SI and as appropriate will review the initial incident reports (IIR) on these and determine which cases need to go to further RCA investigation. In Q3 overall there were 37 deaths reported (expected and unexpected, as well as those in our care and recently discharged). Detail of all deaths was provided to the Quality Committee in February 2016. In December 2015 NHS England published a report into the deaths of people with a learning disability or mental health problems at Southern Health NHS Foundation Trust. A gap analysis is being done to review and improve our processes and procedures around investigating deaths (expected and unexpected), the outcome of the gap analysis will be reported to the Board of Directors in April 2016. The analysis is considering the extent of board leadership and scrutiny, quality of reporting and investigations, information management and involvement of families and other agencies involved in the patient’s care. In January 2016 NHS England also asked all NHS organisations to submit information on the number of deaths and those deaths which were found to be potentially preventable over a 12 month period. Alongside our data submission we provided accompanying notes to explain the definitions and business rules used as very limited national instructions were provided and from conversations with three other providers information was being reported differently. The information on avoidable mortality rates is likely to be published identifying NHS organisations. 9. Serious Incidents (SI) The total number of SI’s in Q2 was 31 and the number in Q3 currently was 23. This represents a further quarterly reduction following the peak seen in Q1 of 2015. As previously reported, as part of the new SI framework introduced from April 2015 the Trust is reporting more incidents at an earlier stage and then, and when more information becomes available requesting downgrades. 10. Suspected and confirmed suicides by quarter The number of suspected suicides in Q3 has fallen further to five. Of these five, three are being managed as SI’s and two are currently not. The trend continues downwards. If the trajectory remains the same there will be a year on year reduction in the number of suspected suicides over the last five years. All of the reported suspected suicides reported as SIs in Q3 occurred in the community in the following teams: South Oxon AMHT, Prison Service Woodhill and CAMHS South. 11. Never Events There have been no incidents meeting the never events criteria for three years.
SI and as appropriate will review the initial incident reports (IIR) on these and determine which cases need to go to further RCA investigation. In Q3 overall there were 37 deaths reported (expected and unexpected, as well as those in our care and recently discharged). Detail of all deaths was provided to the Quality Committee in February 2016. In December 2015 NHS England published a report into the deaths of people with a learning disability or mental health problems at Southern Health NHS Foundation Trust. A gap analysis is being done to review and improve our processes and procedures around investigating deaths (expected and unexpected), the outcome of the gap analysis will be reported to the Board of Directors in April 2016. The analysis is considering the extent of board leadership and scrutiny, quality of reporting and investigations, information management and involvement of families and other agencies involved in the patient’s care. In January 2016 NHS England also asked all NHS organisations to submit information on the number of deaths and those deaths which were found to be potentially preventable over a 12 month period. Alongside our data submission we provided accompanying notes to explain the definitions and business rules used as very limited national instructions were provided and from conversations with three other providers information was being reported differently. The information on avoidable mortality rates is likely to be published identifying NHS organisations. 9. Serious Incidents (SI) The total number of SI’s in Q2 was 31 and the number in Q3 currently was 23. This represents a further quarterly reduction following the peak seen in Q1 of 2015. As previously reported, as part of the new SI framework introduced from April 2015 the Trust is reporting more incidents at an earlier stage and then, and when more information becomes available requesting downgrades. 10. Suspected and confirmed suicides by quarter The number of suspected suicides in Q3 has fallen further to five. Of these five, three are being managed as SI’s and two are currently not. The trend continues downwards. If the trajectory remains the same there will be a year on year reduction in the number of suspected suicides over the last five years. All of the reported suspected suicides reported as SIs in Q3 occurred in the community in the following teams: South Oxon AMHT, Prison Service Woodhill and CAMHS South. 11. Never Events There have been no incidents meeting the never events criteria for three years.
34_BOD_Q3-Quality-Report-Safety-2.docx