16/042
Enclosures: Detailed summary
Report Author:
Srilatha Sadasivam – Quality Intelligence Analyst
Sophie Williams – BPM Acute
Presenter:
Catherine Kinane - Executive Medical
Director
Pippa Barber – Director of Nursing and
Governance
Report History:
Reviewed and considered by the Quality Committee
Board Lead
Catherine Kinane - Executive Medical
Director
Pippa Barber – Director of Nursing and
Governance
Purpose of the Report
The attached board report sets out the key activity for complaints and
Serious incidents for the period March - April 2015
Performance
Policy
Assurance
x
Strategy
Strategic Objective
1
Enhance service user engagement and patient experience
2
Become an exemplary employer, enabling staff to reach their full potential
3
Ensure sound financial management without compromising the quality of care
4
Develop dynamic and innovative clinical models, enhancing the quality, safety
and effectiveness of services
5
Maintain and further establish our position as the provider of choice for mental
health services
6
Enhance the quality and safety of the services by maintaining or exceeding
required standards of care
7
Incorporate sustainability and environmental management as an essential
element of healthcare delivery
x
x
x
x
Corporate Impact Assessment:
Legal or regulatory implications
Failure to respond to incident and complaints could result
in litigation.
Financial or resource implications
None identified
Engagement / Consultation
None identified
Risks identified
Failure to learn from Serious Incidents and complaints
will put patients at risk of harm. Failure to achieve
compliance could affect Trust reputation.
Links to the Board Assurance
Framework or Risk Register
Impact on Quality
May - June Integrated Board Report
Identify any links to the BAF or risk register
It is essential that any learning from Complaints and SIs
June Board
Page 1 of 13
Equality & Diversity
leads to improvements in service delivery and the quality
of the services being provided.
Reducing severity and/or numbers of incidents is an
indicator for External Agencies with regard to the Quality
of Services delivered by KMPT.
SIs are monitored to ensure patient safety is maintained
for all. Ensuring equal access to safe services as some
Complaints could impact on Equality.
Recommendation / Action required
The Board are asked to consider the content of this report
May - June Integrated Board Report
Approval
Discussion
Consideration x
Noting
Information
June Board
Page 2 of 13
Executive Summary
This report contains headline information regarding the Complaint and SI activity for May and June
2015. The total number of serious incidents recorded for May was 16 and June was 15. Out of
these, 29* incidents have been referred up to STEIS in May and June. There were 23 CCG
closures over this period. There have been no new breaches in the period.
104 serious incidents are currently open with STEIS. We liaise with 5 CCG SI closure systems to
meet quality requirements. There are 42 active cases and these are within date. Of the remaining
62, 5 are “stop the clock applied”, and the remaining 57 are pending with the CCGs. The South
Kent Coast and Thanet CCGs have requested for RCA reports to be submitted for all the SIs. The
Canterbury & Coastal and Ashford CCGs have raised various queries or need further
information/evidence. The SI administrator is co-ordinating with the SI leads for each service line to
obtain this information and return it to the CCGs as soon as possible. For the other CCGs, one is
awaiting the release of a Serious Case Review; others will be going forward to the next CCG
Closure panels.
There were 65 new cases in May and June 2015 which were reportable complaints (Level 2 – 4)
and MP enquiries. During this time we closed 82 reportable complaints and also recorded 78
compliments across the service. All aspects of clinical treatment (35 issues), Admission,
Discharge & Transfer arrangements (10) and Attitude of staff (5) recorded the highest number of
issues in complaints.
Patient Experience – Learning from Complaints (65 complaints received)
Top themes, learning and actions for May and June complaints
Accessing treatment at the time of need
Complaints linked to inpatient beds and accessing treatment when needed has risen within the
acute service line. The issue of service users being moved between wards has been raised and
learning and recommendation that a letter is drafted and given to patients and their family
members advising that they may be moved during their inpatient stay to improve communication
and understanding of the care pathway. One complaint that was partially upheld crossed over both
the community and acute service line and related to the family not feeling that either service
responded in a timely manner when they needed it. The crisis team have appointed an additional
member of staff at night to ensure that the quality of the service is improved along with the
standard of care clients receive out of hours. In addition the process of how to arrange a bed has
been reinforced to clinicians to ensure that transport is arranged in a timely manner to decrease
any delay in admission.
Communication
Communication issues appear a number of times during the period with service users feeling that
there has been a lack of communication or limited information being shared with them. This has left
some confused about outcomes and decisions made in appointments and for others resulted in
them not receiving copies of letters. The service will ensure the outcome letter being addressed to
the service user and is copied to the GP, to ensure collaborative working with the service user.
Other issues raised relate to working in partnership with the client to agree a plan of care and the
importance of listening to and hearing what service users are telling us.
Communication within teams, sharing information with others and holding discussions with other
teams is crucial to delivering the correct care to service users. One complaint has recognised that
in house communication between agencies could be improved and have proposed that regular
meetings take place within one CMHT between KMPT and IAPT.
Transitions in and out of Secondary care:
A small number of complaints relate to the interface and sharing of information for clients who are
moving in or out of services. These sat within the CRSL and learning in each case showed that
May - June Integrated Board Report
June Board
Page 3 of 13
increased or improved sharing of information could have produced better outcomes for individuals
and or their families. Using the Children and young Peoples Service to AdultMentalHealth Service
protocol at its earliest stage in a CMHT will certainly help to improve the journey for young clients
who transition and will encourage communication with other agencies at the earliest opportunity.
One complaint identified that a mother had been given incorrect information about who to contact
when her son was discharged back to primary care. The service manager identified that further
training was required for their administration staff to improve this in the future
Out of time complaints
As at 14.07.2015, there are 2 Out of time complaints as below: One for CRSL East and is a local response, Level 2, awaiting copy of response in order to close;
The second is also a level 2 within Acute services and is awaiting a response from service
manager.
Serious incidents
The information below highlights the focus areas and key actions taken during the period within the
Patient Safety Team.
For the reporting period of May and June 2015, there were 12 patient deaths that were reported; 4
of those being suspected suicides and 8 are currently unknown in origin - it is expected that a
cause will be made known via the coroner as part of their investigations.
2 of the suspected suicide deaths were within Community Recovery Service Line (within different
teams); 1 was in Acute inpatients – Older adult and the other was within the Crisis team based at
Priority House. There are no links between these 4 suspected suicides.
There were 3 recorded falls within this reporting period; 2 were within the Older Peoples Service
Line and were in the inpatient wards.
The CRSL are still working with Medway after an increase in serious incidents in late spring early
summer. The patient safety manager, patient safety lead for the CRSL and the assistant director
are working closely and have carried or three ‘risk summit’ meetings and are looking at
interventions and learning from the findings. Two of the incidents were associated with the
personality disorders pathway and they are currently being investigated.
A root cause analysis training package has been finalised and will be piloted in early September
and rolled out from band 7 and above across all service lines in late September.
Duty of Candour Letters
The service lines have started to send out their own duty of candour letters for incidents that are
happening within their service line. The Acute Service Line has incorporated this into the
investigation process and the letter is sent out as the investigator is allocated. This system could
be adopted for all service lines. Eight letters were sent out in June from the Patient Safety
administrator, further letters were sent out by the serious incident investigators. Duty of Candour
letters will be monitored by Datix starting at the end of July
May - June Integrated Board Report
June Board
Page 4 of 13
Deprivation of Liberty Safeguards
The DoLS applications from KMPT wards were:
 April – June 2014 = 12
 July – September 2014 = 22
 October – December 2014 = 65
 January – March 2015 = 25
 April – June 2015 = 30
In June 2015 there were,
26 urgent authorisations for Deprivation of Liberty Safeguards made by KMPT wards (up by 13
from May)
14 KMPT patients subject to urgent authorisations (up by 1 from May)
44KMPT patients subject to a breached urgent authorisation (down by 6 from May)
27 KMPT patients subject to standard authorisations (up by 3 from May)
Control and Restraint
The figures for April and May are highlighted in the table below:
All May data has been extracted from the new Datix WEB – the format of recording this data has
changed therefore further detail for reporting will be made available as security and reporting issue
are resolved.
It is expected to see further reporting on restraint incidents as the Datix WEB system is
now being used to record all incidents.
April
May
Total restraints reported
49
149
Number of Patients
25
91
Of the total reported
Of those prone
14 were prone
48 were prone
8 face to side
na
5 face down
na
14 were immediately
turned *
na
8 were for IM
injections *
na
2 were because the
patient threw
themselves forward
na
Month
Of those prone
May - June Integrated Board Report
June Board
Page 5 of 13
The graph below shows the total number of seclusions during a six month period. Where there are
peaks or increases during the period, further information and assurance is provided to the Quality
Committee from the ward mangers and PSTS leads (Promoting Safer Therapeutic Services).
Conclusion
The Quality Digest continues to be presented and scrutinised at the Quality Committee on a
monthly basis ensuring that themes and trends around serious incidents and complaints are
brought to the attention of the committee in a timely manner enabling concerns to be
highlighted and actioned by the Patient Experience Team, the Patient Safety Manager and
Service Line Leads.
Recommendations
The Board are asked to consider the report.
May - June Integrated Board Report
June Board
Page 6 of 13
Quality Digest Dashboard for May/June 2015 – Integrated Complaints and Serious Incident Analysis
COMPLAINTS/MP
Complaints by Service Line and Level
May/June Total 65 (including Corporate Services)
Subject with highest complaints
All aspects of clinical treatment
Admissions, Discharge & Transfer
arrangements
Appointments, delay/cancellation
(outpatient)
Attitude of Staff
Communication/information to
patients (written and oral)
Serious Incidents by Service Line and Level
May/June Total 30 (Open SIs – 129)
34
10
5
4
4
Severity (*None is no longer a valid Severity
from April 2015)
Closed Reportable
Complaints
Closed
All
May/Jun open
ASL
17
18
CRS
49
40
FOR
6
2
SS
4
3
OPMH
5
7
CS
1
0
Total
82
70
Closed Serious Incidents
All Open/closed Reportable Complaints
All internal Open/Closed Serious Incidents for 1
year
Closed
All
May/Jun Open
OPMH
6
13
1
0
6
33
60
5
27
4
Total
26
129
ASL
SERIOUS INCIDENTS
CRS
FOR
SS
12 Deaths = 4 suspected suicides, 8
Unexpected/Unknown
No Never events
1 AWOL – moderate harm
All Deaths – suspected and actual suicides over last 24 months ( *The process of reporting suspected
suicides has changed from April 2015 with the launch of Web Datix)
There were no Never events
There were no medication incidents
All inpatient falls * of severity moderate and severe between April - June
2015
6 - Acute Inpatient Services - Older Adult
* From April 2015, Falls figure will include both Suspected slips/trips/falls and
Witnessed slips/trips/falls
March-April Integrated Board Report
June Board
Page 7 of 13
COMPLAINTS/MP Enquiries
Acute Service Line
Quality Digest Dashboard for May/June 2015 – Integrated Complaints and Serious Incident Analysis
Complaints & MP Enquiries
Total 16 for May/June (18 complaints open)
Subject with highest complaints
Secondary Location with highest
complaints
All aspects of clinical treatment
Admissions, Discharge &
Transfer arrangements
9
LR Partially Upheld
2
4
LR Upheld
3
Woodlands Ward
2
Patients privacy and dignity
1
2
Attitude of Staff
1
Foxglove Ward
2
LR Not Upheld
Closed - No Consent - General
Response Given
2
Willow Suite
2
Concerns resolved
1
SERIOUS INCIDENTS
Highest Adverse Events
Requires investigation to be
completed to establish if an
incident occurred
Suicide attempt/gesture (not
overdose)
Suicide (actual)
Failed to return from authorized
leave
Injury of unknown origin
Other
Highest Sis by Secondary Location
Severity
Patients Home (Incidents
Only)
5
Liaison Psychiatry Team
2
1
1
Bluebell Ward
1
Fern Ward
1
1
1
3
Woodlands Ward
1
Amberwood Ward
1
Off Site (Incidents Only)
1
5
Adverse events/Incident Categories with the highest number for last 12 months (* These categories
have changed from April 2015)
March-April Integrated Board Report
10
Upnor Ward
North East Kent CRHT
* 5 teams had 1 complaint
Serious Incidents by Month and level
Total for May/June 12 (Currently 33 open SIs)
Highest Complaint outcomes
There were no never events
June Board
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1
COMPLAINTS/MP Enquiries
Community Recovery Service Line
Quality Digest Dashboard for May/June 2015 – Integrated Complaints and Serious Incident Analysis
Complaints & MP Enquiries
Total 33 for May/June (currently 40 Open)
SERIOUS INCIDENTS
Serious Incidents by Month and level
Total for May/Jun- 9 (Currently 60 open Sis)
Subject with highest complaints
Secondary Location with highest
complaints
All aspects of clinical treatment
Communication/information to
patients (written and oral)
Admissions, Discharge &
Transfer arrangements
19
Attitude of Staff
Appointments,
delay/cancellation (outpatient)
2
4
4
2
Highest Adverse Events
Requires investigation to be
completed to establish if an
incident occurred
3
Suicide (actual)
2
Physical
1
Other patient accident
Suicide attempt/gesture (not
overdose)
1
Other self harming behaviour
1
6
5
5
4
LR Partially Upheld
18
Concerns resolved
12
4
* 2 teams had 3 complaints and 1 team
with 2 and other team had one complaint
Highest Sis by Secondary Location
Off Site (Incidents Only)
Patients Home (Incidents
Only)
Canterbury Coastal CMHT
Thanet CMHT
South Kent Coast CMHT
LR Upheld
6
LR Not Upheld
5
Assistance Given
4
Given Information
Service Improvement
Recommended
3
Severity
3
3
1
1
1
1
Top 3 Adverse Events/Incident Categories for last 12 months (* These categories have changed
from April 2015)
March-April Integrated Board Report
Maidstone CMHT
Ashford CMHT
Medway C.M.H.T.
South West Kent CMHT
Dartford Gravesend and
Swanley CMHT
Highest Complaint outcomes
There were no Never events
June Board
Page 9 of 13
1
COMPLAINTS/MP Enquiries
Older Adult Service Line
Quality Digest Dashboard for May/June 2015 – Integrated Complaints and Serious Incident Analysis
Complaints & MP Enquiries
Total 7 for May/June (7 Complaints Open)
Subject with highest complaints
All aspects of clinical
treatment
Transport (ambulances and
other)
Admissions, Discharge &
Transfer arrangements
Serious Incidents by Month and level
Total 78 for May/June (Currently 23 open SIs)
1
1
Highest Adverse Events
Requires investigation to be
completed to establish if an
incident occurred
SERIOUS INCIDENTS
5
Highest Complaint outcomes
2
Woodchurch Ward
Dartford Gravesend and Swanley
CMHTOP
Gregory House - Canterbury
CMHTOP
2
1
Implicating furnishings
Movement to/from
bed/stretcher
1
Suicide (actual)
1
Walking
1
Walking unassisted
1
Other
1
1
LR Partially Upheld
3
Concerns resolved
1
Given Information
1
1
1
Highest Sis by Secondary Location
Top 3 Adverse Events/Incident Categories for last 12 months (* These categories have changed
from April 2015)
March-April Integrated Board Report
Secondary Location with highest
complaints
Medway East CMHT for Older
People
Severity
The Orchards
2
Cranmer Ward
2
Woodchurch Ward
1
Off Site (Incidents Only)
1
Patients Home (Incidents Only)
1
There were no never events.
June Board
Page 10 of 13
COMPLAINTS/MP Enquiries
Specialist Services
Quality Digest Dashboard for May/June 2015 – Integrated Complaints and Serious Incident Analysis
Complaints & MP Enquiries
Total 5 for May/June (3 Complaints Open)
Subject with highest complaints
Appointments,
delay/cancellation
(outpatient)
Admissions, Discharge &
Transfer arrangements
All aspects of clinical
treatment
Highest Adverse Events
2
1
Highest Complaint outcomes
Autistic Spectrum Disorder
1
Concerns resolved
2
MIMHS Team
1
Concerns Not Resolved
1
Outpatient/ Day Therapy
1
LR Partially Upheld
1
West Kent Neuro-Psychiatary
1
1
Highest Sis by Secondary Location
Severity
SERIOUS INCIDENTS
Serious Incidents by Month and level
Total 0 for May/June (Currently 4 open SIs)
Secondary Location with highest complaints
Adverse events for last 12 months
There were no never events
Abuse - other
2
Illicit use of drugs
1
Other - please specify in description *
1
* Other : Death - cause unknown
March-April Integrated Board Report
June Board
Page 11 of 13
COMPLAINTS/MP Enquiries
Forensic Service Line
Quality Digest Dashboard for May/June 2015 – Integrated Complaints and Serious Incident Analysis
Complaints & MP Enquiries
Total 4 for May/June (2 Complaints Open)
Subject with highest complaints
Appointments, delay/
cancellation (outpatient)
Attitude of Staff
Patients property and
expenses
Policy and commercial
decisions of Trusts
Secondary Location with highest
complaints
Highest Complaint outcomes
1
Concerns Not Resolved
3
The Allington Centre
3
1
LR Not Upheld
2
Bedgebury Ward
1
LR Partially Upheld
1
1
1
*1 complaint subject was not recorded
SERIOUS INCIDENTS
Serious Incidents by Month and level
Total 2 for June (Currently 5 open SIs)
Adverse Events (*These categories have
changed from April 2015)
Requires investigation to be
completed to establish if an
incident occurred *
1
Other *
1
SIs by Secondary Location
Severity
The Allington Centre
1
Riverhill Ward
1
MODERATE
1
* Requires Investigation & Other : 1
Death cause unknown; 1 Personal matter
Adverse Events for last 12 months (* These categories have changed from April 2015)
No trend can be identified between location, serious incident and complaints
Physical abuse, assault or violence
2
Other - please specify in description *
4
Self harm - actual
1
Suicide (completed), whether proven or suspected
1
Illicit use of drugs
1
There were no Never events
.
Disruptive, aggressive behaviour - other
1
* Other : 2 Death – cause unknown, 1 Access to personal devices and info through HCW, 1
Personal matte
March-April Integrated Board Report
June Board
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March-April Integrated Board Report
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