Berkshire 2020

Berkshire Healthcare NHS Foundation Trust

ECT

Please supply patient’s information ECT leaflet.

We also have access to other language information from the Electroconvulsive Therapy Accreditation Service (ECTAS). The CQC information leaflet is only given to detained patients.

Please supply patient ECT consent form.

Please supply any ECT reports/investigations
Please be advised the Trust does not release details where patients can be identified in line with UK GDPR , and we are withholdin this ingformation under Section 40 (1) (personal data) of the Act. Section 40 (1) is an Absolute Exemption and therefore is not subjected to the public interest test.

How many ECT in 2020?

There were 190 ECT sessions.

What proportion of patients were men/women?

Out of the 19 total clients, 66.84% were male and 33.16% were female.

How old were they?

19-64 years = 9
65 years + = 10

What proportion of patients were classified BAME?

The proportion of BAME patients who received ECT were <5.
We are unable to provide this information as we are dealing with very small numbers of cases and we believe that providing this information could lead to the identification of individuals as patients of our service and so we are withholding this information under section 40(2) of the FOI Act.

How many were receiving ECT for the first time?

The number of patients receiving ECT for the first time is <5.
We are unable to provide this information as we are dealing with very small numbers of cases and we believe that providing this information could lead to the identification of individuals as patients of our service and so we are withholding this information under section 40(2) of the FOI Act.

How many patients consented to ECT?

100%.

How many ECT complaints were investigated outside the NHS and CCG?

How many patients died during or 1 month after ECT and what was the cause (whether or not ECT was considered the cause)?

How many patients died within 6 months after ECT and what was the cause (whether or not ECT was considered the cause)?

How many patients died by suicide within 6 months of receiving ECT (whether or not ECT was considered the cause)?

How many patients have suffered complications during and after ECT and what were those complications?

Have there been any formal complaints from patients/relatives about ECT?

If so, what was their concerns?

N/A.

How many patients report memory loss/loss of cognitive function?

This is addressed individually and would require a manual search through individual patient records.

What tests are used to assess memory loss/loss of cognitive function?

Six Item Cognitive Impairment Test (6CIT).

Have MRI or CT scans been used before and after ECT?

No.

If so what was the conclusion?

N/A.

How does the Trust plan to prevent ECT in the future?

N/A.

Seclusion

Please supply any SECLUSION reports/investigations

Please be advised the Trust does not release details where patients can be identified in line with UK GDPR, and we are withholding this information under Section 40 (1) (Personal Data) of the Act. Section 40(1) is an Absolute Exemption and is therefore not subject to the public interest test.

How many SECLUSIONS in 2020?

Within our mental health inpatient division, we recorded 239.

What proportion of patients were men/women?

This information was not recorded in 2020. We only began recording the gender of patients on our incident reporting system, Datix, from 2021.

How old were they?

Age	No’ of patients
1-19yrs	24
20-39yrs	143
40+yrs	47
Total	214

Please note, not all patients have their age reported when an incident is reported.

What proportion of patients were classified BAME?

This information was not recorded in 2020. We only began recording the ethnicity of patients on our incident reporting system, Datix, from 2021.

How many SECLUSIONS were investigated outside the NHS and CCG?

How many patients died during or 1 month after SECLUSION and what was the cause (whether or not SECLUSION was considered the cause)?

This information would require a manual search through individual patient records.

How many patients died within 6 months after SECLUSION and what was the cause (whether or not SECLUSION was considered the cause)?

This information would require a manual search through individual patient records.

How many patients died by suicide within 6 months of receiving SECLUSION (whether or not SECLUSION was considered the cause)?

This information would require a manual search through individual patient records.

How many patients have suffered complications during and after SECLUSION and what were those complications?

This information would require a manual search through individual patient records.

Have there been any formal complaints from patients/relatives about SECLUSION?

None.

If so, what was their concerns?

N/A.

How does the Trust plan to prevent SECLUSION in the future?

Through the work we are doing around restraint reduction and also reducing of restrictive practices we hope to reduce the number of seclusion incidents. We were in the process of having a rapid improvement event to gather data and work through Quality Improvement methodology, but this is currently on hold due to Covid-19

Serious Incidents

Please supply any serious incident reports/investigations

How many SERIOUS INCIDENT REPORTS in 2020?

Total of 80, of which 5 were downgraded and 1 remains stop the clock (which is under external investigation before our review can start).

What proportion of patients were men/women?

49% were female and 51% were male.

How old were they?

1-35 years old = 31%
36-64 years old = 32%
65+ years old = 37%

What proportion of patients were classified BAME?

12% of patients were classified as BAME.

How many SERIOUS INCIDENT REPORTS were investigated outside the NHS and CCG?

3 cases under Police investigation. 2 of the 3 have had serious incident (SI) investigation completed by NHS and CCG post-police investigation and 1 remains Stop the Clock, this means do not investigate until the police have concluded their investigations.

How many patients died during or 1 month after SERIOUS INCIDENT REPORTS and what was the cause (whether or not SERIOUS INCIDENT REPORTS was considered the cause)?

How many patients died within 6 months after SERIOUS INCIDENT REPORTS and what was the cause (whether or not SERIOUS INCIDENT REPORTS was considered the cause)?

How many patients died by suicide within 6 months of receiving SERIOUS INCIDENT REPORTS (whether or not SERIOUS INCIDENT REPORTS was considered the cause)?

How many patients have suffered complications during and after SERIOUS INCIDENT REPORTS and what were those complications?

Have there been any formal complaints from patients/relatives about SERIOUS INCIDENT REPORTS?

If so, what was their concerns?

Clarity around Mental Health Terms "Jargon" in the report.
Clarity on how different sections within Mental Health Services work with each other.
Flowchart to help the lay person to understand how the different Mental Health Services flowed from one to the other and how the patient used them.

How does the Trust plan to prevent SERIOUS INCIDENTS in the future?

An output from each SI is an action plan which seeks to reduce the risk of future reoccurrence of similar incidents.

Restraints

Please supply any Restraints/investigations

How many RESTRAINTS in 2020?

Within our mental health inpatient division, we recorded 977.

What proportion of patients were men/women?

This information was not recorded in 2020. We only began recording the gender of patients on our incident reporting system, Datix, from 2021.

How old were they?

Age	No’ of patients
1-19 years	220
20-39 years	362
40-59 years	200
60-79 years	86
80-100+ years	22
Total	89

Please note , not all patients have their age reported when an incident is reported.

What proportion of patients were classified BAME?

This information was not recorded in 2020. We only began recording the ethnicity of patients on our incident reporting system, Datix, from 2021.

How many RESTRAINTS were investigated outside the NHS and CCG?

How many patients died during or 1 month after RESTRAINTS and what was the cause (whether or not RESTRAINTS was considered the cause)?

This information would require a manual search through individual patients records

How many patients died within 6 months after RESTRAINTS and what was the cause (whether or not RESTRAINTS was considered the cause)?

This information would require a manual search through individual patient records.

How many patients died by suicide within 6 months of receiving RESTRAINTS (whether or not RESTRAINTS was considered the cause)?

This information would require a manual search through individual patient records.

How many patients have suffered complications during and after RESTRAINTS and what were those complications?

This information would require a manual search through individual patient records.

Have there been any formal complaints from patients/relatives about RESTRAINTS?

None.

If so, what was their concerns?

N/A.

Are counts of forced injections available?

There were 443 intramuscular (IM) injections reported. Please note, this does not mean they were all forced injections, as some patients prefer IM or even request IM.

How does the Trust plan to reduce restraints in the future?

We have done a lot of work to reduce restraint and delivered updated training to our staff. We will continue to reduce the use of restraint by using Quality Improvement methodology to analyse all restraints used to understand why they were needed and how we can avoid and reduce them. We are also ensuring we are consistently meeting national standards by using the certification process to have this assured by an external organisation.

Medication Errors

Please supply any MEDICATION ERRORS reports/investigations

How many MEDICATION ERRORS in 2020?

There were 1,025 medication errors reported across the Trust, but only 956 of these effected patients and were classified as low or minor risk.

What proportion of patients were men/women?

This information was not recorded in 2020. We only began recording the gender of patients on our incident reporting system, Datix, from 2021.

How old were they?

Age	No’ of patients
1-19 years	19
20-39 years	69
40-59 years	109
60-79 years	238
80-100+ years	388
Total	823

Please note, not all patients have their age reported when an incident is reported.

What proportion of patients were classified BAME?

This information was not recorded in 2020. We only began recording the ethnicity of patients on our incident reporting system, Datix, from 2021.

How many MEDICATION ERRORS were investigated outside the NHS and CCG?

How many patients died during or 1 month after MEDICATION ERRORS and what was the cause (whether or not MEDICATION ERRORS was considered the cause)?

This information would require a manual search through individual patient records

How many patients died within 6 months after MEDICATION ERRORS and what was the cause (whether or not MEDICATION ERRORS was considered the cause)?

This information would require a manual search through individual patient records.

How many patients died by suicide within 6 months of receiving MEDICATION ERRORS (whether or not MEDICATION ERRORS was considered the cause)?

This information would require a manual search through individual patient records.

How many patients have suffered complications during and after MEDICATION ERRORS and what were those complications?

This information would require a manual search through individual patient records.

Have there been any formal complaints from patients/relatives about MEDICATION ERRORS?

None.

If so, what was their concerns?

N/A.

How does the Trust plan to prevent MEDICATION ERRORS in the future?

The Trust will continue to reduce medication errors by:

Encourage more reporting of errors and more importantly near misses
Promote a just culture
Continue to invest in multidisciplinary Medication Safety Officers who review reported errors and disseminate relevant learning from local, national and international sources.
Continue to support the Medication Safety Group who monitor for trends and patterns and review action plans from reported medication errors.
Continue to promote local learning from using learning from medication errors and associated learning materials.
Continue to promote standardisation and simplification of medication processes.