Public Board of Directors papers 29.09.22

1. Safe

1.3 – Moderate+ Incidents

August 2022 Reference

Grade

Description

Outcome

W71283

Moderate Patient acquired diabetic ketoacidosis whilst in Hospital.

For RCA investigation

Identified as a known complication of the procedure. Duty of candour completed, will be reviewed through the M+M process.

W71300

Moderate Injury to rectum during elective surgery for endometrial cancer

W71352

Moderate Anaphylactic reaction to Ambisone

Admitted for observation overnight

W71425

Moderate Patient had unwitnessed fall. CT showed subdural bleed.

Patient remained in Hospital for platelet infusions. Undergoing RCA, to return to ERG.

W71483

Moderate Failure in communication about a CT scan finding, which delayed treatment

RCA investigation underway.

W71668/W71670

Moderate Reaction to Systemic Anti-Cancer Treatment

Transferred to OCCU overnight following adrenaline. Discharge home the following day.

W71704

Moderate Referral not actioned, resulting in a delayed review

Patient now booked in for Radiotherapy. RCA investigation underway.

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