Serious 4f 2 Unwell patient not assessed Patient being transferred to the Transit policy reviewed with Increased staff training to transfer and transit dialysis unit. Ambulance officer nurses to reinforce expectations. about transit care nurse not present. identified patient was vomiting and procedures and Reinforced with St John that they appeared to have decreased level of assessment skills. Review can refuse to take patients if not consciousness. Requested transit of staff transfer of care happy with condition and transit nurse. Not done. practices. arrangements. On arrival patient not breathing. Serious 4c 3 Poor coordination of care Inpatient with severe menorrhagia Review models of care clear Service continuing to review – resulting in prolonged and related cardiac rhythm clinical team ownership. this situation to ensure recovery. symptoms requiring 10 unit systems issues are Review medical staff numbers transfusion, hysteroscopy, surgery, addressed. and supervision. intrauterine balloon tamponade. Review authority for discharge Poor coordination with clinical plan planning. of care not clearly communicated to Communicate with patient about relevant team. plan of care and provide Discharged to treatment and discharge documents. without prescription. On readmission, delayed treatment commenced prior to surgery. Patient recovery delayed. Serious 4c 3 Baby admitted to SCBU Monitoring of mother and baby was Handover procedures reviewed Service continuing to review birth as monitoring of woman not adequate or according to policy. with all parties. this incident to ensure in labour inadequate. Baby severely compromised at birth systems issues are Policy expectations reviewed and required resuscitation and addressed. with midwifery team. Routines admission to SCBU inadequate reinforced. handover from Independent midwife to core midwife. Serious 4c 3 Baby admitted to SCBU after Baby delivered as caesarean Policy expectations reviewed Service continuing to review deterioration. section. Monitoring of baby with team. Routines reinforced. this incident to ensure temperature and respiratory rate systems issues are Care plans updated and staff overnight inadequate. addressed. training increased. Required urgent transfer to SCBU and treatment.
Serious 4f 2 Unwell patient not assessed to transfer and transit nurse not present. Patient being transferred to the dialysis unit. Ambulance officer identified patient was vomiting and appeared to have decreased level of consciousness. Requested transit nurse. Not done. On arrival patient not breathing. Transit policy reviewed with nurses to reinforce expectations. Reinforced with St John that they can refuse to take patients if not happy with condition and transit arrangements. Increased staff training about transit care procedures and assessment skills. Review of staff transfer of care practices. Serious 4c 3 Poor coordination of care resulting in prolonged recovery. Inpatient with severe menorrhagia and related cardiac rhythm symptoms requiring 10 unit transfusion, hysteroscopy, surgery, intrauterine balloon tamponade. Poor coordination with clinical plan of care not clearly communicated to relevant team. Discharged to treatment and without prescription. On readmission, delayed treatment commenced prior to surgery. Patient recovery delayed. Review models of care – clear clinical team ownership. Review medical staff numbers and supervision. Review authority for discharge planning. Communicate with patient about plan of care and provide discharge documents. Service continuing to review this situation to ensure systems issues are addressed. Serious 4c 3 Baby admitted to SCBU birth as monitoring of woman in labour inadequate. Monitoring of mother and baby was not adequate or according to policy. Baby severely compromised at birth and required resuscitation and admission to SCBU inadequate handover from Independent midwife to core midwife. Handover procedures reviewed with all parties. Policy expectations reviewed with midwifery team. Routines reinforced. Service continuing to review this incident to ensure systems issues are addressed. Serious 4c 3 Baby admitted to SCBU after deterioration. Baby delivered as caesarean section. Monitoring of baby temperature and respiratory rate overnight inadequate. Required urgent transfer to SCBU and treatment. Policy expectations reviewed with team. Routines reinforced. Care plans updated and staff training increased. Service continuing to review this incident to ensure systems issues are addressed.