Agenda Item: 10

PUBLIC BOARD OF DIRECTORS MEETING

REPORT

Subject: Patient Safety and Serious Incident Annual Report 2018-19Date of Meeting: Thursday 23rd May 2019Author: Nishaal Abraham, Head of Patient Safety and ComplaintsResponsible Lead: Nishaal Abraham, Head of Patient Safety and ComplaintsLead Director: Melanie Coombes, Executive Director of Nursing & Quality

Purpose (please mark in bold)

TO NOTE INFORMATION DECISION APPROVAL RATIFY

CQC Key Lines of Enquiry (please mark in bold)

SAFE EFFECTIVE CARING RESPONSIVE WELL-LED

Link to the Trust’s strategic goals (please mark in bold where applicable)

DELIVER THE BEST

CARE

INNOVATION IN

HEALTHCARE & RESEARCH

DEMONSTRATE BEST VALUE

IMPROVED WORKING

EXPERIENCE

Financial ImpactLegal Impact Impact to Partnership working: (please mark in bold where applicable, and explain)

FINANCIAL LEGAL ENGAGEMENT PARTNERSHIP WORKING

Some investigations involve multi agency collaboration. Serious Incidents pose a risk to the Trust in terms of reputational damage and the possibility of claims arising from such incidents against the Trust

Confidentiality/ Freedom of Information status: Public Board Report

Committees/ groups where this has been presented before: Quality Compliance Executive

Committees/ groups where this should next be considered: N/A

EXECUTIVE SUMMARY: This annual report provides information and data in relation to the patient safety and Serious Incident (SI) management activity and processes in the Trust. It further provides assurance about the Trust’s performance in accordance with National Frameworks and Commissioner expectations and how organisational learning is facilitated.

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From 1 April 2018 to 31 March 2019 CPFT staff recorded 14561 incidents on Datix. The trend of increased incident reporting continues from the previous years (2017/18 n=14074, 2016/17 n=11769 and 2015/16 n=11382).

The top 5 reporting categories for the Trust has remained consistent for 2018/19 these represent 50% of total incidents reported for the year.

Patient Self Harm (13%) n=1868 Pressure Ulcer (13%) n=1826 Physical (includes all categories) (10%) n=1503 Treatment and procedure (use of control and restraint) (7%) n=1019 Slip/Trip/Fall (7%) n=960

2018/19 SI top five reporting categories were: Of the 86 SIs reported in 2018/19 the main reporting themes were:

Unexpected/potentially avoidable death n=54 Apparent/actual/suspected self-inflicted harm n=7 Slips/trips/falls n=4 Pressure Ulcer n=4 Abuse/alleged abuse n=4

Learning themes emerging from Serious Incidents: Documentation Carer Involvement Communication Clinical processes & procedures

The key priorities for 2019/20: Engaging with staff using a collaborative approach in relation to how we can share and embed

learning Continue developing collaborative approaches to sharing learning within the Trust and with

Commissioners Develop a Duty of Candour e-learning package Continue to roll out and embed the action plan module within Datix Engage with staff in relation to what a patient safety strategy would mean CPFT The Patient Safety Team to run Patient Safety & Complaints surgeries giving staff an opportunity to

drop in and discuss related concerns, ideas for improvement etc in relation to Patient Safety.

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Patient Safety Annual Serious Incident Report 2018/19

1 INTRODUCTION This annual report provides an overview of all patient safety and Serious Incident (SI) activity within the Trust between 1 April 2018 and 31 March 2019. It also sets out the key priorities for 2019/20.

2 BODY OF REPORTThe most important aspect for the Trust is to ensure that the organisation understands how the care for each individual was delivered, identify examples of good practice or where improvements in practice could be made to support patient safety. It is also about ensuring that the Trust continues to report and identify Serious Incidents and manage these in accordance with best practice and in line with the requirements and expectations of regulatory and professional bodies, Commissioners and the public.

There are national and contractual requirements for reporting SIs, investigation of the root causes, and completion and submission of action plans to address any learning required.

The performance of the Trust in its management of SIs is closely monitored by the Clinical Commissioning Group (CCG)/Specialist Commissioning Group (SCG) and reported back through routine monthly Clinical Quality Review (CQR) meetings.

Patient safety requires effective leadership at all levels of healthcare and depends upon building an open and just culture of safety. The way an organisation or healthcare team thinks about and implements patient safety processes may have a significant impact on the people using services and the staff providing them. Nurturing a safety culture is essential to reduce harm in any organisation.

Continuing high levels of incident reporting across the Trust demonstrates that we are committed to building on a positive culture of safety, which exists across all teams and services. As a Trust we are embedding an approach of continuous learning where we aim to put things right when they go wrong by enhancing both the safety and quality of the care provided to our patients. Through supporting staff to become more open, honest and transparent, incident reporting has become embedded into daily practice. The Trust is required to report patient safety incidents via the National Reporting and Learning System (NRLS) hosted by NHS Improvement. This is the mechanism by which the Trust reports incidents to the CQC.

3. DATIX INCIDENTS SUMMARYFrom 1 April 2018 to 31 March 2019 CPFT staff reported 14561 incidents on Datix. This is an increase in the number of incidents reported in 2017/2018 n=14074 and is an increase from 2016/17 n= 11769 and 2015/16 when n=11382 were reported. The overall trend is an increase in incident reporting which should not be considered a negative and could be due to improved staff awareness of what incidents should be reported.

The majority of incidents were graded as no harm or low harm (minimal), followed by moderate harm incidents. Moderate Harm (short-term harm) is defined as causing significant but not permanent harm that requires transfer to an Emergency Department (ED) for treatment, e.g. grade 3 pressure ulcer or inpatient self-harm. Severe Harm (permanent or long-term harm) is defined as causing permanent and significant harm e.g. grade 4 pressure ulcer or inpatient found unconscious in bath, anoxic brain damage.

A breakdown of all the incidents reported showing the level of harm caused is shown below: no harm: 56% (n=8183) low harm: 32 % (n=4654) moderate harm:9% (n=1356) severe harm: 1% (n=96) patient death: 2% (n=243)

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Graph A

2% 0%

32%

9%

56%

1%Incidents By Degree of Harm

Death UNRELATED to a patient safety incident

Death which IS related to a patient safety incident

Low (Minimal Harm)

Moderate (Short Term Harm)

No Harm

Severe (Permanent or Long Term Harm)

Incident Reporting CategoriesThe top 5 reporting categories for the Trust has remained consistent for 2018/19 these represent 50% of total incidents reported for the year.

Patient Self Harm (13%) n=1868 Pressure Ulcer (13%) n=1826 Physical (includes all categories) (10%) n=1503 Treatment and procedure (use of control and restraint) (7%) n=1019 Slip/Trip/Fall (7%) n=960

There has been increase in incidents classified as Treatment/Procedure the use of control and restraint (physical intervention) in 2018/19 n= 975 compared to n=844 in 2017/18. Prone restraint has seen an increase n=62 compared to n= 27 in 2017/18. It is important to note that in some instances the service users put themselves to the floor and this still needs to be reported as a prone restraint.The reasons behind the increase in Physical Intervention incidents is multifaceted and complex and include, clinical and ward leadership, acuity of patients admitted to the wards, ward staffing, training and service changes/operational changes.  The PMVA team review all incidents that relate to the use of Physical Intervention and address any learning with the staff.

Actions Taken: A GAP analysis is being undertaken by the PMVA team in relation to training and National

Physical Intervention standards. Staff training is available for the administration of IM medication with a view to avoid the use of

restraint. Head of Nursing for Adult & Specialist has undertaken an in-depth analysis of all incidents of

violence and aggression across adult inpatient wards, this work will be presented at the next Quality and Safety Committee.

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Graph B

Patient Self Harm

Pressure Ulcer Physical Control and restraint

Slip/trip/fall0

200400600800

100012001400160018002000

Top 5 Incident Reporting Categories

Graph C

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar0

50

100

150

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Patient Self Harm Incidents

2016/2017 2017/2018 2018/2019

Timeliness of ReportingThe majority of incidents were reported on the same day or the next day, which is in keeping with the Commissioners and the Trust’s process of reporting. The longer delays in reporting incidents can be attributed to the unexpected deaths of service users discharged from the Trust in the last 12 months as it is often some months before the Trust is made aware by the Coroner of these deaths.

4. SERIOUS INCIDENT ANALYSIS SUMMARYThe aim of the Serious Incident Group (SIG) is to support the CPFT Trust Board in ensuring that Serious Incidents are investigated, reviewed and acted upon appropriately and that lessons learned are implemented and monitored. SIG continues to provide further scrutiny to the incident investigation and assurance that the relevant personnel have been involved, the key issues have been addressed and that lessons that have been learned are disseminated.

SIG is chaired by Director Nursing and Quality and Medical Director (deputy chair) and has core members which include the Deputy Director of Nursing and Quality, Head of Patient Safety and Complaints, Non-Executive Director (as required), Clinical Director (OPAC) and Directorate Head of Nursing for each Directorate.

SIG continues to evolve and provides support and guidance to all aspects of the Serious Incident process. Any updates or amendments to a report are reviewed and approved by SIG prior to external distribution, for example to the Commissioners or HM Coroner.

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In 2018/19, 86 incidents triggered the SI criteria and were reported as such to the CCG/SCG. Two reported SIs were retracted as on later review it was assessed they no longer met the SI reporting criteria; this was undertaken in agreement with the CCG.

Graph D depicts the comparative number of SIs reported each year from 2016/17

Q1 Q2 Q3 Q40

5

10

15

20

25

30

35

Comparitive SI Data reported per quarter

2016/17 2017/18 2018/19

The decline in the number of SIs being reported can be attributed to the trend of waiting for formal confirmation of cause of death before declaring an SI. The Trust will undertake an initial management review (IMR) of any incident requiring further scrutiny. In addition, a Structured Judgement Review (SJR, mortality review) may be requested (in an event of a death) to support the investigation process or a clinical review may be undertaken. This is an example of how the various governance processes work together in supporting the review of incidents. Whilst an incident reviewed in this way is not investigated via the SI framework it would be reviewed using a structured process. HM Coroner is aware of the mortality process and as such now also requests the SJR to be submitted.

4.1 BenchmarkingIn comparison to other Mental Health Trusts (MHT) in the region, CPFT was the third highest reporter of serious incidents quarterly (Graph D).

It is important to note that whilst there may be comparisons with other MHT in the region, the Trust does not deliver the same services therefore this is not a like for like comparison but rather a broader view of SI trend reporting. Organisations that provide community health services tend to report a disproportionally higher rate of SIs related to Pressure Ulcers than those without, which may explain the lower figures in CPFT.

Graph D

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Q1 201

5/16

Q2 201

5/16

Q3 201

5/16

Q4 201

5/16

Q1 201

6/17

Q2 201

6/17

Q3 201

6/17

Q4 201

6/17

Q1 201

7/18

Q2 201

7/18

Q3 201

7/18

Q4 201

718

Q1 201

8/19

Q2 201

8/19

Q3 201

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8/19

020406080

100

Comparison to other Mental Health Trusts

CPFT MHT 1 MHT 2 MHT 3 MHT 4

4.2 Downgraded SI Incidents and Clinical ReviewsThe Trust may report SIs based on limited information, which, on further investigation, does not meet the criteria for a SI investigation. In such cases, the Trust will request de-escalation from the relevant Commissioner. When making a request for de-escalation the Trust will account for the reason(s) why the incident does not warrant further investigation under the SI process. The Commissioner will make a decision regarding the request for de-escalation. If the request for de-escalation is agreed, the STEIS (Strategic Executive Information System) will be updated by the relevant commissioner.

All incidents that required downgrading/retraction were referred to the CCG for consideration. Two SIs were retracted in 2018/19. One incident related to a potential confidentiality breach which was reviewed and later retracted. Approval for this retraction was received from the CCG and the Information Commissioner Office (ICO).

The second SI was retracted after discussion with the commissioners. The Trust submitted a 72 hour report and the Commissioners confirmed the SI was downgraded.

Clinical reviews (CR) are concise investigation where the incident is rated as having a high risk. These incidents usually have the potential to be serious and have on-going consequences but do not meet the criteria for a Serious Incident.

26 CRs were undertaken during 2018/19 on incidents that were not deemed reportable under SI criteria but required further investigation. This is significantly lower than the 52 CRs were undertaken in 2017/18.

Breakdown of CR themes in 2018/19: Confidential information leak/information governance breach (n=10) Medication incident (n=3) Treatment delay (n=2) Unexpected/potentially avoidable death, not meeting SI criteria (n=2)

The remaining CRs were spread across the reporting categories.

4.3 Breakdown of IncidentsDuring 2018/19 the majority of SIs occurred within the Adult and Specialist Directorate (n=58), n=51 in 2017/18; followed by the Older People and Adult Community Directorate n=22, n=38 in 2017/18), n=4 in the Children’s Directorate compared with (n=1) in 2017/18. 1 incident was reported for the Corporate Directorate compared to n=2 in 2017/18.

Graph E7

0204060 54

1

32

1

51

1

38

2

58

422

1

SI Breakdown by Directorate from 2016/17

2016/17 2017/18 2018/19

4.4 Incident Categories and ThemesOf the 86 SIs reported in 2018/19 the main reporting themes were:

Unexpected/potentially avoidable death n=54 Apparent/actual/suspected self-inflicted harm n=7 Slips/trips/falls n=4 Pressure Ulcer n=4 Abuse/alleged abuse n=4

54 SIs related to the Unexpected/potentially avoidable death. This was the highest reporting category and is on a par with 2017/18 when n=40 of the reported n=92 SIs related to the death of a service user.

4.5 Suicide/Probable Suicide SubsetFrom the 54 unexpected deaths reported above, there were 44 suicides/probable suicides reported between 1 April 2018 and 31 March 2019.

Graph F shows the comparison in probable suicides from 2017/18 n=42, which shows an increase when compared to n=21 2017/18 and n=35 in 2016/17.

It is important to note that the number of unexpected deaths n=12 has decreased from 2017/18 (n=19) which was comparable to 2016/17. This could be attributed to the fact that some of the Post-mortems were inconclusive, some were awaiting toxicology results and as the inquests are still to be held, the cause of death has not been determined by the Coroner. This may result in a reduction in the number of confirmed suicide figures.Graph F

Q1 Q2 Q3 Q402468

10121416

Probable Suicides

2016/17 2017/18 2018/19

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Graph G

Under 17 17-29 30-39 40-49 50-59 60-69 70-79 80+02468

1012141618

Unexpected death breakdown by age

2016/17 2017/18 2018/19

Graph H

2016/17 2017/18 2018/190

102030405060

Unexpected Death By Gender

Male Female

Graph I

Male Female0

2

4

6

8

10

Unexpected Death By Gender

Q1 2018/19 Q2 2018/19 Q3 2018/19 Q4 2018/19

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4.6 Team breakdownGraph J depicts all serious incidents by team

02468

Serious Incidents by Team 2018/19

Of importance when analysing trends in relation to the number of unexpected deaths is the actual date of incident as opposed to the date of reporting of an unexpected death as an SI. This is because the date of reporting an unexpected death as a serious incident does not always equate to the date that the incident occurred.

Late reporting of an unexpected death usually relates to the fact that the Trust is required to report the deaths of people suspected of committing suicide who have had contact with the Trust in the last 12-months. This includes people who have been discharged. Thus, it is sometimes months before the Trust become aware that a person has died and is able to report the death.

4.7 Safeguarding of ChildrenThe National SI framework requires NHS organisations to inform the Care Quality Commission (CQC) of admissions of young people under the age of 18 to an adult ward.

In relation to safeguarding of children, there have been 6 admissions of a young person under 18 to a non-CAMHS unit in 2018/19 which is a decrease from 2017/18, n=13. Admissions numbers have varied when compared to previous years. 2016/17 (n=11), 2014/15 (n=8) and 2015/16 (n=7). Access to CAMHS beds for young people under 18 years remains a significant local and national challenge.4.8 Serious HarmA total of 9 SIs were raised that relate to serious harm caused. Examples include:

Injury sustained due to jumping from a window Serious overdose Attack on care coordinator during a home visit A service user alleged to have caused serious physical harm to a female member of the public

4.9 AbsconscionsThere were zero SIs raised that related to service users who absconded either from home (whilst on leave) or the ward. It is important to note that the AWOL /abscond procedure was followed each time i.e. police contacted, family updated, attempts made to locate the service user.

4.10 Information Governance (IG)2 IG SIs were raised and a further 10 followed the clinical review process, as they did not meet the SI level 2 IG criteria.

All IG related incidents (level 1) were reported to the IG Team to determine whether the incident met the criteria for escalation under IG HSCIC (Health and Social Care Information Centre - the national

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provider of information, data and IT (Information Technology) systems for health and social care guidelines for reporting.

4.11 Timeliness of InvestigationsThe trust reported all the SIs to the commissioners within the 48-hour timeframe when identifying an incident met the SI reporting criteria. A general ongoing theme across all SIs is the Trust performance in relation to the national time frames for investigations.

There has been an increase in the timeliness of submitting the SI reports for 2018/19 when compared to preceding years. The ongoing challenge facing the Trust remains the ability to sustain timely submission of completed SI reports to the CCG, SCG and commissioners as a result of complexities of some of the cases and the capacity of managers to undertake the investigation. The Patient Safety Team continues to work alongside the Directorates to improve the SI process, which has assisted in reducing delays in submitting the reports. The introduction of SIG 2017 has been beneficial in improving overall quality of reports and escalating any issues or concerns which may impact on the submission deadline.

When an investigation becomes more complex or involves external agencies such as the Police the trust has liaised with the CCG to agree a Stop the Clock (STC). At the time of writing there are 5 STC.

During 2018/19 all SI reports were submitted within the CCG agreed timeframe.

Graph K

Q1 Q2 Q3 Q480

85

90

95

100

Timeliness of Submitted SI Reports

2016/172017/182018/19

Perc

enta

ge

5. INQUEST CONCLUSIONS AND OUTCOMESThe Trust’s Inquest Team has provided the causes of death by quarter and year for 2016/17, 2017/18 and 2018/19. This is depicted in Table 1 below, where suicide, narrative and misadventure conclusions were the highest reporting category. The main causes of death were hanging and overdose, which is in line with the findings of the National Confidential Inquiry into Suicides and Homicides, annual report October 2018.

Table 1Inquest conclusions 2016/17 2017/18 2018/19

Suicide 20 26 32Narrative 5 3 4Misadventure 8 3 3Drug-related 1 5 1Natural causes 2 5 7Accidental 3 5 1Open 5 4 2Unlawful Killing 2 0

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Closed without inquest 5 2

Graph L

Hangin

g/liga

ture

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sedru

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lcoho

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ity

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ine de

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Fall at

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trial D

iseas

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ertain

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Carbon

Mon

oxide

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Drownin

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Natural

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eath

Gunsh

ot wou

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Cardiac

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Burns –

self-i

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Closed

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out in

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t048

121620

Inquest Outcomes

2016/17 2017/18 2018/19

Table 2Causes of death as Determined at inquest 2016/17 2017/18 2018/19

Hanging/ligature 11 13 18Asphyxiation 3 2 0Overdose drug or alcohol toxicity 16 11 11Multiple injuries Train line death 5 5 7Fall at home 1 3 1Unascertained 2 3 2Head injury 1 1 1Drowning 3 3 1Natural causes/Accidental Death 3 6 6Gunshot wounds 2 0Haemorrhage 1 2Cardiac Arrest 1 0Burns – self-inflicted 1 0Closed without inquest 5 0Industrial Disease 1Electrocution 1Carbon Monoxide poisoning 1

Graph M

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Hangin

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Asphy

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Overd

osed

rug o

r alco

hol to

xicity

Multipl

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ries T

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line d

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Fall at

home

Indus

trial D

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Unasc

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ned

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Carbo

n Mon

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Inquest Outcomes

2016/17 2017/18 2018/19

6. STOP THE LINEDuring 2018/19 there were 9 reported Stop the Lines, 5 related to Adult and Specialist Directorate of which 3 were de-escalated, and 4 related to Older People’s and Adult Community Directorate of which 2 were de-escalated. The majority of the STL’s related to staffing issues.

7. COMMON THEMES EMERGING FROM THE SI INVESTIGATIONSWe are committed to continually improving the safety of the services we provide to our patients, and we recognise that one way of doing this is to ensure that SIs are identified correctly, investigated thoroughly and most importantly trigger actions that will prevent them from happening again.

Communication Services should ensure that clear referring/re-referring processes between agencies are

in place. They should include procedures for recording communication risk information and to ensure that this information is shared between teams to promote clear collaborative working, which is focused on ensuring patients have safe, supportive interventions from the most appropriate professionals.

To improve communication both verbal and written (SSKIN Hand Document) with external partners, where care needs are identified and where patient consent to share information is obtained.

Engagement of family & carers Teams to record carers views clearly within the progress notes/carers record alongside

the explanation of rationale surrounding decision making, where appropriate consent to share information is given.

All CPFT staff should adhere to the Trust’s Carer’s Charter, ensuring that a carer is identified, if possible, and involved in service user’s care at an appropriate level, and should ensure carers are listened to.

All services should integrate carer/family concerns into the formulation of risk which goes beyond a carer assessment, in line with the Trust’s Zero Suicide initiative.

Clinical documentation Ensure that consent to share information is completed with all patients and clearly

documented on Rio, and next of kin details are recorded in the patient’s clinical record. A detailed discharge letter with the crisis and contingency plan should be sent to the patient

and discharge planning should involve MDT. 13

All letters to be standardised to include crisis contact information, and Crisis, Relapse and Contingency Plans should be recorded in the required section of RiO.

The rationale for decisions made and actions taken or not taken should be documented where appropriate.

Patient observations should be recorded on a first visits in order to establish a baseline reading.

Clinical processes & procedures To ensure that the agreed timescales and standards for completing the Falls Screening

Toolkit and Falls Risk Assessment are followed and that patients identified at risk of falls have a care plan on managing those risks.

Improve data access across services in CPFT for RiO, Epic, SystemOne. Risk assessments should provide a formulation of risk and should be updated through the

service users care pathway. Risk assessments should include an assessment of social factors, psychological factors (hopelessness) and current mental state.

Clinicians should maintain a high level of professional curiosity when seeking to understand and assess risk with limited information. Holding the person at the centre is essential and utilise every opportunity to involve them within their care and to understand their views and opinions at every stage.

Risk assessments should be reviewed on transfers between teams and at the point of discharge.

Multi-disciplinary team review should be completed prior to discharge. Safeguarding concerns need to be incorporated in holistic assessment. It should be evident in the records that teams have considered the most beneficial and

effective treatments for individual patients. This should take into account past history, past treatment responses, clinical presentation and the views and wishes of the family / carer and patient.

Actions from SI’s Design an induction checklist that will cover operational issues regarding chaperone/consent,

access to trust policies and procedures, clinical competencies within the role, and competency regarding genital examination will be a specific sign off and chaperone requirement made clear.

Standardisation of the referral processes into Community Nursing Services to ensure priority applied to referral is in line with clinical need.

Development of a standard operating procedure for the management of opt in letters. System review of email contact, out of hours support and current cohort procedures for

supporting patients on waiting lists, and the development of staff guidelines. Development of clear guidance for the completion of assessment for tele-coaches. Flowchart to be created and available to student nurses to indicate when risk should be

escalated to a qualified member of staff. Student induction pack to be reviewed to ensure expectations of students are clearly outlined.

Establish a link worker between the Adult Locality Teams and FRS to enhance the joint working arrangements.

Care of skin burns included in tissue viability mandatory training.

8.The National Confidential Inquiry into Suicide and Homicide by People with Mental IllnessThe 2018 Annual Report provides the latest figures (from 2006 to 2016) on suicide, homicide, and sudden unexplained deaths and makes recommendations for clinical practice to improve safety in mental health care. Key messages include:

Suicide rates in the general population in UK countries have shown a recent downward trend, though this is less clear in Northern Ireland which continues to have the highest rate.

The highest rates during the report period (2006-2016) were in people in middle age except in Northern Ireland where young adults had higher rates. Similarly, the largest differences in rates between UK countries - higher rates in Northern Ireland and Scotland - were in young adults.

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There were 1,612 patient suicides in the UK in 2016, this figure having fallen in recent years.

The commonest method of suicide by patients continued to be hanging/strangulation, accounting for 776 deaths UK-wide in 2016, almost half of all patient suicides. The second commonest suicide method among patients was self-poisoning, accounting for 365 deaths in 2016, almost a quarter of patient suicides. The previously reported fall in self-poisoning deaths has not continued. The main substances taken in fatal overdose were opiates and the main source (where known) was by prescription.

There were 106 suicides by in-patients in the UK in 2016, around 7% of all patient suicides, continuing a long-term downward trend. However, the fall has been slower in recent years, reflecting the pattern in England.

There were 227 suicides in the 3 months after hospital discharge in 2016, 17% of all patient suicides, a fall since 2011. The highest risk was in the first 2 weeks after discharge and the highest number of deaths occurred on day 3 post-discharge.

During 2006-2016 there were 909 suicides per year on average by patients who had a history of alcohol or drug misuse.

In previous reports we have focused on suicide by male patients. In this report we present findings on female patients who died by suicide during 2006-2016. During this period there were 6,016 suicides by female patients in the UK, 38% of suicides by females in the general population, a higher figure than in males. The number per year has risen in England but the rate, i.e. taking into account the rising number of patients, has fallen. Almost half were aged between 35 and 54 years.

The most common primary diagnoses for females were affective disorders, followed by personality disorder, and personality disorder was more common in females aged under 45 compared to those aged 45 and over.

During 2006-2016, 11% of homicide convictions in the UK were in mental health patients, a total of 785 patient homicides over the report period, an average of 71 homicides per year. 6% were by people with schizophrenia, an average of 37 per year, including both patients and non-patients. In England, the number of patient homicides since 2009 has been lower than in previous years. Our estimate is for 38 patient homicides in 2016.

We have previously reported a rise in recent self-harm (in the previous 3 months) as an antecedent of suicide in mental health patients - self-harm presents an indication of risk and a chance to intervene. In this report we have examined patients who died within 3 months of self-harm. During 2006-2016 there were 4,776 suicides in this group. Suicide was more likely to occur by hanging/strangulation than in those with no history of self-harm, suggesting an escalation in intent.

National Quality Board, Learning from deaths: Guidance for NHS trusts on working with bereaved families and carers This new guidance, issued by the National Quality Board (NQB), is about improving how we engage with families and how we learn when things go wrong. It consolidates existing guidance and provides a perspective from many family members, who have experienced a bereavement within the NHS.The guidance advises trusts on how they should support, communicate and engage with families following a death of someone in their care. The good practice guidance sets out to complement and improve work our trust is already doing to support families.

On the road from Good to Outstanding, implementing some of the guidance would only improve the care and service we provide to patients, families and carers. At present CPFT completes a significant amount of the good practice guidance but we do need to consider how we could implement the following guidance:

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Family and carer participation in Trust training (currently, CPFT does not have a programme for carers and families to participate in Trust’s training specifically in relation to a death or following an SI

Involving families in action planning and assurance process, currently, CPFT does not have a programme to involve families in action planning and assurance processes however, the final report and action plan are shared with the family upon completion of the investigation.

Care Quality Commission (CQC) The Secretary of State for Health and Social Care asked us to work with NHS Improvement to look at issues in NHS trusts that contribute to Never Events taking place. Never Events are incidents with the potential to cause serious patient harm or death that are wholly preventable if national guidance or safety recommendations are followed. The CQC wanted to understand what makes it easier – or harder – for the people and organisations in the NHS to prevent Never Events. They also wanted to see what could be learned from other industries and countries.

The review sought to answer 4 questions: How do trusts regard existing guidance to prevent Never Events? How effectively do trusts use safety guidance? How do other system partners support the implementation of safety guidance? What can we learn from other industries?

The review found: The challenges faced by trusts – although patient safety alerts are generally seen as an

effective way to share safety guidance, the context in which they are landing creates challenges for trusts.

The challenges across the healthcare system as a whole – arm’s-length bodies, including CQC, royal colleges and professional regulators, have a substantial role to play within patient safety, but the current system is confused and complex, with no clear understanding of how it is organised and who is responsible for what. This makes it difficult for them to prioritise what needs to be done and when.

The challenges in educating and training staff – various bodies are responsible for different aspects of clinical and wider professional education in England. This includes universities, royal colleges, deaneries, professional regulators, Health Education England and employers like NHS trusts. It is not easy to establish who is responsible for which elements of education or who has the authority to deem any element of training mandatory, for example around patient safety, and place it consistently within training programmes. With so many different bodies having a role in education, the importance of patient safety training is slipping through the cracks both at undergraduate level and throughout careers.

NHS Improvement (NHSI)NHSI launched a consultation on their proposals for a National Patient Safety strategy for the NHS in Spring 2019. The proposal was for a new national patient safety strategy to support the NHS to be the safest healthcare system in the world. The strategy is being developed alongside the NHS Long Term Plan and will be relevant to all parts of the NHS, be that physical or mental health care, in or out of hospital and primary care.

The proposed aims and principles are for the NHS to: be world leading at drawing insight from multiple sources of patient safety information give staff at all levels the skills and support they need to help improve patient safety, so they

can be the infrastructure for safety improvement working with patients and partner organisations decrease harm in key areas by 50% by

2023/24 and beyond through specific patient safety initiatives.

They propose a focus on three principles that should underpin implementation of the strategy: a just culture, openness and transparency and continuous improvement. These encompass values and behaviours that are fundamental to delivering safe healthcare for patients. While they are not the only principles or ways of describing what should underpin a safety culture, we believe they are the most pertinent to the challenges we face. Together they should form a golden thread that runs through all

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aspects of healthcare from frontline provision and the interaction between patients and clinicians, to national leadership for the healthcare system.

LEARNING FROM INCIDENTSThe Trust continues to use Serious Incidents to support the identification and implementation of policy and/or practice improvements. There have been initiatives aimed at improving patient and staff safety. Further improvements of how the Trust disseminates learning is required and remains a key priority for 2018/19. These include:

Continued engagement with the National Confidential Inquiry into Suicides and Homicides Team.

Continued publication of Quarterly Lessons in Practice Bulletin. Joint working with partners through participation and sharing learning at the Addenbrookes

Joint Mental Health Governance Meeting. Mental Health Leads quarterly meeting to discuss homicides reviews. Participation in the CCG SI learning events. Sharing of the quarterly Patient Safety Reports with Directorates to disseminate the Learning Sharing of the monthly Closed Serious Incidents Summaries with directorates to disseminate

the learning

Trust Patient Safety priorities for 2019/20Our aim is to continually improve the quality and safety of the services that we provide.We have identified priorities that build on improvements from the previous year as well as those required in the coming year. These are influenced by national, regional and local policies and priorities as well as organisational changes and service developments.

The following priorities for 2019/20 are: Engaging with staff using a collaborative approach in relation to how we can share and embed

learning Continue developing collaborative approaches to sharing learning within the Trust and

Commissioners Develop a Duty of Candour e-learning package Continue to roll out and embed the action plan module within Datix Engage with staff in relation to what a patient safety strategy would mean for CPFT The Patient Safety Team to run Patient Safety & Complaints surgeries giving staff an

opportunity to drop in and discuss related concerns, ideas for improvement etc in relation to Patient Safety

11. CONCLUSIONOur aim is to continue to deliver excellent, caring, safe and thoughtful healthcare for patients in Cambridge and Peterborough and that that no patient will endure preventable harm. Over the next year we will strengthen and embed the good practices and processes developed to ensure Patient Safety remains a key focus for CPFT.

2018/19 has been a year of change for the NHS in relation to patient safety with the publication of Opening the door to change: NHS safety culture and the need for transformation, CQC December 2018 and the National Quality Board, Learning from deaths: Guidance for NHS trusts on working with bereaved families and carers, July 2018 both of which will shape how we manage patient safety.

In Patient Safety we will continue working together for patients and ensure that compassion is central to the care we provide and respond with humanity. We have a clear commitment to compassion and to safety and to putting the people who use services at the heart of those services.

We will continue to encourage robust incident reporting and investigation processes allied with an open, honest and mature learning culture which is an important component of delivering safe health care and improving outcomes.

The Patient Safety Team will continue to work with providers to support continual improvement through the analysis of themes and trends and sharing of learning and best practice.

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3. EXCEPTIONSNil of note

4. RISKS AND CONCERNSNil of note

5. ASSURANCE

6. RECOMMENDATIONSThe Quality, Safety and Governance Committee is asked to note this report.

7. APPENDICESNil

Author: Amber Woolner & Nishaal AbrahamTitle: Patient Safety Manager; Head of Patient Safety and ComplaintsDate: May 13th 2019

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