Serious 4a 1 Surgery delay for patient Multiple missed opportunities, to Referral system be reviewed In progress. with severe finger injury. recognise the severity of the and improved to ensure more patient’s infected finger combined timely and formalised booking with theatre delays contributed to the process. patient’s finger being severely Medical handover process to be infected preoperatively and the developed. patient having decreased functional use of his left index finger post operatively. Serious 4a 1 CTG not recognised as RCA review in progress. abnormal baby died two – days Serious 11 1 Client attempted suicide RCA review in progress. within the inpatient facility and died from her injuries. Serious 3 1 Retained needle following No root causes Other learnings Open disclosure education In progress. surgical procedure. identified. package to be developed and provided to clinical staff. Serious 11 1 Outpatient suicide one day RCA review in progress. after contact with service. Serious 4a 1 Delay in diagnosis due to RCA review in progress. delay in accessing imaging result. Serious 1 1 Wrong patient had RCA review in progress. investigative procedure. Serious 11 1 Outpatient suicide within RCA review in progress. seven days of discharge from inpatient area. Serious 4a 1 Patient died from sepsis. Multiple missed opportunities to The development and In progress. Had presented multiple recognise the patient’s deterioration implementation of a new to hospital and was reviewed and missed opportunities for more rapid response system. by numerous teams. senior and experienced staff to Development of an intervene and manage the patient’s recognition and management of deterioration in a timely and effective sepsis’ pathway for the way contributed to the patient’s emergency department. death from overwhelming sepsis.
Serious 4a 1 Surgery delay for patient with severe finger injury. Multiple missed opportunities, to recognise the severity of the patient’s infected finger combined with theatre delays contributed to the patient’s finger being severely infected preoperatively and the patient having decreased functional use of his left index finger post operatively. Referral system be reviewed and improved to ensure more timely and formalised booking process. Medical handover process to be developed. In progress. Serious 4a 1 CTG not recognised as abnormal – baby died two days RCA review in progress. Serious 11 1 Client attempted suicide within the inpatient facility and died from her injuries. RCA review in progress. Serious 3 1 Retained needle following surgical procedure. No root causes Other learnings identified. Open disclosure education package to be developed and provided to clinical staff. In progress. Serious 11 1 Outpatient suicide one day after contact with service. RCA review in progress. Serious 4a 1 Delay in diagnosis due to delay in accessing imaging result. RCA review in progress. Serious 1 1 Wrong patient had investigative procedure. RCA review in progress. Serious 11 1 Outpatient suicide within seven days of discharge from inpatient area. RCA review in progress. Serious 4a 1 Patient died from sepsis. Had presented multiple to hospital and was reviewed by numerous teams. Multiple missed opportunities to recognise the patient’s deterioration and missed opportunities for more senior and experienced staff to intervene and manage the patient’s deterioration in a timely and effective way contributed to the patient’s death from overwhelming sepsis. The development and implementation of a new rapid response system. Development of an recognition and management of sepsis’ pathway for the emergency department. In progress.
Serious-and-Sentinel-Events-Cases-2008_09.docx