Patient-Safety-Learning

Findings While national guidance says that a patient’s risk of harm should not be stratified into categories such as high, medium or low, such stratification remains common in many trusts. This is because other methods of assessing and documenting risk are not available, and because staff fear being blamed if a patient comes to harm without a risk assessment, including risk stratification, having been completed. Current research only demonstrates a link between menopause and low mood, and not between menopause and more severe mental health symptoms. Women are frequently prescribed antidepressant medication when hormone replacement therapy may be a more appropriate treatment for their symptoms. Menopause is not routinely considered as a contributing factor in women with low mood who are assessed by mental health services, and staff do not receive training in this area as standard. While there is a significant amount of national guidance relating to family engagement when treating patients with mental health conditions, mental health practitioners often find it difficult to know how and when to engage with families with complicated relationships or when the patient withdraws their consent for information sharing. There is a lack of training in this area to support staff with decision making. National guidance raised the upper age limit for referral to the Early Intervention in Psychosis pathway in 2016. Some trusts continue to prioritise younger patients for a variety of reasons – including funding, capacity and misconceptions about whether an older person can actually be experiencing a true first episode of psychosis in later life. Safety recommendations HSIB has made four safety recommendations as a result of this investigation. NHS England: HSIB recommends that NHS England works with appropriate stakeholders, including experts with appropriate experience, to create guidance on culture change. A quality improvement programme should also be developed to support practitioners in undertaking psychosocial assessments that are in line with guidance from the National Institute for Health and Care Excellence. Person-centred safety planning should be embedded within the process. Care Quality Commission (CQC): HSIB recommends that the Care Quality Commission evaluates the way in which it reviews how community mental health services assess risk of harm, to ensure its inspections are in line with the latest national guidance. National Institute for Health and Care Excellence (NICE): HSIB recommends that the National Institute for Health and Care Excellence evaluates the available research relating to the risks associated with menopause on mental health and if appropriate, updates existing guidance. Royal College of Psychiatrists (RCPsych): HSIB recommends that the Royal College of Psychiatrists forms a working group with relevant stakeholders to identify ways in which menopause can be considered during mental health assessments. Safety observations HSIB has made the following safety observations: It may be beneficial for mental health organisations to have a dedicated liaison officer who acts as a point of contact for both families and clinicians when navigating involvement in a patient’s care and decision making. It may be beneficial for organisations to involve families in care planning and assessments, and that practitioners are appropriately trained in working with families. It may be beneficial for education bodies to develop training programmes in safety planning and psychosocial assessments, once NHS England has provided guidance on how such assessments should be conducted. It may be beneficial for mental health organisations to ensure their Early Intervention in Psychosis referral process is in line with the national guidance, and that staff are clear about the upper age limit of patients accepted onto the pathway. Safety actions HSIB has noted the following safety action: NHS England has written to all mental health trusts in England to highlight the importance of taking a person-centred approach to psychosocial assessments and safety planning. The communication asks trusts to move away from risk assessment tools that stratify an individual’s risk of suicide or self-harm.

Key findings Most people had positive experiences when dealing with healthcare staff but overall coordination of care and information about it was lacking Many people said their health and needs affected their mental health and made them feel lonely Many people weren’t involved in decisions about care and treatment and were sceptical about patients becoming partners in future Many people struggled to contact the service they needed and faced long waits for an appointment Some people struggled to get any help or support at all for their health and care needs Remote consultations work for some people, but more said they preferred face-to-face appointments

Key recommendations A commitment to a properly funded plan to enable general practice to respond to surges in demand as they occur. Investment in GP practices’ IT and telephone systems, and the support they need to implement upgrades. The urgent roll-out of new and improved, properly funded retention schemes that halt the decline in the GP workforce. A reduction in unnecessary box ticking requirements and unnecessary workload to free up GPs’ time for patient care. A new public education campaign designed by patients and healthcare professionals to advise patients when and how to self-manage illness and when to access general practice or other services.

Key findings National Hip Fracture Database (NHFD) The number of hip fractures changed very little during the pandemic, so this is an ideal marker of the pandemic’s impact on the care of frail and older people and shows how successive waves of Covid-19 affected outcomes (mobility, return home, length of stay and mortality) in Wales. National Audit of Inpatient Falls (NAIF) There were approximately 12,500 inpatient falls in 2021. These led to: over 195 hip fractures loss of confidence and slower recovery distress to families and staff litigation against health boards. Fracture Liaison Service Database (FLS-DB) Based on 1,956 fragility fractures in 2020 and 2,033 fragility fractures in 2021, the number receiving FLS assessment within 12 weeks was similar in 2020 and 2021 (64% and 65% respectively). Recommendations Local health boards should ensure that they have appointed an orthogeriatrician and that they actively support their leadership of multidisciplinary care in each trauma unit. Local health boards should ensure that falls teams in acute, community and mental health hospitals are included in quality improvement activities and are using the data from the National Audit of Inpatient Falls. With falls teams reviewing health board level data and implementing focused quality improvement interventions should help improve the quality and safety of care in hospitals. Health boards without an FLS should contact the Royal Osteoporosis Society and use their implementation toolkit to support them in preparing a business case. Health boards that already have an FLS should ensure it is actively participating in the FLS-DB, and meeting its expected outcomes as defined by the FLS-DB’s set of KPIs.

Key findings Adult asthma: 0.4% died within 30 days of admission to hospital, 0.8% within 90 days COPD: 6.1% died within 30 days of admission, 11.9% within 90 days.