South West London & St Georges Mental Health NHS Trust
South West London & St Georges Mental Health NHS Trust
ECT, Serious Incident, Restraints, Seclusion, Medication Information
FOI – 1110
Please provide ECT information under the FOI act to the following questions: -
Please supply patient’s information ECT leaflet.
All patients are provided with a copy of the RCPsych Information on ECT and the relevant pages of the Trust’ s Consent Record Form. Detained patients are also provided with a copy of the CQC’s Rights Leaflet as attached.
Please supply patient ECT consent form.
Please see the attached document
ECT, Serious Incident, Restraints, Seclusion, Medication Information
FOI – 1110
Please provide ECT information under the FOI act to the following questions: -
Please supply patient’s information ECT leaflet.
All patients are provided with a copy of the RCPsych Information on ECT and the relevant pages of the Trust’ s Consent Record Form. Detained patients are also provided with a copy of the CQC’s Rights Leaflet as attached.
Please supply patient ECT consent form.
Please see the attached document
Please supply any ECT reports/investigations
There has been none
How many ECT in 2020?
We had 353 recorded ECT treatment administered in 2020.
What proportion of patients were men/women?
17 Female and 15 Male 6. How old were they?
| 79yrs | 71yrs | 56yrs | 27yrs | 76yrs | 54yrs | 76yrs | 68yrs | 32yrs | 26yrs |
| 62yrs | 66yrs | 65yrs | 72yrs | 69yrs | 75yrs | 68yrs | 62yrs | 54yrs | 72yrs | 38yrs |
| 39yrs | 58yrs | 50yrs | 67yrs | 20yrs | 67yrs | 78yrs | 30yrs | 43yrs |
What proportion of patients were classified BAME?
There has been none
How many were receiving ECT for the first time?
Approximately 23 patients were receiving ECT for the first time.
How many patients consented to ECT?
Out of the 31 patients 4 consented.
The remainder lacked capacity to consent and were lawfully treated under the provisions of section 58A of the Mental Health Act.
The remainder lacked capacity to consent and were lawfully treated under the provisions of section 58A of the Mental Health Act.
How many ECT complaints were investigated outside the NHS and CCG? There has been none.
How many patients died during or 1 month after ECT and what was the cause (whether or not ECT was considered the cause)?
There has been none
How many patients died within 6 months after ECT and what was the cause (whether or not ECT was considered the cause)?
There has been none
How many patients died by suicide within 6 months of receiving ECT (whether or not ECT was considered the cause)?
There has been none
How many patients have suffered complications during and after ECT and what were those complications?
The term complications are to be understood as something over and above expected side effects. By analogy, pain and constipation are expected side effects of abdominal surgery, but a perforated bowel would be a complication. There have been none.
Have there been any formal complaints from patients/relatives about ECT?
Have there been any formal complaints from patients/relatives about ECT?
No
If so, what was their concerns?
N/A
How many patients report memory loss/loss of cognitive function?
We do not collate this data. Patient’s cognitive functioning is tested at least weekly throughout their course of ECT. Obtaining this data would require accessing all these assessment for all patients undergoing ECT and would amount to a level of work comparable to a piece of research rather than a response to an FOI request.
What tests are used to assess memory loss/loss of cognitive function?
Clinical interview plus structured evaluation in the form of the MMSE and/or MoCA.
Have MRI or CT scans been used before and after ECT?
No. There would be no clinical indication to perform CT or MRI scans before and after ECT 20. If so what was the conclusion?
N/A
How does the Trust plan to prevent ECT in the future?
The Trust has no plans to prevent ECT, which is a treatment approved by NICE under specific circumstances that include ECT as a lifesaving intervention.
Please provide SERIOUS INCIDENT information under the FOI act to the following questions: -
N/A
How does the Trust plan to prevent ECT in the future?
The Trust has no plans to prevent ECT, which is a treatment approved by NICE under specific circumstances that include ECT as a lifesaving intervention.
Please provide SERIOUS INCIDENT information under the FOI act to the following questions: -
Please supply any serious incident reports/investigations Published reports will be available on NHSE website.
How many SERIOUS INCIDENT REPORTS in 2020?
| Serious Incidents | 2020 |
| STEIS Report | 77 |
| Grand Total | 77 |
What proportion of patients were men/women?
| Gender | 2020 |
| Female | 45% (35 ) |
| Male | 55% (42) |
| Grand Total | 77 |
How old were they?
| Age | 2020 |
| Unknown | 9 |
| 56 | 5 |
| 29 | 5 |
| 52 | 4 |
| 53 | 3 |
| 65 | 3 |
| 37 | 3 |
| 59 | 2 |
| 17 | 2 |
| 28 | 2 |
| 75 | 2 |
| 34 | 2 |
| 42 | 2 |
| 19 | 2 |
| 77 | 2 |
| 40 | 2 |
| 43 | 2 |
| 24 | 1 |
| 39 | 1 |
| 41 | 1 |
| 30 | 1 |
| 61 | 1 |
| 78 | 1 |
| 71 | 1 |
| 81 | 1 |
| 58 | 1 |
| 47 | 1 |
| 60 | 1 |
| 49 | 1 |
| 62 | 1 |
| 50 | 1 |
| 68 | 1 |
| 31 | 1 |
| 72 | 1 |
| 26 | 1 |
| 25 | 1 |
| 27 | 1 |
| 79 | 1 |
| 45 | 1 |
| 16 | 1 |
| 96 | 1 |
| 46 | 1 |
| Grand Total | 77 |
What proportion of patients were classified BAME?
| Ethnicity | 2020 | BAME |
| White British | 37 | |
| Unknown / Not Stated | 17 | |
| Other White - White | 12 | 30% (24) |
| Black African - Black Or Black British |
5 | |
| Black Caribbean - Black Or Black British |
2 | |
| Chinese - Other Ethnic | 1 | |
| Other Mixed - Mixed | 1 | |
| White & Black African - Mixed | 1 | |
| White & Black Caribbean - Mixed | 1 | |
| Grand Total | 77 |
How many SERIOUS INCIDENT REPORTS were investigated outside the NHS and CCG?
None
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)?
We do not hold SI data in this way.
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)?
We do not hold SI data in this way.
How many patients died by suicide within 6 months of receiving SERIOUS
INCIDENT REPORTS (whether or not SERIOUS INCIDENT REPORTS was considered the cause)?
| SI's Suicides | 2020 |
| Suspected Suicide (Actual) Hanging | 9 |
| Suspected Suicide (Actual) Overdose | 4 |
| Suspected Suicide (Actual) Fall From Height | 1 |
| Suspected Suicide (Actual) Railway | 1 |
| Suspected Suicide (Actual) Undetermined | 1 |
| Suspected Suicide (Actual) Asphyxiation | 1 |
| Suspected Suicide (Actual) Inconclusive | 1 |
| Grand Total | 18 |
*This is total number of Suspected Suicides reported
How many patients have suffered complications during and after SERIOUS INCIDENT REPORTS and what were those complications?
We do not hold this information
Have there been any formal complaints from patients/relatives about SERIOUS INCIDENT REPORTS?
No
If so, what was their concerns?
N/A
How does the Trust plan to prevent SERIOUS INCIDENTS in the future? The Trust continues to follow the National guidance (Serious Incident Framework 2015) in carrying out Root Cause Analysis investigations for all Serious Incidents, with the aim to identify learning to prevent re-occurence. The Trust ensures that this learning is shared across the organisation.
Please provide restraints information under the FOI act to the following questions: -
Please supply any Restraints/investigations
As contained in Q2 below. Investigations are available on NHSE website if published.
How many RESTRAINTS in 2020?
1383
What proportion of patients were men/women?
189 men, 161 women
How old were they?
How old were they?
| Age | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 |
| Patients Restrained | 2 | 5 | 10 | 11 | 16 | 6 | 9 | 9 | 6 | 7 | 10 | 11 | 10 | 6 | 8 | 7 | 7 |
| Age | 51 | 52 | 53 | 54 | 55 | 56 | 57 | 58 | 59 | 60 | 61 | 62 | 63 | 65 | 66 | 68 | 69 |
| Patients Restrained | 3 | 4 | 4 | 4 | 7 | 4 | 5 | 4 | 1 | 1 | 2 | 2 | 1 | 2 | 3 | 1 | 2 |
| Age | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43 | 44 | 45 | 46 | 47 | 48 | 49 | 50 |
| Patients Restrained |
10 | 15 | 12 | 12 | 10 | 7 | 7 | 10 | 1 | 7 | 3 | 7 | 8 | 4 | 6 | 5 | 3 | 5 | 8 | 4 |
| Age | 70 | 71 | 72 | 73 | 75 | 76 | 77 | 78 | 79 | 81 | 90 | |
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| Patients Restrained |
3 | 1 | 3 | 1 | 1 | 1 | 2 | 1 | 1 | 1 | 1 |
What proportion of patients were classified BAME?
178 BAME, 165 Non-BAME, 7 Not Known
How many RESTRAINTS were investigated outside the NHS and CCG?
We do not capture this data
How many patients died during or 1 month after RESTRAINTS and what was the cause (whether or not RESTRAINTS was considered the cause)?
Two Suspected Suicide (Actual) Hanging and Unexpected Death.
How many patients died within 6 months after RESTRAINTS and what was the cause (whether or not RESTRAINTS was considered the cause)?
Six. 2 ‘Unexpected Deaths’, 3 ‘Deaths Not Due to Patient Safety Incident E.g. Natural
Causes’, 1 ‘Suspected Suicide (Actual) Hanging’.
Causes’, 1 ‘Suspected Suicide (Actual) Hanging’.
How many patients died by suicide within 6 months of receiving RESTRAINTS (whether or not RESTRAINTS was considered the cause)? One
How many patients have suffered complications during and after RESTRAINTS and what were those complications?
Zero
Have there been any formal complaints from patients/relatives about RESTRAINTS?
Yes
If so, what was their concerns?
Are counts of forced injections available?
368
How does the Trust plan to reduce restraints in the future?
Please see the attached document for framework for reducing restraints
Please provide SECLUSION information under the FOI act to the following questions
Please supply any SECLUSION reports/investigations Published reports will be available on NHSE website.
Please provide SECLUSION information under the FOI act to the following questions
Please supply any SECLUSION reports/investigations Published reports will be available on NHSE website.
How many SECLUSIONS in 2020?
302
What proportion of patients were men/women?
90 Men, 48 Women
How old were they?
How old were they?
| Age | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 |
| Patients Restrained | 1 | 2 | 3 | 4 | 11 | 1 | 2 | 6 | 2 | 3 | 3 | 7 | 1 | 2 | 4 | 4 | 2 |
| Age | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 40 | 41 | 42 | 43 | 44 | 45 |
| Patients Restrained |
4 | 4 | 6 | 9 | 6 | 5 | 5 | 3 | 2 | 2 | 2 | 2 | 1 | 2 |
| Age | 46 | 48 | 49 | 50 | 51 | 52 | 53 | 54 | 55 | 58 | 59 | 60 | 62 | 63 | 64 |
| Patients Restrained | 1 | 2 | 4 | 2 | 3 | 1 | 1 | 2 | 3 | 2 | 1 | 1 | 2 | 1 | 1 |
What proportion of patients were classified BAME?
70 BME, 59 Non-BME, 9 Not Known
How many SECLUSIONS were investigated outside the NHS and CCG?
We do not hold this data
How many patients died during or 1 month after SECLUSION and what was the cause (whether or not SECLUSION was considered the cause)?
One. ‘Suspected Suicide (Actual) Hanging’
How many patients died within 6 months after SECLUSION and what was the cause (whether or not SECLUSION was considered the cause)?
One. ‘Suspected Suicide (Actual) Hanging’
How many patients died by suicide within 6 months of receiving SECLUSION (whether or not SECLUSION was considered the cause)? One
How many patients have suffered complications during and after SECLUSION and what were those complications?
Zero
Have there been any formal complaints from patients/relatives about SECLUSION?
Yes
If so, what was their concerns?
Detailed response provide
How does the Trust plan to prevent SECLUSION in the future?
This is part of our reducing restrictive practise strategy. It is also part of the overarching safety in motion programme to promote 7 standards of practice which supports the reduction of violence and aggression and the reduction on the use of seclusion.
Please provide MEDICATION ERRORS information under the FOI act to the following questions: -
Please provide MEDICATION ERRORS information under the FOI act to the following questions: -
Please supply any MEDICATION ERRORS reports/investigations.
Please see the attached document.
How many MEDICATION ERRORS in 2020?
506 incidents reported in 2020/21
What proportion of patients were men/women?
239 female; 142 male; the remaining incidents were non-patient specific 4. How old were they? <18 years old: 4
18-65 years old: 222
66 and over: 36
244 incidents did not have an age recorded, of these, 125 incidents were N/A as were nonpatient specific.
What proportion of patients were classified BAME?
25 incidents were recorded as having a BAME patient
What proportion of patients were men/women?
239 female; 142 male; the remaining incidents were non-patient specific 4. How old were they? <18 years old: 4
18-65 years old: 222
66 and over: 36
244 incidents did not have an age recorded, of these, 125 incidents were N/A as were nonpatient specific.
What proportion of patients were classified BAME?
25 incidents were recorded as having a BAME patient
How many MEDICATION ERRORS were investigated outside the NHS and CCG?
We are unable to provide records of this
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)?
We are unable to provide records of this
How many patients died within 6 months after MEDICATION ERRORS and what was the cause (whether or not MEDICATION ERRORS was considered the cause)?
We are unable to provide records of this
How many patients died by suicide within 6 months of receiving MEDICATION ERRORS (whether or not MEDICATION ERRORS was considered the cause)? We are unable to provide records of this
How many patients have suffered complications during and after MEDICATION ERRORS and what were those complications?
We are unable to provide records of this
Have there been any formal complaints from patients/relatives about MEDICATION ERRORS?
Yes
If so, what was their concerns?
- One person complained that staff lost their medication
- One person complained about a delay in medication being administered
How does the Trust plan to prevent MEDICATION ERRORS in the future?
•By embedding Just Culture across the Trust
•To learn from the incidents report and identify any systemic errors to minimise such errors from happening
•Utilising Trust monthly learning bulletin as a tool to spread learning and share incidents
•To learn from the incidents report and identify any systemic errors to minimise such errors from happening
•Utilising Trust monthly learning bulletin as a tool to spread learning and share incidents