Page 3 of 6
ICS LEARNING FROM INCIDENTS AND FEEDBACK NEWSLETTER ISSUE 3 MARCH 2022
Good Practice:
a) The Senior Clayponds Hospital Management Team and those involved in the
incident demonstrated effective reflection following the incident and evidenced that
changes to practice were immediately implemented to enhance patient safety.
b) Action was taken by the senior management team for all staff to have training on
clinician judgement regarding leaving a patient in the toilet alone or not.
c) The team allocated one member of staff to review all Falls Datixs prior to the
incident to see if themes could be established.
d) Immediate action to arrange training for staff to use the scoop for moving patients
off the floor. All staff are now aware of where the scoop is stored for easy access.
"Ignite the mind's spark to rise the sun in you"
- Florence Nightingale
LTR One (Local Team Review) - Maximising Independence,
Enable/Stroke & Neuro Rehabilitation Service domiciliary joint appointment for patient
diagnosed with Parkinson's. The aim of therapy session was to assess patient's
mobility and also to practice bed transfers. Patient's wife expressed concern regarding
general fatigue and not being able to manage the stairs for bed transfer practice,
however she was not particularly concerned as he was tired every day. Patient was
coughing during the therapy session so SpO2 (84%) & RR (72) were checked. After the
mobility practice, patient carried out some deep breathing exercises and manual
assisted cough techniques, both helped to increase his SpO2 to 89/90%. The
physiotherapist was aware from the patient's wife that the GP was due to
contact/review the patient the next day and so planned to contact the GP later that
evening as immediate communication did not appear to be required however this did
not happen until the next morning. The GP responded to this email a later asking why
the therapists did not call the GP practice on the day of appointment or if need-be
contact 111 or 999. The full NEWS2 assessment was not completed. There was no clear
reason why the GP (or 111 or 999) was not called as it was clear that the 84% SPO2
reading would require immediate action, as per NEWS2 guidelines. The GP made a
home appointment to see the patient and medication given for palliative reasons and
patient remained at home. However, patient was taken by his family to Ealing UCC later
and then transferred to A&E and from there admitted onto a ward. Unfortunately, the
patient passed away in hospital.
Learning
As NEWS2 assessments are not routinely carried out by community therapists the
service needs to ensure training & guidance is clear: A. when to carry out the
NEWS2 assessment & B. what are the correct immediate subsequent actions.
All MI community staff need to complete NEWS2 mandatory training. To ensure
uniformity of NEWS2 delivery across all community therapy teams within Maximising
Independence service.
All MI community staff to have appropriate equipment to complete NEWS2
assessment.