Manchester Newborn Screening Laboratory Quarterly Blood ... · 1 Aisha Rahman & everly Hird...

1 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10

Manchester Newborn Screening Laboratory Quarterly Blood Spot

Screening Report: Quarter 4 2019-20

Manchester Newborn Screening Laboratory, which serves babies born in Greater

Manchester, Lancashire and South Cumbria, received 13143 blood spot samples between 1st

January and 31st March 2020. This report describes performance against the NHS Newborn

Blood Spot Screening Programme Standards. Full details of the standards including

definitions and exclusions can be found at https://www.gov.uk/government/publications/

standards-for-nhs-newborn-blood-spot-screening. The appendix of this document contains

the data for standards 3-7 in table form.

The data for the laboratory reportable standards is presented by maternity unit/NHS trust of the sample taker. For accurate figures, please ensure the trust code is written/stamped on the blood spot card (in the PCT field). The proportion of samples with a missing maternity unit/trust code is presented in figure 1 by CCG. Overall the maternity/ trust code was missing from 115 sample cards (0.9%).

Declines In quarter 4 the laboratory received 56 notifications of declined blood spot screening. Figure 2 shows the trends in declined screens over the past year, by place of birth (born in UK or born outside of UK). The laboratory should be notified of all declines, including those for babies screened elsewhere, rather than directly notifying Child Health.


Key to colour coding

Met achievable threshold

Met acceptable threshold

Within 10% of acceptable threshold

More than 10% below acceptable threshold

Standard 3 – The proportion of blood spot cards received by the laboratory with the

baby’s NHS number on a barcoded label

Acceptable: ≥ 90.0% of blood spot cards are received by the laboratory with the baby’s NHS number on a barcoded label. Achievable: ≥ 95.0% of blood spot cards are received by the laboratory with the baby’s NHS

number on a barcoded label.

Figure 3 displays performance against standard 3.

Overall, 83.7% of samples received January and 31st March 2020 had a barcoded NHS

number label, which is slightly higher than quarter 3 (82.7%). Of 11 maternity units, 4 met

the standard, including two reaching the achievable threshold (East Lancashire and

Lancashire Teaching).

Standard 4 - The proportion of first blood spot samples taken on day 5

Acceptable: ≥ 90.0% of first blood spot samples are taken on day 5. Achievable: ≥ 95.0% of first blood spot samples are taken on day 5. Figure 4 displays performance against standard 4. Overall, 92.0% of samples received January and 31st March 2020 were collected on day 5. Of 11 maternity units, 10 met standard 4, which is similar to quarter 3 (91.5%; 10 units met the standard). Manchester FT and Blackpool met the achievable threshold.


Standard 5 - The proportion of blood spot samples received less than or equal to 3

working days of sample collection

Acceptable: ≥ 95.0% of all samples received less than or equal to 3 working days of sample collection.

Achievable: ≥ 99.0% of all samples received less than or equal to 3 working days of sample collection.

Performance against the transport standard (figure 5) was good. Overall 98.1% samples

were received within 3 working days. 9 Trusts met the standard, including 6 reaching the

achievable threshold. Performance was very similar to the last quarter (98.6% samples

received within 3 working days).

Standard 6 - The proportion of first blood spot samples that require repeating due to an

avoidable failure in the sampling process

Acceptable: Avoidable repeat rate is ≤ 2.0%

Achievable: Avoidable repeat rate is ≤ 1% The avoidable repeat rate for quarter 4 was 2.1%, compared with 2.5% in quarter 3. The

performance for each trust is displayed in figure 6. Five Trusts met the standard. Tameside

met the achievable standard. Figure 7 compares the avoidable repeat rate for samples

collected from in-patients with sample collected from babies at home/ in the community.

The rate was 1.7% for babies at home (similar to quarter 3; 1.8%) and 5.2% for samples

collected from in-patients (7.1% in quarter 3).

Please note that from 23rd March 2020, the national COVID-19 temporary acceptance

criteria was applied. Using the standard acceptance criteria, the avoidable repeat rate for

this quarter would have been 2.5% as an additional 44 samples would have been rejected.

When processing samples we have noticed a definite deterioration in sample quality

presumably as a result of pressures due to the pandemic and awareness of the less stringent

sample acceptance criteria. Please see the Appendix for additional tables displaying what

the rejection rates would have been (by Trust and for in-patients) using the established

criteria.


There were no avoidable repeats for Blackburn in-patients.


Trust STD 3 STD 4 STD 5 STD 6

Blackpool Teaching Hospitals NHS FT 91.1% 95.7% 99.1% 1.2%

Bolton NHS FT 82.1% 92.3% 99.5% 2.4%

East Lancashire Hospitals NHS Trust 95.2% 92.3% 99.5% 2.0%

Lancashire Teaching Hospitals NHS FT 97.2% 93.7% 99.6% 1.1%

Manchester University NHS FT 93.4% 95.3% 99.8% 2.2%

Pennine Acute Hospitals NHS Trust 82.4% 89.1% 97.0% 2.2%

Southport & Ormskirk Hospital NHS

Trust76.6% 93.6% 80.3% 3.8%

Stockport NHS FT 83.7% 92.8% 99.7% 2.4%

Tameside And Glossop Integrated Care

NHS FT89.1% 93.2% 97.8% 0.6%

University Hospitals of Morecambe Bay

NHS FT89.2% 94.5% 96.8% 2.0%

Wrightington, Wigan and Leigh NHS FT 21.9% 93.0% 94.1% 3.0%

Q4 19-20 Table 1 - Summary of performance


Standard 7a - The proportion of second blood spots for raised IRT taken on day 21 to day

24

Acceptable: ≥ 95% of second blood spot samples taken on day 21 to day 24 Achievable: ≥ 70% of second blood spot samples taken on day 21

The acceptable threshold was met for Standard 7a. During quarter 4 there were 6 repeats

for raised IRT (CF inconclusive). Of these, 67% (4) were collected on day 21 and 100% (6) on

day 21-24. CF inconclusive repeats are performed by Screening Link Health Visitors. The data

is presented in figure 7 and by local Child Health Records Department, in table 2.

21 22 23

Blackpool 1 1 2 50% 100%Lancaster 1 1 0% 100%Manchester 1 1 100% 100%

Rochdale 1 1 100% 100%Salford 1 1 100% 100%

Grand Total 4 1 1 6 67% 100%

% collected

day 21-24

Child Health Records

DepartmentGrand Total

%

collected

day 21

Age at Collection of CF Inconclusive

Repeat (days)

Q4 Table 2 - Standard 7a


Standard 7b - The proportion of second blood spot samples for borderline TSH taken

between 7 and 10 calendar days after the initial borderline sample

Acceptable: ≥ 95.0% of second blood spot samples taken as defined Achievable: ≥ 99.0% of second blood spot samples taken as defined Standard 7b was not met. Figure 8 displays the proportion collected 7-10 days after the initial sample and table 3 displays the information by Trust.

7 8 9 10 11 12

Blackpool Teaching Hospitals NHS FT 1 1 100%

Bolton NHS FT 1 1 100%East Lancashire Hospitals NHS Trust 1 1 100%Lancashire Teaching Hospitals NHS FT 1 1 2 50%Manchester University NHS FT - SMH & RMCH 1 1 2 4 100%Manchester University NHS FT - Wythenshawe 1 3 1 5 80%Not Stated 1 1 100%Pennine Acute Hospitals NHS Trust 1 2 2 2 8 63%Southport & Ormskirk Hospital NHS Trust 2 2 100%Tameside And Glossop Integrated Care NHS FT 1 1 100%University Hospitals of Morecambe Bay NHS FT 2 2 100%Wrightington, Wigan and Leigh NHS FT 1 1 0%Grand Total 1 5 8 9 3 2 29 79%

Trust

% collected 7-10

days after

original sample

Grand Total

Number of days between original sample

and collection of repeat sample

Q4 Table 3: Standard 7b


Standard 7c - The proportion of CHT pre-term repeats collected on day 28 or at discharge

Acceptable: ≥ 95.0% of second blood spot samples taken as defined

Achievable: ≥ 99.0% of second blood spot samples taken as defined

Standard 7c was not met. During quarter 3, 116 CHT pre-term repeats (second samples only,

avoidable repeats excluded) were received. Performance by trust is displayed in figure 9.

78% were collected on day 28 or at discharge. 5% were collected too early and required a

further repeat. 16% were collected after day 28.

Of note, 10 out of 19 babies with samples collected after day 28 had transfusions on days

25-28, which would account for the delayed sampling.

Standard 9 - Timely processing of CHT and IMD (excluding HCU) screen positive samples

Acceptable: 100% of babies with a positive screening result (excluding HCU) have a clinical

referral initiated within 3 working days of sample receipt

8 samples screened positive for CHT during quarter 4. 100% of babies were referred within 3

working days.

There were 6 IMD positives (excluding HCU) and all were referred within 3 working days.

Standard 11 - Timely entry into clinical care

Data for standard 11 is displayed in table 4.


Condition Criteria Thresholds

Number of

babies seen by

specialist

services by

condition

specific

standard

Number of

babies

referred

Percentage

seen by

specialist

services by

condition

specific

standard

Comments

IMDs (excluding HCU)

Attend first clinical

appointment by 14 days of

age

Acceptable: 100% 6 6 100%

CHT (suspected on first

sample)



age


CHT (suspected on repeat

following borderline TSH)



age


CF (2 CFTR mutations

detected)



age

Acceptable: ≥ 95.0%

Achievable: 100%4 4 100%

HCU



age

Acceptable: ≥ 95.0%

Achievable: 100%0 0 N/A

CF (1 or no CFTR mutation

detected)



age


appointment by 35

days of age

2 4 50%

1 baby died at 2.5 months prior to being seen by

CF team. One extremely pre-term baby seen on

day 84.

SCD



age


appointment by 90

days of age

5 6 83%1 baby not 90 days yet (88 days old at the time of

this report)

Table 4: Standard 11


Incidents

Figure 10 displays blood spot screening incidents identified by the lab or notified to the lab. A summary table of incidents is included in the

appendix.


Appendix

TrustNumber of all samples

(including repeats)

Number of blood spot

cards including baby's

NHS number

Number of blood spot

cards including ISB

label barcoded baby's

NHS number

Percentage of all blood

spot cards including

babies' NHS number

Percentage of all blood

spot cards including ISB

bar-coded babies' NHS

number

Blackpool Teaching Hospitals NHS FT 666 666 607 100.00% 91.14%

Bolton NHS FT 1590 1588 1305 99.87% 82.08%

East Lancashire Hospitals NHS Trust 1623 1620 1545 99.82% 95.19%

Health Visitor 126 119 1 94.44% 0.79%

Lancashire Teaching Hospitals NHS FT 963 963 936 100.00% 97.20%

Manchester University NHS FT - SMH & RMCH 2393 2387 2234 99.75% 93.36%

Not Stated 115 113 84 98.26% 73.04%

Pennine Acute Hospitals NHS Trust 2544 2537 2095 99.72% 82.35%

Southport & Ormskirk Hospital NHS Trust 248 248 190 100.00% 76.61%

Stockport NHS FT 790 790 661 100.00% 83.67%

Tameside And Glossop Integrated Care NHS FT 634 634 565 100.00% 89.12%

University Hospitals of Morecambe Bay NHS FT 687 685 613 99.71% 89.23%

Wrightington, Wigan and Leigh NHS FT 764 759 167 99.35% 21.86%

Grand Total 13143 13109 11003 99.74% 83.72%

Quarter 4 2019-20: Standard 3


Trust

Number of first

samples taken

on or before

day 4

5 6 7 8 9+ 4 or earlier 5 6 7 8 9 or later

Blackpool Teaching Hospitals NHS FT 1 619 19 2 1 5 0.15% 95.67% 2.94% 0.31% 0.15% 0.77%

Bolton NHS FT 1 1330 78 19 5 8 0.07% 92.30% 5.41% 1.32% 0.35% 0.56%

East Lancashire Hospitals NHS Trust 2 1368 90 12 2 8 0.13% 92.31% 6.07% 0.81% 0.13% 0.54%

Health Visitor 0 0 0 0 0 104 0.00% 0.00% 0.00% 0.00% 0.00% 100.00%

Lancashire Teaching Hospitals NHS FT 2 865 34 3 7 12 0.22% 93.72% 3.68% 0.33% 0.76% 1.30%

Manchester University NHS FT 1 2043 72 12 7 8 0.05% 95.33% 3.36% 0.56% 0.33% 0.37%

Not Stated 0 74 3 0 1 0 0.00% 94.87% 3.85% 0.00% 1.28% 0.00%

Pennine Acute Hospitals NHS Trust 5 2144 204 21 13 20 0.21% 89.07% 8.48% 0.87% 0.54% 0.83%

Southport & Ormskirk Hospital NHS Trust 1 221 8 3 2 1 0.42% 93.64% 3.39% 1.27% 0.85% 0.42%

Stockport NHS FT 0 706 43 6 1 5 0.00% 92.77% 5.65% 0.79% 0.13% 0.66%

Tameside And Glossop Integrated Care NHS FT 1 578 35 2 2 2 0.16% 93.23% 5.65% 0.32% 0.32% 0.32%

University Hospitals of Morecambe Bay NHS FT 1 623 22 3 2 8 0.15% 94.54% 3.34% 0.46% 0.30% 1.21%

Wrightington, Wigan and Leigh NHS FT 1 674 41 5 0 4 0.14% 92.97% 5.66% 0.69% 0.00% 0.55%

Grand Total 16 11245 649 88 43 185 0.13% 91.98% 5.31% 0.72% 0.35% 1.51%


Excludes samples with missing dates


Maternity Unit

Number of samples

received in 3 or fewer

working days of

sample being taken

Total number of

samples received

Percentage of

samples received by

laboratories in 3 or

fewer working days

of sample being

taken

Blackpool Teaching Hospitals NHS FT 658 664 99.1%

Bolton NHS FT 1502 1510 99.5%

East Lancashire Hospitals NHS Trust 1535 1542 99.5%

Health Visitor 104 110 94.5%

Lancashire Teaching Hospitals NHS FT 951 955 99.6%

Manchester University NHS FT 2267 2271 99.8%

Not Stated 86 88 97.7%

Pennine Acute Hospitals NHS Trust 2444 2520 97.0%

Southport & Ormskirk Hospital NHS Trust 196 244 80.3%

Stockport NHS FT 788 790 99.7%

Tameside And Glossop Integrated Care NHS FT 618 632 97.8%

University Hospitals of Morecambe Bay NHS FT 660 682 96.8%

Wrightington, Wigan and Leigh NHS FT 718 763 94.1%

Grand Total 12527 12771 98.1%



Status code and description of avoidable

repeat

Blackpool

Teaching

Hospitals

NHS FT

Bolton NHS

FT

East

Lancashire

Hospitals

NHS Trust

Lancashire

Teaching

Hospitals

NHS FT

Manchester

University

NHS FT

Not StatedHealth

Visitor

Pennine

Acute

Hospitals

NHS Trust

Southport &

Ormskirk

Hospital NHS

Trust

Stockport

NHS FT

Tameside

And Glossop

Integrated

Care NHS FT

University

Hospitals of

Morecambe

Bay NHS FT

Wrightington,

Wigan and Leigh

NHS FT

Grand

Total

0301: too young for reliable screening (≤ 4

days)0 0 3 1 0 0 0 4 0 0 1 1 1 11

0302: too soon after transfusion (<72 hours) 0 6 8 2 7 1 0 3 0 2 0 0 0 29

0303: insufficent sample 6 14 10 3 8 1 0 7 0 4 1 3 4 61

0304: unsuitable sample (blood quality):

incorrect blood application2 15 4 5 22 2 2 16 3 14 1 3 10 99


compressed/damaged 0 0 0 0 2 0 0 5 1 0 1 1 0 10

0306: Unsuitable sample: day 0 and day 5 on

same card0 0 0 0 0 0 0 0 0 0 0 0 0 0

0307: unsuitable sample for CF: possible

faecal contamination0 5 0 0 4 0 0 4 1 0 0 1 2 17

0308: unsuitable sample: NHS number

missing/not accurately recorded0 0 2 0 4 2 4 7 0 0 0 2 4 25

0309: unsuitable sample: date of sample


0310: unsuitable sample: date of birth not

accurately matched0 0 0 0 0 0 0 0 0 0 0 0 0 0

0311: unsuitable sample: expired card used 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0312: unsuitable sample: >14 days in transit,

too old for analysis0 0 0 0 0 0 0 1 0 0 0 0 0 1

0313: unsuitable sample: damaged in transit 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Avoidable Repeat Requests 8 34 30 10 47 6 6 53 9 18 4 13 22 260

Number of first samples received/

babies tested647 1442 1495 925 2151 96 120 2420 240 761 620 663 726 12306

Avoidable Repeat Requests Rate 1.2% 2.4% 2.0% 1.1% 2.2% 6.3% 5.0% 2.2% 3.8% 2.4% 0.6% 2.0% 3.0% 2.1%

Transfusion Reapeats are not included in the Avoidable Repeat calculation

Quarter 4 2019-20: Standard 6 by Trust


Status code and description of avoidable repeat

Blackpool Victoria Hospital

Burnley General Hospital

Furness General Hospital

North Manchester

General Hospital

Not in hospital

Ormskirk & District General

Royal Albert

Edward Infirmary

Royal Blackburn Hospital

Royal Bolton

Hospital

Royal Lancaster Infirmary

Royal Manchester

Childrens Hospital

Royal Oldham Hospital

Royal Preston Hospital

St Mary's Hospital,

Manchester

Stepping Hill

Hospital

Wythenshawe Hospital

Tameside General Hospital

Grand Total

0301: too young for reliable screening (≤ 4 days)

0 1 0 0 9 0 1 0 0 0 0 0 0 0 0 0 0 11

0302: too soon after transfusion (<72 hours)

0 8 0 0 1 0 0 0 6 0 0 3 2 7 2 0 0 29

0303: insufficent sample 1 3 1 1 45 0 0 0 1 1 1 3 0 1 1 2 0 61

0304: unsuitable sample (blood quality): incorrect blood application

0 3 0 4 59 2 4 0 5 0 1 2 1 9 3 6 0 99

0305: unsuitable sample (blood quality): compressed/damaged

0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 1 1 10

0306: Unsuitable sample: day 0 and day 5 on same card

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0307: unsuitable sample for CF: possible faecal contamination

0 0 0 0 15 0 0 0 1 0 0 1 0 0 0 0 0 17

0308: unsuitable sample: NHS number missing/not accurately recorded

0 0 0 1 20 0 3 0 0 0 0 1 0 0 0 0 0 25

0309: unsuitable sample: date of sample missing/not accurately recorded

0 2 0 0 29 1 0 0 0 0 0 1 0 2 0 1 0 36

0310: unsuitable sample: date of birth not accurately matched

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0311: unsuitable sample: expired card used

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0312: unsuitable sample: >14 days in transit, too old for analysis

0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1

0313: unsuitable sample: damaged in transit

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Avoidable Repeat Requests 1 9 1 6 185 3 8 0 7 1 2 9 1 12 4 10 1 260

Number of first samples received/ babies tested

70 169 17 93 10859 18 61 3 164 42 12 175 110 282 68 110 53 12306

Avoidable Repeat Requests Rate 1.4% 5.3% 5.9% 6.5% 1.7% 16.7% 13.1% 0.0% 4.3% 2.4% 16.7% 5.1% 0.9% 4.3% 5.9% 9.1% 1.9% 2.1%


Quarter 4 2019-20: Standard 6 by Current Hospital


Projection of avoidable repeat rate by Trust for Q4 2020 had the standard acceptance criteria been used

Status code and description of avoidable

repeat

Blackpool

Teaching

Hospitals NHS

FT

Bolton

NHS FT

East Lancashire

Hospitals NHS

Trust

Lancashire

Teaching

Hospitals NHS

FT

Manchester

University NHS

FT

Not

Stated

Health

Visitor

Pennine

Acute

Hospitals

NHS Trust

Southport &

Ormskirk

Hospital NHS

Trust

Stockport

NHS FT

Tameside And

Glossop

Integrated Care

NHS FT

University

Hospitals of

Morecambe

Bay NHS FT

Wrightington,

Wigan and

Leigh NHS FT

Grand

Total

0301: too young for reliable screening (≤ 4

days)1 0 3 2 0 0 0 4 1 0 1 1 1 14

0302: too soon after transfusion (<72 hours) 0 6 8 2 7 1 0 3 0 2 0 0 0 29

0303: insufficent sample 6 21 15 5 9 4 0 12 0 4 1 4 4 85


incorrect blood application4 18 4 7 23 2 2 22 3 15 1 3 11 115


compressed/damaged 0 0 0 0 2 0 0 5 1 0 1 1 0 10

0306: Unsuitable sample: day 0 and day 5 on

same card0 0 0 0 0 0 0 0 0 0 0 0 0 0

0307: unsuitable sample for CF: possible

faecal contamination0 5 0 0 4 0 0 4 1 0 0 1 2 17

0308: unsuitable sample: NHS number


0309: unsuitable sample: date of sample


0310: unsuitable sample: date of birth not

accurately matched0 0 0 0 0 0 0 0 0 0 0 0 0 0

0311: unsuitable sample: expired card used 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0312: unsuitable sample: >14 days in transit,

too old for analysis0 0 0 0 0 0 0 1 0 0 0 0 0 1

0313: unsuitable sample: damaged in transit 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Avoidable Repeat Requests 11 44 35 15 50 9 6 64 10 19 4 14 23 304

Number of first samples received/

babies tested647 1442 1495 925 2151 96 120 2420 240 761 620 663 726 12306

Avoidable Repeat Requests Rate 1.7% 3.1% 2.3% 1.6% 2.3% 9.4% 5.0% 2.6% 4.2% 2.5% 0.6% 2.1% 3.2% 2.5%


Quarter 4 2019-20: Standard 6 by Trust - using the standard acceptance criteria


Projection of avoidable repeat rate by current hospital (in-patients) for Q4 2020 had the standard acceptance criteria been used

Status code and description of avoidable repeat

Blackpool Victoria Hospital

Burnley General Hospital

Furness General Hospital

North Manchester

General Hospital

Not in hospital

Ormskirk & District General

Royal Albert Edward

Infirmary

Royal Blackburn Hospital

Royal Bolton

Hospital

Royal Lancaster Infirmary

Royal Manchester

Childrens Hospital

Royal Oldham Hospital

Royal Preston Hospital

St Mary's Hospital,

Manchester

Stepping Hill

Hospital

Tameside General Hospital

Wythenshawe Hospital

Grand Total

0301: too young for reliable screening (≤ 4 days)

1 1 0 0 11 0 1 0 0 0 0 0 0 0 0 0 0 14

0302: too soon after transfusion (<72 hours)

0 8 0 0 1 0 0 0 6 0 0 3 2 7 2 0 0 29

0303: insufficent sample 1 4 1 1 64 0 0 0 4 1 1 4 0 1 1 0 2 85

0304: unsuitable sample (blood quality): incorrect blood application

0 3 0 7 68 2 4 0 6 0 1 4 1 10 3 0 6 115

0305: unsuitable sample (blood quality): compressed/damaged

0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 1 1 10

0306: Unsuitable sample: day 0 and day 5 on same card

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0307: unsuitable sample for CF: possible faecal contamination

0 0 0 0 15 0 0 0 1 0 0 1 0 0 0 0 0 17

0308: unsuitable sample: NHS number missing/not accurately recorded

0 0 0 1 20 0 3 0 0 0 0 1 0 0 0 0 0 25

0309: unsuitable sample: date of sample missing/not accurately recorded

0 2 0 0 30 1 0 0 0 0 0 1 0 2 0 0 1 37

0310: unsuitable sample: date of birth not accurately matched

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0311: unsuitable sample: expired card used

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0312: unsuitable sample: >14 days in transit, too old for analysis

0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1

0313: unsuitable sample: damaged in transit

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Avoidable Repeat Requests 2 10 1 9 216 3 8 0 11 1 2 12 1 13 4 1 10 304

Number of first samples received/ babies tested

70 169 17 93 10859 18 61 3 164 42 12 175 110 282 68 53 110 12306

Avoidable Repeat Requests Rate 2.9% 5.9% 5.9% 9.7% 2.0% 16.7% 13.1% 0.0% 6.7% 2.4% 16.7% 6.9% 0.9% 4.6% 5.9% 1.9% 9.1% 2.5%


Quarter 4 2019-20: Standard 6 by Current Hospital - using the standard acceptance criteria


Early On time Late Total

Blackpool Teaching Hospitals NHS FT 0 1 1 2 50% 50%

Bolton NHS FT 1 5 4 10 50% 60%

East Lancashire Hospitals NHS Trust 1 10 2 13 77% 85%

Lancashire Teaching Hospitals NHS FT 0 14 2 16 88% 88%

Manchester FT 0 22 5 27 81% 81%

Pennine Acute Hospitals NHS Trust 4 19 3 26 73% 88%

Stockport NHS FT 0 5 0 5 100% 100%

Tameside And Glossop Integrated Care NHS FT 0 3 0 3 100% 100%

University Hospitals of Morecambe Bay NHS FT 0 5 1 6 83% 83%

Wrightington, Wigan and Leigh NHS FT 0 7 1 8 88% 88%

Grand Total 6 91 19 116 78% 84%

Quarter 4 2019-20: Standard 7c

Trust

Number of Pre-term CHT second samples collected: % Prem repeats

collected on day 28

or at discharge

% Prem repeats

collected on day 28

or earlier

Incident

Number

Incident

Date

Incident

Severity

Incident

HarmSummary of incident Further details

Lab/ Ward/

Maternity Unit

2107782 04/01/20 2 - minor 1 - no harmBlood spot collection error: delay/

failure to collect screening sample

Delayed postnatal care.

Sample collected day 12.

SMH Community

Midwives

2101378 20/11/19 4 - major 1 - no harm

Blood spot labelling error: another

baby's bar-coded demographic

sticker, detected prior to reporting

Mismatch of handwritten

mother's details with

details on barcode.

Lancaster Community

Midwives

2109211 08/01/20 1 - low 1 - no harm

Blood spot transport issue: sample(s)

delayed/ lost in transit or not

dispatched, resulting in retesting of

baby

SMH Community

Midwives

2109785 12/01/20 1 - low 1 - no harmBlood spot collection error: delay/


Patient expected visit on

day 5. Sample collected

day 6.

Wythenshawe

Community Midwives

2109813 15/01/20 2 - minor 1 - no harm

Blood spot labelling error: unlabelled/

inadequately labelled sample found

on ward

Disposed off Ward 68, SMH (NICU)

2112433 30/01/20 1 - low 1 - no harm




baby

First sample not recorded

as received in clerk' s

office or lab. Repeat

collected day 15.

Ward C2,

Wythenshawe

2113111 03/02/20 4 - major 6-external

Blood spot labelling error: manually

labelled with another baby's

demographic details

Blood spot card

contained a mixture of

demographic details from

two different babies.

Bolton Community

Midwives


failure to collect screening samplePostnatal visit missed

SMH Community

Midwives

2114152 08/02/20 2 - minor 1 - no harmBlood spot collection error: delay/


Assumed baby in-patient

with mother (under

gynaecology) but baby

was at home. Sample

collected day 7

SMH Community

Midwives

2115783 14/02/20 3 - moderate 2 - slight

Blood spot labelling error:

handwritten NHS number belonging

to another baby (other demographic

details correct)

Pennine Community

Midwives



Postnatal visit missed,

then no access. Collected

day 8.

SMH Community

Midwives

2120295 14/03/20 1 - low 1 - no harm

Blood spot labelling error: unlabelled/

inadequately labelled sample found

on ward

Ward 68, SMH (NICU)

2121043 13/03/20 3 - moderate 2 - slight

Blood spot labelling error:

demographic sticker contained errors

e.g. another baby's NHS number

(some details correct)

Twins. Rank and birth

weight swapped. 2nd

sticker underneath on

each sample with details

of the opposite.

East Lancs Community

Midwives

2124409 23/03/20 1 - low 2 - slight




baby

First sample not recorded

as received in clerk' s

office or lab. Repeat

collected day 13.

Ward C2,

Wythenshawe

Manchester Newborn Screening Laboratory Quarterly Blood ... · 1 Aisha Rahman & everly Hird...

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