Somerset NHS Foundation 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/.

The Summary Hospital-level Mortality Indicator (SHMI) compares the actual number of patients who die following hospitalisation against the number of patients who would be expected to die on the basis of average for trusts across England, given the characteristics of the patients treated at that Trust. The SHMI includes deaths that have occurred in hospital or within 30 days of discharge from hospital.

A SHMI number of 1 indicates the observed number of deaths was higher than expected A SHMI of 2 indicates the observed number of deaths was as expected and a SHMI of 3 indicates the observed number of deaths was lower than expected, when compared to the national baseline .

SHMI data is published half yearly by NHS Improvement. The data is calculated using Hospital Episode Statistics (HES) data linked to Office for National Statistics (ONS) death registrations data and is published quarterly using a 12 month reporting period.

With any given number of expected deaths, a range of observed deaths is considered “as expected” however if the number falls outside this range, the Trust is then deemed to have a higher or lower SHMI than expected. A higher than expected SHMI should trigger an investigation by the Trust but cannot immediately be attributed to poor performance.

SHMI source data can be found on the NHS Improvement website at: https://digital.nhs.uk/data-and-information/publications/clinical-indicators/shmi. 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/.