Issue - meetings

Covering report and presentation attached.

The Chief Nurse at BHRUT advised that the Trust was now above the national average for incident reporting – an indication of a healthy organisation. Few of the reported incidents were serious or harmful in nature.  The most common categories of incidents reported included pressure ulcers (on which the Trust had done a lot of work to reduce the occurrence of) delays to treatment, falls within the hospital, medication errors (these were mainly of no harm/near miss incidents) and maternity services. The number of serious incidents reported had reduced.

Learning was undertaken from serious incidents with the Trust identifying root cause analysis and providing families with copies of reports at the conclusion of and investigation. Meetings were also held with local CCGs in order to discuss learning points from incidents.

All complaint responses were reviewed by the Chief Nurse. Complaints were now more focussed on the whole on specific issues and the Trust welcomed the chance to meet face to face with complainants. The Trust had recently received its first Regulation 28 report from a coroner in 18 months concerning a patient who had died following a liver biopsy.    

Data could be circulated by the Trust giving comparisons of incident reporting against national averages. One maternal; death had recently been reported by the Trust, the first such occurrence for two years although two terminally ill mothers who had given birth were also required to be included in the statistics.

The Trust had not received any reports of theatre equipment being used for anything other than medical use. There was a two hour window for the dispensing of prescriptions but these were still reported as near misses if not dispensed at the target time. Staff would be disciplined if necessary but only if incidents were sufficiently serious in nature.

The Trust Chief Nurse agreed that it was unacceptable that patients should develop pressure ulcers and investigated each such case with the appropriate team. IT was aimed to improve such mattes where possible via education, training and support to staff. It was clarified that the statistics covered formal complaints or incidents reported at all the Trust’s hospitals and satellite clinics. Cases dealt with by the Trust Patient Advice and Liaison Service were not included. An initial response would be sent to a complainant within three days which sought to agree a timescale for the completion of the full investigation and response.

It was noted that Barking & Dagenham had not received the Trust’s Quality Account and the Trust would aim to ensure the draft was sent to partners earlier in future years.

The Committee noted the position.