Dudley Integrated Health and Care NHS Trust

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 England website at: https://www.england.nhs.uk/patient-safety/national-patient-safety-incident-reports/. 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 England website at: https://www.england.nhs.uk/patient-safety/national-patient-safety-incident-reports/. 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/.