See number of serious incidents recorded in our hospitals, mental health trust and ambulance service
PUBLISHED: 18:03 08 March 2018
More than 1,000 serious incidents (SIs) were recorded within NHS trusts in Suffolk and north Essex in two years, it has been revealed.
SIs in health care are adverse events where the consequences to patients, families, carers, staff or organisations are so significant that an investigation is needed.
They include unexpected or avoidable deaths and injuries.
In 2016/17, West Suffolk Hospital logged 97 SIs, more than doubling from 43 the previous year, according to research by medical negligence solicitors Blackwater Law.
Executive chief nurse Rowan Proctor, pictured, said staff were encouraged to reported SIs to enable lessons to be learnt and prevent similar incidents being repeated.
She added: “Our openness and commitment to learning is part of what makes us an ‘outstanding’ rated trust by the Care Quality Commission. We have a genuine focus on continuous learning and improvement at all levels of the trust, and we’ve recently appointed a quality improvement practitioner to help embed this even further.”
She pointed out that SIs were rare, with the trust dealing with more than 210,000 outpatient contacts and caring for more than 66,000 patients in A&E in 2016/17.
Ipswich Hospital reported 87 SIs last year, a rise from 61 in 2015/16.
However, its partner trust at Colchester saw a drop over the two years, from 147 to 130.
Nick Hulme, chief executive of the two hospitals, said the findings were positive as they showed the trusts encouraged staff to raise concerns and had a “no-blame culture”.
He added: “We always want to learn and make sure we put into place procedures for better practice going forward, reducing risk and improving quality.”
Suffolk and Norfolk’s mental health trust recorded 242 SIs in 2016/17, an increase from 216 the previous year.
However, Dawn Collins, director of nursing, quality and patient safety, said the trust logged 40 fewer SIs in April to December 2017 compared to the same period the previous year.
Ms Collins said every SI was investigated to see how services could be improved.
The trust has introduced enhanced training for staff in this area and recruited additional “investigation improvement managers”.
“As a result of investigations, where there is a need for improvement or a lesson to be learned we take efficient action, and we ensure that learning is shared throughout our whole organisation,” Ms Collins added.
The region’s ambulance service recorded more SIs in 2016/17 than any other ambulance trust in England and Wales.
The East of England Ambulance Service logged 95 of these events last year – an increase from 83 in 2015/16.
Following changes to NHS Improvement framework, these figures include near misses where no patients were harmed, bosses said.
Of the 95 serious incidents reported in 2016/2017, 44% would previously have been considered a SI - a drop from 71% the previous year.
Tracy Nicholls, deputy director of clinical quality, said the trust had seen a “sustained increase” in staff reporting such incidents, which was “positively welcomed”.
She added: “Our focus has been on quality improvement and over the past two years we’ve seen a reduction in harm to patients as a result in this change of approach. Our ongoing priority is delivering a high level of service and care to our patients.”
Trusts must follow national NHS Improvement framework when dealing with SIs.
A Suffolk man whose daughter suffered an anoxic brain injury while under Ipswich Hospital’s care is campaigning for a change in the way SIs are investigated.
Chris Rudland’s daughter Jessica, 26, is struggling with long-term impairments following a visit to A&E in August 2015, just 15 days after giving birth to her son Lewin.
Miss Rudland went into cardiac arrest while in hospital and was put into an induced coma. Her family say she suffered brain damage due to oxygen starvation.
A SI investigation into Miss Rudland’s care was carried out by Ipswich Hospital, but her family were unhappy with the results and demanded an independent review.
Mr Rudland, 58 and from Martlesham Heath, has since gathered more than 1,400 signatures on a petition for all SIs within NHS trusts to be investigated externally.
He said: “All I ever asked for was an honest, open and transparent investigation into Jessica’s treatment and care.”