Thank you for your correspondence received on 16th April requesting information from our Trust.
Under the terms of the Freedom of Information Act 2000 we are able to provide you with the following information:
Please provide ECT information under the FOI act to the following questions: -
1.Please supply patient’s information ECT leaflet
Supplied 17th April 2020.
2. Please supply patient ECT consent form.
Supplied 17th April 2020.
3. Please supply any ECT reports/investigations. * Investigation by the Trust or an external investigation - for 2019.
No such investigations in relation to ECT.
4. How many ECT in 2019?
The number of patients receiving ECT treatments during 2019 was 67.
The number of electroconvulsive therapy (ECT) treatments carried out by our Trust in 2019 was 759.
*Please note that all figures provided include data for Bradford District Care Trust, as our Trust provides ECT treatment for them under a contract. Therefore figures provided are inclusive of these treatments.
5. What proportion of patients were men/women? *
6. How old were they? *
7. What were the diagnoses and in what proportions? *
8. What proportion of patients were classified BAME? *
9. How many were receiving ECT for the first time? *
10. How many patients consented to ECT? *
*We can confirm that we have not treated anybody under 18. However, to calculate the ages of patients at the time of their ECT treatment, over a 12 month period, would take a manually labour intensive and time lengthy process; as would determining their diagnoses, or calculating the proportion of patients classified BAME, whether they were male or female, or whether they were receiving ECT for the first time. To clarify; whilst personal data is recorded within a patient’s health care notes, this personal data, cannot be separately identified and reported from our electronic information system in a ‘numeric’ format. As such, we would need to physically search through the health care notes of each individual patient over a 12 month period to establish this information – a manually labour intensive and time lengthy process. Please refer to the footnote below on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
11. How many ECT complaints were investigated outside the NHS and CCG?
None in relation to ECT.
12. How many patients died during or soon after ECT (up to one year) and what was the cause (whether or not ECT was considered the cause)?
We have had nobody die during the procedure of ECT or immediately after, however, it would require a manual task to go through all of the patients to find out if people had died up to one year after, regardless of cause. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
13. How many patients died a few months after ECT (up to one year) and what was the cause (whether or not ECT was considered the cause)?
Please see our response above.
14. How many patients died by suicide within a few months (up to one year) of receiving ECT (whether or not ECT was considered the cause)?
As it is a coroner who decides whether a death is a suicide – we are unable to say from our electronic reporting system whether self-harm incidents were specifically attempts to end life. To clarify; whilst all incidents are reported via our electronic Risk Management system, DATIX, clinical data is recorded within a patient’s health care notes. As such, we would need to physically search through the notes of every patient over a 12 month period to identify records of deaths where a coroner’s verdict was suicide or killed himself/ herself within a few months (up to one year) of receiving ECT treatment (whether or not ECT was considered the cause). This would require a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
15. How many patients have suffered complications during and after ECT (within a year) and what were those complications?
To establish whether patients had complications at the time of their treatment, or up to 12 months after treatment, we would need to physically search through the health care notes of every patient over a 12 month period – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
16. Have there been any formal complaints from patients/relatives about ECT?
None in relation to ECT.
17. If so, what were their concerns?
Not applicable.
18. How many patients report memory loss/loss of cognitive function?
Again; such clinical data is recorded within a patient’s health care notes, and this detailed medical data, cannot be separately identified and reported from our electronic information system in an extractable ‘number’ format. As such, we would need to physically search through the health care notes of every patient – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
19. What tests are used to assess memory loss/loss of cognitive function?
Our Memory Assessment Service (MAS) work alongside other professionals and multi-disciplinary teams (MDTs), such as our Psychology and Psychotherapy Service which includes psychotherapists, clinical psychologists, consultant psychiatrists in psychotherapy and highly experienced counsellors, who undertake a variety of cognitive and neuropsychological assessments.
20. Have MRI or CT scans been used before and after ECT? *
21. If so what was the conclusion? *
Our Trust does not conduct MRI nor CT scans.
22. How does the Trust plan to prevent ECT in the future? Many people consider ECT a human rights abuse to be stopped.
ECT is a medical treatment within mental health, therefore rules and legalities are at the forefront, and these must be adhered to.
We do not have plans to ‘prevent ECT’; however, we ensure that we work within set robust legal frameworks:
The Mental Health Act 1983.
The Mental Capacity Act, 2005.
Please provide SERIOUS INCIDENT information under the FOI act to the following questions: -
1. Please supply SERIOUS INCIDENT REPORTS patient’s information leaflet.
Whilst we do not produce our own patient information leaflet on Serious Incident Reporting, the resources below are all available publicly;
NHS Connecting for Health. Checklist for Reporting, Managing and Investigating Information Governance Serious Untoward Incidents 2010; http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/links/suichecklist.pdf
National Framework for Reporting and Learning from Serious Incidents Requiring
Investigation - Published in 2009 by the National Patient Safety Agency; https://www.england.nhs.uk/wp-content/uploads/2015/03/serious-incident-framwrk-15-16-faqs-fin.pdf
Seven Steps to Patient Safety. 2004; http://www.nrls.npsa.nhs.uk/resources/?entryid45=59787&q=0%c2%acseven+steps
+to+patient+safety%c2%ac
Department of Health. The never events policy framework. October 2012;
http://www.dh.gov.uk/health/2012/10/never-events/
National Patient Safety Agency. Being open: communicating patient safety incidents with patients, their families and carers. NPSA. 2009; http://www.nrls.npsa.nhs.uk/resources
National Patient Safety Agency. National Framework for Reporting and Learning from SIRIs. 2010; http://www.nrls.npsa.nhs.uk/resources/?entryid45=75173
National Patient Safety Agency. Three Levels of RCA Investigation – Guidance;
2008. www.npsa.nhs.uk/rca
Health and Social Care Information Centre. Checklist Guidance for Reporting, Managing and Investigating Information Governance Serious Incidents Requiring Investigation – June 2013; https://www.igt.hscic.gov.uk/help.aspx
Care Quality Commission. Essential standards of quality and safety. CQC. 2010; www.cqc.org.uk
2. Please supply patient SERIOUS INCIDENT REPORTS consent form. Do you explain to people what Serious Incidents are + is this an informed / formal discussion?
Investigations from serious incidents are shared with all of those affected; this includes escalating any potential for further harm and mitigating risks to other persons as appropriate. The scale and scope of the investigation / information shared is proportionate to the incident.
Our Trust is bound by a Duty of Candour (DoC): a legal duty to inform and apologise to patients if there have been mistakes in their care that have led to harm.
All incidents are reported via our electronic Risk Management system, DATIX. Even if an incident appears to be minor or trivial is still be reported. The Strategic Executive Information System (STEIS) captures all Serious Incidents. Serious Incidents (as defined in the Serious Incident Framework) can include but are not limited to patient safety incidents. For the purpose of the Trust’s incident reporting system, a 'serious incident' (SI) is defined as; "an accident or incident when a patient, member of staff (including those working in the community), or a member of public suffers injury or unexpected death, or the risk of death or injury in hospital, or health service premises or other premises where healthcare is provided or where actions of health service staff are likely to cause significant public concern. Incidents involving service users in our care or who have received specialist mental health care in the last 6 months”.
The principal accountability of our Trust is to patients and their families/carers. The first consideration following a serious incident is that the person/persons involved must be cared for, their (and other patients) health and welfare secured and further risk mitigated. A systematic Root Cause Analysis identifies factors that contributed to the incident, it looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which an incident happened with aims to ensure no further harm occurs.
In cases of patient safety, the patients are fully involved. For communicating with patients and their families after a SIRI, we follow recommendations provided in the NPSA Being Open Guidance. www.nrls.npsa.nhs.uk/beingopen
3. Please supply any serious incident reports/investigations.
With regards your request to be provided with serious incident investigation reports; having reviewed the matter against the Information Commissioners Office Anonymisation Code of Practice; available here:-
https://ico.org.uk/media/for-organisations/documents/1061/anonymisation-code.pdf
In essence, providing such detail has the potential that:-
- The organisations party to the underlying data could conceivably re-identify individuals from the disclosed data set.
- The staff member could also potentially identify themselves in the data set, by virtue of recognising themselves from the data disclosed.
In either scenario above, there would be a resultant data breach.
Therefore, under the terms of the Freedom of Information Act (2000), we would be unable to provide you with actual incident reports as they contain detail which relates to and has the potential to identify particular living individuals, therefore personal data which is exempt from disclosure under Section 40(2) of the Act by virtue of Section 40(3)(a)(i), as disclosure of such personal data would breach the data protection principles set out in the Data Protection Act (2018) and the EU General Data Protection Regulation.
4. How many SERIOUS INCIDENT REPORTS in 2019?
Our Trust reported 36 incidents as serious in 2019 (total).
5. What proportion of patients were men/women? *
6. How old were they? *
7. What were the diagnoses and in what proportions? *
8. What proportion of patients were classified BAME? *
9. How many were receiving SERIOUS INCIDENT REPORTS for the first time? *
*Our incident reporting system (DATIX) is purposely designed to record incident data. Details such the gender / ethnicity / diagnosis / age, may not be recorded in incident reporting, as there is no formal means of capturing this type of data in DATIX. Such personal / medical details are recorded within each individual patient’s health care notes. Furthermore, we report serious incidents externally via the Strategic Executive Information System (STEIS). As such, the above information is not data that we hold in a reportable ‘numeric’ format as we would need to cross reference each individual STEIS report, with the original DATIX report, and conduct a physical search of the records of each relevant service user’s health care notes – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
10. How many patients consented to SERIOUS INCIDENT REPORTS? Are the "patients" consulted + agree to the serious incident reports - is there a way of ensuring their views are incorporated? with an independent advocate present?
Please see our response to question 2.
11. How many SERIOUS INCIDENT REPORTS were investigated outside the NHS and CCG?
None; however they are reported externally via STEIS.
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)?
The nature of a serious incident is that it is primarily in relation to deaths as STEIS captures all Serious Incidents which are defined as accidents or incidents when a patient, member of staff, or a member of public suffers injury or unexpected death, or the risk of death – see our response to question 4.
13. How many patients died a few months after SERIOUS INCIDENT REPORTS (within a year) and what was the cause (whether or not SERIOUS INCIDENT REPORTS was considered the cause)?
Please see our response above.
14. How many patients died by suicide within a few months (within a year) of receiving SERIOUS INCIDENT REPORTS (whether or not SERIOUS INCIDENT REPORTS was considered the cause)?
Please see our response to question 12 above. As it is a coroner who decides whether a death is a suicide, we would need to physically search through the notes of every patient over a 12 month period to identify records of deaths where a coroner’s verdict was suicide or killed himself/ herself within a few months (up to one year) of a serious incident (whether or not the serious incident was considered the cause). This would require a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
15. How many patients have suffered complications during and after SERIOUS INCIDENT REPORTS and what were those complications?
Please see our response to question 12 above.
16. Have there been any formal complaints from patients/relatives about SERIOUS INCIDENT REPORTS?
No.
17. If so, what was their concerns?
Not applicable.
18. How many patients report memory loss/loss of cognitive function?
Please see our response to question 12 above. To establish whether patients reported memory loss/loss of cognitive function, we would need to physically search through the notes of every patient. This would require a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
19. What tests are used to assess memory loss/loss of cognitive function?
Please see our response to question 19 (ECT set of questions) above.
20. Have MRI or CT scans been used before and after SERIOUS INCIDENT REPORTS?
21. If so what was the conclusion?
Our Trust does not conduct MRI nor CT scans.
22. How does the Trust plan to prevent SERIOUS INCIDENTS in the future?
Our Trust is committed to continually improving the quality and safety of all of our services. We have attached our procedure “The Management of Incidents Including Serious Incidents Procedure, RM-0002”, which outlines our strategy to improve safety, systems and our services in order to protect our patients, visitors, staff and members of the public.
Please provide restraints information under the FOI act to the following questions: -
1. Please supply RESTRAINTS patient’s information leaflet.
We work within a set of robust legal frameworks, therefore we adhere to the; Mental Health Units (Use of Force) Act 2018;
http://www.legislation.gov.uk/ukpga/2018/27/contents/enacted
Although we do not have a specific ‘restraints patient’s information leaflet’; Physical restraint is undertaken in accordance with our Policy for The positive and safe support for people who may present with behaviour that challenges – C0021 (see attached).
2. Please supply patient RESTRAINTS consent form.
Due to the unplanned/emergency nature of restraint incidents, we do not have a ‘patient restraint consent form’, however, as restraint is only used as an emergency response where there is a risk of immediate harm occurring and there is no safe, less restrictive alternative, staff are skilled in identify triggers and the best ways that restraint can be avoided.
3. Please supply any Restraints/investigations.
With regards your request to be provided with restraint investigation reports; having reviewed the matter against the Information Commissioners Office Anonymisation Code of Practice; available here:-
https://ico.org.uk/media/for-organisations/documents/1061/anonymisation-code.pdf
In essence, providing such detail has the potential that:-
- The organisations party to the underlying data could conceivably re-identify individuals from the disclosed data set.
- The staff member could also potentially identify themselves in the data set, by virtue of recognising themselves from the data disclosed.
In either scenario above, there would be a resultant data breach.
Therefore, under the terms of the Freedom of Information Act (2000), we would be unable to provide you with actual incident reports as they contain detail which relates to and has the potential to identify particular living individuals, therefore personal data which is exempt from disclosure under Section 40(2) of the Act by virtue of Section 40(3)(a)(i), as disclosure of such personal data would breach the data protection principles set out in the Data Protection Act (2018) and the EU General Data Protection Regulation.
4. How many RESTRAINTS in 2019? (There should be no restraints we know they lead to death hence Seni's law).
Information supplied 17th April 2020
4. How many RESTRAINTS in 2019?
|
2019 |
|
|
All Physical Restraint Incidents |
1,896 |
|
Prone Restraints |
208 |
|
Rapid Tranquilisation Restraints |
239 |
|
Mechanical Restraints |
54 |
5. What proportion of patients were men/women? *
6. How old were they? *
7. What were the diagnoses and in what proportions? *
8. What proportion of patients were classified BAME? *
9. How many were receiving RESTRAINTS for the first time? *
10. How many patients consented to RESTRAINTS? *
To calculate the ages of patients at the time of their restraint, over a 12 month period, would take a manually labour intensive and time lengthy process; as would determining their diagnoses, or calculating the proportion of patients classified BAME, whether they were male or female, whether they were receiving restraint for the first time, or whether they consented to the restraint. To clarify; our restraint incident reporting system (DATIX) is purposely designed to record incident data. Details such as gender / ethnicity / age / diagnosis etc, are recorded within each individual service user’s health care notes. As such, we would need to cross reference each individual DATIX report, with a physical search of the records of each relevant service users health care notes - a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
11. How many RESTRAINTS were investigated outside the NHS and CCG ?
None.
12. How many patients died during or soon after (within a year) RESTRAINTS and what was the cause (whether or not RESTRAINTS was considered the cause)?
We have had nobody die during the process of restraint, and none that have died as an immediate result of restraint: however, to establish if people had died of other causes within a year of a restraint incident would require a manual task as we would need to cross reference each individual DATIX report, with a physical search of the records of each relevant service users health care notes, for a 12 month period - a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
13. How many patients died a few months (within a year) after RESTRAINTS and what was the cause (whether or not RESTRAINTS was considered the cause)?
Please see our response above.
14. How many patients died by suicide within a few months of receiving RESTRAINTS (whether or not RESTRAINTS was considered the cause)?
As it is a coroner who decides whether a death is a suicide, we would need to physically search through the notes of every patient over a 12 month period to identify records of deaths where a coroner’s verdict was suicide or killed himself/ herself within a few months (up to one year) following a restraint incident (whether or not the restraint was considered the cause) – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
15. How many patients have suffered complications during and after RESTRAINTS and what were those complications?
To establish whether patients had complications up to 12 months after their restraint, we would need to physically search through the health care notes of every patient over a 12 month period – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
16. Have there been any formal complaints from patients/relatives about RESTRAINTS?
Yes - one.
17. If so, what was their concerns?
The Service user was unhappy with the physical restraint used on her by members of staff.
18. How many patients report memory loss/loss of cognitive function?
To establish whether patients reported memory loss/loss of cognitive function, we would need to physically search through the notes of every patient. This would require a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
19. What tests are used to assess memory loss/loss of cognitive function?
See our response to question 19 above.
20. Have MRI or CT scans been used before and after RESTRAINTS?
21. If so what was the conclusion?
Our Trust does not conduct MRI nor CT scans.
22. How does the Trust plan to reduce restraints in the future?
Our Trust plans to reduce incidents of restrictive practice through learning lessons and post incident reviews Please see attached; “Procedure for the positive and safe support for people who may present with behaviour that challenges, C-0021”, specifically the section on; 1.5.2 Primary- Preventative strategies.
Please provide SECLUSION information under the FOI act to the following questions: -
1. Please supply patient’s information SECLUSION leaflet.
We do not produce a specific ‘patient’s information SECLUSION leaflet’, however, the use of such restrictive interventions, are in line with our “Procedure for the use of Seclusion and Long Term Segregation (C-0022)”.
2. Please supply patient SECLUSION consent form.
The use of such restrictive interventions, even if the service user has agreed or requested it, are afforded the same procedural safeguards as the Procedure for the use of Seclusion and Long Term Segregation (C-0022)
3. Please supply any SECLUSION reports/investigations.
With regards your request to be provided with seclusion investigation reports; having reviewed the matter against the Information Commissioners Office Anonymisation Code of Practice; available here:-
https://ico.org.uk/media/for-organisations/documents/1061/anonymisation-code.pdf
In essence, providing such detail has the potential that:-
- The organisations party to the underlying data could conceivably re-identify individuals from the disclosed data set.
- The staff member could also potentially identify themselves in the data set, by virtue of recognising themselves from the data disclosed.
In either scenario above, there would be a resultant data breach.
Therefore, under the terms of the Freedom of Information Act (2000), we would be unable to provide you with actual incident reports as they contain detail which relates to and has the potential to identify particular living individuals, therefore personal data which is exempt from disclosure under Section 40(2) of the Act by virtue of Section 40(3)(a)(i), as disclosure of such personal data would breach the data protection principles set out in the Data Protection Act (2018) and the EU General Data Protection Regulation.
4. How many SECLUSIONS in 2019?
216.
5. What proportion of patients were men/women? *
6. How old were they? *
7. What were the diagnoses and in what proportions? *
8. What proportion of patients were classified BAME? *
9. How many were receiving SECLUSION for the first time? *
10. How many patients consented to SECLUSION? *
*To calculate the ages of patients at the time of their seclusion, over a 12 month period, would take a manually labour intensive and time lengthy process; as would determining their diagnoses, or calculating the proportion of patients classified BAME, whether they were male or female, whether they were receiving seclusion for the first time, or whether they consented to the seclusion. To clarify; details such as gender / ethnicity / age / diagnosis etc, are recorded within each individual service user’s health care notes. As such, this is not information that we hold in a reportable ‘numeric’ format as we would need to conduct a physical search of the records to establish this information - a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
11. How many SECLUSIONS were investigated outside the NHS and CCG?
None.
12. How many patients died during or soon after (within a year) of SECLUSION and what was the cause (whether or not SECLUSION was considered the cause)?
To establish if people had died up to a year after an incident of seclustion would require a manual task as we would need to conduct a physical search of the records of each relevant service users health care notes, for a 12 month period - a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
13. How many patients died a few months after SECLUSION and what was the cause (whether or not SECLUSION was considered the cause)?
Please see our response above.
14. How many patients died by suicide within a few months of receiving SECLUSION (whether or not SECLUSION was considered the cause)?
As it is a coroner who decides whether a death is a suicide, we would need to physically search through the notes of every patient over a 12 month period to identify records of deaths where a coroner’s verdict was suicide or killed himself/ herself within a few months (up to one year) following a seclusion incident (whether or not the seclusion was considered the cause) – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
15. How many patients have suffered complications during and after SECLUSION and what were those complications?
To establish whether patients had complications up to 12 months after their seclusion, we would need to physically search through the health care notes of every patient over a 12 month period – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
16. Have there been any formal complaints from patients/relatives about SECLUSION?
Yes – one.
17. If so, what was their concerns?
The service user stated that they had been sleep deprived since admission and would like to know why they had been placed in seclusion.
18. How many patients report memory loss/loss of cognitive function?
To establish whether patients reported memory loss/loss of cognitive function, we would need to physically search through the notes of every patient. This would require a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
19. What tests are used to assess memory loss/loss of cognitive function?
Please see our response to question 19 above.
20. Have MRI or CT scans been used before and after SECLUSION?
21. If so what was the conclusion?
Our Trust does not conduct MRI nor CT scans.
22. How does the Trust plan to prevent SECLUSION in the future?
Our Trust plans to reduce incidents of seclusion through learning lessons and post incident reviews Please see attached; “Procedure for the positive and safe support for people who may present with behaviour that challenges, C-0021”, specifically the section on; 1.5.2 Primary- Preventative strategies.
Please provide MEDICATION ERRORS information under the FOI act to the following questions: -
1. Please supply patient’s information MEDICATION ERRORS leaflet.
Whilst we do not produce a patient information leaflet on medication errors, our Trusts “Medicines Code, MM-0004” (see attached) sets out the minimum acceptable standards by which all medicines including Controlled Drugs (CDs) are managed by our Trust and staff.
2. Please supply patient MEDICATION ERRORS consent form. So when medical errors were reported was the "patient" informed, where their views of the error taken into account?
Our Trust is bound by a Duty of Candour (DoC): a legal duty to inform and apologise to patients if there have been mistakes in their care that have led to harm.
The principal accountability of our Trust is to patients. The first consideration following a medication error is that the person/persons involved must be cared for, their health and welfare secured and further risk mitigated. A systematic investigation identifies factors that contributed to the medication error, and looks to understand the context in which the incident happened with aims to ensure there is no further harm or re-occurrence. In cases of patient safety, the patients are fully involved.
3. Please supply any MEDICATION ERRORS reports/investigations
With regards your request to be provided with medication error investigation reports; having reviewed the matter against the Information Commissioners Office Anonymisation Code of Practice; available here:-
https://ico.org.uk/media/for-organisations/documents/1061/anonymisation-code.pdf
In essence, providing such detail has the potential that:-
- The organisations party to the underlying data could conceivably re-identify individuals from the disclosed data set.
- The staff member could also potentially identify themselves in the data set, by virtue of recognising themselves from the data disclosed.
In either scenario above, there would be a resultant data breach.
Therefore, under the terms of the Freedom of Information Act (2000), we would be unable to provide you with actual incident reports as they contain detail which relates to and has the potential to identify particular living individuals, therefore personal data which is exempt from disclosure under Section 40(2) of the Act by virtue of Section 40(3)(a)(i), as disclosure of such personal data would breach the data protection principles set out in the Data Protection Act (2018) and the EU General Data Protection Regulation.
4. How many MEDICATION ERRORS in 2019?
There were 467 medication errors reported in 2019; this includes errors that were detected prior to administration of the medication (i.e. near misses) as our Trust encourages and supports a culture of reporting near misses so that we can learn and prevent future errors.
5. What proportion of patients were men/women? *
6. How old were they? *
7. What were the diagnoses and in what proportions? *
8. What proportion of patients were classified BAME? *
9. How many were receiving MEDICATION ERRORS for the first time? *
10. How many patients consented to MEDICATION ERRORS? *
*To calculate the ages of patients at the time of a reported medication error (which includes a near miss), over a 12 month period, would take a manually labour intensive and time lengthy process; as would determining their diagnoses, or calculating the proportion of patients classified BAME, whether they were male or female, whether they were receiving a medication error for the first time. To clarify; details such as gender / ethnicity / age / diagnosis etc, are recorded within each individual service user’s health care notes. As such, this is not information that we hold in a reportable ‘numeric’ format as we would need to conduct a physical search of their records to establish this information - a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
11. How many MEDICATION ERRORS were investigated outside the NHS and CCG?
None.
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)?
To establish if people had died up to a year after a medication error (or near miss), whether or not the medication error was considered the cause - would require a manual task as we would need to conduct a physical search of the records of each relevant service users health care notes, for a 12 month period, a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
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)?
Please see our response above.
14. How many patients died by suicide within a few months of receiving MEDICATION ERRORS (whether or not MEDICATION ERRORS was considered the cause)?
As it is a coroner who decides whether a death is a suicide, we would need to physically search through the notes of every patient over a 12 month period to identify records of deaths where a coroner’s verdict was suicide or killed himself/ herself within a few months (up to one year) following a medication error (or near miss) whether or not the medication error was considered the cause – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
15. How many patients have suffered complications during and after MEDICATION ERRORS and what were those complications?
To establish whether patients had complications up to 12 months after their medication error, we would need to physically search through the health care notes of every patient over a 12 month period – a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
16. Have there been any formal complaints from patients/relatives about MEDICATION ERRORS in 2019?
No.
17. If so, what was their concerns?
Not applicable.
18. How many patients report memory loss/loss of cognitive function?
To establish whether patients reported memory loss/loss of cognitive function, we would need to physically search through the notes of every patient. This would require a manually labour intensive and time lengthy process. Please refer to the footnote on the "appropriate limit" on the amount of time that can be spent on locating and extracting the information required to answer a Freedom of Information request (Section 12 exemption).
19. What tests are used to assess memory loss/loss of cognitive function?
Please see our response to question 19 above.
20. Have MRI or CT scans been used before and after MEDICATION ERRORS?
21. If so what was the conclusion?
Our Trust does not conduct MRI nor CT scans.
22. How does the Trust plan to prevent MEDICATION ERRORS in the future?
Our Trust adheres to Medicines Management processes and guidelines which ensure that medicines are managed and used appropriately and safely.
Medication errors have important implications for patient safety, and their identification is crucial in order to prevent adverse events. Medication safety reports are produced for the Medicine Optimisation Group (MOG) and Trust wide Clinical Governance (TWCG) by our Medication Safety Officer on behalf of the Medicines Safety Committee. These reports are intended to provide an overview of all recorded medication related incidents/errors recorded on Datix across the organisation.
We encourage the reporting of medication errors and near misses, to support learning and a better understanding of the root cause, so that we can develop policies and procedures to prevent further incidents.
* Please note: the Freedom of Information Act imposes a statutory limit, known as the "appropriate limit" on the amount that can be spent on locating and extracting the information required to answer a Freedom of Information request. This limit is currently set at £450, which the legislation deems to be equivalent to 18 hours of staff time.
Section 12 of the Freedom of Information Act 2000 makes provision for public authorities to refuse requests for information where the cost of dealing with them would exceed the appropriate limit.
Where we receive a request which is estimated to be above this appropriate limit, we can apply relevant fees and charges attributable to the processing of that request. In estimating whether a request will incur charges, we will take into account the retrieval process covering the entire request. In view of our outlining that compliance with parts of your request would involve a wholly manual / labour intensive and time lengthy process, it is our estimation that compliance with these parts of your request will exceed this appropriate set limit.
If you are not satisfied with our decision regarding your request, you have the right to appeal and should in the first instance write to our Freedom of Information Officer, who will escalate your appeal to the Executive Team FoIA Lead. Our maximum response time to conduct our review of your appeal will be 40 working days.
If you are still not satisfied you can contact the Information Commissioner’s Office, who oversees Freedom of Information and Data Protection in the UK.
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Information Commissioner’s Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF |
If there is anything that you need further clarification on, please do not hesitate to contact us.
Yours sincerely
Anne-Marie Field
Information Governance Support Officer
Email: foi.lypft@nhs.net