Patient safety incident response plan
Effective date: September 30th, 2023
Estimated refresh date: March 2024
NAME TITLE DATE
Author Paul Butler McLees August 2023
Reviewer James Wright August 2023
Authoriser Amjad Uppal August 2023
Contents
Introduction …………………………………………………………………………………………………………..2
Our services …………………………………………………………………………………………………………..2
Defining our patient safety incident profile ………………………………………………………….3
Our patient safety incident response plan: national requirements ……………………….5
Our patient safety incident response plan: local focus ……………………………………..… .8
Glossary and acronyms ……………………………………………………………………………………..…10
Patient safety incident response plan
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Introduction
This patient safety incident response plan sets out how the Gloucestershire Health and
care NHS Foundation Trust hereafter referred to as GHC. intends to respond to patient
safety incidents over a period of 12 to 18 months. The plan is not a permanent rule
that cannot be changed. We will remain flexible and consider the specific
circumstances in which patient safety issues and incidents occurred and the needs of
those affected.
The plan is underpinned by our trust policies on incident reporting and investigation
available to all staff via our organisation’s intranet available to staff only..
Our services
Gloucestershire Health and Care NHS Foundation Trust provides joined-up mental
health, physical health and learning disability services to people of all ages across
Gloucestershire. We do this in our hospitals, in community buildings and primarily in
people’s own homes.
Further information about our organisation can be found on the GHC website.
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Defining our patient safety incident profile
The patient safety risk process is a collaborative process. To define the GHC patient
safety risks and responses for 2023/24 the following stakeholders were involved.
Staff – through the incidents reported on the GHC Datix incident system
Senior leaders across the services – through a series of briefings and a task and
finish group.
Patient groups – through a review of the thematic contents of complaints and
Patient advice and liaison service PALS. contacts*
Commissioners/ICS partner organisations – through partnership working with the
ICS patient safety and quality leads
* GHC aims to incorporate wider patient perspective into future PSIR planning through
the introduction of patient safety partners PSP’s..
More information on the national PSP programme can be found on the NHS England
website
https://www.england.nhs.uk/patient-safety/framework-for-involving-patientsinpatient-safety/
The GHC patient safety risks were identified through the following data sources:
Analysis of three years’ of Datix incident data 2019 – 2022
Detailed thematic analysis of Datix incident data 2021
Key themes from complaints/PALS/claims/inquests
Key themes identified from specialist safety & quality committees e.g.,
deteriorating patient, falls, pressure ulcers.
Output of stakeholder event discussions
Themes from the earning from deaths reviews undertaken in 2021/2022
A review of the Trust Corporate Risk Register.
A review of 10 years of claims and litigation managed by GHC legal team and
NHS Resolution
Local patient safety risks related to national priorities have been defined as the list of
risks covered by national priorities that GHC anticipates will require a response in the
next 12 months. Table 1 sets out the full list of national priorities that require a
response.
The top local patient safety risks have been defined as the list of risks identified
through the risk stakeholder approach and the data mining described above. These
Patient safety incident response plan
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local identified risks represent opportunities for learning and improvement in the GHC
health system. Table 2 lists these top local patient safety risks.
The criteria GHC have used for defining the top local patient safety risks is as follows:
Potential for harm – People: physical, psychological, loss of trust patients,
family, caregivers. service delivery: impact on quality and delivery of
healthcare services; impact on capacity, public confidence: including political
attention and media coverage
Likelihood of occurrence – persistence of the risk, frequency and potential to escalate
Our patient safety incident response plan:
national requirements
Some events in healthcare require a specific type of response as set out in national
policies or regulations. These responses may include review by or referral to another
body or team, depending on the nature of the event.
Incidents meeting the Never Events criteria 2018. and deaths thought more likely than
not due to problems in care i.e., incidents meeting the Learning from Deaths criteria
for PSII. require a locally led PSII.
Table 1 below sets out the national mandated responses.
National priority Response
1 Incidents that meet the criteria
set in the Never Events list
2018
Locally led PSII
2 Deaths clinically assessed as
more likely than not due to
problems in care including the
death of a person in receipt of
care by serious self-harm
Locally led Care Review Tool
3 Child deaths Refer for Child Death Overview Panel
review.
Locally led PSII or other response. may be
required alongside the Panel review
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4 Deaths of persons with learning
disabilities
Refer for Learning Disability Mortality Review
LeDeR..
Locally led PSII or other response. may be
required alongside the Panel review
5 Safeguarding incidents in
which:
Babies, child and young people
are on a child protection plan;
looked after plan or a victim of
wilful neglect or domestic
abuse / violence.
Adults over 18 years old. are in
receipt of care and support
needs by their Local Authority
The incident relates to FGM,
Prevent radicalisation to
terrorism.; modern slavery &
human trafficking or domestic
abuse / violence.
Refer to local authority safeguarding lead.
Healthcare providers must contribute towards
domestic independent inquiries, joint targeted
area inspections, child safeguarding practice
reviews, domestic homicide reviews and any
safeguarding reviews and enquiries. as
required to do so by the Local Safeguarding
Partnership for children. and local
Safeguarding Adults Boards.
7 Incidents in screening
programmes
Refer to local Screening Quality Assurance
Service for consideration of locally led learning
response.
See: Guidance for managing incidents in
NHS screening programmes
8 Deaths of patients detained
under the Mental Health Act
1983., or where the Mental
Capacity Act 2005. applies,
where there is reason to think
that the death may be linked to
problems in care incidents
meeting the Learning from
Deaths criteria.
Locally led PSII by the provider in which the
event occurred with GHC participation if
required
9 Mental health related
homicides
Referred to the NHS England and NHS
Improvement Regional Independent
Investigation Team for consideration for an
independent PSII
Locally led PSII may be required with mental
health provider as lead if required
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11 Domestic Homicide A Domestic Homicide is identified by the police
usually in partnership with the Community
Safety Partnership CSP. with whom the overall
responsibility lies for establishing a review of
the case. Where the CSP considers that the
criteria for a
Domestic Homicide Review DHR. are met,
they will utilise local contacts and request the
establishment of a DHR Panel. The Domestic
Violence, Crime and Victims Act 2004, sets out
the statutory obligations and requirements of
providers and commissioners of health
services in relation to domestic homicide
reviews.
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Our patient safety incident response plan:
local focus
GHC considers that all of the 7 incident types set out in this table have relevance for
all of our patient services. To this end this is an organisation wide PSIRP and there are
no separate PSIRP’s plans for individual services.
Incident type Description Response
1 Clinical care An incident involving sub optimal care of
the deteriorating patient
AAR
2 Waiting list in
CAMHS services
An incident or severe harm to a young
person related to the delay in start of
treatment following referral for children and
adolescent mental health service CAMHS.
with a moderate or severe mental health
condition
PSII
3 Validation of
results
Potential for patient harm as a consequence
of non-communication and action of
diagnostic results
AAR
PSA
4 Digital
systems
Emerging risks identified as a result of the
use of our digital systems
PSII
5
Clinical care
Category 3 and above or unstageable
pressure ulcers developed in the
community while the person was receiving
care from both community nurses and
another care provider
AAR
6 Falls
Unwitnessed falls with harm resulting in
fracture or haemorrhage requiring
secondary care intervention for patients
over 80 years of age admitted to our
inpatient wards
AAR
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7 Medication
An incident involving the misuse or unsafe
management of opioids, Gentamycin,
Vancomycin, Clozapine, diabetes medicines
and thromboprophylaxis
AAR
8 Unexpected PSI Identified increase in incidence of subject or
theme which has potential for harm PSII
9 Other
Patient safety incidents which meet criteria
for harm or potential harm not included in
the subjects above
See below
Where an incident does not fall into any of the categories 1 – 10; an investigation
and/or review method such as a SWARM Huddle or AAR may be used by the local
team except PSII which should not be undertaken by staff who have not received the
specialist training required to undertake PSII..
The completion of a narrative response on the Datix incident mo