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Archive for Serious Incidents

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Serious Incidents

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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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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