east midlands ambulance service - serious inside report - march 2013

7/29/2019 East Midlands Ambulance Service - Serious Inside Report - March 2013

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Time Required 10 mins Paper No. PB/13/46

Report to: PUBLIC BOARD OF DIRECTORS MEETINGDate: 25 March 2013

Subject: Serious Incident (SI) Performance Report

Report by: Karen Glover, Director of Nursing and Quality

Purpose of Report

To provide a summary of the Trusts performance against key targets for the reporting andmanagement of serious incidents.

It also provides a thematic analysis on serious incidents reported by the Trust to date and

details lessons learned and action taken in response to mitigate risk.

Implications:Quality (including Patient Safety, Staff Safety, Dignity and Patient Experience)

Ensuring learning from serious incidents is implemented wherever possible for serviceimprovement

Human Resources including Equality

N/ALegal

N/APolicy

N/AFinancial (including any funding requirements)

N/AMedia/Communications

Poor performance meeting the 2 working day reporting deadline could potentially leaveTrust vulnerable

Details of any identified risk(s):

Non timely completion of SI actions

Risk AssessmentConsequence(A)

Likelihood (B) Score (A x B)


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The table below shows Divisional performance (numbers in brackets indicate near misses):

DIVISIONAL

PERFORMANCE

YTD (as of 28/2/13)

Derbyshire

Emergency

OperationsCentre(EOC)

Leicestershire & Rutland

Lincolnshire

Northants Nottinghamshire

Other e.g.Trust/HART YTD Total

Total Number SIreported(includingnear misses and NEs)

4 25 (4) 4 7 (1) 8 3 2 (1) 53 (6)

Reported as SI, thendowngraded

2 1 1 0 1 1 0 6

Local Never Events 1 0 0 1 1 0 0 3

% reported to thecentral team within 1working day

100%(4/4)

60% (15/25) 50% (2/4) 85% (6/7) 87% (7/8) 33% (1/3) 1 (1/2)67%(36/53)

Of the 25 EOC reported incidents 15 are as a result of lack of Divisional resource and can be represented as follows:

Derbyshire Leicestershire &Rutland

Lincolnshire Northants Nottinghamshire Other e.g.Trust/HART

4 2 3 2 4 0

4.0 Open SI Investigations

The table below provides a summary of all 27 open serious incidents as at end of February. This includes 4 that remain open following submission

to the Commissioner for closure.


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Level of Harm Key:

1 No harm/ near miss

2 Minor harm- requires minor treatment/ remains independent

3 Moderate harm- requires hospital treatment/ no permanent harm4 Severe harm- permanent injury/ requires help with activities of daily living

5 Death

Theme Source

of SI

Division Call

Category

Level of

harm/patientoutcome

Date on

STEIS

Description Immediate action taken

CareManagement

PALSConcern

Notts Red1 1 22/02/2013 Care Management:Paramedic attended patientwith chest pain and difficultyin breathing. There wereconcerns regarding theParamedics attitude and care

management The patient wasadmitted the following day onto an acute cardiac unit atCity Hospital.

Paramedic stood down frompatient-facing duties andinvestigation commenced

CareManagement

Divisional Director

North Red 2 3 20/02/2013 The following two incidentsinvolve one EMAS paramedicand occurred on the sameday.

Incident 1: CareManagement. EMAS calledto attend a 68 year old femalewho was found on the floor(24hr+). The lady was notsuitably immobilised and theEmergency Care Assistantprovided care in transit with

no pre-alert. The lady waslater found to have a broken

Paramedic stood down frompatient facing duties andinvestigation commenced.

Police and EMAS SafeguardingTeam involved(Incident 1)


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Theme Sourceof SI

Division CallCategory

Level ofharm/patientoutcome

Date onSTEIS


three ampoules of morphinewere left on the roof of a

response car by a paramedicprior to driving away.Retrieved by a member of thepublic who had found themby the roadside nearby.

Competency/knowledge of staff

involved assured before return tooperational duties.

Local NeverEvent

IR1 Northants Green 2 2 14/01/13 Never Event RTC: DCA crewwas transporting a patientwith a suspected fracture

neck of femur (NOF) on aspinal board to hospital.Whilst en route the side of theambulance stretcher gaveway resulting in the patientand spinal board falling offthe stretcher onto the floor ofthe ambulance.

On initial investigation therewas no five point harnessfitted to this stretcher and thecrew reported that thestretcher side bar pin is worn.

This has been reported as aLocal Never Event.

Stretcher removed from vehicleand collected by fleet15/01/2013. Report indicated no

fault or concern with thestretcher.

Patient visited by EMAS staff.Patient sustained no furtherinjuries from incident.

Initial review vehicle had no 5point harness. This had been

removed by PTL prior to12/01/2013 due to being heavilysoiled.

Safety bulletin issued to all staff

Safe Carriage SOP revised

Vehicle check sheet for this

vehicle has not been located.

IR1 completed by crew.

A 72 Hour report was submittedto Commissioners.

Incorrect CallCoding

PALS EOC Red 1 5 11/01/13 Incorrect Call Coding: A callwas received reporting a carhad gone in to the central

reservation wall on a bridge.The caller stated smoke was

Call audits requested as part ofinvestigation standard procedure

Correct procedures reiterated tocall taker


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Theme Sourceof SI



Date onSTEIS


coming from the car and oneperson was in the car. That

person was possibly trapped.The call was coded TrafficAccident Green 1 20 minuteresponse.

As an entrapment had beenmentioned and informationprovided that the patient wasnot alert. This should have

been coded as a Red 2. Alater call by the fire servicestated that CPR was inprogress (16 minutes afterthe initial call).

DelayedTreatment

IR1 EOC Red 2 0 10/01/13 Delayed Treatment:AMVALE Crew verballyallocated and dispatched toattend a Red 2 call for a

patient at a Care Home.AMVALE crews do not haveMobile Data Terminals (MDT)and normally update time ofarrival once clear from anincident. A second call wasreceived from the Care Home18 minutes later asking forETA. A secondary call sign

was allocated attended andconveyed patient to hospital.Patient outcome unknown.

Initial investigations indicatedAMVALE crew returned to basebelieving they had been stooddown by control. This was

approximately 45 minutes priorto the shift ending. Control wasnot aware of this information.

Amvale notified to reinforcecorrect procedure to all their staff

CareManagement

IR1 Lincs Red 1 5 09/01/13 Care Management:Ambulance called to attend a44 year old patient in cardiacarrest. Patient found to be inthe bath on crew arrival.Patient removed from bath

and CPR commenced.Paramedic back up was

Police involved as possiblesuspicious circumstances.


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Theme Sourceof SI



Date onSTEIS


approx. 40 minutes.

During subsequent journey toonward Acute Trust patientsuffered respiratory arrest.

InformationGovernance

IR1 Northants N/A N/A 07/01/13 Information Governance:On way to standbyParamedic opened window ofcab. A gust of wind carried aPRF out of the window.

Crew was unable to stop tolocate paperwork.

Investigation commenced.

Crew reminded to removepaperwork from vehicles as soonas possible and to storeappropriately in vehicles.

Missing Drugs IR1 emailfromDivision

Lincs N/A N/A 04/01/13 Missing drugs: Adiscrepancy with Codeinetablets has been reported atLouth and SkegnessAmbulance Stations.

Police notified

Review access and storage ofmedicines management carriedout by Division

IncorrectCoding

FC EOC Green 2 andRed 1

Not known 04/01/13 Incorrectly coded: Callreceived for a 50 year oldfemale and incorrectly coded

Second call correctly codedas Red1.Patient transferred to hospitalwith pre-alert to hospital.

Feedback provided to call takerto reinforce correct codingprocedure

Delayed

Response

R1 EOC Green 2 Unknown 03/01/13 Delayed response: Call

received from a member ofthe public for a male withfacial injuries. Due to high999 demand call held for 1hour 7 minutes.

The first available crewarrived on scene 1 hour 12minutes after the call was

made.

Call audits requested as part of

investigation standard procedure


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Theme Sourceof SI



Date onSTEIS


CareManagement

Coroner Leicester-shire

Red1 5 21/12/12 Death in Custody.Crew attended a patient at

the Magistrates Courtfollowing attempted hanging.

On arrival crew attemptedAdvanced Life Support. Theintubation was later found tobe oesophageal rather thantracheal.

Consideration given to standingcrew down but not considered

necessary all protocols werefollowed and no caremanagement failure indications

InformationGovernance

IR1 Trust N/A N/A 13/12/12 Information Governance:A contractor working on theTRACE computer system,which administers the leasecar fleet, saved some data tohis personal web spaceduring a period ofmaintenance.

An EMAS student alerted theTrust to the fact he haddetected that personal detailswere freely accessible on theinternet

Document removed from theserver.

Third party contractorinterviewed by IG and ICTmanagers.

Notification to all Staff involvedbeen sent out.

Trust IG Lead informed

Information Commissionernotified

Road TrafficCollision

IR1 Lincs A&E Green 2 5 11/12/12 Road Traffic Collision

999 call to assist patient whohad fallen out of bed &sustained a leg laceration &head injury.

En route to the hospital,travelling at normal roadspeed the vehicle veered offthe road with the patient on

board. Patient sustained ahead injury and died.

Investigation delayed due toPolice investigation. Staff cannot

be interviewed as medically unfitand currently absent from work.The investigation will exceed the60 days timeline for submission.It has been marked as out of ourcontrol by the PCT.


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Theme Sourceof SI



Date onSTEIS


CareManagement

PALS Notts A&E Green 2 5 11/12/12 Care Management:

999 call to attend an elderlymale patient having fallen inthe bath & sustained a headinjury. Alleged caremanagement failure centeredon inadequate assessment ofpresenting condition. Patientdied in ED.

Crew stood down from patientfacing duties.

DelayedResponse

Coroner EOC Urgent 5 29/11/12 Delayed response: 4 hourUrgent call was received at14:50 for a 76 year old withUTI & uncontrolled diabetes.Ambulance on scene at21:27. Patient deterioratedand died in hospital.


Equipment

Failure

EMAS

PTLemail

Northants

A&E

Red1 5 27/11/12 Equipment failure:

Paramedic attended acardiac arrest. Duringresuscitation noticed that thepatients chest suddenlybecame rigid & he wasunable to ventilate. Patientdied.

All T-pieces removed from all

Divisions

Referral to MHRA

Clinical bulletin issued

Crew not stood down asdetermined that no patient safetyrisks remained

DelayedResponse

IR125248

EOC GP Urgent 5 24/10/12 Delayed response: Callreceived as an urgentbooking (4 hours requested)at 16.45 for a patient withurinary retention. Due to highdemand, patient was notcollected within the giventimeframe. At 20.54 contact

was made with the NursingHome. A Nurse at the

Investigation commenced



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Theme Sourceof SI



Date onSTEIS


location was offered theoption to upgrade the booking

to an emergency call, butadvised the EMD the patientcondition did not warrant anupgrade.

At 22.02 an ambulance hadstill not been allocated on theurgent booking. Anemergency call was received

from the Nursing Home toadvise the patient had aDNAR and had died. Theystated that an ambulancewas no longer required.

IR1 Delayed

Treatme

nt

Notts Urgent 5 10/09/12 Delayed Treatment Patient

required transfer via Bariatric

vehicle. Vehicle found with no

power to the rear saloon.

Following temporary repair

arrived at the patients home

3 hours after initial

assessment. Patient

condition deteriorated on

handover and later died in

hospital

Review of Trust-wide bariatriccapabilities has beenundertaken by Commercial

Director

SDM ensured cascade trainingto PTLs and crew involved forMegasus Stretcher and VikingHoist

Bariatric vehicle inspected andapproved as roadworthy

PTLs trained in use of bothbariatric hoist and stretchers forcascade training- evidencerequested to demonstrateclosure of this action

InappropriateActions

Police Derbys N/A N/A 01/06/11 Inappropriate Actions: 23year old female attended apolice station in May and

made a safeguardingallegation against a member

Staff member initially stooddown pending investigation

Case investigated by the policeno charges brought


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Theme Sourceof SI



Date onSTEIS


of EMAS staff.Staff member returned to duty

once EMAS satisfied it wasappropriate to do so

5.0 Trust Themes

The following table and graph show themes since 1st April 2012. Numbers in brackets indicate near misses.

THEMES 2012/13Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb

YTD

Total

2011/

12

Allegation against HC Professional 3

Breach of Confidentiality 1 1 2 2

Care Management 1 1* 1 2 4 3* 3 15** 13# (6)

Delayed Handover 4

Delayed Response 2 1 1 1 (1) 1 1 (1) 3 1 2 13 (2) 19## (3)

Incorrect code/Delayed Treatment 1 1 1 1 2 1 4 11 2

Drug Management/Loss 3 3 #

RTC 1 (1) 1 1* 3* (1) 3 (1)

Safeguarding Allegation 1 1 0

Service Failure 1Vehicle Incident 1 1 (1) 1 3 (1) 1 (1)

Patient/staff accidental injury 1 1 2

Patient Abscond 1 1

Grand Total (Near Miss) 3 (1) 5 2 1 3 (1) 3 5 (2) 8 7 13 3 53 (4) 50 (11)

Downgraded SIs 1 3 1 1 6 4

Never Events 1 1 1 3 0*Shows never event # shows downgraded incident 2011/12


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Staff are now routinely temporarily stood down from patient facing duties following care management Sis until such time as their safety to

practice can be confirmed. This may be following appropriate retraining or competency assessment. Dates of last appraisal and Essential

Education are identified as part of the investigation process and if these have not been undertaken in the previous 12 months the

individuals are prioritised.

Revision of the Safe Carriage SOP to make staff responsibilities with regard to safely securing patients clear and clarify action to be taken

if patients cannot be adequately secured. Introduction of a C Spine assessment and management training video podcast.

RTC

Re re-categorisation of RTC from R2 to R1 with associated QIA approved by TEG

Process for ensuring driver reassessments following RTCs strengthened

Drug-related incident Deep dive review of all drug related SIs being undertaken by the Head of Clinical Audit, Governance & Research (Accountable Officer for

Controlled Drugs) for April QGC

Reminder of responsibilities relating to medicines management included in Clinical Update email

Breach of confidentiality

Deep dive review of all information governance related SIs being undertaken by the Information Governance Manager for April QGC

Article included in the CEO bulletin to reinforce crew responsibilities in relation to information governance

Incorrect coding

Deep dive review undertaken by Patient Safety & Experience Manager and presented to February QGC and associated action plan being

monitored by Clinical Governance Group until closure.

8.0 Patient Safety Harm Rates

The chart below shows the level of harm for all patient safety incidents including Sis since 1 st April 2012. It should be noted that the level of harm

cannot necessarily be attributed to acts or omissions by EMAS staff. Other factors may prevail e.g. patients preexisting condition.


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No harm

24%

Minor

47%

Moderate

24%

Severe

3%

Death

2%

No harm

Minor

Moderate

Severe

Death

One indicator used by some organisations as a safety measure is the number of SI as a percentage of the total PSIs reported. The table belowshows the comparison between 2011/12 and the current year to date. It is important to note the year to date percentage is highly likely to go downdue to retrospective IR1 data entry.

2011/12 2012/13 to date 28 FebPSI total 150 120SI Total 50 53SIs as percentage of PSIs 33% 44%

9.0 Never Events

Never events are defined as

serious, largely preventable patient safety incidents that should not occur if the available preventative measureshave been implemented by healthcare providers. To be a never event, an incident must fulfill the following criteria:

The incident has clear potential for or has caused severe harm/death.

There is evidence of occurrence in the past (i.e. it is a known source of risk).

There is existing national guidance and/or national safety recommendations on how the event can be prevented and support for

implementation.

The event is largely preventable if the guidance is implemented.

Occurrence can be easily defined, identified and continually measured


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EMAS has not had any nationally prescribed Never Events year to date.

The Director of Nursing and Medical Director have agreed the following Never Events for contractual inclusion in line with other ambulance

services in the Midlands and East SHA region

Patient falling or jumping from moving vehicle

Patient falling from an ambulance trolley

Ambulance involved in a blameworthy fatal collision (either pedestrian or other vehicle occupant)

EMAS have reported no Local Never Events in February 2013.

east midlands ambulance service - serious inside report - march 2013

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