Elderly care conference 2017 - Learning the lessons from claims and inquests, Amelia Newbold
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Amelia's presentation looks at recent clinical negligence data, common risks to elderly patients, the impact on staff and looking forward.
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Elderly care conference 2017 - Learning the lessons from claims and inquests, Amelia Newbold
- 1. Elderly care conference 2017 Stream C – learning the lessons from claims and inquests Amelia Newbold
- 2. Learning the lessons from claims and inquests Amelia Newbold, Risk Management Lead 27 April 2017 Join the conversation #ECC_BJ
- 3. Clinical negligence data – 2015/16 • 10,965 new claims (4.6% reduction) • Annual cost (damages and costs) £1.5bn (23% increase) • Increase in annual value of claims by around 9% • Additional ‘hidden costs’ to the NHS
- 4. CNST data – age demographics 813 426 244 924 496 200 939 564 228 1205 714 317 1206 776 339 0 200 400 600 800 1000 1200 1400 65 - 74 75 - 84 85+ Number of Claims by Age Group Split by Year of Notification 2010/11 2011/12 2012/13 2013/14 2014/15
- 5. Elderly patients – risks • Complexities of medical conditions/needs – Increased high risk procedures – Multidisciplinary team/organisation involvement
- 6. Elderly patients – common themes and issues • Injury/harm contributed to by: o Delays/failure to recognise and/or escalate deteriorating patients o Shortcomings in communication and record keeping o Confirmation bias o Deficiencies in risk assessments o Failures in cross checking
- 7. Learning • ‘Just Culture’ to promote learning • Usually one error by one individual which affects another, with someone else contributing, against the backdrop of a system which is faulty
- 8. Case Study • Mr A - 86 years old, admitted from nursing home to SAU ?upper-gastrointestinal bleed. • Documented memory problems and dizziness. • Falls Risk Assessment recorded a score of zero for confusion/ agitation or dementia, despite the family reporting a several month history of memory problems, worsening due to recent chest infection. • Inconsistent messages about whether bed rails should be used – Mr A bed bound, dependant on nursing care and bedrails used at nursing home.
- 9. Case Study • Bedrails used on SAU but no bedrails assessment undertaken nor was rationale documented. • Family was sufficiently concerned about falls risk to speak to staff, but not documented. • Mr A transferred to medical ward. Based on information available to her, ward manager did not think bedrails required. • Mr A sustained unwitnessed fall, fractured left hip and sadly passed away shortly afterwards. • Candour with the family about what happened – apology provided.
- 10. Impact on staff • Volume of evidence and witnesses – impact on costs AND delivery of front line clinical services • Opportunity for reflection and learning • A clinician’s perspective - video
- 11. Looking forward • National Quality Board - Guidance on Learning from Deaths (March 2017): – Introduces a number of minimum requirements. – Designed to complement the Serious Incident Framework and initiate a standardised approach to investigations. • Candour. • Safe Spaces.
- 12. Questions?
- 13. Contact us Amelia Newbold – amelia.newbold@brownejacobson.com T: +44 (0)115 908 4856 / M: +44 (0)7917 557385
Editor's Notes
- Appreciate there are people here from NHS and care sector – we are looking at claims against the NHS but the identifiable trends and lessons that can be learnt would arguably apply across the care sector Context within the NHS 2015/16 New clin neg claims fell in number by 4.5% to 10,965 compared with 11,497 the year before (14/15). Damages paid to patients rose and the annual cost of clinical negligence in NHS in England (damages and costs) rose from £1.2bn in 2014/15 to £1.5bn in 2015/16 - an increase of 23% Average value of awards is increasing by around 9% per year – well above inflation, a trend likely to continue particularly in light of the recent changes ot the discounts rate In addition to these figures, there is a much greater impact on the NHS – hidden costs of resources being diverted from frontline care with staff who are involved in inquests and claims requiring time ‘off the day job’ to meet with legal department/external sols/prepare statements and give evidence There is also the impact on staff – understandably can be a stressful time, can in some cases lead to staff going off on sick leave
- In terms of elderly patients – whilst the number of new claims went down in 2015/16, number of claims involving patients over 65 years of age is increasing Reflects a national trend based on the growing elderly population at large
- All living longer – expectations Most high risk patients – present with multiple co morbdities Involve multiple specialities/teams of clinicians – creates potential risks for communication and information sharing – which we will see later v relevant to many cases
- As Tracy has mentioned, there is a real drive towards learning from claims and inquests in order to prevent harm We have been undertaking Deep dive reviews for our Trust clients – analysing the claims and inquests we have been involved in in order to identify trends – Recognise it is based on a limited number of cases – time lag - and is a snapshot in time but aim is to build on the NHS Resolution scorecards and support the other work Trusts are doing – e.g. identify areas for training We know from our own experience that a significant proportion of inquest and claims relate to elderly patients. Common clinical issues: Pick one of the most common causes of harm, relevant also in care sector – FALLS And look at the causes/contributory factors we most commonly see poor record keeping (e.g. failures to note key clinical issues as part of falls risk assessment and a failure to complete risk assessment forms correctly); failure to review and update risk assessments; and poor communication (between staff and between staff and patients) and issues around handovers between staff with key information getting lost in transition to the detriment of patients’ safety. In fact, although poor communication and record keeping were consistent themes within the most of the cases we reviewed they were issues particularly relevant to the cases involving the elderly patients. This, in part, is a reflection of the co-morbidities these patients often present with and the necessary involvement of multidisciplinary teams.
- Safe Spaces
- Prior to her admission, the Deceased had noted memory problems along with dizziness on standing. However, the Falls Risk Assessment recorded a score of zero for confusion/ agitation or dementia, despite the family reporting that she had a several month history of memory problems, worsening due to recent chest infection. This score remained zero until the fall, despite a low Abbreviated Mental Test (AMT) score, occupational therapy commenting that confusion was impacting on mobility and nursing staff reporting concerns about MC trying to get out of bed. There were inconsistent messages about whether bed rails should be used. The Deceased’s family was sufficiently concerned about falls risk to speak to staff, but there is no documentation of any discussions.
- The outcome was, however, favourable to the Trust, in that a narrative conclusion was given which did not criticise the Trust. Through the investigation process the Trust developed an excellent relationship with the deceased’s family and was open and honest about the cause of the fall, providing an apology for what happened at the earliest opportunity. The family’s expressed wish was for action to be taken to prevent the possibility of this happening to another patient and the Trust provided information to explain what measures had been taken to reduce this risk. These included the dissemination of a ‘learning board’ to every ward and bank and agency staff. A civil claim was not been pursued. This case highlights the importance of building good relationships with patients and family members. Learning Communication with staff and patients/families Patients and families are an invaluable source of information – need to be listened to! In addition, good communication from the outset with families is more likely to engender trust. Estimated that 25% of claims are pursued after something has gone wrong because patients/families not felt listened to/involved and told about things Between staff – risk area with elderly care because claims/inquests involving elderly patients often involve evidence from a number of different witnesses, involving different specialities and staff at different levels, including consultants, junior doctors, nurses, HCAs and also dieticians, occupational therapists and physio clear, coherent and thorough handovers and sharing of key information across departments/ Also organisations, where appropriate Documentation – the importance of updating falls risk assessments to include relevant information from patients/families. Not deviating from a care plan even where risk of harm appears on face of it to be small. Nursing staff in particular need to be aware of the need to check what risk assessments/care plans in place and why based on a patients symptoms and clinical needs and then ensure these are followed If there are good reasons for changing the agreed plan, document this The importance of not deviating from a care plan even where the risk of harm to the patient appears on the face of it to be small. Nursing staff, in particular, need to be aware of the need to check what risk assessments/care plans are in place – and why based on a patient’s symptoms and clinical needs - and then ensure these are followed.
- Opportunity for reflection and learning Failure as the best way to learn
- In brief, this new National Guidance seeks to implement some of the recommendations from the recent CQC review into the way NHS trusts review and investigate deaths of patients in England ‘Learning, candour and accountability’ (December 2016). The CQC found that learning from deaths was not being given sufficient priority in some organisations (with particular concerns in relation to patients with learning difficulties and mental health problems) and that valuable opportunities for improvements were being missed. The report also pointed out that there is more the NHS can do to engage families and carers and to recognise their insights as a vital source of learning. The National Guidance Board has now published this latest Guidance - National Guidance on Learning from Deaths (March 2017) which is a Framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths, including maternal and neonatal deaths and stillbirths. This introduces a number of minimum requirements in respect of providers’ current approach to reviewing and reporting deaths and is designed to complement the Serious Incident Framework and initiate a standardised approach to investigations. From April 2017, Trusts will be require to collate and publish specified information about deaths on quarterly basis, with greater involvement at Board level and alongside this establish an ongoing learning process. By September 2017, Trusts will also be required to publish an updated policy setting out how it responds to and learns from deaths and the approach taken to undertaking case record reviews, using an evidence based methodology.