Case Number 3694
Request Date 08/07/2014
Completion Date 20/08/2014

 

Details of the Request

  1. For each of the past five financial years – 2009-10 to 2013-14 – I would like the total number “serious untoward incidents” recorded at the trust.
     
  2. For each of the last five years, I would also like the total number of “never events” (or similar) recorded at the trust.
     
  3. For the 2013/14 financial year, I would like a breakdown containing details of each serious untoward incident and never event. The breakdown should include a description of what happened, an indication of whether the patient suffered harm and if so, the extent of the harm, as well as the name of the hospital where it happened.

 

Details of the Response

1 and 2. Total number or Serious Incidents Requiring Investigation (SIRI’s) recorded:

Financial Year Number of SIRI’s Never Events
2009/2010 25 1
2010/2011 15 0
2011/2012 48 3
2012/2013 73 1
2013/2014 93 3

 

3. Total number and type of SIRI’s recorded in the financial year 2013/14.

In all instances the patient suffered harm however it is not possible to indicate the extent of the harm. 12 of these incidents took place at Ashford Hospital, one Trust-wide and the remainder at St. Peter’s Hospital.

Type Date Reported
Pressure ulcer Grade 4 March 2014
Pressure ulcer Grade 3 March 2014
Pressure ulcer Grade 4 February 2014
Delayed diagnosis December 2013
Pressure ulcer Grade 3 March 2014
Slips/Trips/Falls March 2014
Pressure ulcer Grade 3 March 2014
Slips/Trips/Falls February 2014
Delayed diagnosis February 2014
Maternity Services - Unexpected admission to NICU (neonatal intensive care unit) February 2014
Pressure ulcer Grade 3 February 2014
Slips/Trips/Falls January 2014
Pressure ulcer Grade 3 February 2014
Pressure ulcer Grade 3 February 2014
Pressure ulcer Grade 3 February 2014
Pressure ulcer Grade 3 February 2014
Pressure ulcer Grade 3 December 2013
Slips/Trips/Falls December 2013
Pressure ulcer Grade 3 December 2013
Child Serious Injury December 2013
Pressure ulcer Grade 3 October 2013
Pressure ulcer Grade 3 January 2014
Slips/Trips/Falls February 2014
Delayed diagnosis February 2014
Slips/Trips/Falls February 2014
Intracerebral haemhorrge following elective angio procedure January 2014
Surgical Error November 2013
Delayed diagnosis November 2013
Delayed diagnosis March 2014
Delayed diagnosis March 2014
Pressure ulcer Grade 4 January 2014
Maternity Services - Unexpected admission to NICU (neonatal intensive care unit) March 2014
Pressure ulcer Grade 3 January 2014
Pressure ulcer Grade 3 January 2014
Pressure ulcer Grade 3 March 2014
Slips/Trips/Falls March 2014
Pressure ulcer Grade 3 March 2014
Pressure ulcer Grade 3 March 2014
Pressure ulcer Grade 3 December 2013
Slips/Trips/Falls December 2013
Slips/Trips/Falls December 2013
Pressure ulcer Grade 3 November 2013
Delayed diagnosis November 2013
Failure to act upon test results November 2013
Pressure ulcer Grade 3 October 2013
Pressure ulcer Grade 3 January 2014
Pressure ulcer Grade 3 January 2014
Pressure ulcer Grade 3 January 2014
Pressure ulcer Grade 3 December 2013
Maternity Services - Intrauterine death February 2014
Pressure ulcer Grade 3 December 2013
Pressure ulcer Grade 3 December 2013
Maternity Services - Maternal Death February 2014
Patient died of asphyxiation following an evening meal August 2013
Pressure ulcer Grade 4 October 2013
Slips/Trips/Falls October 2013
Concealed pregnancy September 2013
Pressure ulcer Grade 4 August 2013
Slips/Trips/Falls October 2013
Drug incident (Insulin) October 2013
Delayed diagnosis November 2013
Maternity Services - Unexpected neonatal death November 2013
Surgical Error September 2013
Safeguarding Vulnerable Child August 2013
Maternity Services - Unexpected admission to NICU (neonatal intensive care unit) August 2013
Drug Incident (general) April 2013
Slips/Trips/Falls May 2013
Maternity Services - Unexpected admission to NICU (neonatal intensive care unit) May 2013
Maternity Services - Unexpected admission to NICU (neonatal intensive care unit) May 2013
Pressure ulcer Grade 4 May 2013
Pressure ulcer Grade 4 April 2013
Radiology/Scanning incident April 2013
Slips/Trips/Falls August 2013
Missed fracture, patient may require reconstructive surgery May 2013
Baby deteriorated following extubation and reintubated. April 2013
Slips/Trips/Falls May 2013
Maternity Services - Intrapartum death July 2013
Pressure ulcer Grade 3 July 2013
Misplacement of Central Venous Catheter into the carotid artery rather than the jugular vein June 2013
Pressure ulcer Grade 4 July 2013
Slips/Trips/Falls July 2013
Delayed diagnosis August 2013
Slips/Trips/Falls July 2013
Maternity Services - Unexpected neonatal death July 2013
Pressure ulcer Grade 3 May 2013
Slips/Trips/Falls June 2013
Pressure ulcer Grade 4 May 2013
Pressure ulcer Grade 3 May 2013
Sub-optimal care of the deteriorating patient June 2013
Slips/Trips/Falls June 2013
Pressure ulcer Grade 3 June 2013
Slips/Trips/Falls June 2013
Slips/Trips/Falls June 2013

 

The rise in Serious Incidents Requiring Investigation over the years is following the request from our Clinical Commissioning Group (CCG) to report all stage 3/4 Pressure Ulcers and all falls resulting in a Fractured Neck of Femur. We have recently undertaken targeted work in both areas by our specialist nurses and have since seen a significant decrease in our reporting.