ECT

1. Please supply patient’s information ECT leaflet.

2. Please supply patient ECT consent form

3. Please supply any ECT reports/investigations

4. How many ECT in 2021?

5. What proportion of patients were men/women?

6. How old were they?

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

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

9. How many patients consented to ECT?

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

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

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

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

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

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

16. If so, what was their concerns?

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

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

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

20. If so, what was the conclusion?

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

Serious Incidents

1. Please supply any serious incident reports/investigations?

These would contain patient identifiable information and therefore cannot be supplied.

2. How many SERIOUS INCIDENT REPORTS in 2021?

28

3. What proportion of patients were men/women

15 Male

12 Female

1 incident was involving a piece of equipment

4. How old were they?

Range 8 – 94 years old

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

Unsure – not all documented

6. How many SERIOUS INCIDENT

REPORTS were investigated outside the NHS and CCG?

1 will be as part of a homicide

7. 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)?

17

1 Intracerebral Haemorrhage

1 Urosepsis

1 End of Life

1 fall

1 still not yet ascertained by the Coroner

1 Severe coronary artery atherosclerosis

11 Suspected Suicides (TBC)

8. 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)?

No further deaths than above

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

11 (TBC)

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

TBC

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

Not to my knowledge

12. If so, what was their concerns?

N/A

13. How does the Trust plan to prevent

SERIOUS INCIDENTS in the future?

We will implement the Trust’s developing Patient Safety Incident Response Plan (PSIRP). This is in response to the Patient Safety Incident Response Framework (PSIRF) which itself is published by NHS England following their development of the Patient Safety Strategy.

These changes are currently being prepared for roll-out across the NHS estate nationwide by the National Patient Safety Team.

Restraints

1. Please supply any

Restraints/investigations?

0

2. How many RESTRAINTS in 2021?

1855

3. What proportion of patients were men/women?

Men 51.5%, Women 47.7%, Unknown 0.8

4. How old were they?

Under 12         0.0%

12 - 17 yrs     0.9%

18 - 24 yrs     17.5%

25 - 34 yrs     18.5%

35 - 44 yrs     13.6%

45 - 54 yrs     25.3%

55 - 64 yrs     12.7%

65 - 74 yrs       6.3%

75 yrs and older     4.3%

Unknown         0.9%

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

Global Majority 91.4%

Racialised Communities 5.7%

Undisclosed 2.9%

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

We don’t have any information to share at this time in relation to restraints investigated outside the NHS/CCG for 2021.

7. 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 is unfortunately not available without accessing each patient’s clinical record.

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

This information is unfortunately not available without accessing each patient’s clinical record.

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

This information is unfortunately not available without accessing each patient’s clinical record.

10. How many patients have suffered complications during and after

RESTRAINTS and what were those complications?

This information is unfortunately not available without accessing each patient’s clinical record.

11. Have there been any formal complaints from patients/relatives about

RESTRAINTS?

3

12. If so, what was their concerns

Complainant reported the patient was thrown on their bed by a member of staff who was alone and unsupported by other staff to undertake an appropriate hold.

Complainant reported patient was restrained without appropriate use of de-escalation techniques. The patient could not recall an

increase in observations following restraint.

Complainant reported patient was restrained when they tried to leave the ward – complainant asked who authorised the restraint and who was involved.

13. Are counts of forced injections available?

Yes,

Rapid Tranquilization 397

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

We had a planning meeting for the Positive and Safe Group for the coming year on the 18^th May and the Agenda Plan for the coming year will get updated imminently following the meeting. The Trust has signed up half of our Inpatient Wards to the MH Collaborative/Reducing Restrictive

Interventions Project, currently collecting baseline data, with a plan to start in August. The Nationally agreed target is to reduce use of Restraint, Seclusion (only prescribed for 1 person in the

Trust, but not used in over 2 years) and Rapid Tranquilisation by 25%. This project work will be implemented and monitored through the Positive and Safe Group and will be reflected in the new Agenda Plan. And learning from this project will then get rolled out to the rest of the wards as appropriate.

Seclusion

1. Please supply any SECLUSION reports/investigations

N/A

2. How many SECLUSIONS in 2021?

0

3. What proportion of patients were men/women?

N/A

4. How old were they?

N/A

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

N/A

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

N/A

7. How many patients died during or 1 month after SECLUSION and what was the cause

(whether or not SECLUSION was considered the cause)?

N/A

8. How many patients died within 6 months after SECLUSION and what was the cause

(whether or not SECLUSION was considered the cause)?

N/A

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

N/A

10. How many patients have suffered complications during and after

SECLUSION and what were those complications?

N/A

11. Have there been any formal complaints

No

from patients/relatives about SECLUSION?

12. If so, what was their concerns?

N/A

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

The Nationally agreed target is to reduce use of Restraint, Seclusion (only prescribed for 1 person in the Trust, but not used in over 2 years) and Rapid Tranquilisation by 25%. This project work will be implemented and monitored through the Positive and Safe Group and will be reflected in the new Agenda Plan. Learning from this project will then get rolled out to the rest of the wards as appropriate.

“Seclusion is only used as a last resort in our inpatient learning disability unit. It is not used in Mental Health inpatient units within our Trust. There were no instances of seclusion in calendar year 2021. In order to reduce the use of seclusion to a minimum, patients should have comprehensive Positive Behavioural Support and Positive Behavioural Management Plans in place, allowing staff to identify behavioural indicators, distraction techniques and de-escalation plans to prevent the patient reaching the point of

Seclusion.   When used, seclusion must be used for the shortest possible time.

The use of seclusion should never be used to manage a patient’s self-harming behaviour and a patient’s welfare remains of paramount concern to the Trust. However, occasions may arise where a patient poses a risk of harm to themselves as well as to others. Seclusion should only be used in those circumstances when professionals are satisfied that the need to protect others outweighs any increased risk to the patient and that the increased risk to the patient can be properly managed.

The use of seclusion should only be considered where de-escalation techniques have been unsuccessful.” Seclusion policy

Medication Errors

1. Please supply any MEDICATION ERRORS reports/investigations

Please see incidents report attached

2. How many MEDICATION ERRORS in 2021?

760

3. What proportion of patients were men/women?

Men 43.4%

Women 56.3%

Unknown 0.3%

4. How old were they?

Under 12 1.2%

12-17 4.6% 18-24 4.4%

25-34 6.6% 35-44 7.1%

45-54 9.0%

55-64 12.2%

65-74 13.8%

75 or older 41.1%

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

White 89.3%

BAME 6.4%

Unknown 4.3%

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

None known

7. 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)?

Information not available without accessing patients records

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

MEDICATION ERRORS was considered the cause)?

Information not available without accessing patients records

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

Information not available without accessing patients records

10. How many patients have suffered complications during and after

MEDICATION ERRORS and what were those complications?

Information not available without accessing patients records

11. Have there been any formal complaints from patients/relatives about MEDICATION

ERRORS?

9

12. If so, what was their concerns?

Please see complaints report attached

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

All medications errors are reviewed as part of the Trust’s incident management process. Themes and trends are identified and training/resources made available to support colleagues to get medicines right. Individual training, support and supervision around managing medicines is available for colleagues.