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ICS LEARNING FROM INCIDENTS AND FEEDBACK NEWSLETTER ISSUE 3 MARCH 2022
Complaint One - Made by a mother relating to her daughter's care in the
Child Development Service (CDS) and with Child and Adolescent Mental Health Service
(CAMHS) - Learning Disabilities (LD). The complaint included not being able to get
advice for a medication recently prescribed for her daughter; lack of communication
between administrators and clinical staff between services; not feeling heard when
concerned about diagnostic overshadowing and lack of support in helping her with her
daughter's behaviour.
Learning
CAMHS-LD and CDT to further explore opportunities to work collaboratively including
thinking about shared records and MDT reports, so that messages are clearer to parents and
carers.
Staff to set their 'out of office' message to ensure it is clear when on leave and who is
covering or who to contact.
When taking messages, ensure accurate information is shared about when to expect a call
back so the caller's expectations are met.
When on leave, ensure staff are aware and know who to contact as an alternative and
provide alternative resources for contact or information such as GP/111 etc.
Ensure regular testing is done to make sure equipment such as landlines and team mobiles
are working. If any issues arise please contact maintenance/ICT services for
repair/alternative solutions and report as an incident.
Serious Incident One - 79-year-old female patient sustained a fractured
left hip during her admission to Clayponds Hospital, Jasmin ward. The patient was
recuperating after a right hip fracture sustained on the 3rd June 2021. She had been an
inpatient for approximately 6 weeks to improve mobility and independence. The day
before she was due to be discharged she sustained a left hip fracture following a
witnessed fall in the toilet on Jasmin Ward. The fall occurred at 4.55am on the 30th July
2021 after she was left alone in the toilet. She had walked to the toilet with the
supervision of a healthcare assistant who went to retrieve clean clothing/pads before
ensuring that the patient was in a seated position. As a consequence of the fall the
patient suffered a left hip fracture and was transferred to Northwick Park Hospital. The
patient underwent surgery for a left hip hemiarthroplasty on the 31st July 2021. The
patient recovered well after the fall and her mobility has returned to previous levels.
Learning
Although an error of judgement occurred as the patient was not seated before being
left alone in the toilet, a number of other factors were considered in regard to the lack
of clarity/detail regarding the guidance to around whether patients can be left alone
unsupervised and in what circumstances.
Clearer guidance about how to supervise patients would help staff to be supported
when trying to make decisions to leave patients alone for a short time.
Clear guidance about which equipment to use in which scenario would help staff to
reduce the risk when transferring patients after a fall.
This incident was escalated to managers, however the original Datix was not
updated once harm was known and this resulted in a delay in investigating the
incident.