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					BARNET AND CHASE FARM HOSPITALS NHS TRUST

REPORT TO:                                   Trust Board

REPORT FROM:                                 Head of Patient and Public Involvement
                                             Head of Risk
                                             Joint Acting Head of Complaints

REPORT SPONSORED BY:                         Director of Nursing

DATE:                                        9th September 2004

SUBJECT:                                     Quality and Governance
                                             Annual Report for Complaints;
                                             PALS and Risk quarterly reports.

FOR:                      Information / Discussion
_________________________________________________________

1.      EXECUTIVE SUMMARY

        This is the Annual Report on Complaints for 2003/2004 and includes
        Legal Claims. It also details activity in the first quarter of 2004-2005,
        April – June 2004 giving information about compliments, complaints,
        claims and PALS (Patient Advice and Liaison Service) issues together
        with risk trends.

        The data is brought together in an integrated report to give the Board
        an all-round look at quality and governance issues in the Trust enabling
        them to trace trends across the organisation and to note the action and
        learning points distilled and implemented into practice from one report.

        The National Patient Safety Agency (NPSA) has set out ‘Seven steps
        to patient safety’1. They are:

                 1.   Build a safety culture
                 2.   Lead and support your staff
                 3.   Integrate your risk management activity
                 4.   Promote reporting
                 5.   Involve and communicate with patients and the public
                 6.   Learn and share safety lessons
                 7.   Implement solutions to prevent harm




1
 National Patient Safety Agency, Seven steps to patient safety, an overview guide for NHS staff,
NPSA 2004
      In developing an integrated quality and governance approach the
      Trust is systematically implementing the seven steps to patient
      safety.

2.    RECOMMENDATION

      The Board is asked to note this report.


3.    INTRODUCTION

      Issues highlighted through Risk Management, PALS (Patient Advice
      and Liaison Services) Complaints and Legal Claims are key indicators
      of quality and governance in the Trust. Through this integrated report
      the Board is presented with information from both an organisational
      and a patient-focused perspective.

4.    QUALITY AND GOVERNANCE REPORT

4.2   The Complaints, PALS and Risk teams continue to undergo change.
      Pauline Ferns was appointed to the substantive post of Head of Risk,
      with effect from 7th July 2004. We are currently recruiting to fill a
      vacancy within the risk team created as a result of her appointment.
      We were unsuccessful in appointing a Head of Complaints and the
      post was re-advertised with a closing date of 26th August for interview
      in September. Otherwise the Complaints teams are up to strength on
      both sites and a PALS Officer has been appointed to the vacancy at
      Barnet PALS starting in October. Kay Laurie, Head of Patient and
      Public Involvement is currently line managing both the PALS and
      Complaints teams.

      At Chase Farm hospital the Complaints and PALS teams re-located in
      July to the old flower shop at the main entrance. As this is a much
      more accessible location for patients and visitors we expect to see
      contacts with the PALS service increase, as they did at Barnet hospital
      when the service there relocated from Thames House to a retail unit in
      the hospital main entrance.

      The Chase Farm site Risk team has also relocated and is now based
      on the 2nd Floor of the Clocktower Building along with the Health and
      Safety team.

4.3   QUALITY REPORT – Q1 2004/2005 (1 April 2004 – 30 June 2004)

4.3.1 COMPLIMENTS

      Letters, cards and donations in appreciation of care and treatment are
      received throughout the Trust. Previously, letters of compliment
      received by the Chief Executive’s office have been reported in the
      complaints report. However as these only represented a small

                                      2
      proportion of the overall, we are working with the Head of Fundraising
      to achieve a more coordinated approach to acknowledging the support
      and generosity of our patients, their families and friends.

      Both PALS teams have had a number of people calling in to pass on
      praise to staff. Callers are offered ‘employee of the month’ nomination
      forms and their messages of appreciation are emailed to the relevant
      wards and departments and copied to Matrons and service managers.
      The new bedside magazine for in-patients will include a slip for patients
      to give feedback and to nominate staff for employee of the month.

4.4   THE COMPLAINANTS ‘PATHWAY’

      Across the Trust we are developing a ‘Complainant’s Pathway’ to help
      ensure that we are able to make every effort to resolve concerns or
      complaints at the earliest possible opportunity. A number of changes
      to the way in which complaints and concerns are dealt with have been
      introduced, both in the Trust and in response to new regulations. Most
      recently, the arrangements for ‘Independent Review’ have changed
      and this is covered in more detail later in this report. Further changes
      to the ‘local resolution’ process are expected next year following the
      publication of the fifth report of the Shipman Inquiry and the Head of
      Patient and Public Involvement is participating in development work on
      local resolution being undertaken by the Department of Health.

4.4.1 The PALS (Patient Advice and Liaison) Service
      Early intervention and speedy resolution

      The establishment of the PALS (Patient Advice and Liaison) service in
      the main entrances at each hospital has meant that in a significant
      number of instances, there is the opportunity for speedy and informal
      ‘local resolution’ of patients or families concerns.

      The PALS services logged 834 first contacts in Quarter 1. They were
      categorised into ‘types’ as follows:

            Advice or information
            Comment or suggestion
            How to make a complaint
            Concern or complaint
            General queries
            Health related issues
            Praise

      All issues raised with PALS are taken seriously. They are recorded,
      dealt with and reported to the Trust Board in the same way that formal
      complaints are.




                                      3
                             PALS type Q1 2004/5

             500

             450

             400
                                                           Potters Bar Hospital
             350
                                                           Finchley Memorial
             300                                           Hospital
   Number




                                                           Edgware Hospital
             250

             200                                           Chase Farm Hospital

             150                                           Barnet Hospital

             100

                 50

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This illustrates the range of issues in which the PALS teams are asked
for help and advice. Early intervention can be very effective in sorting
the issue out without the patient or family member feeling it necessary
to resort to the formal complaints procedure.

The next chart compares activity in the PALS and Complaints teams.
These broad categories as used for the performance data gathered by
the Department of Health nationally. For detailed explanation of the
subject categories, see Annex 2, page 26.




                                4
           Complaints and PALS Overview by subject Q1 2004/5


                                    Number
                         0   100      200       300       400

           Adm/Dsch
                 Aids
              Apt Inpt
            Apt Outpt
              Attitude
              Clinical
     Communications
  Complaints handling
             Consent
                Hotel                                             PALS
               Others                                             Complaints
           Pt records
                Policy
           PrivDignity
           Procedure
          Pts property
            Transport
           Ind Sector
          Code open
       Wait response




4.4.2 FORMAL (WRITTEN) COMPLAINTS
      The complainant’s right to a formal investigation

       A total of 118 formal complaints were made in Quarter 1 2004/5 with
       three quarters of these made by the complainant directly to the Chief
       Executive. The remainder were complaints in which the PALS teams
       had been unable to facilitate a resolution to the complainant’s
       satisfaction.

       In all cases the complainants may exercise their right to make a formal
       complaint, in accordance with NHS complaints guidance requiring that
       ‘complainants are treated courteously and sympathetically and as far
       as possible involved in decisions about how their complaints are
       handled and considered’.



                                      5
                                          PALS becoming formal Complaints
                                                           PALS     Complaints
                                  Barnet PALS               542           18
                                  Chase Farm PALS           252           10

       The percentage of formal (written) complaints where local resolution is
       completed within 20 working days is one of the ‘balanced scorecard’
       performance indicators for the NHS star ratings.


                                        Formal Complaints by site Q1 2004-5

                                  70
           Number of complaints




                                  60
                                  50
                                  40                                  Barnet Hospital
                                  30                                  Chase Farm Hospital
                                  20
                                  10
                                  0
                                                   1
                                                 Site



       Performance on formal complaints in the 6 months to March 2004 was
       recorded at 72% but this fell to 65% in Q1 2004/5. The Trust target is
       to attain a performance for the year of 75%. Because the PALS teams
       now resolve the more straightforward issues those issues that go
       through the formal process tend to be more complex and may involve
       more than one department. Consistently completing local resolution
       within 20 days will require close supervision at directorate level.

Complaints Response
Performance Times            Number Number          % response % response Out           Av days
Q1 2004/5                    received responded to < 20 days     > 20 days    standing response
Medical & Emergency                 53          30            77            7         8       15
Surgical & Anaesthetics             31          20            55            9         6       16
Estates & Facilities                 2            2           50            1         0       25
Women's & Children's                22          10            50            5         9       22
Diagnostics Therapies Cancer        10            7           71            2         1       15
Totals                             118          69          65%           24%        24       16

       It is important to note that under the revised complaints regulations,
       from 1st August 2004 complainants may refer any complaint they feel is
       not resolved within 6 months to the Healthcare Commission and seek
       an Independent Review.


                                                        6
     The chart below compares the activity on PALS and Complaints for
     each of the Clinical Divisions. As can be seen, the ratio of PALS to
     formal Complaints is broadly comparable, with somewhat fewer issues
     in Women’s and Children’s being addressed via PALS.


                                               PALS vs Formal Complaints Q1 2004/5

                                        250
        Number of issues / complaints




                                        200



                                        150
                                                                                                       Formal Complaint
                                                                                                       PALS
                                        100



                                         50



                                          0
                                              Medicine & Surgery & Estates & Diagnostics Women's &
                                              Emergency Anaesthetics Facilities Therapies Children's
                                                                                 Cancer

                                                                   Division


4.4.3 INDEPENDENT REVIEW AND OMBUDSMAN
      Reforms to the Complaints procedures

     The NHS Complaints procedures are part way through a reform
     process. New regulations were introduced on 1st August 2004 in
     relation to the ‘second stage’ of the Complaints procedure
     ‘Independent Review’.

     Under the ‘old’ system, complainants could ask the Trust for an
     Independent Review of their complaint. During 2004 there will be a
     transitional period whilst ‘old’ system Independent Reviews are
     completed. From 1st August 2004 complainants may ask the
     Healthcare Commission (HC) to review their complaint if they are
     unhappy with the Trust’s response, or if the Trust has been unable to

                                                                      7
        complete the formal local resolution stage within 6 months. It is
        desirable that every effort be made to resolve a complaint to the
        satisfaction of a complainant within six months, this is better for
        complainants and staff alike and would also minimise the potential for a
        referral to the Healthcare Commission.

4.4.4 HEALTHCARE COMMISSION
      Listening to both sides of the story

        It would appear that the process the Healthcare Commission are
        following in reviewing an application is broadly similar to that used by
        the Health Services Commissioner (Ombudsman). The Director of
        Operations for the Healthcare Commission has stated that:

                 ‘The Commission aims to deliver a fair, consistent and timely
                 process. Feedback we have received shows that people want a
                 fair system for both the complainant and the complained
                 against. We will give both parties the opportunity to put their
                 side of the story, to agree the terms of reference of any
                 investigation and to have access to all relevant documentation’. 2

        At the end of August, as this Board report was drafted, the Trust had
        already been notified of 5 applications for Independent Review that had
        been received by the Healthcare Commission. The Healthcare
        Commission requires a comprehensive pack of information about the
        progress of the complaint so that they can review the matter and
        decide what the next step should be. The Trust has two weeks in
        which to produce the information required.

        In the period 1 April 2003 to 31 March 2004 the following actions were
        taken in respect of Independent Review (IR):

                21 Request for IR were received
                15 Requests were referred back for further local resolution
                6 Independent Review Panels have been / are to be held


4.4.5 HEALTH SERVICES COMMISSIONER
      The ‘Ombudsman’

        If a complainant is dissatisfied about the Independent Review process
        or decision, they can ask the Ombudsman to investigate their
        concerns. Under the complaints arrangements, there is no further
        appeal process after the Ombudsman has considered the complaint.
        The Ombudsman’s recommendations are made to Parliament.




2
 Speak Out, Marcia Fry, Head of Operations, Healthcare Commission, Health Service Journal, 19
August 2004.

                                                8
                       Independent Review & Ombudsman




                                     July 2003 - August 2004
                                 0    2       4   6   8   10   12

              Request IR (old)

                  Denied (old)

          Request IR (new HC)

             Denied (new HC)
                                                                    Q2 2003/4
             Panels held (old)                                      Q3 2003/4
                                                                    Q4 2003/4
             Panels held (HC)
                                                                    Q1 2004/5
            Reports published                                       (Q2 2004/5)

              Ref Ombudsman

             Omb Investigation

        Investigation Complete



4.4.6 TRENDS IN PALS AND COMPLAINTS
      Ensuring that lessons are learned and shared

      A key aspect of quality and governance is to have processes that
      enable risk issues to be filtered out and escalated to the right level in
      the Trust. We need to ensure that senior staff contribute to the
      resolution of such issues and consequent action planning. As the Trust
      Complaints Policy is being revised to take into account changes to the
      Independent Review processes a discussion paper is being written that
      considers how the pro-active risk assessment might be applied to
      PALS and Complaints issues. This would link PALS and Complaints
      to the existing Trust risk process.

      The majority of non-clinical issues centred on estates and facilities –
      parking, cleanliness, slips, trips and falls by visitors. Quite some time
      was taken up assisting people enquiring about jobs. Financial
      enquiries were about reimbursement of fares, parking fees and lost
      property.


                                          9
                                            PALS Non-Clinical Q1 2004/5

                            100                                                     Estates & Facilities
                             90
       Number of Contacts    80
                             70                                                     Finance Directorate
                             60
                             50
                                                                                    Human Resources
                             40
                             30
                             20                                                     Nursing Directorate
                             10
                              0
                                                    Directorate                     Operations Directorate



4.4.7 WHAT WERE THE ISSUES PEOPLE COMPLAINED ABOUT?

    When we start to look in detail at the reasons people contacted the
    PALS service, or went on to make a formal complaint, we have the
    opportunity to target areas for improvement. As we saw earlier, the
    patterns are similar, so PALS issues, in particular, may also serve as
    an ‘early warning’ of problems on the horizon as they are greater in
    number than those which come as formal complaints. The broad
    ‘subject’ categories that are collected by the NHS indicate the general
    issues:


                                       PALS overview by subject Q1 2004/5

                                                                     Number of contacts
                                                0          50          100       150       200        250
                                 Adm/Dsch
                                        Aids
                                    Apt Inpt
                                  Apt Outpt
                                    Attitude
                                     Clinical
                            Communications
       Subject




                                   Consent
                                       Hotel
                                      Other
                                 Pt records
                                      Policy
                                 PrivDignity
                                 Procedure
                               Pts Property
                                  Transport
                                 Ind Sector


    We collect more detailed information about issues, and the next chart
    gives a Trust wide overview of patients concerns.



                                                                10
                                                               PALS Issues by Subject Q1 2004/5
                                                 0   10   20                30               40                50                      60
                                Accessibility
                                     Att Amin
                                   Att H Prof
                                    Att Medic
                                Att Midwives
                                  Att Nurses
                                Blood Tests
                                Breach Conf
                                  Clled Oper
                               Clled Op Rpt
                                      Parking
                                         Food
                                  Contacting
                                   Discharge
          Number of contacts




                                Environment
                                         Falls
                                  Hyg Clean
                                     Job enq
                               Acc Med Rec
                                       MRSA
                                OP apt post
                                rep OP post
                                         Pain
                                  Pharmacy
                                    Pressure
                                  PrivDignity                                                                 Diag Therapies & Cancer
                                     Property
                                      Results                                                                 Estates & Facilities
                                     Signage                                                                  Finance
                                   Transport
                                   Fares enq                                                                  Human Resources
                                     HP treat
                                    Med treat                                                                 Medical & Emergency
                                    Mid treat
                                 Understand                                                                   Nursing Directorate
                                   Wait A&E                                                                   Operations Directorate
                                     Wait OP
                                     Wait Apt                                                                 Surgical & Anaesthetics
                                 Wait Oper
                                   Wait Test                                                                  Women's & Children's
                                         Xray




                                                                  11
Detailed descriptions of these categories, together with Directorate or Clinical Divisional data are given at Annex 1, pp 22-25
                                                                  12
Detailed descriptions of these categories, together with Directorate or Clinical Divisional data are given at Annex 1, pp 22-25
4.4.8 OUTCOMES AND LEARNING

      Responding positively to concerns and complaints is essential if we are
      to improve our services. For example looking at some of the issues in
      the chart above we have taken the following actions:

      Parking      - We have reduced the parking charge at Barnet Hospital
      from £10.30 to £3 per day and will be publicising the availability of
      concessionary £8 weekly tickets through our new inpatient magazine.

      Blood tests – We have introduced an appointment system to reduce
      long waits at our out-patient blood test clinics. Some GPs have not
      been advising patients of the new arrangements and we are contacting
      those GPs to ensure that this information is passed on. Patients are
      generally much happier with the new system. We have also relocated
      the Barnet Hospital blood test clinic to Level 0 so that we could provide
      more comfortable facilities for those waiting.

      Falls by patients or visitors – Falls are reported on Datix as PALS or
      Incidents. A ‘Falls’ project has been set up to address this issue from a
      risk management perspective.

4.5   LEGAL CLAIMS
      Seeking redress through the Courts

      A legal claim may be made through the civil courts by a patient or their
      family against the Trust. If the matter was previously being
      investigated as a complaint then the complaints procedure is
      suspended. Sometimes matters move very quickly into the legal
      process, others may become legal claims only after several years. In
      the case of a claim for damages to a child this may occur at any time
      before the child reaches 25 years of age.

4.5.1 Trends in Legal Claims

      The total number of claims received in 2003/4.was 83 with the highest
      number in one quarter being 17 arriving in Q3 (October to December
      2003).




                                      13
                              Claims 2004/5 by Speciality

                                        Total = 83
                          0      2      4        6     8    10

                A&E

          Gen Surgery

                Gynae

        Histopathology

        Gen Medicine

              Geriatric

            Paed med                                              Q1 Total
                                                                  Q2 Total
        Mental Health
                                                                  Q3 Total
          Non Clinical                                            Q4 Total
             Obstetric

        Opthalmology

          Orthopaedic

            Pathology

          Radiography

             Vascular



4.5.2 Current Legal Claims

     At 30 June 2004 there were altogether 154 legal claims at various
     stages in the process. The legal process can take several years to
     conclude during which time the cases remain open. In the following
     tables information is presented firstly on the number of claims on each
     site by clinical specialty. The second graph indicates how these have
     been coded using the NHS Litigation Authority numbering system to
     identify the type of incident.




                                        14
                                        Live Claims at 30 June 2004

                                               Number
                                    0    10   20    30   40   50

                           A&E
                    Dermotology
                    Day Hospital
                            ENT
                          Gastro
                General Surgery
                          Gynae
                       Histology
                General Medcine
   Specialty




               Geriatric Medicine                                     Barnet Hospital
                  Paediatric Med                                      Chase Farm Hospital
                     Non Clinical                                     Edgware Hospital
                      Obstetrics
                       Oncology
                   Opthalmology
                   Orthopaedics
                       Pathology
                    Radiography
                  Surgical Other
                 Surgical Paeds
                         Urology



On the next page we show the numbers of current legal claims and the
type of incident concerned. These are all the legal cases that were
open at 30th June 2004.

The codes for these incidents are set by the NHS Litigation Authority
and reflect the varied types of legal claims that are made. The list of
codes is given in full in Annex 3, page 27.




                                              15
                        Live Claims at 30 June 2004 by Incident Type

                 O755
                 O740
                 O660
                 O650
                 O600
                 O550
                 O540
                 O520
                 O510
                 G240
                 G220
                 G190
                 G180
                 G170
                 G160
        Number




                 G140                                       Barnet Hospital
                 G130
                 G120                                       Chase Farm Hospital
                 G110                                       Edgware Hospital
                 G090
                 G080
                 G070
                 G050
                 G040
                 G030
                 G020
                 G010
                   BD
                 A840
                 A820
                  999
                  998
                  790
                  680

                        0    10    20      30     40   50
                                  Incident Type




4.5.3 New legal claims

     In Q1 of 2004/05 (1st April 2004 – 30th June 2004) a total of 23 new
     legal claims were received by the Trust:




                                            16
                                         Q1 2004/05 New Claims by Specialty

                                                  Number
                                     0       2         4    6       8

                     Dermotology

                             ENT

                           Gastro

                      Gen Survery

                           Gynae

                     Gen Medicine
         Specialty




                      Non Clinical
                                                                        Barnet Hospital
                                                                        Chase Farm Hospital
                         Obstetric
                                                                        Edgware Hospital
                        Oncology

                      Orthopaedic

                           Physio

                            Other

                       Paediatrics

                          Urology




4.6   RISK MANAGEMENT
      Integrating Risk Management activity

      This report contains incident management information from Datix, the
      Trust’s new incident reporting system, which has been operational
      since February 2004. Since Datix’s launch the Risk Team have noted
      a steady rise in the number of reportable incidents and interpret this as
      an indication of the growing confidence of staff in the reporting
      mechanism. However, we need to encourage more staff to report
      events and to deliver the message throughout the organisation that
      people can report anonymously.

4.6.1 Incident Overview

      A total of 1168 ‘events’ (incidents, near misses or hazards) were
      recorded in the Trust during Q1 - April to June 2004. This is an
      increase of 430 on the fourth quarter of last year. However, on analysis
      of the data it appears that there has been a decrease in reporting from
      the Women and Children’s Division by 23 events over the last quarter
      while significant increases have been noted in Medicine (239) and



                                                  17
     Surgery (109). There is also an upward trend in reporting for
     Diagnostics & therapies (25) and Estates & Facilities (33).

     The fall in the number of reports from the Women and Children’s
     Division is probably due to the vacant Risk Facilitators post within the
     Division. This is currently being addressed and the closing date for the
     post is 26th August 2004.

4.6.2 Learning

     The graph shows significant incidents in medicine and surgery. This is
     primarily due to the number of slip, trips and falls reported and
     medication errors reported.

4.6.3 Action

     The Falls Strategy group is examining incidents and identifying
     strategies to reduce the number of falls and will monitor effectiveness.
     The medicine management group is examining incidents and
     identifying strategies to reduce the number of medication errors in the
     Trust.


4.6.4 Root Causes

     The Risk Management Team are currently fully absorbing the new
     model into our organisational culture of incident investigation and
     prevention. As expected, the organisation still has a great deal to learn
     from the process itself and how it can be used to optimal effect. The
     IR2 form is used to allow staff to clearly define root causes of an event.
     The Risk Management Team have designed Risk Management
     Workshops for senior managers in the organisation, which include the
     root cause analysis.

4.6.5 Actions

     All senior managers within the organisation must attend the Risk
     Management Workshop. Staff need to be trained in the Root Cause
     Analysis model particularly if they are involved as lead investigators for
     serious incidents. In addition Managers who are involved in
     responding to Complaints will find root cause analysis helpful in their
     investigation and development of action plans to address problems.




                                     18
                                                                                                                                                      Near Miss
                                                        Risk Events by Division and Type Q1 2004/5
                                                                                                                                                      NonClinical
                                                                                                                                                      Incident
                            700                                                                                                                       Hazard

                            600

                            500
Cumulative Frequency




                            400

                            300

                            200

                            100

                                  0   Diagnostics
                                                    Estates and                   Human       Medical and                 Surgical and
                                                                                                                                         Women's
                                       Therapies                   Finance                                   Nursing                        and
                                                     Facilities                 Resources     Emergency                   Anaesthetics
                                      and Cancer                  Directorate                               Directorate                  Children's
                                                    Directorate                 Directorate    Division                     Division
                                        Division                                                                                          Division
                       Near Miss           2            1             0             0             8             0              6             3
                       NonClinical        0             0             0             0             0             0              1             0
                       Incident           70            55            0             1            645            2             275           87
                       Hazard             3             1             1             0             5             0              2             0

                                                                            Division / Directorate




                                                                                  19
                                                                                  Reported Risks by CMG Q1 2004/5


                                                                                                     Num ber

                                               0                 50         100         150   200        250   300   350   400   450   500
                  Accident and Emergency                                          113
                              Anaesthetics                 19
                         Breast Screening          1
                                    Cancer         1
                                 Cardiology                 25
                       Childrens Services                   27
                  Diabetes / Endocrinology         3
                         Gastroenterology          5
                           Head and Neck            8
                    Medicine for the Elderly                                                                                     435
CMG / Specialty




                            Med Neurology          1                                                                                         Hazard
                       Med Genito-Urinary          1
                                                                                                                                             Incident
                         Med Dermatology           1
                                                                                                                                             Non Clinical
                        Med Haematology                10
                               Non Clinical                                     103                                                          Near Miss

                              Orthopaedics                                 76
                      Outpatients Services               19
                                  Pathology            10
                                  Pharmacy              13
                                  Radiology             16
                     Respiratory Medicine                       33
                         Surgical Services                                            128
                                 Therapies             9
                                    Urology                21
                        Womens Services                               57




                                                                                                    20
5    Patient Implications

     Ensuring that patients and their carers can get advice and help straight
     away when they have a problem is demonstrated to improve patients’
     experiences. Nationally patient’s experiences are measured through
     the patient focus aspects of the balanced scorecard. Addressing those
     areas that patients highlight as giving them cause for concern supports
     the drive for improvement in results on Patients’ Surveys.

6    Service Implications

     Taking and sharing the learning from Risk, PALS and Complaints will
     ensure that service improvement is driven forward.

7    HR Implications

     The learning from risk and the feedback from patients are used in staff
     induction and in-service training. The number of enquiries to PALS
     about jobs indicates that it may be useful to place vacancy bulletins in
     public areas.

8    Financial Implications

     Prompt action when problems occur can help reduce financial risks to
     the organization.

9    Capital / Estates implications

     The PEAT (Patient Environment Action Team) group follows up estates
     issues arising from these reports.

10   Equalities Implications

     The PALS and Complaints services can access the Trust Interpreter
     Service as required. Enabling people to raise concerns informally,
     either in person or by telephone demonstrates that it is a more
     accessible route than formal letters of complaint. This is particularly
     important for people who may be disadvantaged.

11   Risk Implications

     Ensuring that patients, their families and friends can raise concerns
     easily and informally ensures that potential risk issues can be
     identified. We are looking at how the pro-active risk assessment tool
     can be used to screen for unacceptable risks raised with PALS or
     Complaints. Timely and effective intervention is an essential aspect of
     managing risk to the organization.




                                     21
12   NEXT STEPS

     The Board will receive Quality and Governance Reports on a quarterly
     basis.

13   CONCLUSION

     In the last three months there has been significant progress in the
     following areas:

           Location of PALS services where they can be easily accessed
            on both sites
           Enhanced reporting through Datix
           Integration of the PALS and Complaints services
           Centralisation of the Risk team
           Appointment of a substantive Head of Risk

     The priorities now are to agree a revised integrated PALS and
     Complaints Policy and operational procedures that clarify and simplify
     what needs to be done when a concern or complaint is raised with a
     member of Trust staff.

     We also need to embed the new arrangements for responding to
     Healthcare Commission Independent Review requests in order to meet
     the two-week response time.

     We need to continue to imbed risk into the Trust and to support this we
     will be running workshops with the Divisions and the Directorates to
     enable the generation of risk registers for these areas. The workshops
     commence in September 2004 and aim to be completed by March
     2005.




                                    22
                                                                                            ANNEX 1
Directorate and Clinical Division PALS analysis


                                PALS Q1 2004/5 Analysis of Issues

                                          Total contacts - 66
                            0        5       10       15        20        25
               Att Amin
              Att H Prof
            Blood Tests
             Contacting
             Hyg Clean
                  MRSA
                   Other
  Subject




                 rep OP
              Pharmacy
             PrivDignity
                Results
              Fares enq
               HP treat
              Med treat
              Wait A&E
              Wait Test
                                                                         Diag Therapies &
                    Xray                                                 Cancer




                                PALS Q1 2004/5 Analysis of Issues

                                          Total Contacts 167
                            0        10       20       30        40        50
               Att H Prof
               Att Medic
              Att Nurses
            Blood Tests
              Clled Oper
                Clled Op
              Contacting
              Discharge
            Environment
                    Falls
              Hyg Clean
                Acc Med
  Subject




                   Other
            OP apt post
            rep OP post
              Pharmacy
                Property
                 Results
               Transport
                 HP treat
               Med treat
                Mid treat
             Understand
               Wait A&E
                Wait Apt
             Wait Oper
               Wait Test
                    Xray                                              Medical & Emergency



                                                       23
                             PALS Q1 2004/5 Analysis of Issues
                                       Total contacts = 146
                             0        10        20             30           40
                 Att Amin
               Att H Prof
                Att Medic
             Att Nurses
              Clled Oper
            Clled Op Rpt
              Contacting
               Discharge
            Environment
               Hyg Clean
                   MRSA
                    Other
            OP apt post
  Subject




            rep OP post
                      Pain
               Pharmacy
                Pressure
              PrivDignity
                 Property
                  Results
               Transport
               Fares enq
                 HP treat
                Med treat
                 Mid treat
            Understand
                Wait A&E
                 Wait OP
              Wait Oper
                Wait Test                                           Surgical & Anaesthetics




                             PALS Q1 2004/5 Analysis of Issues

                                        Total Contacts = 54
                             0    5        10   15        20         25     30

               Att Medic
            Att Midwives
              Att Nurses
            Breach Conf
              Clled Oper
            Clled Op Rpt
Subject




              Contacting
              Hyg Clean
            Acc Med Rec
                   Other
             OP apt post
             rep OP post
                 Results
                HP treat
               Wait A&E
                                                                      Women's & Children's




                                                     24
                              PALS Q1 2004/5 Analysis of Issues

                                                Total contacts - 84
                               0       10           20        30      40           50

                Att Amin
            Blood Tests
                 Parking
                     Food
             Contacting
Subject




           Environment
                     Falls
              Hyg Clean
          Acc Med Rec
                    Other
                 Signage
               Transport
                                                                           Estates & Facilities




                              PALS Q1 2004/5 Analysis of Issues

                                                Total contacts - 19
                          0        1        2        3        4       5        6        7


          Accessibility




              Parking
Subject




                 Other




              Signage




            Fares enq

                                                                                   Finance




                                                         25
                        PALS Q1 2004/5 Analysis of Issues

                                   Total contacts - 35
                    0         10           20            30        40




          Job enq
Subject




            Other


                                                              Human Resources




                        PALS Q1 2004/5 Analysis of Issues

                                     Total contacts = 5
                          0           1              2              3


          Accessibility



            Att H Prof
Subject




                MRSA



                 Other

                                                              Nursing Directorate




                                                26
                                                                       ANNEX 2
PALS & Complaints                            Car parking
Coding - Subject                             Food and catering
                                             Problem contacting department
Admission or discharge or transfer           Discharge Arrangements
arrangements                                 Environment
Aids and appliances or equipment             Falls
or premises                                  Hygiene and Cleanliness
Delay or Cancellation for in-patient         Patient did not have access to
appointments                                 Interpreter
Delay or cancellation for out-patient        Job enquiry
appointments                                 Access to medical records
Attitude of staff                            Mixed sex wards
All aspects of clinical treatment            Concerns about MRSA
Communication or Information                 Outpatient appointment postponed
Complaints Handling                          Outpatient appointment postponed
Consent to treatment                         more than once
Discrimination                               Other
Independent sector services                  Pain issues
commissioned by Health Authority             Pharmacy issues
HA or PCT commissioning                      Pressure sores
Hotel services including food                Privacy and dignity
Mortuary and post mortem                     Lost or damaged property
arrangements                                 Waiting for results
Code of openness complaints                  Signage or directions
Others                                       Transport
Personal records                             Fares reimbursement query
Policy and commercial decisions of           Aspect of Health professionals
trusts                                       treatment
Patients privacy and dignity                 Aspect of Medical staff treatment
Failure to follow agreed procedure           Aspect of nurses treatment
Patients property and expenses               Patient could not understand staff
Transport                                    Length of wait in A & E
Independent sector services                  Length of wait in out-patient clinic
commissioned by Trust                        Length of wait for outpatient
                                             appointment
PALS and Complaints                          Length of wait for operation
CODING Sub-subjects                          X-ray issues

Access to areas                              RISK Coding
Attitude of Admin staff
Attitude of Health Professionals             NMISS         Near Miss
Attitude of Medical Staff                    NINCID        Not an incident
Attitude of Midwives                         INCID         Incident
Attitude of Nurses                           HAZ           Hazard
Blood Testing issues
Breach of Confidentiality
Cancelled operation
Cancelled operation more than
once


                                        27
Key to Claims Incident Types

Code    Incident Type
O755    Foreign body left in situ
0740    Lack of assistance/care
O660    Surgical foreign body left in situ
O650    Perineal tear- 1st degree, 2nd degree, 3rd
        degree
O600    Repeated attempts at forceps delivery
        and/ventous
O550    Failure to make timely response to
        abnormalities in FHR
O540    Failure to adequately monitor 1st stage of
        labour
O520    Failure to correctly interpret USS - follow up
        or action
O510    Failure of antenatal screening to detect
        congenital abnormality
GO600   Repeated attempts at forceps delivery and/or
        Ventouse
G240    Self harm
G220    Lack of adequate facilities / equipment
G190    Failure to interpret x-ray correctly
G180    Failure to x-ray
G170    Medication errors
G160    Failure to carry out adequate post-operative
        observations
G140    Failure of follow-up arrangements
G130    Failure to warn/informed consent
G120    Improper delegation to unsupervised junior
G110    Performance of operation that is not
        indicated
G090    Intra-operative problems
G080    Delay in performing an operation
G070    Surgical foreign body left in situ
G050    Failure/delay in referring to hospital
G040    Failure/delay in admitting to hospital
G030    Failure to recognize complication of
        treatment
G020    Wrong diagnosis made
G010    Failure to diagnose/delay in diagnosis
BD      Birth defects
A840    Lack of preoperative evaluation
A820    Inadequate monitoring intra-operatively
999     Inappropriate discharge
998     Bacterial infection
790     Fail/delay treatment
680     Other




                                       28

				
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