Friendship group affiliated to HVN

1. Please supply patient’s information ECT leaflet & Consent

See attachments.

2. How many ECT in 2023?

137

3. What proportion of patients were men/women?

79% Female

21% Male

4. How old were they?

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

86% of patients are recorded as 'White - British'. 14% do not have a recorded ethnicity.

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

Of the patients receiving an ECT in 2023, 6 had been referred to Talking Therapies previously.

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

Of the patients receiving an ECT in 2023, 9 had not received an ECT previously

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

0

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

0

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

0

11. If so, what was their concerns?

N/A

1. How many RESTRAINTS in 2023?

585

Caveats: This indicator include events reported on the use of force and restrictive interventions, that contain reported use of physical restraint, calendar year 2023, and at a location within MHLDSG

2. What proportion of patients were men/women?

3. How old were they?

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

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

Somerset NHS Foundation Trust are unable to narrow down to exact months.

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

Somerset NHS Foundation Trust are unable to narrow down to exact months.

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

Yes

8. If so, what was their concerns?

• 3hr round trip under restraint to hospital for nasogastric tube feeding
• Restrained during endoscopy procedure

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

Please see attached copy of the Proactive Care Policy which sets out our approach to reducing restrictive interventions.

1. How many SECLUSIONS in 2023?

572

2. What proportion of patients were men/women?

44% female

56% male

3. How old were they?

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

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

1

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

4

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

Yes

8. If so, what was their concerns?

The complaints listed below include mentions of seclusion / isolation

• Patient fell in a side room and had no bell to alert staff
• Relative of patient felt that they were isolated.

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

Please see attached copy of the Proactive Care Policy which sets out our approach to reducing restrictive interventions.

1. How many MEDICATION ERRORS in 2023?

The total medication errors reported within the service group was 125 for 2023.

Caveats: This indicator include events reported on the incident form, that contain reported medication errors that affected a patient, calendar year 2023, and at a location within MHLDSG. Some errors do not have patient level information due to the type of error being reported.

2. What proportion of patients were men/women?

3. How old were they?

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

5. 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)?

Somerset NHS Foundation Trust are unable to narrow down to exact months.

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

Somerset NHS Foundation Trust are unable to narrow down to exact months.

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

Yes

8. If so, what was their concerns?

• Oramorph was administered through patient’s cannula
• Cortisone injection put into new scar tissue
• Incorrect medication administered
• Patient was given a drug in 30 minutes rather then the hour it should have been taken
• Medication stopped that shouldn’t have been
• Medication error - Delay with receiving alternative medication

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

Incident trends are actively monitored across the Trust.  Where serious incidents/ clusters of incidents are identified the Trust Patient Safety and Medicines Safety Teams liaise with relevant staff to formulate plans and put in place mitigations to try to prevent similar future incidents.  The type of response will depend on the type of incident and the system factors that contributed to it.