The Christie NHS FT Annual Report & Accounts 2019-20

The Christie NHS Foundation Trust Annual Report & Accounts 2019-20

Serious Incidents There were two serious incidents reported this year. These related to:

Wider excision of incorrect scar*

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• Unintentional ABO-incompatible transfusion of red cells

*Stepped down from a Never Event following serious incident panel review **Private patient, joint investigation with The Christie Private Clinic

Serious incident panels are chaired by a Non-Executive Director and also comprise of two Executive Directors. The panel reviewed each of these incidents, for which lessons learned were identified and implemented.

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. Each incident handler is asked to ensure that a Duty of Candour conversation happens within ten working days for each patient safety incident graded 3, 4 or 5. The handler may arrange for a more appropriate person to talk with the patient or their family, for example the consultant or a senior nurse. Information from this initial discussion is taken account of within the incident investigation and the person undertaking the Duty of Candour keeps in touch with the patient or their family as appropriate during the investigation. At the end of the investigation, feedback is given on the outcome which will include any learning that has been identified. Never Event There has been 1 never event in 2019/20

• Unintentional ABO-incompatible transfusion of red cells

Pressure Ulcers We aimed for no category 3 or 4 pressure ulcers and a threshold of no more than 30 category 2 hospital acquired pressure ulcers in 2019/20. The chart below demonstrates that we ended the year

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