Quality report 2021-2022

Patient Safety Incidences The Christie is regarded nationally as a high reporting, low harm organisation. The Trust uploads information about its patient safety incidents into the National Reporting and Learning System (NRLS) on a monthly basis. Twice yearly reports are published and made available into the public domain by the NRLS, based on the incidents submitted by the Trust. In addition, monthly updates are published on the NHS Improvement website. The Christie has a small number of in-patient beds, compared with other hospitals, and over 95% of its activity is ambulatory care (out-patients and day cases).

Patient Safety Incidences

1000 1500 2000 2500 3000 3500 4000 4500 5000

4635

3675

3235

2887

2777

2037

1347

873

814

0 500

41

36

23

8

4

2

0

0

0

Low

Moderate

Total

No harm

Severe

Death

2019/20 2020/21 2021/22

There has been an increase in reported patient safety incidents in 2021/22. This is in line with increased activity following the pandemic as well as changes to internal reporting, triage processes and national reporting requirements. 3.4.4 Serious Incidents There were 7 serious incidents reported this year. These related to: • A patient who contracted Covid-19 as an inpatient and subsequently sadly died* • Unexpected death following an ascitic drain insertion* • Missed opportunity to clinically review an outpatient • There was a potential missed opportunity to identify anaphylaxis** • There was a potential missed opportunity to arrange a clinical review when they telephoned The Christie Hotline** *The serious incident panel concluded that these incidents did not meet the definition of a serious incident ** Serious incident investigation in progress 3.4.5 Duty of Candour We have a Duty of Candour policy which is based on the requirements of Regulation 20 of the Health and Social Care Act and evidence gained from national data regarding recommendations from major inquiry reports, government initiatives and the experience of other countries. • A delay in transferring a patient with signs of acute stroke* • Unexpected death following an oesophageal stent insertion*

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