Dudley and Walsall Mental Health Partnership NHS Trust manages service across 3 hospitals and 23 community sites offering a range of mental health services to adults and children.
Serving the Dudley and Walsall areas, the trust offers a range of services including an adult in-patient service, crisis resolution, memory service for older people and eating disorders.
All NHS Trusts are obliged to report any occurrence of a Patient Safety Incident, which are defined as “any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving NHS-funded healthcare” (Guidance notes on NRLS official statistics publications – September 2017).
These encompass a wide range of types of incident including medication or prescription errors, pressure ulcers, medical device or equipment failures and surgical errors, among many others. All Patient Safety Incidents are recorded against the level of harm that occurred as a result, ranging from no harm through to death. The defined levels of harm are:
No harm – Where no harm or damage was caused to the patient
Low harm – Extra observation or treatment was required as a result of the incident
Moderate harm – Requiring extra treatment including extra surgical intervention, cancelling treatment, transfer to another area and short-term harm as a result of the incident
Severe harm – Permanent or long-term harm as a result of the incident
Death – Where death has occurred as a result of the incident
Patient Safety Incident data is published twice a year and can be found on the NHS Improvement website at: https://improvement.nhs.uk/resources/organisation-patient-safety-incident-reports-22-march-2017/. This data is public sector information licensed to Blackwater Law under the Open Government Licence v3.0: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/.
Whenever a Patient Safety Incident occurs the NHS Trust must also record the category (nature) of the incident against a list of 11 defined categories. The same categories of incident apply to acute, community and acute specialist trusts and range from clinical assessment (including diagnosis, scans, tests, assessments) to medical device/equipment or the implementation of care and ongoing monitoring/review. A similar but slightly different list of categories applies to mental health trusts and includes incidents such as disruptive, aggressive behaviour; self-harming behaviour and consent; communication and confidentiality.
Here we show the top 3 most commonly recorded categories by the individual Trust during the six-month time period for which this data relates to.
Patient Safety Incident data, including the list of categories, is published every six months and can be found on the NHS Improvement website at: https://improvement.nhs.uk/resources/organisation-patient-safety-incident-reports-22-march-2017/. This data is public sector information licensed to Blackwater Law under the Open Government Licence v3.0: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/.
All NHS Trusts have been expected to eliminate all instances of mixed-sex accommodation, unless it is in the best interest of the patient, for instance where there is a need for urgent or critical care. In such cases, mixing may be justified and therefore will not be a breach and will not be counted in these statistics.
Any reported occurrence of shared mixed sex accommodation shown here is classed as an unjustifiable breach and therefore should not be occurring under the NHS guidelines. The Department for Health states:
“There is no justification for placing a patient in mixed-sex accommodation where this is not in the best interests of the patient and better management, better facilities or the removal of organisational constraints could have averted the situation.” Department for Health (2010) Eliminating Mixed Sex Accommodation.
Data is gathered and published monthly to report on any unjustified breaches of NHS sleeping accommodation guidelines. This includes any areas where patients are admitted and cared for on beds or trolleys, even if they do not stay overnight and includes day surgery units as well as clinical decision units; but excludes any areas where patients have not yet been admitted – such as accident and emergency cubicles.
Mixed sex accommodation breach source data can be found on the NHS Improvement website at: https://www.england.nhs.uk/statistics/statistical-work-areas/mixed-sex-accommodation/msa-data/. This data is public sector information licensed to Blackwater Law under the Open Government Licence v3.0: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/.
Patients who are on a Care Programme Approach (CPA) should, within 7 days of discharge from mental health inpatient services, receive a follow-up. The national threshold for follow-ups within this timeframe is 95% and therefore any trust that has a figure below 95% is falling short of the guidance.
CPA relates to the package of care those with mental health problems may receive.
Follow-ups within 7 days of discharge are viewed as an important step in helping to reduce the number of suicides and cases of self-harm which typically peak immediately after a patient is discharged from a mental health inpatient service.
Mental health discharge and follow-up data is published quarterly and can be found on the NHS England website at: https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/. This data is public sector information licensed to Blackwater Law under the Open Government Licence v3.0: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/.
The NHS define Never Events as “patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. Each Never Event has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event” (Never Events Policy and Framework, revised January 2018, NHS Improvement).
Never Events are considered to be the most serious incidents, which should in theory never occur if proper guidelines are followed. Any occurrence of a Never Event should be reported by the NHS Trust and an investigation followed in order to ensure steps are identified to prevent any future occurrence of a Never Event. Never Events can arise from a variety of situations and the NHS have devised a clear framework detailing the exact categories of incident that constitute a Never Event. These 15 categories are shown in the data presented on this site, as is the number of each incident type that has occurred during the relevant time period.
Never Events data is available quarterly and can be found on the NHS Improvement website at: https://improvement.nhs.uk/resources/never-events-data/. This data is public sector information licensed to Blackwater Law under the Open Government Licence v3.0: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/.