Gloucestershire Health And Care NHS Foundation Trust
Gloucestershire Care Services NHS Trust and 2gether NHS Foundation Trust merged in October 2019 to create Gloucestershire Health and Care NHS Foundation Trust.
Figures for this Trust
Number of Patient Safety Incidents & harm caused
April 2020 to March 2021
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
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.
Percentage of A&E attendances dealt with in 4 hours
Within England 95% of patients who attend A&E or make an emergency admission should be admitted, transferred or discharged within 4 hours of arrival. This means that depending on the severity of their condition, patients need to be admitted into the hospital for further treatment or observations, transferred into another NHS organisation or separate care (such as social services) or discharged home.
This data includes those who make an unplanned attendance at either a 24-hour A&E department, a single speciality A&E department or a walk-in/urgent care centre. An A&E department must see, on average, more than 200 separate patients each month before it is obliged to provide this data.
The NHS report on bed occupancy rates as an indicator as to what capacity each individual trust is running at.
The figures presented here relate to the overall percentage of beds that are occupied overnight during the reporting period.
It is thought by some commentators that bed occupancy levels greater than 85% can lead to compromised patient safety and higher hospital acquired infection rates (Bagust A et al , British Medical Journal, Vol 319).
All NHS Trusts must report when an elective operation has been cancelled at the lastminute for non-clinical reasons. For the purposes of reporting, a last-minute cancellation is deemed to have occurred after the patient has arrived at the hospital, or on the day of the operation or surgery. The operation must have been cancelled for non-clinical reasons for it to be reported.
Examples of a non-clinical reason for cancelling an operation include: ward beds being unavailable, equipment failures, administrative errors and emergency cases needing the theatre. This includes all planned and elective operations, including day cases. However, in accordance with the Cancelled Operations Guidance available on the NHS England website, any operation that is rescheduled to a time that is within 24 hours of the original operation time and date is classed as a postponement rather than a cancellation, as long as this only occurs once (any further postponements are then classed as a cancellation).
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.
Percentage of patients followed up within 7 days of mental health discharge
October to December 2019
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.
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.
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