Friendship group affiliated to HVN

FOI3616

ECT Questions

1. Please supply patient’s information ECT leaflet.

Any use of ECT is carried out outside of this Trust. We do not have copies of leaflets/ forms that are supplied.

2. Please supply patient ECT consent form.

As 1 above

3. Please supply any ECT reports/investigations

Any use of ECT is carried out outside of this Trust. We cannot report information at an individual patient level.

4. How many ECT in 2024?

We have now been advised all ECT questions are to be answered by Leeds Trust.

5. What proportion of patients were men/women?

As 3 above

6. How old were they?

As 3 above

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

As 3 above

8. How many people covered by the equality act received ECT?

As 3 above

9. How many people were offered talking therapy prior to ECT?

The information is not held in reportable fields within the patient records but is held in text entries which would have to be reviewed in order to extract the required information

10. How many were receiving ECT for the first time?

As 3 above

11. How many patients consented to ECT?

As 3 above

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

Investigations could occur which we are not aware of.

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

As 9 above

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

As 9 above

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

As 9 above

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

As 3 above

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

No complaints have been raised via PACS regarding ECT

18. If so, what was their concerns?

As 17 above

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

As 3 above

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

As 3 above

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

As 9 above

22. If so, what was the conclusion?

As 9 above

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

There is no plan regarding reduction in ECT, it is only used as last resort or maintenance

Restraint Questions

1. Please supply any Restraints/investigations

2794

2. How many RESTRAINTS in 2024?

2794

3. What proportion of patients were men/women?

4. How old were they?

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

6. How many people covered by the equality act were restrained?

All

7. How many RESTRAINTS were investigated outside the NHS and CCG?

Investigations could occur which we are not aware of.

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

As 3 above

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

As 3 above

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

As 3 above

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

As 3 above

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

5 complaints have been raised via PACS regarding restraint interventions

13. If so, what was their concerns?

1. SU alleges staff lost their glasses during restraint incident and requesting reimbursement. Also, restraint resulted in SU being injured (cut to back)

2. Parent alleged that staff restrained SU for pulling flowers out of the hospital gardens

3. SU alleges he was forcibly restrained by staff, hurt in the process and that staff laughed at SU.

4. Parent felt staff were punishing SU by restraining and giving medication due to SU becoming unsettled when told could not have remote as SU had caused damage to previous remotes on the ward

SU unhappy was not provided with debrief report following restraint incident

14. Are counts of forced injections available?

As 3 above

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

BDCFT is committed to a no force first approach to managing risk of violence and aggression (be that towards self or others) in all settings. Most commonly regulated restraint is practiced by trained staff after all other steps have been taken in our inpatient services. We routinely monitor use of restrictive practice on a monthly basis in our positive and proactive forum.All staff receive training in trauma informed care and conflict resolution alongside when and how to implement safe holds. The Trust seek to engage people in managing their own behaviour and risk, adopting a formulation based approach. We share examples of good practice from our various units, so people can learn from one another about what works in mediating the need to use of restrictions. Our goals is of course to never need to use restrictions (though this might not be completely realistic). We ensure people have information shared with them about the potential for use of restrictions on admission and in cases where all other approaches have failed we offer people (staff and service users) a debriefing space in the aftermath to reduce the risk of re-traumatisation and to learn proactively about how to reduce the risk of needing such interventions in future which feeds into people’s risk management plans.  

16.How many of these restraints were face down restraints?

12

Seclusion Questions

1. Please supply any SECLUSION reports/investigations

50

2. How many SECLUSIONS in 2024?

50

3. What proportion of patients were men/women?

4. How old were they?

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

6. How many people covered by the Equality Act were secluded?

All

7. How many SECLUSIONS were investigated outside the NHS and CCG?

Investigations could occur which we are not aware of.

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

As 3 above

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

As 3 above

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

As 3 above

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

As 3 above

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

2

13. If so, what was their concerns?

1. SU unhappy been in seclusion for 10 days.

2. Friend of SU unhappy SU had been in

seclusion 6 months due to threatening behaviour.

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

BDCFT is committed to a no force first approach to managing risk of violence and aggression (be that towards self or others) in all settings. Most commonly regulated restraint is practiced by trained staff after all other steps have been taken in our inpatient services. We routinely monitor use of restrictive practice on a monthly basis in our positive and proactive forum. All staff receive training in trauma informed care and conflict resolution alongside when and how to implement safe holds. We seek to engage people in managing their own behaviour and risk, adopting a formulation based approach. We share examples of good practice from our various units, so people can learn from one another about what works in mediating the need to use of restrictions. Our goals is of course to never need to use restrictions (though this might not be completely realistic). We ensure people have information shared with them about the potential for use of restrictions on admission and in cases where all other approaches have failed we offer people (staff and service users) a debriefing space in the aftermath to reduce the risk of re-traumatisation and to learn proactively about how to reduce the risk of needing such interventions in future which feeds into people’s risk management plans.  

Medication errors

1. Please supply any MEDICATION ERRORS reports/investigations

784

2. How many MEDICATION ERRORS in 2024?

784

3. What proportion of patients were men/women?

4. How old were they?

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

6. How many people covered by the equality act endured medication errors?

All

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

Investigations could occur which we are not aware of.

8. 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)?

As 3 above

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

As 3 above

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

As 3 above

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

As 3 above

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

13

13. If so, what was their concerns?

1. Relative unhappy SU’s prescription had not been handed over to GP, causing delays in accessing medication

2. Relative of SU raised concerns that she was

told SU was not taking his insulin or lamotrigine whilst an inpatient

3. Relative of SU unhappy DNs are not

administering insulin on time.

4. Relative of SU reports wrong antibiotics

prescribed caused kidney failure and hospitalisation

5. Wife of SU raised complaint re poor practice in

issuing prescribed medication.

6. Relative of SU states recently found that SU

had not been taking medication for months due to her care coordinator being on extended unplanned leave (they normally order meds for her and has them delivered)

7. Dad of SU reports SU (child) was given COVID

vaccine without consent.

8. Mum of SU alleges prescribed wrong

medication.

9. Parent states regularly chasing service

regarding SU's prescription as he is often without medication and having a difficult time as the prescription isn't set up on repeat

10. Wife of SU unhappy SU had to wait 15 days for

antibiotic cream. DN said would put prescription through twice but didn’t.

11. SU concerned about prescription and volume

of anxiety medication, thinks a mistake has been made

12. Mum of SU felt SU was being overmedicated

whilst an inpatient.

13. Relative of SU unhappy with SU pain

management, alleges DNs refused to administer morphine and levo which was prescribed by GP. Led to difficulty breathing, agitation and distress.

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

All medication errors and near misses which take place are reported on the Trust Incident Report and Risk Register System. Each incident is reviewed and investigated by an allocated manager. After investigation, the manager will close the incident with a list of actions which have resulted from the error/near miss which occurred. The staff involved in the error will complete a reflection where appropriate and further training for the staff may be carried out, if required. All medication incidents are also sent to the medicines safety officer for information.

An incident report summary is printed every quarter and the medicines safety officer reviews this to review any themes and trends in any medication incidents/near misses which may have occurred. This is then added to the quarterly medicines management and safety meeting where the report is discussed, and any areas of concern/learning are highlighted. A report is then produced from the medicines management meeting, and this is presented to Clinical Board and Patient Safety and Learning Group.

A medicines bulletin is produced by the medicines safety officer every 2 months, and this highlights any recent medication incidents/near misses that have occurred within the Trust. The bulletin also highlights any learning and changes to practice which may have resulted from the incidents which took place.

Training sessions are carried out for nurses and doctors where they are encouraged to report all near misses for any medication incidents, this is so we can continuously learn and develop our practice to prevent harm from occurring in the future from a medication error.

The medicines safety officer attends the weekly nurse call-out meeting to discuss any medication incidents which occurred in the past week and to share any learning so this can be disseminated to all the teams across the Trust.

The Medicines Safety Officer is also part of wider system groups with other organisations to share learning across the region and nationally as needed.