Item 14 Appendix. Safety Improvement Plan ( )

Safety Improvement

Plan (2015-2018)

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Contents

1.0

The Leeds Teaching Hospitals NHS Trust (Trust) - Safety Improvement Plan . 2

1.1

Safety Improvement Plan Executive Leadership, aim and themes ... 3

1.2.1 Cross cutting themes; ... 3

Patient deterioration and inpatient falls ... 3

Pressure ulcers ... 4

Acute kidney injury ... 4

1.2.2 Safety specific area; ... 5

Maternity events ... 5

1.2.3 Disease specific area; ... 5

Sepsis ... 5

1.2

Patient and carer engagement in our Safety Improvement Plan ... 6

2.0

Implementing the Safety Improvement Plan ... 7

3.0

Aligning the Trust Safety Improvement Plan to NHSLA insurance scheme

contribution ... 7

4.0

Summary ... 8

5.0

Appendices ... 8

Appendix A: Patient Deterioration ... 9

Appendix B: Inpatient Falls ... 10

Appendix C: Pressure Ulcers ... 11

Appendix D: Acute Kidney Injury ... 12

Appendix E: Maternity Events ... 15

Appendix F: Sepsis ... 23

1.0

The Leeds Teaching Hospitals NHS Trust (Trust) - Safety

Improvement Plan

The Trust’s Safety Improvement Plan (SIP) sets out the organisation’s plans for the next 3-5 years in relation to quality and safety and builds on existing quality improvement work as outlined in the Quality Improvement Strategy 2014-2017. The SIP has identified the quality and safety initiatives to be undertaken that will significantly reduce patient harm at the Trust. The Trust commenced some of these quality improvement programmes of work in 2014, working alongside Haelo and the Yorkshire and Humber Improvement Academy. Other quality improvement programmes have been assigned heightened priority following notification of CQUIN involvement for 2014-15:

 Cross cutting system

- Patient deterioration; reduce the incidence of cardiac arrest calls by 70% on pilot wards by July 2015

- Inpatient falls; reduce the incidence of inpatient falls by 50% on pilot wards by April 2015

- Pressure ulcers; reduce the incidence and prevalence of pressure ulcers; improvement programme and trajectory will be developed alongside the SIP

- Acute kidney injury; recognition and treatment of patients developing acute kidney injury; standards to be agreed in national CQUIN 2015/16

 Safety specific

- Maternity events; reduce the incidence and harm from wrongful birth1, loss of a baby and care delivery events by 50% by March 2018

 Disease specific

- Sepsis;Recognition and initiation of treatment for patients with sepsis; standards to be agreed in national CQUIN 2015/16

Wrongful Birth: A medical negligenceclaim brought by the parents of a child born with birth defects, alleging that negligent treatment or advice deprived them of the opportunity to avoid conception or terminate the pregnancy

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Through implementing the SIP, skills in quality improvement and expertise will be developed and spread across the organisation. Measurement will be used for improvement alongside evidence-based guidance to improve current performance.

1.1

Safety Improvement Plan Executive Leadership, aim and themes

The executive sponsor for the SIP is Julian Hartley (Chief Executive Officer). The aim of our SIP is to; reduce avoidable harm in the Trust by 50%, by March 2018, through the implementation of Quality Improvement Programmes relating to:

 patient deterioration

 inpatient falls

 pressure ulcers

 acute kidney injury

 maternity events

 sepsis

The SIP comprises four cross-cutting themes, one safety specific area and one disease specific area, as set out in the national guidance. The themes were identified through a prioritisation process which involved reviewing safety measurement and monitoring data, including the Trust’s claims profile. Each theme/area is summarised below:

1.2.1 Cross cutting themes;

Patient deterioration and inpatient falls

Haelo, an innovation and improvement centre in Salford, are currently supporting the Trust to facilitate two Break-Through Series (BTS) Collaborative programmes of work (patient deterioration and inpatient falls) since June 2014. There are a total of 32 pilot wards in different specialities involved across the Trust.

The first BTS collaborative aims to ‘Reduce the incidence of cardiac arrest calls by 70%

on pilot wards by July 2015.’ Common themes arising from serious untoward incidents relating to deteriorating patients include;

Topic Selection & Mission Expert Meeting LS1 LS2 LS3 Sustaining Improvement Dissemination (Publications, etc.) Enlist Participants (10-100 teams) Prework Framework

& Changes AP1 AP2 AP3*

Spread A P D S A P D S A P D S Ongoing Supports

• Email listserv • Calls & webinars • Team reports • Site visits • Assessments • Sponsor

*AP3: continue reporting data as needed to document success

LS = Learning Session AP = Action Period

 lack of reliability in the recording of vital signs (e.g. NEWS scores), associated observation requirements

 poor communication across teams and at handover between shifts regarding patient condition

 delays in the appropriate escalation and response

The second BTS collaborative aims to ‘reduce the incidence of inpatient falls by 50% on

pilot wards by April 2015.’ Inpatient falls resulting in harm are recognised as a patient safety priority. The BTS collaborative is being used as a catalyst to engage with ward teams who test and identify solutions to falls prevention.

The Learning Session 3 events for both BTS collaboratives are scheduled to be held on 13th (deteriorating patient) and 14th (inpatient falls) January 2015. From January-March 2015 there will be further focused internal Trust capability building for the BTS collaborative Trust wide faculty members, who are supporting ward teams with their improvement projects. During this period, a change package will be developed by the Faculty which will detail successful interventions that have been tested in the pilot ward areas. From April-June 2015 the change package will be implemented across all BTS collaborative wards and a plan will be developed of how the change package will be up-scaled and spread across the entire Trust. A summit/celebration is also scheduled for both collaboratives in mid-June 2015. Further information about these BTS collaboratives can be found in Appendix A-B.

Pressure ulcers

Within the Trust there is an established Tissue Viability Team who are currently engaged in work to prevent pressure ulcers across the organisation. Some of the work this team has undertaken during 2014 includes;

 the introduction of an assessment and management tool which is being adapted for use in paediatric patients and also in the community

 trust training and awareness in relation to pressure ulcer identification and treatment

 the launch of a revised method of investigating category 3 and unstagable pressure ulcers using a MDT approach and involves the patient voice

 Two Band 5 tissue viability nurses who provide intensive support and provide training to staff at the point of care and prioritise their workload and ward areas depending on pressure area incidence intelligence from the Datix incident management system

 Included in the Trust’s Ward Health Check audit tool

In 2015 the team intend on building on this activity and run a BTS collaborative in relation to pressure ulcers and involve both internal and external community partners. The aim will focus on reducing the incidence and prevalence of pressure ulcers, with the trajectory to be developed alongside the SIP and in accordance with the national CQUIN.

Acute kidney injury

A fluid management and acute kidney group that has been established has wide representation from across the Trust from a range of specialists from all healthcare professions and includes trainees. The group will help the Trust to implement:

1. NICE Acute Kidney Injury Clinical Practice Guideline 169 and Quality Standard (expected publication February 2015)

2. NICE Intravenous Fluid Therapy Clinical Practice Guideline 174 and Quality Standard 66

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NHS England mandated a level III safety acute kidney injury warning that must be implemented across all NHS trusts by March 2015 and therefore all patients that have biochemical evidence of acute kidney injury will be flag up on the results server/PPM with an accompanying sentence advising review of the Trust’s acute kidney injury guidelines.

The fluid management and acute kidney group are currently running the acute kidney injury algorithm in shadow format to allow baseline data to be generated. From this the incidence of acute kidney injury will be identified. A programme of interventions to change practice including education and metrics from NICE guidance, will be implemented.

Therefore the acute kidney injury programme aim for the SIP is still to be defined but will be in relation to the recognition and treatment of patients developing acute kidney injury and the standards will be agreed in accordance with the national CQUIN 2015/16.

An example of some of the work that has been undertaken to date by the group includes; 1. Intravenous fluid therapy audits and education on oncology

2. Understanding attitudes to acute kidney injury

3. Trust intravenous fluid therapy guideline-draft format, preparing to submit based on the work from the previous fluid management group

4. Development of nursing educational packages on acute kidney injury and intravenous fluid therapy

5. Development of medical trainees educational packages on acute kidney injury and intravenous fluid therapy

6. Baseline audit on acute kidney injury utilising NICE audit tool on patients referred to renal within the Trust

7. Development of screen savers for acute kidney injury and intravenous fluid therapy 8. Development of new fluid balance charts to encourage more accurate recording and

calculation of urine output

9. Linking the work of the group to the electronic prescribing with respect to acute kidney injury and intravenous fluid therapy

10. Baseline demographics on the incidence of acute kidney injury across the Trust allowing us to focus on hotspots and also utilise as a metric in terms of quality improvement

11. Development of care bundles the patients with acute kidney injury tailored for MAU, ER, SAU etc

1.2.2 Safety specific area;

Maternity events

The safety specific event within our SIP relates to maternity events. More information can be found about this in Section 3.0, Appendix E and G.

1.2.3 Disease specific area;

Sepsis

The one disease specific area within our SIP relates to sepsis. The Trust’s Sepsis group was established in February 2013 and in 2015 will move from quarterly to bi-monthly meetings. The main aims of the group are to;

 standardise sepsis care across the Trust

 provide education on sepsis care

 promote reliable and effective care across the Trust

 quantify and assess the quality of care delivered in relation to sepsis

To date the Trust’s Sepsis group have focused on working with coding and informatics to try and improve the recording of sepsis and how these cases will be identified for audit purposes. An audit tool is being trialled in early 2015 by the renal teams to see how this works outside of the Emergency Department. Education sessions have also been held in two specialties and further sessions are planned, including at the March Grand Round session in March 2015.

Within the Emergency Department baseline audit work has been undertaken and some small scale Plan Do Study Act (PDSA) test of change cycles have been trialled which have tested the ‘Red Flag Sepsis’ concept. Reducing time to first antibiotic and fluids by treating patients with sepsis red flags in resus rather than in the main department. This is in line with the UK Sepsis Trust clinical toolkits that were launched along with and NHS patient safety alert in September (http://sepsistrust.org/info-for-professionals/clinical-toolkits/). The first cycle of this in November 2014 was very successful and thus are looking at testing this again later in early 2015. A point of care lactate testing machine (rather than blood gas analyser) will be trialled to encourage compliance with lactate measurement and if successful could rollout across the Trust.

Following the results of the National Confidential Enquiry

into Patient Outcome and Death (NCEPOD) audit findings, NICE guidelines, UK Sepsis Trust clinical toolkits and CQUIN for 2014-15, the Trust will align practice around the prompt recognition and initiation of treatment for patients with sepsis. The group will also lead on the updating of the Leeds Health Pathway in relation to the treatment of sepsis and the use of the BUFALO recognition and response guidance.

1.2

Patient and carer engagement in our Safety Improvement Plan

The Trust is committed to involving patients and carers in the delivery of the improvement projects outlined in the SIP, as part of the wider engagement strategy. One way in which the Trust may consider doing this, is through using a Patient Safety Briefing. The national ‘Sign up to Safety’ programme guidance suggests using the ‘airline style’ patient safety video briefing and accompanying leaflet:

http://harmfreecare.org/Patient+safety+briefing+film+launched+ which has been developed by Haelo, in partnership with Guy’s and St Thomas’ NHS Foundation Trust, and is based on a patient safety card developed by Guy’s and St Thomas’. This example aims to provide patients with ‘airline style’ safety advice about their stay in hospital in an attempt to reduce avoidable complications - such as blood clots, pressure ulcers, or falls. Thereby underpinning many of the avoidable complications included in the SIP. Based on the concept of safety advice given on aeroplanes before they take off, patients will be shown a film and provided with an information card to read to help them look after themselves during their hospital stay. The safety advice looks at simple things patients can do while in hospital to make their stay safer. The advice focuses on eight areas;

 Falls prevention

 Blood clots

 Infection prevention

 Speaking to staff if patients have any problems or questions  Medicine safety

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 Pressure ulcer avoidance

 Correct personal information

 Discharge from hospital

NHS Trusts can currently show the film to patients in two of ways: it can be easily incorporated into Trust websites so patients can watch it before they come into hospital; and hospitals with the Hospedia patient media system could also have the film uploaded free of charge to show patients once in hospital. The Guy’s and St Thomas’ Patient Safety Card is also free to download for local use and printing.

The Trust’s Clinical Standards and Patient Safety team have recently reviewed the Patient Safety Card and have developed an alternative ‘Staying Safe in Hospital’ leaflet which is scheduled to go out for consultation across the Trust in early 2015. Following feedback on this and wider consultation on the use of an accompanying video, a decision will be made whether or not to develop an accompanying video or use the Guy’s and St Thomas’ version. Patients and carers will be included in the delivery of the improvement projects outlined in the SIP via;

 Engaging patients and carers when undertaking Plan-Do-Study-Act tests of change when undertaking quality improvement initiatives in relation to the areas outlined in the SIP

 Getting regular feedback through focused interviews with patients who have suffered harm relating to areas outlined in the SIP

 Gathering patient stories

2.0

Implementing the Safety Improvement Plan

The project aim, driver diagrams, actions, measurement strategy, workstream and project team structure are included in Appendices A-F.

3.0

Aligning the Trust Safety Improvement Plan to NHSLA insurance

scheme contribution

The Trust will align its SIP with the financial incentive (10% of the Trust’s annual CNST contribution) available to members from the NHS Litigation Authority (NHSLA). The Trust is applying for the NHSLA contribution to support work in the maternity events element of the SIP. Maternity Services in general have an established high risk profile and the Trust has one of the largest maternity units in the country, delivering a complex tertiary care service to a diverse population.

The NHSLA has suggested that those claims falling into red and amber should be the priority areas of focus. Data for the Trust shows that those claims falling into the red category solely relate to Obstetrics. Obstetric claims account for 38% of the total value of claims within the Trust; nationally Obstetric claims account for the highest volume and highest value of claims at the NHSLA.

In order for the Trust SIP to be considered for a discretionary NHSLA incentive payment, outlined below is an overview of the Maternity programme’s evidenced business case. The business case states the existing levels of harm or avoidable deaths recorded by the Trust and associated by claims, the number of claims, the costs of those claims, the areas to be focused on to reduce these claims and what we want to do to and how much this would cost.

Information about understanding the Trust Maternity Services safety culture is a key intervention in supporting litigation. A recent survey carried out by the Trust (The Wayfinder project) helped to gather information about the patient safety culture within the Maternity Service and the organisation as a whole.

In support of communication, a plan for developing Safety Briefings for patients is currently being implemented across the Trust. The Maternity Service has a current communication strategy focused on learning from incidents and understanding our claims profile. The service has engaged with wider partners to implement recommendations from the local health needs assessment. Furthermore, the service has signed up to be a pilot for the Saving Babies Lives Care Bundle from the Department of Health. The four key elements of this are; stopping smoking, monitoring babies growth during pregnancy, reminding pregnant women of the importance of babies movements and monitoring during labour. These elements are reflected in our strategic approach to reducing harms and the associated costs of litigation.

Three clear aim statements have been established within the maternity team (women’s CSU) that will reduce avoidable harm by 50% in the organisation, through focusing on different aspects of maternity services over the next three years. These are;

 50% reduction in (the cost implications of a) wrongful birth by March 2018

 50% reduction in (the cost implications of) loss of a baby by March 2018

 50% reduction in (the cost implications of) care delivery events (cerebral palsy and developmental delays events by March 2018

4.0

Summary

The Trust are committed to the Sign up to Safety Campaign and have benefited from the opportunity to develop a SIP. The SIP has provided an overarching framework to include all of the main quality improvement projects the Trust will be undertaking between 2015-2018. Mortality reviews in early 2015 will inform further the aim statements, measures (outcome, process and balancing), driver diagrams and project plans for projects outlined in the SIP.

5.0

Appendices

Appendix A: Patient deterioration project Appendix B: Inpatient falls project

Appendix C: Pressure ulcer project Appendix D: Acute kidney injury project Appendix E: Maternity events project Appendix F: Sepsis project

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Appendix A: Patient Deterioration

Driver Diagram

Project Timeline

3 June 2014

29 July 14

30 September 14

13 Jan 15

Appendix B: Inpatient Falls

Driver Diagram

Project Timeline

3 June 2014

30 July 14

1 October 14

14 Jan 15

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Appendix C: Pressure Ulcers

Appendix D: Acute Kidney Injury

Up Date Fluid Management/acute kidney injury Work stream Nov 2014

Work Actions Assurance Leads

Fluids Management Group established two years ago with multi-professional representation (medical staff, surgeons, clinical biochemists, pharmacists, nurses and trainees). The Group produced a Fluid Balance Policy and integrated IV therapy into medication charts. The fluid balance chart included IV fluid prescribing guidance which was devised by trainees. Guidance was finalised May 2012.

Design of existing fluid balance charts standardised across all adult areas. Measuring guidance poster produced for clinical areas to help improve assessment of fluid balance. Added to nursing documentation index list.

Hydration and fluid management education included on the Introduction to Professional Practice programme (nursing) which forms part of a new nursing recruits induction programme.

Intravenous fluid therapy guidance for all

prescribers to be included in the patient safety clinical assess-ment section within the new prescription booklet.

All nursing staff to be reminded that new booklet and measuring guidance exists through communication by Head of Nursing - Medicines Management. To be included in induction training for registered and unregistered practitioners.

Undertake evaluation of sessions, obtain

feedback and review content.

Audit of new prescription chart once booklet has been

implemented.

Electronic staff records to demonstrate staff attended sessions at induction.

Evidence of training on induction programme through electronic staff records.

Acute Kidney Injury study day including hydration to be held on 6 November 2014 Jo Caldicott Head of Nursing Medicines Management Jo Caldicott Jo Caldicott Tracy-Jane Lister, Specialist Nurse, Medicines Management

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Work Actions Assurance Leads

Competency package on hydration is in process of design for use by unregistered practitioners.

Lectures on IV fluid therapy that include the importance of hydration are delivered through out the Foundation Year and Core Medical Trainee lecture programme. Students and doctors receive training on hydration and IV fluids therapy through five years of curriculum and through delivery of the Recognising and Responding to Acute Patient Illness and Deterioration (RRAPID) course. An App is also available to support this course.

Establishment of new Acute Kidney Injury and Fluid

Management Group. Leeds Teaching Hospitals Guidelines on Acute Kidney Injury are on the Trust Intranet.

Inform staff re new alert system re AKI based on creatine

Finalise package. To be considered as part of a work stream of the Clinical Support staff (un-registered) Development Steering Group.

E-learning package on acutely ill patient, including importance of maintaining adequate hydration and IV fluid therapy management under development. Development of education strategy to support roll out of NHS England Level 3 Safety Alert on electronic Acute Kidney Injury warning based on rises in Creatine

Agree ToR for new group

Design screen savers

Evidence of wide use within clinical areas

Evidence of medical staff undertaking E-learning package

Education training strategy in place

Screen savers displayed

Jo Caldicott Tracy-Jane Lister Dr Andrew Lewington Consultant Renal Physician and Director of Undergraduate Medical Education Dr Andrew Lewington Dr Andrew Lewington/Jo Caldicott Dr Mike Bosomworth Dr Mike

Work Actions Assurance Leads

increases.Work closely with Biochemistry Screen savers re AKI and alert system.

Update and revise new fluid balance booklet re user feedback.

Integrate AKI work stream with deteriorating patient work stream

New alert system piloted

Collect user feedback and amend existing booklet

Member of AKI group to join deteriorating patient group Bosomworth Andrew Lewington/Jo Caldicott Jo Caldicott Dr Andrew Lewington

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Appendix E: Maternity Events

What are the areas we could make the most difference? What does success look like? What is your goal statement? Primary Driver Measures

What do we need to do for the success

to be realised? What resources do we need?

1 Wrongful birth 50% reduction in wrongful birth by March 2018 Outcome Measure (1) Training Process Measure (8)

 Improve training and education of staff

 Practice Facilitator to support training delivery

 Training for existing staff to provide antenatal surveillance

 Additional training for midwifery staff in relation to mid trimester scanning

Resources

Process Measure (10)

 Ensure adequate capacity of screening services to support effective screening

 Additional scanning equipment

 Additional IT equipment

Leadership Process Measure

(5)

 Ensure all staff compliant with screening protocol

 Introduce failsafe measure

 Identified Project Lead

 Structured audit programme

 Midwifery supervision support

 Improved audit capacity to undertake audits to monitor compliance

 Project Manager to lead project and changes in policies and processes

 Funding to support appointment of project lead

 Designated contact supervisor of midwife (SOM) role

50%

reduction in

wrongful birth

by March

2018

Training

Resources

Leadership

 Implement and improve training and education of staff in relation to fetal surveillance

 Increase screening capacity with additional ultrasound machine and appropriately trained staff

 Procure new IT system for Antenatal records

 Appoint project manager to lead project

 Implement structured audit programme to monitor compliance with screening protocols / screening uptake and staff training

What are the areas we could make the most difference? What does success look like? What is your goal statement? Primary Driver Measures

What do we need to do for the success

to be realised? What resources do we need?

2 Loss of a baby 50% reduction in loss of a baby by March 2018 Outcome Measures (1-4)

Training Process Measure ₍₈₎

 Improve training and education of staff

 Reduce errors in relation to CTG interpretation

 Practice Facilitator to support training delivery

 Additional training for midwifery staff in relation to mid trimester scanning

 Funding to support CTG training

Resources

Process Measure (9) Process Measure

(10)

 Improve links with public health in relation to smoking cessation / obesity / substance misuse

 Implementation of PAP-A screening

 Additional staffing resources to provide parent education / smoking cessation advice / substance misuse support / bereavement support

 Additional scanning equipment / screening resources for PAPP-A

 Additional IT equipment

Leadership Process Measure ₍₆₎

 Improved antenatal surveillance

 Improve access to hard to reach communities with comprehensive follow up

 Implement “Best Start Strategy” and Saving Babies Lives Care Bundle locally

 Structured audit programme

 Identified Project Lead

 Midwifery supervision support

 Improve access to hard to reach communities with comprehensive follow up

 Implement “Best Start Strategy” locally

 Implement Stillbirth Care Bundle

 Standardize perinatal review process and share lessons learnt

 Increase Audit capacity

 Funding to support appointment of project lead and designated contact SOM

50%

reduction in

loss of a baby

by March

2018

Training

Resources

 Implement and improve training and education of staff in relation to monitoring fetal wellbeing antenatally

 Improve links with public health in relation to smoking cessation / obesity / substance misuse

 Improve and standardize information given re key public health issues

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areas we could make the most difference? What does success look like? What is your goal statement? Primary Drivers Measures

What do we need to do for the success

to be realised? What resources do we need?

3 Reduction in care delivery events (cerebral palsy and developmental delay) 50% reduction in care delivery events by March 2018 Outcome Measures (1,3 and 4)

Training Process Measure

(8)

 Improve training and education of staff

 Practice Facilitator to support training delivery

 Funding to support CTG training and NLS training

 Additional neonatal life support training

 CTG Masterclass training for all core midwifery delivery suite staff and medical staff

Resources

Process Measures (11)

and (12)

 Provision of wireless telemetry for CTG monitoring in labour

 Provision of improved resuscitation measures in line with national standards (blended resuscitaires)

 Additional equipment to provide wireless monitoring

 Additional resuscitation equipment

Leadership Outcome Measures (3 and 4) Process measures (7)

 Implementation of case loading model for women with previous poor

obstetric history

 Identified project lead

 Structured audit programme

 Increased audit capacity

 Additional staff to support case loading model

 Increased audit capacity

 Funding to support appointment of project lead

50%

reduction in

care delivery

events by

March 2018

Training

Resources

Leadership

 Implement and improve training and education of staff in relation to monitoring fetal wellbeing in intrapartum period

 Provision of wireless telemetry for CTG monitoring in labour

 Provision of resuscitation equipment to meet national standards

 Implementation of case loading model for women with previous poor obstetric history

 Provision of improved resuscitation measures in line with national standards (blended resuscitaires)

There are several workstreams that underpin the three programmes of work outlined above.

Workstream Goal Actions-every 90 days Lead

1 Training Implement and improve training and education of staff

 Quarterly review of training interface

 Monitor incidents

 Commission education courses

Project Lead

Risk Management Lead Head of Midwifery

2 Resources Procure equipment

Appoint staff

 Procurement process

 Recruitment process

Head of Midwifery Head of Midwifery

3 Leadership Support safety culture

 Appoint Project Lead

 Monitor compliance

 Integrate midwifery supervision

Head of Midwifery Project Lead Contact SOM Measure Description Data

Source Numerator Denominator

Frequenc

y Chart Goal Sample

Outcome Measures Maternity related Incidents and claims (1)

DATIX Number of maternity related incidents and amount of associated costs

Current claim profile

Quarterly 50% reduction in maternity related

incidents associated costs

100% of maternity related incidents and claims

Perinatal morbidity and mortality rates (2) Perinatal morbidity and mortality rates

Number of stillbirths over 22 weeks and early neonatal deaths

Quarterly

Babies diagnosed

with HIE (3) Audit

Number of babies diagnosed with HIE

Total number of

babies born Quarterly

Incidents involving misinterpretation of CTG’s (4)

DATIX Number of incidents involving _{misinterpretation of CTG’s} Total number of

incidents Monthly

Process Measures

NSCC standards (5) Audit KPI’s

Number of incidents and amount of associated costs

Current claim profile

Quarterly 100% compliance with NSCC

standards

100% of women and babies eligible for screening Saving Babies Lives

Care bundle Audit

 Number of women who have stopped smoking in pregnancy

CO readings Quarterly 100% compliance with Saving

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elements (6)

 Number of babies identified as small for gestational age

 Number of incidents relating to management of reduced fetal movements

 Number of incidents related to errors in CTG interpretation / escalations of concerns Compliance with use of customised growth charts Compliance with record keeping in relation to fetal movements Compliance with fetal monitoring protocols elements Incidents associated with delay in delivery (7)

DATIX Number of incidents associated with delay in delivery

Total number of

incidents Monthly

Training measures e.g. number of staff trained (8)

Number of staff trained Total number of

staff Monthly 80% of all midwifery staff trained

100% of all midwifery staff

Parent education sessions (9)

Number of parents attending education sessions

Total number of

parents Monthly

80% of all parents to attend

training session 100% of all parents

Screening measures e.g. volumes (10)

Number of scans Monthly

Wireless telemetry available when required (11)

Number of wireless telemetry units

available 6 monthly

Wireless telemetry available to 80% of women requesting it

All women delivering in TRUST Maternity units Resuscitaires

compliance with national

recommendations (12)

Number of resuscitaires using blended gas

Total number of

resuscitaires 6 monthly

100% resuscitaires comply with national recommendations

All resuscitaires within TRUST

Name Role Responsibilities

Julie Scarfe Head of Midwifery Recruitment and workforce / embed safety culture

Colette Sparey Clinical Director Implementation of project strategy / embed safety culture

Tracey Glanville Clinical Lead Supporting implementation of project strategy

Mary Armitage Deputy Head of Midwifery Training and education / workforce and procurement of equipment

Sharon English Lead Neonatologist Supporting implementation of project strategy

Paula Jenkins Contact Supervisor Integration between supervision and governance

Agnes Woodhouse Risk Management Monitoring incidents

Anne-Marie Walsh Trust Risk Manager Monitoring and feedback on claims

Claims Data LTHT

The bar graph below shows the Trust’s top 5 Incident types in Obstetrics claims with an incident date of 01/04/09-31/03/2014.

28 23 19 15 10 0 5 10 15 20 25 30 Failure to adequately monitor 1st Stage of Labour Failure to diagnose/ delay in diagnosis Failure to monitor 2nd stage of labour Perineal tear (1st, 2nd and 3rd degree) Failure to recognise complication of treatment

Top 5 Obstetric Claims by Incident Type

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Looking at the top 3 incident types giving rise to claims in more detail:-

1. Failure to Adequately Monitor the 1st Stage of Labour

There are 28 claims in this category. The prevalent trend elicited 17/28 (60.7%) claims relate to mis-interpretation of CTGs and have resulted in either a stillbirth or long term damage to the child.

2. Failure to Diagnose/ Delay in Diagnosis

There are 23 claims in this category.

3/23 (13%) relates to delay in diagnosing and treating ectopic pregnancy. 6/23 (26%) relate to perineal tears and bladder damage.

3/23 (13%) claims relate to retained products of conception.

3. Failure to Monitor 2nd Stage of Labour

There are 19 claims in this category. There are no particularly repetitious themes but 3/19 (15.7%) cases relate to a resultant stillbirth.

Failure in Antenatal Screening /Wrongful Birth

Although this does not feature in the top 5 incident types for the last 5 financial years this type of claim has a significant financial cost to the Trust (£3.03m), it does feature in the NHSLA’s scorecard for the relevant incident period, it is wholly preventable and therefore is included in the trust’s Safety Improvement Plan.

Conclusions Drawn

The majority of claims provided in the NHSLA’s scorecard (red quadrant) fall in to Leeds Teaching Hospitals NHS Trust’s top 5 incident type categories.

Linking Claims to Incidents

The 4 high value claims within obstetrics can be categorised under the headings of ‘wrongful birth’, ‘loss of a baby’ and ‘care delivery events’. A review of these claims and the subsequent recommendations has identified the 3 main drivers in which it is anticipated that investment into will make the most difference namely Leadership, Training and Resources.

Looking at the Trust’s obstetric claims with incident dates from 1st April 2009 until 31 March 2014 the bar graph below shows the number of claims linked to an incident and/or subsequently leading to an investigation. Of note is that where there are claims linked to more than 1 incident, not all of the incidents are relevant to the claim.

69 51 16 5 1 1 1 0 10 20 30 40 50 60 70 80 0 Incident 1 Incident 2 Incidents 3 Incidents 4 Incidents 5 Incidents 6 Incidents

Linked to an Incident/investigation

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ASSURANCE ON Delivery of Sepsis Care in LTHT

Policy standards

Current compliance with standards

Actions taken/required (including responsibilities and

timescales Strength of Assurance

Mechanism (*See definitions below)

Level of

Compliance/performance (*See definitions below)

1. Quantifying severe sepsis and septic shock cases treated across LTHT

Reliable and accurate reporting of severe sepsis and septic shock cases managed across LTHT

Standard: 100% of cases reported either as primary or secondary diagnoses.

Moderate ↔

Informatics search based on ICD10 clinical codes:

R65.0 SIRS with infective cause R65.1 SIRS with infective cause and organ dysfunction

R57.2 Septic shock

Low

Search from Jan-July 14 identified only 34 adult cases. Extremely unlikely to be representative of true numbers

Work with clinical coding and clinical teams to improve clarity of diagnosis and data extrication – see action tracker

2. Standardise sepsis pathways across LTHT

Standardised clinical guidelines across all clinical areas in line with best current evidence and Royal College Guidance. To include recognition and response guidance (BUFALO) and quantitative resuscitation guidance (EGDT)

Standard: 1 pathway on Leeds Health pathways appropriate for use in all clinical areas

Strong ↔

Maintain single pathway hosted through Leeds pathways with yearly review of content

Low

Currently at least 3 proformas in use across the Trust.

Debate around best practice following release of PROcess RCT. 2 further RCT’s expected to publish data this year regarding Early Goal directed Resuscitation.

Promote use of BUFALO across all sites.

Abolish ED sepsis pathway Await further evidence prior to re-design of Leeds pathways guidance. Discussion re

implications of this evidence to be discussed by the group

3. Delivery of care to patients with severe sepsis and septic shock

Compliance and achievement of key performance indicators for delivery of care to those patients with severe sepsis and septic shock

Standard:Surviving sepsis campaign guidance

BUFALO

Review of mortality cases attributed to sepsis

Moderate

Standardised audit templates to be completed by each CSU and fed back through sepsis working group

Strong

Case reviews of patients where cause of death identified as sepsis

Low ↔

ED and outreach audits only ones currently performed

ED audit shows good overall achievement of indicators (>80%) but time to achievement is area for improvement.

Low

Currently no specific process in place for review by sepsis group

Quarterly CSU audits of cases of severe sepsis and septic shock and delivery of BUFALO care package

Selection of cases to be brought to specifically identified M&M meeting as part of annual work planner.

4. Education of staff and patients

Deliver training and education packages as part of mandatory training

Standard 75% staff on acute care wards by end 2015 100% by end 2016

Moderate

Delivery through individual CSU clinical governance forum

Strong

As part of staff mandatory training record

Low

Unsure on staff numbers to whom this has been delivered to this year.

Develop mandatory e learning package for use with ESR Education programme as part of deteriorating patient workstream to highlight sepsis care

ED clinical nurse educators to all new ED starters on critical care teaching day and as part of induction programme – in place for new starters Sept 14.

Teaching package on ED VLE as part of induction – in place for Aug 14

Patient information leaflets regarding this (e.g.UK sepsis trust)

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Strong Assurance from an external source, or independent internal audit or review

Moderate Assurance from an internal source, or non-independent audit or review

Weak Assurance is not comprehensive or is not evidence based

Level of

compliance/performance

Definition

High Fully meets or exceeds the standard/threshold

Medium Partially met, making good progress towards achieving the standard/threshold and on-track

Appendix G: NHSLA Proforma

Heading Content

Area of focus Maternity services provided by Leeds Teaching Hospitals NHS Trust (TRUST) in the community and Acute Setting with specific focus on:

 Wrongful birth;

 Loss of a baby;

 Care delivery events

Number Over the last 5 financial years (by incident date), 4 clinical negligence claims have been instigated against TRUST which have been in the red quadrant of the NHSLA’s scorecard (High volume high value) and are priority areas of focus.

Looking behind the figures provided on the NHSLA scorecard for maternity, there are 144 claims lodged against obstetrics at TRUST with an incident date of 01/04/09-31/03/2014. Not all of these claims have been reported to the NHS Litigation Authority as some cases are still in their initial investigative stages.

Looking at these claims in detail and by incident type the top 5 incident types in descending order are: Failure to adequately monitor the 1st stage of labour; failure to diagnose/delay in diagnosis; failure to monitor 2nd stage of labour; perineal tear (1st, 2nd and 3rd degree tear); and failure to recognise a complication of treatment.

Value The combined value of these claims is £21,612,302 comprising £16,530,000 for claims in the red quadrant and £5,082,305 claims in the blue quadrant.

Goal The main goal is to reduce the harm and associated costs in relation to wrongful birth, loss of a baby and care delivery events. If TRUST implemented its goals, by March 2018 it could:

-Reduce wrongful birth by 50%. -Reduce loss of a baby by 50%.

-Reduce care delivery events resulting in cerebral palsy and developmental delay by 50%.

Implementing these goals would represent significant improvements to the safety of its maternity patients and substantial financial savings to the organisation and wider NHS. We anticipate a financial benefit to the NHSLA in the region of at least £8,265,000 and possibly nearer to £10 million pounds over three years if our safety improvement plans are successfully funded and implemented.

Actions The Key actions:

 to reduce the cost of harm in relation to wrongful births will be to ensure compliance with the National Screening Committee standards with a focus on training, resources and equipment

27

 to reduce the cost of harm in relation to the loss of baby will be to support implementation of the Saving Babies Lives Bundle with a focus on training , resources and leadership particularly in relation to strengthening links with public health, and monitoring fetal wellbeing ante-natally

 to reduce the cost of harm in relation to care delivery events with a focus on training in relation to monitoring fetal wellbeing in the intrapartum period, resources

Measures The Safety Improvement Plan contains a Measurement Strategy outlining proposed Outcome, Process and Balancing Measures. The Measurement Strategy continues to be developed in accordance with the refinement of the Plan, Aims and Driver Diagrams.

Financial data

Practice facilitators Band 6 x2 Ultrasound machine x1 CTG Master class £8K CTG telemetry x4

Audit Claims reduction post x1 Community IT system £200K NALS training £10K

Sonography training £3600 PAPP-A blood test tbc (Spread sheet attached)

Contribution The Maternity contribution represents 38% of the Trust’s total contribution to the NHSLA. The delivery of the Safety Improvement Plan in Maternity Services is very much dependent on funding from the NHSLA.

Timing An overarching implementation timeline is reflected in the GANTT chart in Section 4.

Benefits Potential 50% reduction in harm and associated costs relating to wrongful birth, loss of a baby and care delivery events. This will be demonstrated in the reduction of the number of incidents as outlined in the table 5.1. A summary of litigation cost is provided below. By implementing the measures outlined the trust would expect to see reduction in costs of approximately £8 280 000 based on the high value claims listed.

Injury

Value

Nr

Claims

Cerebral Palsy

£

6,900,000

1

Developmental Delay

£

2,300,000

1

Wrongful Birth

£

3,030,000

1

Loss Of Baby

£

4,300,000

1

Grand Total

£

16,530,000

4