11 2 person was Injury occurred during the restraint Calming and restraint should be Improved admitted to inpatient unit procedure where both the coordination undertaken by trained health only. communication and sustained injury. and the technique used were between secondary When a young person requires contributing factors to the injury. It and tertiary health Patient outcome: fracture admission immediate referral to tertiary appeared that the restraint procedures providers for timely of the humerus. provider should be actioned. used by the two organisations differed and efficient Admission to an secondary health and the roles and responsibilities of the transfer of young unit should be for the shortest time employees of the two organisations people. necessary. need clarifying. Staff appropriately trained. 4B SAC1 Shoulder dystocia. Baby transferred to tertiary hospital and RCA commenced. RCA commenced subsequently died. Possible Patient outcome: deficiencies in foetal monitoring. neonatal death. 4A SAC 1 Patient discharged Patient presented via ambulance as a SMO lead patient handover. Improvements and without full investigations. result of a car accident. changes to Three definitive shift start times to handover Patient outcome: Upon arrival patient was assessed and assist with handover. embedded. unexpected death was discharged home. Patient died five following accident. days later. A subsequent post mortem Improved number of found that patient died as a direct result senior medical staff of injuries that were received in the in post. motor vehicle accident. 6G SAC2 Fall whilst an inpatient. Patient on bed rest and aware of the To ensure those patients on bed rest Reminders to requirement for bed rest. Leaned to have equipment placed within a safe nursing staff and Patient outcome: locker and fell out of bed. Patient reaching distance, and have access to care assistants. displacement of existing assessed and found to have displaced their call bell. fractured tibia/fibula. the previous relocation of tibia/fibia. Taken back to theatre for another relocation.
11 2 person was admitted to inpatient unit and sustained injury. Patient outcome: fracture of the humerus. Injury occurred during the restraint procedure where both the coordination and the technique used were contributing factors to the injury. It appeared that the restraint procedures used by the two organisations differed and the roles and responsibilities of the employees of the two organisations need clarifying. Calming and restraint should be undertaken by trained health only. When a young person requires admission immediate referral to tertiary provider should be actioned. Admission to an secondary health unit should be for the shortest time necessary. Improved communication between secondary and tertiary health providers for timely and efficient transfer of young people. Staff appropriately trained. 4B SAC1 Shoulder dystocia. Patient outcome: neonatal death. Baby transferred to tertiary hospital and subsequently died. Possible deficiencies in foetal monitoring. RCA commenced. RCA commenced 4A SAC 1 Patient discharged without full investigations. Patient outcome: unexpected death following accident. Patient presented via ambulance as a result of a car accident. Upon arrival patient was assessed and was discharged home. Patient died five days later. A subsequent post mortem found that patient died as a direct result of injuries that were received in the motor vehicle accident. SMO lead patient handover. Three definitive shift start times to assist with handover. Improvements and changes to handover embedded. Improved number of senior medical staff in post. 6G SAC2 Fall whilst an inpatient. Patient outcome: displacement of existing fractured tibia/fibula. Patient on bed rest and aware of the requirement for bed rest. Leaned to locker and fell out of bed. Patient assessed and found to have displaced the previous relocation of tibia/fibia. Taken back to theatre for another relocation. To ensure those patients on bed rest have equipment placed within a safe reaching distance, and have access to their call bell. Reminders to nursing staff and care assistants.
Serious-and-Sentinel-Events-Cases-2008_09.docx