AH ANNUAL REPORT 2018

• A Data Quality dashboard is embedded within our
Data Quality Process which includes key data items
from throughout the patient pathway, to monitor data
quality and facilitate improvement
• Workshops and refresher training sessions arranged
to ensure staff are fully aware of the importance of
Data Quality and the integrity of the data is accurate
at source
• The annual audit plan has covered a number of
patient checks including
- A&E waiting times
- Demographic changes
- Missing NHS numbers
- 18 weeks Referral to Treatment (RTT) & Outcomes
- Duplicate registrations
- Ethnicity monitoring
- Pathway starts
- GP checks
2.2.9 Information Governance (IG)
Toolkit Attainment Levels
Alder Hey’s Information Governance Assessment
Report overall score for 2017/18 was 76% and was
graded as ‘satisfactory’ (green). Additionally, the Trust’s
internal auditors assessed compliance with the IG
Toolkit and reported ‘significant assurance’.
2.2.10 Clinical Coding Error Rate
Alder Hey Children’s NHS Foundation Trust was
required to undertake an Information Governance
Toolkit audit during the reporting period; the error rates
reported in the latest published audit for that period for
diagnoses and treatment coding, i.e. clinical coding,
were:
• Primary Diagnoses Incorrect 4.5%
• Secondary Diagnoses Incorrect 19%
• Primary Procedures Incorrect 7%
• Secondary Procedures Incorrect 10%
The results should not be extrapolated further than the
actual sample audited and the services audited during
this period included:
• 200 Random Finished consultant episodes
2.2.11 Learning from Deaths
During the period 1st April 2017 to 31st March 2018, 65
inpatients died. This comprised the following number of
deaths which occurred in each quarter of that reporting
period:
• 18 in the first quarter;
• 16 in the second quarter;
• 17 in the third quarter;
• 14 in the fourth quarter.
By 1st April 2018, 39 case record reviews and two
investigations have been carried out in relation to the
65 deaths included in the previous paragraph. Whilst
many adult trusts only conduct mortality reviews on
cases where deaths are unexpected or flagged through
an incident, it is the policy of Alder Hey that all inpatient
deaths are reviewed.
In two cases a death was subject to both a case record
review and an investigation. The number of deaths
in each quarter for which a case record review or an
investigation was carried out was:
• 18 in the first quarter;
• 14 in the second quarter;
• 7 in the third quarter;
• 0 in the fourth quarter (due to be completed in the
coming period)
None (representing 0%) of the patient deaths during the
reporting period are judged to be more likely than not to
have been due to problems in the care provided to the
patient.
These numbers have been estimated using the
mortality review process established in Alder Hey
Children’s NHS Foundation Trust. Every child that dies
in the Trust has a Hospital Mortality Group review (a
group consisting of professionals from across the Trust
and specialties) and usually at least one departmental
review prior to this.
Although there were no avoidable deaths in the
reporting period over this time, that have been reviewed
so far, the Trust has continued to learn from our
mortality process and instituted appropriate changes
(even though the issue addressed by the change
was not thought to have contributed to the patient’s
death). In our process, we also identify external factors
impacting on the children who then die in the Trust.
As part of its process, the Hospital Mortality Review
Group identifies children who, with early intervention
or education, may not have died. Of course, such
factors are also examined by multi-agency Child Death
Overview Panels (CDOP). External factors impacting
on children that then die at Alder Hey include external
traumatic incidents which could have been avoided
(in which circumstances the conclusion of HMRG
is that death could have been prevented). This is
classed as an example of a ‘potentially modifiable
factor’. This is also highlighted by co–sleeping resulting
in a SUDI (sudden unexplained death of an infant).
There is currently a campaign ongoing in Merseyside
highlighting the risks of co-sleeping that should impact
on the SUDI presentations
Alder Hey Children’s NHS Foundation Trust 102
Annual Report & Accounts 2017/18