ࡱ>     3bjbj[[ 7x99*+  ``vvv84/ ///////$913Z2/v2/` j G/"""vv /" /""V)* P<LN* .]/0/Z*xE4CE4**&E4v*"2/2/ /E4 &: FOI - /sui 1st April 2014 to 31 March 2015 All information is provided by financial year as this is how the information is recorded and reported internally and externally The total number of serious incidents meeting NHS England StEIS Serious Incidents criteria and reported 1st April 2014 to 31st March 2015 = 30 Question 1 Age range (Years)Question 2 What did the incident involve (NHS England StEIS Serious Incident Reporting Criteria)Question 3 Outcome for the patient65-85Pressure Ulcer Grade 3 Serious Harm (Grade 3 pressure ulcers are categorised as serious harm)Children aged 18 and underSurgical Error Never EventModerate HarmN/AWard Closure N/AN/AWard Closure N/A86-100Other Outcome from Coroners Inquest:- Died as a consequence of a combination of naturally occurring disease and injuries, together with treatment of the injuries, sustained when she was knocked to the floor in the corridor of a Hospital by another patient, running away from police officers65-85Surgical Error Never EventLow harm41-64Surgical Error Never EventLow harm65-85Safeguarding Vulnerable Adult At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.N/AWard Closure N/A41-64Serious self-inflicted injury inpatient Outcome from Coroners Inquest:- SuicideN/AAdverse media coverage or public concern about the organisation or the wider NHS N/AChildren aged 18 and underSafeguarding Vulnerable Child N/A41-64Pressure Ulcer Grade 3 Serious Harm (Grade 3 pressure ulcers are categorised as serious harm)65-85Surgical Error Serious HarmN/AWard Closure N/AN/ACommunicable Disease and infection issue N/A41-64Maternal unplanned admission to ITU Moderate harmN/AScreening Issues No harm65-85Communicable Disease and infection issue At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.41-64Surgical Error Never EventLow harm65-85Allegation against Healthcare Professional (assault) Low harm41-64Maternity Service Never EventNo harm65-85Adverse media coverage or public concern about the organisation or the wider NHS N/A reported to StEIS for media interest only65-85Safeguarding Vulnerable Adult At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.Not held on datixUnexpected Death (general) N/A reported to StEIS for media interest onlyChildren aged 18 and underSafeguarding Vulnerable ChildNo harmN/AAdverse media coverage or public concern about the organisation or the wider NHS N/A reported to StEIS for media interest only41-64Surgical Error No harm65-85Pressure Ulcer Grade 3 Serious Harm (Grade 3 pressure ulcers are categorised as serious harm)65-85Pressure Ulcer Grade 3 Serious Harm (Grade 3 pressure ulcers are categorised as serious harm) 1st April 2015 to 31 March 2016 All information is provided by financial year as this is how the information is recorded and reported internally and externally The total number of serious incidents meeting NHS England StEIS Serious Incidents criteria and reported 1st April 2015 to 31st March 2016 = 23 Question 1 Age range (Years)Question 2 What did the incident involve (NHS England StEIS Serious Incident Reporting Criteria)Question 3 Outcome for the patient41-64Unexpected potentially avoidable death Outcome from Coroners Inquest:- Accidental DeathChildren aged 18 and underUnexpected potentially avoidable death Patient died Awaiting Coroners InquestNot held on datixAdverse media Coverage N/A reported to StEIS for media interest only41-64Unexpected Death At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.65-85Adult Safeguarding Inquest not held as cause of death natural causes65-85HCA/Infection Control incident meeting SI criteria Outcome from Coroners Inquest:- Died from Pseudomembranous colitis caused by C.Difficile infection , a known complication of antibiotic therapy which was given to treat suspected sepsis 65-85Medication incident meeting SI criteria Patient died Awaiting Coroners Inquest65-85Unexpected Death Outcome from Coroners Inquest:- Died as a consequence of a combination of naturally occurring disease and a recognised complication of anticoagulation therapy 86-100Unexpected/potentially avoidable injury causing serious harm Severe Harm65-85Treatment Delay meeting SI criteria Outcome from Coroners Inquest:- Deceased had a complicated medical history, and who required anticoagulation, suffered a known but rare complication of that therapy, resulting in internal bleeding and his ultimate passing65-85Diagnostic Incident including delay meeting SI Criteria Moderate harm65-85Medical Device Incident meeting SI Criteria NOT A Never Event Moderate harm65-85Medication Incident Meeting SI Criteria At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.65-85Treatment Delay meeting SI criteria Outcome from Coroners Inquest:- Misadventure Children aged 18 and underWrong Tooth Extraction Moderate harm65-85Wrong Site Block Low ham65-85Unexpected / potentially avoidable death At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.65-85Adult Safeguarding Moderate harm41-64Diagnostic incident including delay meeting SI criteria (including failure to act on test results) At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.86-100Unexpected death (General) At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.65-85Pressure Ulcer Grade 3 Serious Harm (Grade 3 pressure ulcers are categorised as serious harm)Children aged 18 and underAbuse/alleged abuse of child patient by third party No harmChildren aged 18 and underCommissioning incident meeting SI criteria Outcome from Coroners Inquest:- Natural Causes  1st April 2016 to 31 March 2017 All information is provided by financial year as this is how the information is recorded and reported internally and externally The total number of serious incidents meeting NHS England StEIS Serious Incidents criteria and reported 1st April 2016 to 31st March 2017 = 32 Question 1 Age range (Years) Question 2 What did the incident involve (NHS England StEIS Serious Incident Reporting Criteria)Question 3 Outcome for the patient41-64Unexpected / potentially avoidable injury causing serious harm Serious Harm41-64Diagnostic incident including delay meeting SI criteria Serious Harm86-100Pressure ulcer meeting SI criteria Serious Harm (Grade 3 and 4 pressure ulcers are categorised as serious harm)N/AHCAI/Infection control incident meeting SI criteria N/ANot held on datixUnexpected / potentially avoidable death Outcome from Coroners Inquest:-Died as a result of respiratory failure as a result of his naturally occurring MND, contributed to by his pneumonectomy and the administration of the high flow oxygen in error19-44Abuse/alleged abuse of adult patient by third party Low HarmNot held on datixUnexpected potentially avoidable injury Serious HarmChildren aged 18 and underUnexpected potentially avoidable death Outcome from Coroners Inquest:- Natural Causes 86-100Unexpected / potentially avoidable deathDiscussed with Coroner:- Natural Causes was recorded on the death certificateN/AHCAI/Infection control incident meeting SI criteria N/A41-64Unexpected potentially avoidable serious injuryOutcome from Coroners Inquest: - died as a consequence of injuries sustained in an accidental fall on a background of naturally occurring disease. 65-85Unexpected / potentially avoidable injury causing serious harm Serious harm65-85Unexpected potentially avoidable death At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.65-85Alleged Abuse of patient by staff N/A No case to answerChildren aged 18 and underAbuse/alleged abuse of child patient by third party Outcome from Coroners Inquest:- Natural CausesChildren aged 18 and underAbuse/alleged abuse of child patient by third party Low harm65-85Unexpected potentially avoidable death At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.Not held on datixDiagnostic incident including delay meeting SI criteria Serious Harm65-85Diagnostic incident including delay meeting SI criteria At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.65-85Diagnostic incident including delay meeting SI criteria At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.N/AHCAI/Infection control incident meeting SI criteria N/A65-85Unexpected potentially avoidable serious injury At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.Children aged 18 and underAbuse/alleged abuse of a child by third party Serious Harm65-85Pressure Ulcer Grade 3 Serious Harm b(Grade 3 and 4 pressure ulcers are categorised as serious harm)N/A Adverse media coverage or public concern about the organisation or the wider NHS N/A65-85Unexpected potentially avoidable serious injury At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.Children aged 18 and underMedical equipment/devices meeting SI criteria Never EventLow harm65-85Unexpected potentially avoidable death Patient died but the incident may not have always been directly contributory to the death. We are aware that at some point following the incident the patient has since died N/AScreening issue meeting SI criteria SonographyLow harmN/AHCAI/Infection control incident meeting SI criteria D&V - Ward ClosureN/A65-85Unexpected potentially avoidable death At some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.86-100Unexpected potentially avoidable serious injuryAt some point following the incident the patient died, however the incident was not necessarily a direct contributory factor to the death.      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