Public Board of Directors papers 27.01.22

This section of the strategy sets out how the systematic triangulation and analysis of aggregated data can be used to minimise the risk of a recurrence and underpin the trust’s commitment to improving safety by learning and sharing lessons. Root cause analysis can be used on aggregated incidents, complaints, PALS information and claims in order to analyse the trends and identify changes in practice. The following routine reports will be written and circulated as set out below. 14.1 Monthly report to Board of Directors and Management Board This report contains as a minimum: • Total number of patient safety incidents in the previous month where harm was sustained • The number of serious incident panels held in the preceding month • The number of Never Events that happened in the preceding month • Number of complaints per month and by year • Number of complaints relating to care and treatment • Number of PALS contacts per month • Number of claims by month and by year and the value of any payment made in the preceding month • A summary of the incidents pertinent to patient safety that were subject to an executive review in the preceding month • The number of inquests and the inquest finding 14.2 Quarterly aggregated patient safety & experience report This report is presented to the Risk and Quality Governance Committee, the Patient Safety Committee, the Patient Experience Committee, the Clinical and Research Effectiveness Committee, and The Quality Assurance Committee. It contains as a minimum: Methodology – How the data has been collated and produced and will indicate if any specific topics/themes were looked at during the collation of data. These may be identified in response to specific requests or concerns from executive directors or senior managers within the trust. Any difficulties or anomalies in the data collection should be explained if possible. Quantitative analysis – Numerical data • Number of patient safety incidents and type • Number of staff and others safety incidents and type

• Incidents by category • Incidents by severity • Learning from incidents

• Breakdown of complaints by division • Number of new and ongoing claims • Number of PALS contacts • Clinical audit outcomes • Status of implementation of NICE publications

Qualitative analysis – A discussion of the ‘deep dive’ review of issues highlighted in the preceding quarterly report that has been presented to the relevant Trust committee for consideration, for example • An increase in particular incident trends or incidents occurring in a particular location • Issues raised in complaints or PALS contacts, this report to be commissioned at the Patient Experience Committee • Breakdown of issues raised in claims

Risk management strategy and Policy 2021-2024 Document ref: RM01 Version 04

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