We are sorry to hear that you, a family member, or someone you care for has been involved in a patient safety incident whilst under the care of the George Eliot Hospital NHS Trust. It is important to us that we listen, understand and learn from your experience. The incident will be reviewed as part of a Patient Safety Incident Investigation (PSII). This booklet is designed to provide you with information about what to anticipate during this process and how you can participate if you wish to do so.
We understand that the investigation cannot alter the events in your case, but the primary goal of a PSII is to assist the Trust in understanding what happened, so we can learn how things can be changed and improved to prevent it from happening again.
Your involvement in this process is valued, so that you can understand what happened and how we as a Trust are committed to change and improve.
What is a patient safety incident?
The definition of a patient safety incident is:
"Unintended or unexpected incidents which could have or did lead to harm for one or more patient’s receiving healthcare." - Patient Safety Incident Response Framework (PSIRF)
PSIRF is a framework followed by all NHS Trusts in England in how to identify, and respond to patient safety incidents.
Not all patient safety incidents require an investigation and may benefit from a different type of learning response under the PSIRF framework such as a hot debrief or after action review.
If you would like to read more about PSIRF, you can find it here: https://
What is a patient safety incident investigation?
The purpose of a patient safety incident investigation is to identify what happened and why, so that we can try and reduce the chances of it happening again, in this case by using an investigation process.
We will look at the circumstances that led to the incident, and review procedures, practices using a systems-based approach to identify areas that need to be changed or improved. The purpose of this process is not to blame the individuals involved but to listen, learn and make improves where necessary. Everyone involved will be treated respectfully and with compassion.
What to expect?
As soon as possible after recognition of the incident you should be informed that the incident has happened and be provided with an apology. This is called Duty of Candour and is a legal obligation required by all Trusts to ensure they are open and honest when things have not gone as planned.
For further information on the duty of candour please visit the Care Quality Commission (CQC) website at: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-20- duty-candour
Once the Trust have identified that a patient safety incident investigation is the appropriate response, a lead investigator will be appointed. This will be a specially trained member of staff to lead the investigation, who was not involved in the care provided.
You will be contacted either by the investigation lead or an allocated main point of contact. They will introduce themselves, talk to you about the incident and the investigation process.
They will explore your support needs and preferences for being involved in the process including how and when you would like to be contacted.
You will be provided with their contact details, and they can arrange for you to share your experience and provide any questions or concerns that you would like answered as part of the investigation. They will keep you informed of progress and timescales as you prefer.
Here is a list of ways you can get involved that will be offered by your point of contact:
- Receive further information about the investigation
- To share experience of the incident
- To ask any questions that you would like looked at in the investigation
- To see a copy of the draft report
- To see a copy of the final report
- The opportunity to discuss the final report
Scale and scope of the investigation
The lead will decide on the scale and scope of the investigation. The scale of the investigation depends on its complexity and if yours is the only incident being reviewed as part of the investigation. In some cases, there may be more than one of the same incident and these will be investigated together.
The scope of the investigation is when the ‘Terms of Reference’ are set. These act as a guide for those involved in the investigation as to what will be included and what questions need to be answered. You will be offered the opportunity to review and discuss the terms of reference by your point of contact. If any of your questions are outside the scope of the investigation, you will be informed why and supported to the right people to answer this for you.
The lead investigator will gather relevant information to answer the questions set out in the ‘Terms of Reference’. This information will be used to understand exactly what happened:
- Medical notes (electronic / paper)
- Trust policies and guidelines
- National policies and guidelines
- Verbal or written accounts from people who experienced the incident
- Visits to ward or area where incident occurred
- Other work systems and processes that may have affected the outcome such as the internal/external environment, tools and technology, tasks and person(s) which provide context and potential contributory factors to the learning response.
From identifying a clear picture of what happened, we can explore all the different factors that may have contributed to the incident. A systems-based method of investigation will be used to identify areas that need to be changed or improved. An action plan will be created from our findings to prevent or reduce the likelihood of further reoccurrence. Specialists will form part of an investigation panel supporting the lead investigator in reviewing the information by giving their domain knowledge which is relevant to the investigation.
Checking and finalising the report
Once the lead investigator has written the first draft, they will send it to an investigation panel for review and relevant area/service leads to ensure the information is accurate and actions are achievable. Your point of contact will also establish if you would like the report to be shared with you to check and ensure the information is factually accurate. If you do, you will be provided with the draft report or sections of the report and allocated sufficient time to check for accuracy. The final report will be taken to our Clinical Improvement Group (CIG) for approval.
Closing the investigation
At the end of the investigation, you will be offered the final report which provides the findings and conclusion of the investigation. We appreciate this may be a difficult time and we will offer you a meeting with the lead investigator to discuss what they found in the investigation, and how they decided on their suggested actions. You will also have the opportunity to ask any questions you may have. They will also talk though any support you might need moving forward and will help you organise this if you would like to.
Other investigations
If the investigation lead knows there is going to be another investigation alongside or immediately after this one, they will tell you. For example, following an unexplained death there will be an inquest led by the coroner, or it may be directed to a Medical Examiner.
Once the investigation process is complete, we need to start implementing the action plan included in the report. An organisation called the Integrated Care Boards (ICB) monitor actions from the report to ensure we complete them within the specific timescales. You may be able to get involved in sharing your experience to drive these improvements. Please discuss with your point of contact if this is something you would be interested in.
Hopefully, you will be able to move forwards feeling reassured by the investigation outcome. Your valuable involvement will also help to reduce the risk of the same thing happening again.
If you are unhappy with the investigation speak to your main point of contact in the first instance, to see if the problem can be resolved.
The investigation should have answered most if not all of your questions. If you still have questions that were not able to be answered, then please inform your point of contact who will provide you with the details of relevant departments or organisation that can help.
Mind is a registered charity who provide support and advice to anyone who is suffering with their mental health. If you have been affected emotionally following the incident you experienced or if you are finding the investigation process difficult, you can contact Mind. You can find general support resources and information about local services at https:/
Samaritans are a registered charity providing support to anyone in emotional distress or anyone who is struggling to cope. If you have been emotionally affected by the serious incident you were involved in, you can contact the Samaritans for free and there will always be someone there to listen to you and talk to you. You can find more information at https:/
Bereavement care is a free services designed to help and support people struggling to deal with bereavement. If you have been affected by a bereavement, you can find more information at: www.
Citizens Advice can give high quality, independent advice about any problems or questions you might have. They can provide you with the knowledge and confidence to find a way forward. They have a network of national and local independent charities that can provide free and confidential advice. You can find out more at https:/
This booklet was brought to you by the Patient Safety Team at George Eliot Hospital NHS Trust.
If you have any further questions, please contact the team on 02476865244. Or email geh.patientsafety@nhs.net
George Eliot Hospital is a smoke free environment. For help and advice to stop smoking you can call the national helpline on 0300 123 1044 or visit: https://
Copyright
Except where otherwise noted, this item is licensed under the CC BY license (https://
If you are a rights holder and are concerned that you have found material on our patient information resources website, for which you have not given permission, or is not covered by a limitation or exception in national law, please contact us using the Feedback form providing your contact information and full details of the material.