Patient Safety Investigation Branch Pressure Damage Deep Dive Investigation 15 th October 2015 Sammie Gradwell, NHSE London Region.

Patient Safety Investigation Branch (PSIB) A paper by Vincent and Adams in 1999 concluded that: “in-depth analysis of a small number of incidents will bring greater dividends than a cursory examination of a large number”

Deep Dives … More than research or just a good quality RCA Exemplar investigations 2-5 deep dives Subject specific Narrow focus Led by expert investigators Use of best practice techniques Investigated as if never seen before Review of intelligence, evidence and progress to date Review of 10 + completed RCA investigations Data review (intelligence and baseline) Literature review Review of exemplar sites (on the issue) Research other sources of info. in industry Review other sources of info. internationally Patient stories Economic case Exemplar investigation report Comprehensive list of specified causative factors Suite of recommendations / solutions with application guidance

Patient Safety Investigation Branch: NHS England Domain Five - Patient Safety

What we do:(Luxury)

Project Start-up: July 2014

The early days:

Mid Investigation:

What we found (regarding the investigation process)

Summary of the Cases Patient Multiple co morbidities. In her own home. Immobile. Care agency staff. Developed a blister. Delay in pressure relieving boot and other strategies. Developed a category 4 PD. It is now healing. Patient multiple co-morbidities. In a residential care home. Community nursing staff visiting. Mobile on day 1 and deteriorated. Patient developed multiple grade 3 and 4 PD over her body and deteriorated rapidly. She was subsequently transferred to a nursing home and died.

Delay in referrals – to Community nursing & TVN. Delay in pressure relieving strategies being implemented. Delay in care planning. Must and Waterlow scores not completed. Wrong categorisation of PD. Pictures/Wound charts and assessment of the progress of the PD was not undertaken. Poor record keeping. Common CDP’s / SDP’s

Human Factors issues arising from the investigations. HuF Tools used Cognitive interviews – with Drawings Contributory factors framework

Human Factors issues arising from the NHS Care in both investigations. Workload from competing tasks Cumulative fatigue Distraction Poor leadership Familiarity with new technology Overload leading to narrow focus / reduced situational awareness

Wrong Focus of staff Overloaded Situational Awareness – Narrow focus/task orientated Cumulative fatigue Speed of referral – process Root Causes for Investigation 1

Requirement to have PD training. Inappropriate placement into a Residential Home however in line with current assessment criteria. Poor knowledge of PD both in the prevention and identification of PD. Root Causes for Investigation 2 Residential Care Home

Monitoring of Capacity and Capability of staff and quality of service by senior managers. Workload and working conditions led to staff being overloaded and fatigued and cutting corners. Trust polices on PD management and training are confusing. Root Causes for Investigation 2 The Trust

There is a need to develop a high standard of PD training for Residential Care Homes. There is an opportunity to look at the possibility of Residential Care Homes, with extra training, to look after patients with category 1 and 2 PD. Community Nursing teams are under resourced or lack experienced staff. Community Nursing need a greater level of expertise in managing patients with grade 3 and 4 PD. Senior managers need to ensure that they have early warning systems in place to alert them when care has fallen below what would be reasonably expected. National Learning

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