Quality Account 2010/11 - James Paget University Hospitals

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Case Study: Health Service Ombudsman During 2010/11 five cases were referred to the Health Service Ombudsman for review. None were accepted for investigation. However, one complaint was upheld and investigated by the Ombudsman in 2010 although it was reported in 2009. The Trust received a complaint from the relatives of a lady who was taken ill whilst on holiday in the area. She attended a local GP who telephoned our Emergency Assessment and Discharge Unit (EADU) for advice as this lady had a rare congenital disorder. The Consultant gave advice over the telephone that the patient should see her specialist on her return home. The patient returned home immediately but passed away the next day. The family complained and stated the patient died because she was not admitted to hospital for assessment. The case was referred to the Health Service Ombudsman who investigated the complaint and the complaint was upheld, as the Trust was unable to provide sufficient evidence of the conversation between our consultant and the GP on the telephone. As a result of the Ombudsman’s report into this complaint the Trust developed an action plan to prevent a similar occurrence in the future. This included: Telephone Advice: The Trust had no information on the patient because it was a telephone enquiry for advice which had not been documented in EADU. The patient was on holiday and therefore had no hospital notes. The Trust now utilises the EADU referral forms to document telephone advice given to GP's which are retained on the unit. The Trust now ensures that when GPs telephone the unit they are given advice regarding what to do if a patient deteriorates, including a reminder that GPs are able to admit directly to EADU if they are concerned. The Trust accepted the Ombudsman’s recommendations and a copy of the action plan was shared with the family, together with an apology. A number of complaints were received by the Trust throughout February and March 2011, which resulted in some negative media reports, where the standard of care at the Trust was being questioned. Maintaining the reputation of the Trust, our staff and the services we provide is a priority at all times. We have, where possible, provided accurate information to the media without compromising patient confidentiality. We have also acknowledged where mistakes have been made, apologised where appropriate and agreed on ways forward to resolve the issues. We have also received many positive comments and compliments from users of our services via thank-you cards, letters, emails and correspondence on the NHS Choices website: “What impressed me most was that I was treated as an individual.” “Throughout I was nursed with care and compassion.” “Thanks for everything. I could not have wished for better treatment. The staff were great, all of them. The Food was excellent. The bed was very comfortable. The level of care un-surpassable.” James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 54 of 62
PALS The Patient Advice and Liaison Service (PALS) supports patients, relatives, carers and members of the public who need information about the healthcare system. They deal with general enquiries about the healthcare services available, resolve problems by identifying the right people to talk to and explain how to make a complaint if a concern is unresolved. During 2010/11 there were 806 enquiries via PALS, as demonstrated by the graphs below. 100 90 86 PALS Enquiries 10/11 01.04.10 to 31.03.11 (Total Number = 755) 80 80 Number of Enquirers 70 60 50 40 56 64 67 61 63 60 38 48 65 67 30 20 10 0 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Month and Year Case Study 4: Patients and visitors raised with PALS the lack of staff available at lunchtimes to give help to patients (to encourage patients with confirmed dementia/or the inability to eat their main hot meal). Family members sometimes cannot attend during the week, due to work or family commitments, and the staff do not always have the time to assist all the patients who require one on one support at lunchtimes. With this in mind we decided to have mealtime service providers that are given training and liaise with the sister on the ward to find out which patients need encouragement or some help. Patients who require assistance at mealtimes have red jugs and red trays so they can be easily identified. We now have a strong team of nine volunteers that attend at lunchtimes Monday – Friday and are in the process of recruiting more meal time helpers. This will improve the wellbeing of our patients by stimulating and encouraging them to eat their main lunchtime meal. This aids a quicker recovery and makes the patient’s journey through the hospital that little bit easier for them and their families. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 55 of 62
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James Paget University Hospitals NH
Page 4 and 5:
Contents Page Foreword by Chief Exe
Page 6 and 7: The old and the very young are know
Page 8 and 9: Statement of directors' responsibil
Page 10 and 11: Current position: Patient Falls 120
Page 12 and 13: Priority 1b: Patient safety - Reduc
Page 14 and 15: Five work streams have been agreed
Page 16 and 17: No Commissioning for Quality and In
Page 18 and 19: No Commissioning for Quality and In
Page 20 and 21: The services provided by James Page
Page 22 and 23: Clinical Audits Audit Name Applicab
Page 24 and 25: (NHSBT UK Transplant Registry) Audi
Page 26 and 27: Case Study 2: Upper Gastrointestina
Page 28 and 29: The Trust has a dedicated lead for
Page 30 and 31: NHS number and GMC code validity Ja
Page 32 and 33: What others say about the Trust Car
Page 34 and 35: Current Position: Inpatient Pressur
Page 36 and 37: Metric 3 - Venous Thromboembolism (
Page 38 and 39: Monthly CVC BSI Rates 14 12 Rate of
Page 40 and 41: Metric 8 - Nutrition & Hydration Ma
Page 42 and 43: Patient Safety Incidents As at 18 t
Page 44 and 45: Never Events Never Events are serio
Page 46 and 47: Existing Commitments and National P
Page 48 and 49: Patient Experience National In-pati
Page 50 and 51: An action plan has been developed f
Page 52 and 53: Maternity National Survey The respo
Page 54 and 55: Question Area Conclusions Recommend
Page 58 and 59: Patient Experience Measures Patient
Page 60 and 61: • 100 Key Scores Comparison 90% 8
Page 62 and 63: NHS Great Yarmouth & Waveney NHS Gr
Page 64: Glossary of Abbreviations A&E C dif
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Quality Account 2010/11 - James Paget University Hospitals

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