Public BoD papers 26.5.22

1. Safe

1.3 – Moderate+ Incidents

April 2022 Reference

Grade

Description

Outcome

W69060 2022/7846

Death

Treatment related death within 30 days of SACT.

Progressing to serious incident investigation.

W68911 2022/6969

Clinical impact unknown at present. Patient booked into clinic to discuss treatment options. Progressing to full patient safety investigation

Moderate Lost to follow up for 12 months post first line SACT.

Clinical impact unknown at present. Patient booked into next available clinic. Progressing to full patient safety investigation.

W69020

Moderate Internal surgical referral not acted upon. 5 month delay.

Referral letter to medical oncology consultant never received in 2019 for a patient following wedge resection for lung metastases.

W69059 2022/7851

Moderate

Clinical impact unknown at present. Progressing to full patient safety investigation.

Patient required intubation and ventilation. Review via Critical Care Mortality and Morbidity meeting.

W68859

Moderate A known complication of central line placement occurred (pneumothorax).

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