Serious 8 Patient expected to be Miscommunication between Review and update with Police to Completed. assessed absconded Police and Duly Authorised Officer ensure that assessment happens in awaiting Mental resulting in delay of assessment the most appropriate setting. Patient Health Act until the following day. subsequently assessed with no assessment. adverse outcomes. Serious 4C Patient developed Risk not adequately assessed and Review risk assessment and In progress. severe pressure sore. documented to facilitate optimal monitoring. treatment. Review communication between Poor communication between clinical teams. community and hospital in a Formation of Pressure Injury and compromised patient resulting in Prevention Team (PIPI) has been severe pressure injuries following actioned. a surgical procedure and subsequent hospital stay. Underlying development of pressure sores in the community due to 28 days sitting and sleeping in chair with feet on foot rest. Theatre/recovery time added significantly to the pressure injury on heals blister noted day two – post-discharge. Serious 4A Administration of Treatment commenced based on Future decisions will follow new Completed. medication resulting in patients presenting symptoms and clinical protocol. termination of a diagnostic information available at potentially viable the time leading to misdiagnosis pregnancy. of an ectopic pregnancy.
Serious 8 Patient expected to be assessed absconded awaiting Mental Health Act assessment. Miscommunication between Police and Duly Authorised Officer resulting in delay of assessment until the following day. Review and update with Police to ensure that assessment happens in the most appropriate setting. Patient subsequently assessed with no adverse outcomes. Completed. Serious 4C Patient developed severe pressure sore. Risk not adequately assessed and documented to facilitate optimal treatment. Poor communication between community and hospital in a compromised patient resulting in severe pressure injuries following a surgical procedure and subsequent hospital stay. Underlying development of pressure sores in the community due to 28 days sitting and sleeping in chair with feet on foot rest. Theatre/recovery time added significantly to the pressure injury on heals – blister noted day two post-discharge. Review risk assessment and monitoring. Review communication between clinical teams. Formation of Pressure Injury and Prevention Team (PIPI) has been actioned. In progress. Serious 4A Administration of medication resulting in termination of a potentially viable pregnancy. Treatment commenced based on patients presenting symptoms and diagnostic information available at the time leading to misdiagnosis of an ectopic pregnancy. Future decisions will follow new clinical protocol. Completed.