Deb

It's always a difficult one giving individual feedback and maintaining confidentiality of staff involved in incidents. It would not be appropriate to feedback that a member of staff had been taken down the HR route or been disciplined for example. In relation to whether it was a "serious" incident one would hope investigators looked at whether the lapse in care/observation-taking caused or contributed to the patient's deterioration. Yes, it was below accepted standards of care but what was result of this. Despite observations not being recorded, was the patient's condition monitored and escalated appropriately anyway. All factors to be considered. This would influence the level of investigation. You provide details on datix, but it is up to the investigator/team to establish the facts including obtaining information from those involved, whether there were any other circumstances to be considered, any other issues or concerns with the practice of those involved, the effect of the act or omissions on the patient etc. Your description of the incident prompts these considerations. If your description was not clear, or the investigator felt they needed more information from you, then they hopefully would have approached you to discuss further. We should also identify good practice and what is done well as part of an investigation. Audit is an important part of ensuring lessons are learnt and any changes are embedded. I would encourage staff to shadow their risk/governance team to get a better understanding of the issues and/or ask to be involved in root cause analysis of incidents after appropriate training.