Public Board of Directors papers 27.01.22

1. Safe

1.3 – Moderate+ Incidents

December 2021 Reference

Grade

Description

Outcome

Patient died within 48 hours of a palliative surgical procedure. Known complication but unintended consequence of surgery

Clinical impact directly attributable to death unknown at present. Review of unintended event via surgical mortality and morbidity process.

W66990

Death

Out-patient fall; patient attending the hospital for radiotherapy treatment fell getting out of a taxi. Patient sustained a fracture neck of femur.

Clinical impact; unable to complete the further 16 fractions of radiotherapy. Will require further assessment for treatment in 3 weeks following rehabilitation period. Reported to StEIS.

W66528 2021/24963

Major

Clinical impact; required immediate intervention and a further day case surgical procedure. Review of unintended event via surgical mortality and morbidity process.

W66445

Moderate Ureteric injury as a known complication but unintended consequence of surgery.

W66450

Moderate Failure to arrange a clinic appointment and further scan for a patient following MDT discussion in April 2021.

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

Letter explaining requirement for adjuvant treatment never reached patient or GP. 10 month delay commencing treatment. Emergency procedure required following a surgical procedure. Known complication but unintended consequence of surgery

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

W66462

Moderate

Clinical impact; return to theatre for emergency procedure and re-admission to critical care unit. Review of unintended event via surgical mortality and morbidity process.

W66992

Moderate

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