Case Number 8716
Request Date 18/07/2022
Completion Date 12/09/2022

 

Details of the Request

With reference to the following reporting guidelines set out by NHS Improvement (see page 15, prescribed information 27.1 to 27.5, linked here)

  1. Please tell me in the reporting period 2021/22 the number of deaths that occurred at your Trust for which a case record review or investigation has been carried out which the provider judges as a result of the review or investigation were more likely than not to have been due to problems in the care provided to the patient, with an explanation of the methods used to assess this.
  2. Please provide me with a brief overview of the FIRST FIVE incidents in 2021/22 identified in question 3 (i.e. cases of deaths that were more likely than not caused by problems in care),
  3. Finally, can you please summarise what the Trust learnt and what actions have been taken as a result of the aforementioned cases / investigations.

 

Details of the Response

1) Please tell me in the reporting period 2021/22 the number of deaths that occurred at your Trust for which a case record review or investigation has been carried out which the provider judges as a result of the review or investigation were more likely than not to have been due to problems in the care provided to the patient, with an explanation of the methods used to assess this.

There were 5 cases during the reporting period specified that have been judged as equal to or greater than 50/50 avoidability, falling within the categories in your note above. We use the Royal College of Physicians SJR methodology to assess this.

 

2) Please provide me with a brief overview of the FIRST FIVE incidents in 2021/22 identified in question 3 (i.e. cases of deaths that were more likely than not caused by problems in care), withholding any identifying information that would run into a Section 40 exemption.

  1. Three cases were deaths in patients who acquired Covid-19 whilst in hospital, these cases underwent a modified review based on Royal College of Physicians SJR template.
  2. The SJR reviews of this case raised concerns over the management of nutrition and hydration in a vulnerable patient.
  3. This was a case that went straight to a Serious Incident (SI) investigation, this concerned recognition of a deteriorating patient and a delay in surgery.

 

3) Finally, can you please summarise what the Trust learnt and what actions have been taken as a result of the aforementioned cases/investigations.

  1. The hospital acquired COVID deaths have been reported as an SI and investigated as a cluster, looking at themes. The report for this SI is still being completed however we have undertaken detailed analysis as part of this work. The majority of these patients were frail elderly with multiple health conditions that made them vulnerable to contracting COVID and having a poor outcome. One of the biggest issues identified was delays in discharge keeping patients in hospital longer than necessary where there is a greater risk of the contracting an infection. The Trust responded with a number of actions around ‘right to reside’ to ensure that patients were discharged at the first opportunity that was safe to do so, where treatment and follow up could be safely carried out in the community, rather than remaining in an acute hospital.
  2. Recommendation from the SJR was that due to the concerns identified an SI should be raised to allow for more detailed investigation and actions. Further investigation is underway including a referral for a safeguarding enquiry. Actions to date have included update of ward staff training in the areas of nutrition and hydration, and instigation of a twice weekly grand round to ensure multi-disciplinary input from dieticians and other therapists.
  3. The learning from this case is that earlier recognition of diagnosis would have led to earlier surgical intervention which could have changed the outcome for this patient. Actions are to complete an audit around Emergency Department referrals to Specialties and presentation of rare diagnoses at MDT forum.