Sentinel 4C Delay in monitoring Root cause analysis being Recommendations not finalised at In progress. and response to the undertaken. time of reporting. coagulation status of the patient may have contributed to bleed in brain (subarachnoid haemorrhage) and patient death. Serious 4A Delayed radiological Diagnostic error highlighted where Departmental audits undertaken. Completed. diagnosis resulting in spinal lesion missed on CT scan paralysis. undertaken. Not identified until subsequent MRI taken to diagnose back pain and leg weakness. Full disclosure and apology to patient and family. ACC treatment injury completed. Serious 4E Delay in receiving Referral prioritised incorrectly as Review of Medical Imaging referral Completed. radiological diagnosis non-urgent. process completed. leading to disease Examination completed 10 Recommendations for improvement progression of bladder months post referral. currently being implemented. cancer. Wait list managed back within guidelines of six to seven weeks. Serious 4E in diagnosis of Root cause analysis undertaken Review medical staff orientation, In progress. cancer. finding issues with the handling of Explore system to flag all abnormal abnormal scan results. results. Serious 6 Inpatient fall resulting Patient mobilising with distant Falls programme introduced. Completed. in fractured hip. supervision following clinical assessment in preparation for discharge, and fell.
Sentinel 4C Delay in monitoring and response to the coagulation status of the patient may have contributed to bleed in brain (subarachnoid haemorrhage) and patient death. Root cause analysis being undertaken. Recommendations not finalised at time of reporting. In progress. Serious 4A Delayed radiological diagnosis resulting in paralysis. Diagnostic error highlighted where spinal lesion missed on CT scan undertaken. Not identified until subsequent MRI taken to diagnose back pain and leg weakness. Full disclosure and apology to patient and family. ACC treatment injury completed. Departmental audits undertaken. Completed. Serious 4E Delay in receiving radiological diagnosis leading to disease progression of bladder cancer. Referral prioritised incorrectly as non-urgent. Examination completed 10 months post referral. Review of Medical Imaging referral process completed. Recommendations for improvement currently being implemented. Wait list managed back within guidelines of six to seven weeks. Completed. Serious 4E in diagnosis of cancer. Root cause analysis undertaken finding issues with the handling of abnormal scan results. Review medical staff orientation, Explore system to flag all abnormal results. In progress. Serious 6 Inpatient fall resulting in fractured hip. Patient mobilising with distant supervision following clinical assessment in preparation for discharge, and fell. Falls programme introduced. Completed.
SSE_cases_2010_11_FINALv1.docx