8 and 11 2 Despite efforts to stop There was a lack of Ensure all information documented by the Subject to HDC patient they ran from communication between the mental health team is consistent and available Investigation. hospital and jumped off a mental health and ward staff as to general hospitals in instances where current bridge. Sustained to the level of observation mental health intervention is being given. multiple injuries. required. Review and formalise the processes, for assigning and prioritising levels of observation. Review practices related to patients who present following a self harm attempt are medically cleared and remain in hospital as they are too sedated for a mental status examination to be completed. Lakes 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 High falls risk patient was Historical contract with Showering assistance contract with No further incidents. not supervised by staff to assist male staff terminated. appropriately qualified patients showering had been staff in the shower terminated in all other wards resulting in a fall and apart from this ward. dislocation of hip requiring surgical intervention. Sentinel 4B 1 Identified as a placental Baby electronic monitoring Obstetrician conducted review of case to CTG scheduled within abruption however (CTG) not adequate. identify time of compromising. next six months and inadequate monitoring of thereafter. Transfer of care not Independent review of midwifery care. complicated labouring implemented in a timely CTG and documentation Baby electronic monitoring (CTG) training mother and delay in manner. education under for midwives. transfer of care resulting development. Review policies/processes to identify in compromised baby. Transfer guideline transfer criteria. implemented.
8 and 11 2 Despite efforts to stop patient they ran from hospital and jumped off a bridge. Sustained multiple injuries. There was a lack of communication between the mental health and ward staff as to the level of observation required. Ensure all information documented by the mental health team is consistent and available to general hospitals in instances where current mental health intervention is being given. Review and formalise the processes, for assigning and prioritising levels of observation. Review practices related to patients who present following a self harm attempt are medically cleared and remain in hospital as they are too sedated for a mental status examination to be completed. Subject to HDC Investigation. Lakes 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 High falls risk patient was not supervised by appropriately qualified staff in the shower resulting in a fall and dislocation of hip requiring surgical intervention. Historical contract with staff to assist male patients showering had been terminated in all other wards apart from this ward. Showering assistance contract with staff terminated. No further incidents. Sentinel 4B 1 Identified as a placental abruption however inadequate monitoring of complicated labouring mother and delay in transfer of care resulting in compromised baby. Baby electronic monitoring (CTG) not adequate. Transfer of care not implemented in a timely manner. Obstetrician conducted review of case to identify time of compromising. Independent review of midwifery care. Baby electronic monitoring (CTG) training for midwives. Review policies/processes to identify transfer criteria. CTG scheduled within next six months and thereafter. CTG and documentation education under development. Transfer guideline implemented.
Serious-and-Sentinel-Events-Cases-2008_09.docx