Freedom of Information request 198-2122

Trust HQ
Edward Jenner Court
1010 Pioneer Avenue
Brockworth
Gloucester
GL3 4AW
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E-mail: freedomofinformation@ghc.nhs.uk Website: www.ghc.nhs.uk
DATE: 31/08/2021
Freedom of Information Request – Ref: FOI 198-2122
Thank you for your recent Freedom of Information request. Please find our response below.
1. The number of serious incidents which were:
a. Reported to the trust
b. For which a review was started, and
c. Of the reviews started, the number which were completed within the 60 day limit. During the financial year of 2017-2018, 44 serious incidents were reported by Gloucestershire Health and Care NHS Foundation Trust GHC.. 44 incidents received comprehensive investigation using Root Cause Analysis methodology as directed by the Serious Incident Framework. Of these 44, 39 investigations were completed within the 60 working day target. The remaining 5 investigations were extended for a number of reasons, including the complexity of investigation and cooperation with families involved. The average duration of days taken to complete the investigations during this financial year is 65 working days. The longest time in days to complete a SIRI investigation is 179, the reason for this is the complexity of the investigation and a 3-month extension was agreed at an early stage with commissioners. The number of investigations that were outstanding but not yet due at the point of new financial year was 7.
During the financial year of 2018-2019, 36 serious incidents were reported by GHC and received comprehensive investigation using Root Cause Analysis methodology as directed by the Serious Incident Framework. 28 of these investigations were completed within the 60 working day target, with the remaining 7 investigations were extended due to sickness, delay in appointing an investigator and delay in starting the report because of cooperation with those involved in the incident. The average time taken to complete the investigations during this financial year is 65 working days. The longest time to complete an investigation is 105 working days. The number of investigations that were outstanding but not yet due at the point of new financial year was 11.
During the financial year of 2019-2020, 38 serious incidents were reported by GHC and received a comprehensive investigation using Root Cause Analysis. Due to multiple operational pressures as a result of COVID-19, only 9 investigations were completed within the 60 working day target. The average time taken to complete an investigation during this financial year was 85 working days, with the longest investigation taking 216 working days. The number of investigations that were outstanding but not yet due at the point of new financial year was 9.
During the financial year of 2020-2021, 39 serious incidents were reported by GHC and received a comprehensive investigation. Due to further COVID-19 operational pressures only 22 of these SIRIs were completed within the 60 working day target. The average amount of days taken to complete the investigations is 71. The longest time taken to complete a SIRI investigation during this financial year is 143 working days. The number of investigations that were outstanding but not yet due at the point of the new financial year was 7.
2. The average duration in days taken to complete all serious incident reviews. 3. The longest time in days taken to complete any serious incident review
4. The number of serious incident reports outstanding at the end of each financial year; and at the end of July 2021 Delays in returning SIRI submissions were supported by a direct communication from the NHS National Patient Safety Team, helpfully revisited in the bulletin of March 2021:
In focus: Responding to patient safety incidents
It is a year since the first national lockdown was announced and the NHS came under pressure in its ability to treat patients admitted with the COVID-19 virus. The messages we shared at the time in relation to reporting patient safety incidents and undertaking investigations remain in place.
These include:
Patient safety incident reporting:
• Encourage everyone to continue reporting anything of concern; their reports are of immense value locally and nationally.
• Continue to upload incident data from local risk management systems to the National Reporting and Learning System as promptly as possible
• All NHS organisations who are employers must report COVID-19 workforce deaths that meet the criteria of the Health and Safety Executive’s RIDDOR reporting of COVID-19 guidance.
Serious Incidents SIs. and Never Events:
• Continue to report SIs and Never Events using your normal reporting systems. Use your clinical and professional judgement when considering what to identify as a SI.
• Ongoing pressures on services may make it more difficult to undertake SI investigations. Organisations do not have to meet the 60-day timeframe for investigations during this period. They should be pragmatic about the sign off and closure of investigations, noting that formal panel meetings are not required to close investigations.
• Consider approaches for rapidly responding to patient safety incidents: Use huddles, after-action reviews, risk assessments and case record reviews, as well as investigations to identify ways to reduce future risk.
Should you have any queries in relation to our response in this letter, please do not hesitate to contact me. If you are unhappy with the response you have received in relation to your request and wish to ask us to review our response, you should write to:-
– Head of Legal Services / Associate Director of Corporate Governance Gloucestershire Health and Care NHS Foundation Trust
Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth
GLOUCESTER GL3 4AW
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E-mail: —
If you are not content with the outcome of any review, you may apply directly to the Information Commissioner’s Office ICO. for further advice/guidance. Generally, the ICO will not consider your case unless you have exhausted your enquiries with the Trust which should include considering the use of the Trust’s formal complaints procedure. The ICO can be contacted at: The Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.
Yours sincerely,
Freedom of Information Officer
On behalf of Gloucestershire Health & Care NHS Foundation Trust