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Archive for Serious Incidents

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Serious Incidents

Right Care, Right Person

I am requesting the following information under the Freedom of Information Act:

1. Please state which police force/s serve the area covered by the Trust

2. Any reports, assessments or data – internal or published – where the Trust has monitored the implementation and impact of Right Care, Right Person by the local police force/s

3. Details of any serious incidents or patient safety incidents where Right Care, Right Person was a factor

I would like the information sent by email.

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Physician Associate Safety Events

Under the Freedom of Information Act 2000, please can you disclose the following information:

1. The number of patient safety events involving a physician associate or anaesthesia associate in the last five years. (Broken down by calendar years: 2020, 2021, 2022, 2023, 2024)
1a) Broken down by types of injuries resulting from these safety events. (Broken down by same years as above)
1b) Broken down by injury causes. (Broken down by same years as above)
1c) Broken down by injury severity (no harm, slight, moderate, severe, catastrophic). (Broken down by same years as above)

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Restorative Justice in Sexual Safety and Patient Complaints

1. NHS Sexual Safety in Healthcare Charter
a) Has your Trust signed up to the NHS England Sexual Safety in Healthcare Charter (2023)?
b) If yes:
o Please confirm the date of adoption
o Provide any internal implementation plans, policy updates, or cultural change programmes associated with the Charter
c) Does your Trust interpret the Charter’s emphasis on person-centred and trauma-informed approaches as including or supporting the use of restorative practices?
2. Restorative Practices in Complaint Resolution
a) Does your Trust use dialogue-based or restorative approaches in patient complaints more generally (e.g., apology meetings, mediation, facilitated dialogue)?
b) If yes, please describe the approach and provide any supporting documents.
3. Use of Restorative Justice or Restorative Practice
a) Has your Trust ever used restorative justice or restorative practices in the context of:
o Sexual harassment, assault, or misconduct involving staff or patients?
o Patient complaints involving interpersonal harm or conflict?
b) If yes to either, please provide:
o A brief description of the approach used
o Any relevant policies, procedures, or internal guidance
o Any staff training materials relating to restorative practice
o Any available summary evaluations or outcome reports without any identifying details included.

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Coroners’ Prevention of Future Deaths Reports

I am writing to request information under the Freedom of Information Act 2000.

The request relates to Coroners’ Prevention of Future Deaths Reports (PFDs or Reg 28 letters) issued for deaths ruled to have been caused by suicide.

Please provide the following information for the time period between 1st January 2019 (or the date of inception for your trust) and 5th May 2025, inclusive.

1. Please send me a copy of every PFD relating to suicide that the Trust received. Please include PFDs received where the Trust was a listed addressee and/or where the Trust was copied for information as an ‘interested person’.

2. Please also send me a copy of the Trust’s response to each PFD, clearly marking to which PFD the response refers.

3. Please send me a copy of any internal correspondence which relates to each PFD, clearly marking to which PFD the correspondence refers. This should include:

Minutes from meetings
Email conversations between staff and contractors
Details of any staff training undertaken
Memos sent

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Sexual Incidents

Under the Freedom of Information Act 2000, please provide me with the following information about incidents of sexual harm and physical violence that have taken place at your trust. Incidents of sexual violence include, but are not limited to, sexual harassment, sexual abuse, sexual assault and rape. (See after the question for clarification on these definitions.)

In order to assist you, I understand that some, if not all of this information should be recorded in the trust’s safety incident reporting system, or it may be recorded by your HR team.

If possible, please use one of the attached spreadsheets to provide your answers. Please also explain any gaps in your data.

Please ensure that the data you provide is for financial years, not calendar years.

Total sexual safety incidents

1. How many sexual safety incidents did the trust record in the financial year 2024-25? (This includes incidents by all alleged perpetrators against all alleged victims: staff, patients, visitors, members of the public)
1.1 How many of these incidents took place on the trust premises?
1.2 How many sexual safety incidents on the trust premises did the trust record in the financial year 2023-24?*
1.3 How many sexual safety incidents on the trust premises did the trust record in the financial year 2022-23?*

(*My previous FOI asked for total incidents for 2022-23 and 2023-24 but did not specifically ask for only those incidents that occured on the trust premises. If your previous response only covered incidents on the trust premises please answer ‘no change’.)

Sexual safety incidents by staff against patients

2. How many sexual safety incidents allegedly perpetrated by staff against patients did the trust record in the 2024/25 financial year?

Sexual violence and misconduct by patients against other patients

3. How many sexual safety incidents allegedly perpetrated by patients against other patients did the trust record in the 2024-25 financial year?

Sexual safety incidents by patients against staff

4. How many sexual safety incidents allegedly perpetrated by patients against staff did the trust record in the 2024-25 financial year?

Sexual safety incidents by staff against other staff

5. How many sexual safety incidents allegedly perpetrated by staff against other staff did the trust record in the 2024-25 financial year

Age of alleged victims

Please provide figures for the 2024-25 financial year:

6. How many of the sexual safety incidents did the trust record where the victim was a patient:
6.1 Under 18 (this includes under 16 and under 13)
6.2 Under 16 (this includes under 13)
6.3 Under 13

Only include incidents that occured on the trust’s premises.

Physical violence

7. How many incidents of physical violence perpetrated by patients against staff did the trust record in the 2024-25 financial year?
7.1 Do the trust’s records of physical violence by patients distinguish between intentional/deliberate and un/non-intentional violence? (Unintentional violence might be due to lack of capacity, e.g. a symptom of dementia.)
7.2 If the trust does breakdown physical violence into intentional/deliberate and un/non-intentional violence, please provide the following data for the 2024-25 financial year:
• Number of intentional/deliberate incidents of physical violence by patients against staff.
• Number of un/non-intentional violence incidents of physical violence by patients against staff.

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Incidents Reviews

Under the FOIA, please could you provide the following reviews mentioned in the ‘quality dashboard’, published in January 2025 board papers:

Please provide copies of these reviews, and detail the full findings of each review, and the resulting actions from the trust/ system.

Please note I’d like to see the specific findings of each review, rather than summaries.

– “The 78 incidents reported by MIIUs related to the pathway from the NHS 111 service and wider IUCS service are subject to a task and finish group review led by the GHC IUCS Governance Lead. All incidents where harm is unknown/suspected are subject to an end-to-end pathway review with input from the IUCS Clinical Lead”.

– “The sustained trend of high use of Rapid Tranquilisation (RT) has seen a rise to 110 incidents in December 2024. The Positive and Safe Group have confirmed this relates to care of specific patients at Wotton Lawn Hospital, for which individualised care plans are in place. Quality Committee received a deep dive into restrictive practices in November 2024 but has sought a further overview of details related to rapid tranquilisation given the sustained levels.”

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Risk Management

Could you advise the following about your use of Risk Management systems in your trust?

1. What risk, compliance or incident management software do you currently use?

2. Which vendor provides this software?

3. What is your annual license fee for this software?

4. When is the contract renewal date for this software?

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293-2024

1. Since January 1, 2020, how many incidents have been reported to your Trust involving a wrong implant or prosthesis? Please note that this is any incident falling under the following definition: “Placement of an implant/prosthesis different from that specified in the procedural plan, either before or during the procedure. The incident is detected any time after the implant/prosthesis is placed in the patient.” For each incident, please provide the month, year and the implant or prosthesis involved in the procedure. In addition, please confirm the total number of cases reported between January 1, 2020 and December 31, 2024.
2. How many incidents fell under the definition of a serious incident, in line with the Patient Safety Incident Response Framework (or, prior to that, the Serious Incident Framework)? Please state which cases met this definition.
3. How many incidents fell under the definition of a Never Event? Please state which cases met this definition.
4. How many incidents led to serious, moderate, or slight harm to the patient?
5. What were the causes of implant/prosthesis incidents?

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