Friendship group affiliated to HVN

**Please note, to avoid the risk of identification, where number of patients is 5 or less, C&I NHS FT have provided a default number of patient as <5**

Restraints

Seclusion

Medication Error

Q6

How old were they?

Q6

How old were they?

Q6

How old were they?

Age range

Number of patients

Age range

Number of patients

Age range

Number of patients

18-24

96

18-24

14

18-24

25

25-34

176

25-34

37

25-34

34

35-44

82

35-44

10

35-44

53

45-54

83

45+

12

45-54

41

55-64

34

Total

73

55-64

74

65+

24

**The remainder of incidents did not have the patient age recorded**

65+

30

Total

495

Total

257

**The remainder of incidents did not have the patient age recorded**

**The remainder either did not directly involve patients or the patient age was not recorded**

Q8

What proportion of patients were classified BAME?

Q8

What proportion of patients were classified BAME?

Q8

What proportion of patients were classified BAME?

Ethnicity

Number of patients

Ethnicity

Number of patients

Ethnicity

Number of patients

Bangladeshi

7

Bangladeshi

<5

Bangladeshi

6

Black African

98

Black African

16

Black African

23

Black Caribbean

44

Black Caribbean

10

Black Caribbean

21

Chinese

<5

Indian

<5

Chinese

<5

Indian

8

Mixed white and black Caribbean

<5

Indian

8

Mixed white and Asian

<5

Not stated

<5

Mixed white and black African

8

Mixed white and black African

16

Other Asian

6

Mixed white and black Caribbean

<5

Mixed white and black Caribbean

12

Other Black

<5

Not stated

<6

Not stated

8

Other ethnic category

<5

Other Asian

8

Other Asian

16

Other mixed

<5

Other Black

6

Other Black

10

White – British

13

Other ethnic category

7

Other ethnic category

<5

White - other white

12

Other mixed

<5

Other mixed

24

Total

57

Pakistani

<5

White – British

154

**The remainder of incidents did not have patient ethnicity recorded**

White – British

105

White – Irish

18

White – Irish

9

White - other white

73

White - other white

42

Total

488

Total

243

**The remainder of incidents did not have patient ethnicity recorded**

**The remainder of incidents did not have patient ethnicity recorded**

Questions

Information held Y/N

Investigation Outcome

A description of the nature the type of work that would need to be undertaken (e.g. searching X number of files– 1 hour)

Unit

Sampling Time taken per unit

Number of units required

Estimate time to retrieve the information,based on sampling time

Electro-Convulsive therapy (ECT)

8. What proportion of patients were classified BAME?

Y

Section 12 applies, as it would require C&I to cross reference both ECT record and Carenotes.

Section 12 exemption applied

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

Y

Section 12 applies, as it would require C&I to cross reference both ECT record and Carenotes.

Section 12 exemption applied

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

Y

Section 12 applies, as it would require C&I to cross reference both ECT record and Carenotes.

Section 12 exemption applied

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

Y

Due to the decision that section 12 applies, no enquires have been made.

Section 12 exemption applied

RESTRAINTS

3. Please supply any Restraints/investigations

Y

See SECTION 12 tab

Section 12 exemption applied

7. What were the diagnoses and in what proportions?

Y

Section 12 applies
This will take more than 18 hours to gather as it requires going into each service users record individually.

This information is stored on DATIX (incident recording system). This requires pulling all restraint incidents for 2019 onto a spreadsheet. Each incident comes with an allocated reference number. C&I would have to copy that reference number or the SU's name and then go into a different system (Carenotes) which holds service users records and then look for their diagnosis individually. Some service users have multiple diagnosis, so we would need to read through them to ascertain which of the diagnosis is more prominent. a sample of 3 was done and the least amount of time it took to get one was 8 minutes. To do 500 incidents, will amount to 4000 minutes.

1

8 minutes

500

66hours

9. How many were receiving RESTRAINTS for the first time?

Y

This information will take more than 18 hours to pull out as we will need to look for and go into patients record including record from previous admission with other places (if applicable) to ascertain this.

This information requires C&I looking into a service users admission records and searching for the word restraint in their written summary and then read them to check when they were first restrained. Alternatively, checking on DATIX for all incident of restraints dating back to other previous admissions which could be from a previous year. Doing this for one service user took C&I around 10 minutes. To do 500 incidents would be around 5000 minutes

1

10minutes

500

83hours

SECLUSION

3. Please supply any SECLUSION reports/investigations

Y

Section 12 applies to all the above therefore no further work was carried out on this question.

Section 12 exemption applied

7. What were the diagnoses and in what proportions?

Y

This will take more than 18 hours to gather as it requires going into each service users record individually.

This information is stored on DATIX (incident recording system). This requires C&I pulling all seclusion incidents for 2019 onto a spreadsheet. Each incident comes with an allocated reference number. A manual search of the   reference number or the SU's name would have to be done on a different system (Carenotes) which holds service users records and then look for their diagnosis individually. Some service users have multiple diagnosis, so C&I need to read through them to ascertain which of the diagnosis is more prominent. A sample of 3 was done and the least amount of time it took to get the information for one service user was 8 minutes. C&I then have to put the numbers together and calculate the proportion after that. It would take about 584 minutes for 73 service users.

1

8min

73

9.7hours

9. How many were receiving SECLUSION for the first time?

Y

This information will take more than 18 hours to pull out as we will need to look for and go into patients record including record from previous admission with other places (if applicable) to ascertain this.

This requires C&I looking into service users admission records and searching for the word restraint in their written summary and then read them to check when they were first restrained. Alternatively, checking on DATIX for all incident of restraints dating back to other previous admissions which could be from a previous year. Doing this for one service user took C&I around 10 minutes. It is also likely not to be accurate information, if the service users was admitted in another organisation and had been restrained there we would not have access to that information.

1

10min

73

12hours

MEDICATION ERRORS

3. Please supply any MEDICATION ERRORS reports/investigations

Y

Section 12 applies to all the above therefore no further work was carried out on this question.

Section 12 exemption applied

7. What were the diagnoses and in what proportions?

Y

Section 12 applies
This will take more than 18 hours to gather as it requires going into each service users record individually.

Two different databases need to be searched. Databases are not connected, therefore, would require C&I to manually search all incidents of medication error from DATIX and cross reference patients record on Carenotes.                                                                                                

1

3min 40s

321

19.5hours

9. How many were receiving MEDICATION ERRORS for the first time?

Y

Section 12 applies
This will take more than 18 hours to gather as it requires going into each service users record individually.

This would require us to extract each patient's identifiable data from previously completed report (all medicine incidents in 2019)/ Extract a report of all incidents for that patient since the Trust has used Datix database/ Delete all non-medicine incidents from the report by going manually through the report and selecting only the medicine incidents/ Identify if any patients have more than one medicine incident reported/ Repeat for each patient.

1

15min

321

80hours

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

N

Section 12 applies
This will take more than 18 hours to gather as it requires going into each service users record individually.

Multiple databases have to be manually reviewed. Cross reference to ensure correct patient selected/Determine whether patient is deceased/If yes, search Carenotes record for information as to the cause of death/If no information on COD (most cases), Open Coroner's shared drive/Locate folder for relevant year/locate deceased service user file/Examine correspondence in file to determine if cause of death is available

1

4min

321

20hours

13. How many patients died a few months after MEDICATION ERRORS and what was the cause (whether or not MEDICATION ERRORS was considered the cause)?

N

Section 12 applies
This will take more than 18 hours to gather as it requires going into each service users record individually.

This would require us to manually search for patient from information gathered/Cross reference to ensure correct patient selected/Determine whether patient is deceased/If yes, search Carenotes record for information as to the cause of death/If no information on COD (most cases), Open Coroner's shared drive/Locate folder for relevant year/locate deceased service user file/Examine correspondence in file to determine if cause of death is available/If no COD from Coroner available, search Datix using patient details for all incidents involving that service user/locate death incident report/Examine Datix incident report for available details of death to see if likely suicide

1

5min 30s

321

29hours

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

N

Section 12 applies
This will take more than 18 hours to gather as it requires going into each service users record individually.

This would require us to manually search for patient from information gathered/Cross reference to ensure correct patient selected/Determine whether patient is deceased/If yes, search Carenotes record for information as to the cause of death/If no information on COD (most cases), Open Coroner's shared drive/Locate folder for relevant year/locate deceased service user file/Examine correspondence in file to determine if cause of death is available/If no COD from Coroner available, search Datix using patient details for all incidents involving that service user/locate death incident report/Examine Datix incident report for available details of death to see if likely suicide

1

7min

321

37hours

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

Y

We are able to identify the number of patients by the level of injury recorded on electronic reporting system, please see below. However each report would need to be reviewed to establish the exact detail of harm:                                                                   Minor Injury: 7                                                                                 No Injury: 314

This would require us to cross-reference two databases. Read the individual entries to find any evidence of recording complications following the medicine incident.

1

7min 20s

321

39hours

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

Y

Due to the decision that section 12 applies, no enquires have been made.

Section 12 exemption applied

17. If so, what was their concerns?

Y

Due to the decision that section 12 applies, no enquires have been made.

Section 12 exemption applied

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

Y

Due to the decision that section 12 applies, no enquires have been made.

Section 12 exemption applied

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

Y

Due to the decision that section 12 applies, no enquires have been made.

Section 12 exemption applied

20. Have MRI or CT scans been used before and after MEDICATION ERRORS?

Y

Section 12 applies
This will take more than 18 hours to gather as it requires going into each service users record individually.

This would require us to search for the patient using the data from Datix/ Cross-reference & make sure it is the correct patient/ Search patient's Carenotes for entries following the medicine incident' date/ Read the individual entries to find any evidence of MRI or CT scans performed and results. Alternatively, uploaded documents in patient's electronic notes could be searched to find the scan results. The scan results are not necessarily uploaded into patients' notes on each occasion, so the patients' progress notes would need to be searched manually as well.

1

11min 30s

321

61.5hours

21. If so what was the conclusion?

Y

Section 12 applies
This will take more than 18 hours to gather as it requires going into each service users record individually.

See above

Serious incidents

1. Please supply SERIOUS INCIDENT REPORTS patient’s information leaflet.

Due to the decision that section 12 applies, no enquires have been made.

2. Please supply patient SERIOUS INCIDENT REPORTS consent form.

Due to the decision that section 12 applies, no enquires have been made.

3. Please supply any serious incident reports/investigations

Due to the decision that section 12 applies, no enquires have been made.

4.How many SERIOUS INCIDENT REPORTS in 2019?

Due to the decision that section 12 applies, no enquires have been made.

5. What proportion of patients were men/women?

Due to the decision that section 12 applies, no enquires have been made.

6. How old were they?

Due to the decision that section 12 applies, no enquires have been made.

7. What were the diagnoses and in what proportions?

Due to the decision that section 12 applies, no enquires have been made.

8. What proportion of patients were classified BAME?

Due to the decision that section 12 applies, no enquires have been made.

9. How many were receiving SERIOUS INCIDENT REPORTS for the first time?

Due to the decision that section 12 applies, no enquires have been made.

10. How many patients consented to SERIOUS INCIDENT REPORTS?

Due to the decision that section 12 applies, no enquires have been made.

11. How many SERIUOS INCIDENT REPORTS were investigated outside the NHS and CCG?

Due to the decision that section 12 applies, no enquires have been made.

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

Due to the decision that section 12 applies, no enquires have been made.

13. How many patients died a few months after SERIOUS INCIDENT REPORTS and what was the cause (whether or not SERIOUS INCIDENT REPORTS was considered the cause)?

Due to the decision that section 12 applies, no enquires have been made.

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

Due to the decision that section 12 applies, no enquires have been made.

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

Due to the decision that section 12 applies, no enquires have been made.

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

Due to the decision that section 12 applies, no enquires have been made.

17. If so, what was their concerns?

Due to the decision that section 12 applies, no enquires have been made.

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

Due to the decision that section 12 applies, no enquires have been made.

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

Due to the decision that section 12 applies, no enquires have been made.

20. Have MRI or CT scans been used before and after SERIOUS INCIDENT REPORTS?

Due to the decision that section 12 applies, no enquires have been made.

21. If so what was the conclusion?

Due to the decision that section 12 applies, no enquires have been made.

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

Due to the decision that section 12 applies, no enquires have been made.