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TRUST BOARD IN PUBLIC Date: 17th December 2015 Agenda Item: 4.1

REPORT TITLE: Serious Incident Report for November 2015

EXECUTIVE SPONSOR: Fiona Allsop

REPORT AUTHOR (s): Katharine Horner

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

n/a

Action Required:

Approval ( ) Discussion (����) Assurance (����)

Purpose of Report:

This paper provides the Board of Directors with a report on the serious incidents declared in November and an update on the overall position with regard to the management of serious incidents within the Trust.

Summary of key issues

• The Trust reported two serious incidents in November 2015, both occurred in month.

• Falls and clinical diagnosis remain the two key categories of serious incident.

• As at 10th December 2015 the Trust has eighteen serious incidents open with the CCG, of which six have been submitted for closure.

• There are no overdue SI reports.

• There is no backlog.

Recommendation:

The Board is asked to note the contents of this report.

Relationship to Trust Strategic Objectives & Assurance Framework:

SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about

Corporate Impact Assessment:

Legal and regulatory impact Compliance with CQC, MHRA and Audit Commission

Financial impact Serious incidents often become claims

Patient Experience/Engagement

Risk & Performance Management Reporting, investigation and learning from serious incidents informs risk management

NHS Constitution/Equality & Diversity/Communication

Attachment:

TRUST BOARD REPORT Serious Incident Report – period: November 2015

1. Introduction 1.1 A report on Serious Incidents (SI) is produced each month to provide assurance that they

are being managed, investigated and acted upon appropriately and that action plans are developed from the Root Cause Analysis investigations.

1.2 This paper looks specifically at those incidents that are considered as SIs following the

guidance from the NHS England’s ‘Serious Incident Framework” published March 2015. 1.3 A summary of open SIs is published weekly and circulated to Execs. 1.4 SI reports are reviewed by the Sussex Scrutiny Group. The Patient Safety and Risk Lead

presents the reports to the panel and provides feedback to the Trust Serious Incident Review Group.

2. Patient Safety Incidents in November 2015

2.1 There were a total of 596 incidents reported on Datixweb in November 2015 of which 471

(79%) were clinical/patient safety incidents. These incidents breakdown as follows:

20% of patient safety incidents reported in November resulted in harm, a reduction on 29% in October. There has been a significant reduction in low harm incidents which will be explored at the December Patient Safety sub-committee meeting.

2.2 The incident categories are shown for those incidents reported as moderate harm, severe

harm or death.

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3. Serious Incidents declared in November 2015

3.1 The Trust declared two serious incidents in November 2015. 2015/35021 Fall The patient was mobilising independently to the toilet when he lost his balance as he left the bathroom. The fall resulted in a fractured neck of femur. 2015/37068 MRSA infection On 13th November 2015 a premature baby was transferred to East Surrey Neonatal Unit for ongoing care. An infection screen for MRSA / ESBL undertaken on admission, the result was negative. A second infection screen was conducted two days later in line with the units practice of screening all babies weekly and the result was again negative. The baby's general condition deteriorated and the decision was made to transfer to a tertiary centre. A pre-transfer infection screen demonstrated MRSA positive on nasal swab and the MRSA protocol was initiated prior to transfer. On the 26/11/2015 a suspicion of infection at the port of entry was reported following removal of an intravenous cannula. The baby was transferred the same day. On 29/11/2015 the Microbiologist informed the Neonatal Unit that blood cultures taken prior to transfer were positive for MRSA.

3.2 SI themes over the last 12 months

The serious incidents are shown by the month in which they occurred, not the month in which they were declared. The date of knowledge and therefore declaration may be different. Patient falls and clinical diagnosis are the two main themes of serious incidents over the last twelve months.

4. Weekly overview A weekly open SIs overview summary is sent to the Patient Safety and Risk Lead and the Chief Nurse which indicates overall Trust and Divisional performance in completing SI investigations within the National timeframe. The Serious Incident Review Group closely monitors the investigation and submission process. The Divisions are asked to include an update on RCA reports to the Patient Safety and Clinical Risk Sub-Committee. This is the latest reported Trust position at 10th December 2015.

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5. Serious Incident investigations closed by the CCG in November 2015

The Scrutiny Panel did not close any Serious Incident investigations in November 2015.

6. Recommendation The Trust Board are asked to discuss the report and take assurance regarding the management of SIs and the on-going work to improve performance on completing SI investigations within the National timeframe.

Name of Director Fiona Allsop Title of Director Chief Nurse December 2015