Serious 4A and B 2 A patient had treatment The review team found that a Review recommended: Action plan in of a more extensive report was not reviewed by the progress. notification to all SMOs regarding the nature than would usually medical team until six months event have been offered had it later. offering the patient an apology and been known that the This was due to incomplete explanation with the outcome of the patient had metastatic records and communication of review disease at the time that information. update of the risk register and mitigations treatment options were to reflect the outcome of this event. being considered. Serious 4D NC Patient admitted for a The review team found that the Review recommended: Action plan complete fractured arm and foot drop and nerve problems and closed. Followup response to complaint and apology vascular injury went most likely resulted during care audit of – type of anaesthesia remain a clinical onto develop nerve injury provided and subsequent to documentation is decision and associated foot drop original injury. planned. risks that arise when assumptions are during admission. made and included in clinical documentation be communicated to staff feedback regarding expected documentation standard. Serious 4G NC a patient was The review team found the Review recommended: Action plan complete anaesthetised it was anaesthetic consent was and closed. Followup review of service practice for gaining identified that consent for mistaken for procedural consent audit planned. consent to support compliance with the procedure had not when pre-procedure checks informed consent policy been gained. The patient were completed. redesign of service pre procedure check was woken and the lists procedure rescheduled. provide findings to team revising informed consent policy and teams involved review orientation.
Serious 4A and B 2 A patient had treatment of a more extensive nature than would usually have been offered had it been known that the patient had metastatic disease at the time that treatment options were being considered. The review team found that a report was not reviewed by the medical team until six months later. This was due to incomplete records and communication of information. Review recommended: notification to all SMOs regarding the event offering the patient an apology and explanation with the outcome of the review update of the risk register and mitigations to reflect the outcome of this event. Action plan in progress. Serious 4D NC Patient admitted for a fractured arm and vascular injury – went onto develop nerve injury and associated foot drop during admission. The review team found that the foot drop and nerve problems most likely resulted during care provided and subsequent to original injury. Review recommended: response to complaint and apology type of anaesthesia remain a clinical decision risks that arise when assumptions are made and included in clinical documentation be communicated to staff feedback regarding expected documentation standard. Action plan complete and closed. Followup audit of documentation is planned. Serious 4G NC a patient was anaesthetised it was identified that consent for the procedure had not been gained. The patient was woken and the procedure rescheduled. The review team found the anaesthetic consent was mistaken for procedural consent when pre-procedure checks were completed. Review recommended: review of service practice for gaining consent to support compliance with informed consent policy redesign of service pre procedure check lists provide findings to team revising informed consent policy and teams involved review orientation. Action plan complete and closed. Followup audit planned.
Serious-and-Sentinel-Events-Cases-2008_09.docx