BERKSHIRE 2021

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

provided

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 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 ECT in 2021?

There were 257 ECT sessions.

What proportion of patients were men/women?

Out of the 20 total patients, 8 were male and 12 were female.

How old were they?

19-64 years = 7

65+ years = 13

What proportion of patients were classified people of the global majority or racialised communities ("POC / BAME")?

We are unable to provide this information as we are dealing with special category data 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?

0.

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

0.

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

1.

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

0.

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

0.

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

2.

If so, what was their concerns?

Complaint 1: Miscommunication about ECT not being provided due to Covid-19 (community patient)

Complaint 2: Perceived delay on ECT (inpatient)

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.

Serious Incidents

Please supply any serious incident 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 SERIOUS INCIDENT REPORTS in 2021?

Total of 72, of which 4 were downgraded and 1 was a stop the clock.

What proportion of patients were men/women?

Female: 58%

Male: 42%

How old were they?

1 - 35 years old: 27%

36 - 64 years old: 33%

65+ years old: 40%

What proportion of patients were classified people of the global majority or racialised communities ("POC / BAME")?

We are unable to provide this information as we are dealing with special category data 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 SERIOUS INCIDENT REPORTS were investigated outside the NHS and CCG?

1.

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)?

0.

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)?

0.

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

0.

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

0.

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

1.

If so, what was their concerns?

Family needed clarity from SI report as unhappy with jargon.

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. We also have a Quality Improvement Programme which uses intelligence from Serious Incidents to inform our priorities.

Restraints

Please supply any Restraints/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 RESTRAINTS in 2021?

Within our mental health inpatient division, we recorded 1,076 restraints.

What proportion of patients were men/women?

Female: 801

Male: 227

Other / not known: 8

Please note, there are some incident reports which do not have the patients gender listed. Therefore, we are not able to provide a breakdown for these patients without completing a manual search through individual patient records.

How old were they?

10 – 12: 6

13 – 17: <5

18 – 20: 192

21 – 25: 222

26 – 30: 166

31 – 35: 86

36 – 40: 126

41 – 50: 70

51 – 60: 120

71+: <5

Please note, there are some incident reports which do not have the patients age listed. Therefore, we are not able to provide a breakdown for these patients without completing a manual search through individual patient records.

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.

What proportion of patients were classified people of the global majority or racialised communities ("POC / BAME")?

We are unable to provide this information as we are dealing with special category data 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 RESTRAINTS were investigated outside the NHS and CCG?

0.

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 patient 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?

There was 1 patient who had a physical injury after being restrained.

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

2.

If so, what was their concerns?

Complaint 1: Allegation that patient was assaulted during restraint.

Complaint 2: Allegation of staff being heavy handed during restraint (this comment was included within the seclusion complaint).

Are counts of forced injections available?

There were 402 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?

Extensive work has been done and is ongoing ensuring compliance with the Use of Force Act requirements. A QI piece of work is being undertaken by two wards who are the highest contributor to restraints. We are also working on smaller improvements that reduces restrictions and so reduces flashpoints where patients may become frustrated and angry. We have maintained our improvement on the reduction of prone restraint.

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 2021?

Within our mental health inpatient division, we recorded 231 seclusions.

What proportion of patients were men/women?

Female: 74

Male: 143

Other / not known: <5

Please note, there are some incident reports which do not have the patients gender listed. Therefore, we are not able to provide a breakdown for these patients without completing a manual search through individual patient records.

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 old were they?

18 – 20: 24

21 – 25: 45

26 – 30: 45

31 – 35: 28

36 – 40: 8

41 – 50: 25

51 – 60: 18

71+: <5

Please note, there are some incident reports which do not have the patients age listed. Therefore, we are not able to provide a breakdown for these patients without completing a manual search through individual patient records.

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.

What proportion of patients were classified people of the global majority or racialised communities ("POC / BAME")?

We are unable to provide this information as we are dealing with special category data 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 SECLUSIONS were investigated outside the NHS and CCG?

0.

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?

1 (please note, this patient’s complaint included comments on seclusion and restraints).

If so, what was their concerns?

Unhappy they were placed into seclusion.

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

A quality improvement piece of work is underway and 2 countermeasures are currently being tested regarding communication between staff and patients to reduce frustration and flashpoints.

Medication Errors

Please supply any MEDICATION ERRORS 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 MEDICATION ERRORS in 2021?

There were 69 medication errors reported across the Trust.

What proportion of patients were men/women?

Female: 30

Male: 31

Other / not known: 8

Please note, there are some incident reports which do not have the patients gender listed. Therefore, we are not able to provide a breakdown for these patients without completing a manual search through individual patient records.

How old were they?

18 – 20: <5

21 – 25: <5

26 – 30: 12

31 – 35: <5

36 – 40: 8

41 – 50: 8

51 – 60: 25

71+: <5

Please note, there are some incident reports which do not have the patients age listed. Therefore, we are not able to provide a breakdown for these patients without completing a manual search through individual patient records.

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.

What proportion of patients were classified people of the global majority or racialised communities ("POC / BAME")?

We are unable to provide this information as we are dealing with special category data 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 MEDICATION ERRORS were investigated outside the NHS and CCG?

0.

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?

1.

If so, what was their concerns?

Incorrect medication administered.

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.