Referral to acute assessment Review of triage procedures and education to Referred to coroner. team resulted in appointment clarify expected response according to assessed RCA completed – arrangements for the following triage. implementation of day, however suicide Review risk assessment processes and recommendations completed overnight. documentation under way. Improve PATT participation in supervision. Review and clarify various of community team. Review community clients’ care plans and assessments. Ongoing evaluation of processes and systems needs to be implemented. Taranaki Serious Event code* SAC 1/SAC 2/ Description of event Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Serious 6 2 Patient fall resulting in a Falls risk assessment, Encourage patient to seek assistance or Completed. fractured hip. completed prior to event, did not supervision if feels unsafe. indicate a high risk. Patient to get back into bed as had been doing this independently without assistance. Serious 9 SAC 2 Inpatient assaulted CCTV cameras to be installed. Review staff In presence progress. in the copatient resulting in two intensive psychiatric care unit, Minimum of one staff member to be present Completed and fractures to the right leg. including supervision of patients within the intensive psychiatric care unit at any ongoing. Surgical repair was in the courtyard. given time. required. Not all staff were up to date with Assessments are to be completed, based on Completed and calming and restraint training. patient acuity, to determine requirement of ongoing. supervision in the courtyard.
Referral to acute assessment team resulted in appointment arrangements for the following day, however suicide completed overnight. Review of triage procedures and education to clarify expected response according to assessed triage. Review risk assessment processes and documentation Improve PATT participation in supervision. Review and clarify various of community team. Review community clients’ care plans and assessments. Ongoing evaluation of processes and systems needs to be implemented. Referred to coroner. RCA completed – implementation of recommendations under way. Taranaki Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Serious 6 2 Patient fall resulting in a fractured hip. Falls risk assessment, completed prior to event, did not indicate a high risk. Patient to get back into bed as had been doing this independently without assistance. Encourage patient to seek assistance or supervision if feels unsafe. Completed. Serious 9 SAC 2 Inpatient assaulted copatient resulting in two fractures to the right leg. Surgical repair was required. Review staff presence in the intensive psychiatric care unit, including supervision of patients in the courtyard. Not all staff were up to date with calming and restraint training. CCTV cameras to be installed. In progress. Minimum of one staff member to be present within the intensive psychiatric care unit at any given time. Completed and ongoing. Assessments are to be completed, based on patient acuity, to determine requirement of supervision in the courtyard. Completed and ongoing.