Freedom of Information Request – Ref: FOI 367-2025
Thank you for your recent Freedom of Information request. Please find our response below.
You asked:
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.
1. “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.”
Our response:
End to End Reviews
17.02.2025
Case 1
19 years female, previous HI following fall from a horse 8 weeks prior, still had symptoms.
111 HA followed headache pathway as unable to use HI as greater than 7 days, unable to consider hx as a result. Referred to MiiU as profiled for headaches on DoS. Sent to ED, scanned and NAD. Agreed HA was compliant as followed profiled service.
24 hour disposition but did not give option of next day GP as 17:30 in the evening? Why not.
Action: JE to review how many times headaches have been returned for the MiiUs in the last year as felt may not be appropriate for this service.
Case 2
30 years old female with abdominal pain and vomiting. Has already been seen in MiiU and referred to SAU. Called 111 due to worsening pain.
Clinician override, from call was trying to avoid patient going to ED but could not refer directly to CAS so referred back to MiiU. Clinician audit non-compliant and should have referred back to PC, feedback has been shared with clinician and audits since for MiiUs have been complaint.
Case 3
70 years male with abdominal pain, chest and upper back pain pathway followed, went to clinician for review. Had been seen by GP previously. Felt that he had pancreatitis and needed treatment. Clinician override. Wanted to see a GP for a second opinion, clinician stated ‘I will make you an appointment with a GP at Cirencester Minor injuries Unit’
MiiUs not profiled for chest and upper back pain on DoS. Awaiting audit results. PC should have been chosen as endpoint.
Case 4
Elderly male with 7 week hx of cough, had been seen by GP previously and treated with antibiotics.
HA rejected both pharmacy 1st and PC and referred to MiiU. Agreed not appropriate, highlighted on audit. NHSE are reviewing the reasons for DoS rejections due to multiple times ‘other’ is chosen. Symptom duration also discussed as each call treated as a new symptom.
Case 5
45 years old female with abdominal pain. Ongoing symptoms of RT sided abdominal pain. HA followed groin pain pathway as response to groin pain and swelling confirmed. MiiU profiled for PC groin pain. Discussion as 5pm on a Sunday afternoon and outcome varies from a weekday, this would have reached as GP PC outcome if it was a weekday but top of the DoS at weekend is MiiU. Discussion as to why this is, as if GP required during the week why should if differ at weekends.
Seen in ED, referred to gynae, dx of endometriosis
Action – KR to follow up DoS ranking with HS. JE to review number of times PC groin pain/swelling has been returned for MiiUs in the last year.
Agreed theme for next E2E should be 1-hour dispositions, KR/NE will collate cases.
Please see the links below:
You asked:
2. “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.”
Our response:
Extract from the Quality Committee minutes to confirm Rapid Tranquilisation:
8.4 Gordon Benson further highlighted a gradual increase through July and September 2024, which indicated some special cause of variation happening. A deep dive was carried out in response to this, which found there was a relatively small proportion of the inpatient population who were responsible for the rise in intervention and rapid tranquilisation episodes. Gordon Benson reported that the peak in this data, also correlated with a high level of harm to self and harm to others by individuals at this the time. It was noted that rapid tranquilisation was not used frequently within the general population and that this was regarding multiple occurrences to a small number of individuals.
8.5 Gordon Benson explored the data further at individual level, and reported that the current heightened activity related to a small number of patients across Priory ward, Wotton Lawn Hospital: Greyfriars PICU and Mulberry Ward Charlton Lane hospital. It was noted that between July and September, one patient had accounted for 27% – 48% of all rapid tranquilisation.
Next steps:
Should you have any queries in relation to our response, please do not hesitate to contact us. 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:
Louise Moss
Head of Legal Services / Associate Director of Corporate Governance
c/o Gloucestershire Health and Care NHS Foundation Trust
Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth, GL3 4AW
E-mail: louise.moss@ghc.nhs.uk
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.