We have worked closely with some of our key clients to develop a process for harvesting and recording high quality data from each incident or dispute, such that we can subject the data to analysis, triangulation, and thematic review.

Partner, Richard Greensit leads on this work for Hempsons and it has resulted in him presenting key findings to the Getting it Right First Time (GiRFT) Assurance Board and other governance boards to explore, develop and embed new governance arrangements and clinical practices to prevent future liabilities and patient harm.

Case study

In-depth review of emergency department (“ED”) claims for a major teaching hospital.

The trust’s ED claims had gradually increased to become the largest by volume (reflecting the national picture). One of its strategic aims was to identify learning from past and current claims (as part of its Getting it Right First Time assurance board activities), targeting interventions and changes in process to improve patient experience and safety and reduce the number of claims arising from this significant area of clinical activity.

The trust has a drive towards creating a ‘just culture of safety’ and our expertise and analysis was called upon to support learning.

Analytics

We presented the trust with NHS Resolution’s scorecard data but then applied further detailed data based on our coding matrix, where we identify for each claim granular issues such as:

• grade of personnel involved in the clinical incident
• whether the incident occurred on a weekday, weekend or during a public holiday (when staffing might be an issue)
• in- or out-of-hours
• the clinical specialty
• the specific injuries
• whether there was a complaint and whether any concessions were made in the response
• whether there was an SI or duty of candour investigation and whether either identified substandard care
• whether we have obtained critical or supportive expert evidence
• patient comorbidities
• detailed reasons for the alleged negligence
• whether any admissions of negligence had been made in the claim

How we added to the client’s capabilities

By introducing our own data, we can triangulate specific aspects of the dataset to enable thematic review and draw out insight to support risk management strategies. The trust had no mechanism for recording claims data which could then be triangulated in this way.

Strategic insights

We were able to identify quality insights from the claims profile, including common occurring injuries and the fact that most claims had, against expectations, arisen from in-hours activity, mainly during a weekday; none of which occurred during a public holiday.

As an example of the strategic insights we were able to deliver through this exercise, we identified that 72% of cases where there had been an admission of negligence had not been subject to SI investigation. This suggested that in a proportion of those cases:

• the SI mechanism had either failed to identify a serious incident had occurred at the time, or
• the criteria for initiating an SI investigation was perhaps not sensitive enough to catch cases where negligence had in fact occurred and the patient had come to some harm as a result

This was an important strategic insight for the trust, as it was mindful that the best learning and risk management would come as soon after the clinical incident as possible. It undertook further work around its SI process, specifically in the ED, to understand if any cases had ‘missed’ an SI investigation which ought to have been caught at the time, to recalibrate the system if so and to ensure that there was awareness of the SI process.

The purpose of a Hempsons diagnostic review of legal services is to evaluate work processes, procedures and cultures which support and inform how learning from incidents is captured and used to implement learning and improved patient safety outcomes.

There is a considerable amount of information available across the NHS and within your organisation to support learning from incidents and inform patient safety improvements. All NHS trusts will be very familiar with reports and data aimed at learning produced by Getting it Right First Time (GIRFT), NHS Resolution through their scorecards, HSIB maternity investigations, and CQC reports, to name but a few sources. Your organisation will also produce a significant amount of internal learning data, including incident reporting, mortality reviews, complaints investigations, internal investigation reports and action plans, prevention of future deaths reports from coroners, and claims outcomes.

Despite the considerable amount of data and information produced to inform learning and improve patient safety, do you fully maximise the learning from these different streams? And understand the true extent of risk being carried by your organisation?

All too often we hear that the way in which trust legal, patient safety, complaints and learning teams work in silos, results in missed opportunities for identifying, capturing, evaluating, embedding and evidencing learning opportunities from all available data streams.

Understanding your risk profile and having systems in place to manage all data is more crucial than ever following the publication of the Patient Safety Incident Response Framework (PSIRF), the new framework for investigating patient safety incidents. We go into more detail on this issue in our article: “The Patient Safety Incident Response Framework (PSIRF) has been published”.

To understand whether the internal systems and processes in your organisation support a commitment to learning, and to understand whether your organisation may be carrying underappreciated or unidentified risk, you need to understand:

• how learning from the investigation of adverse incidents, complaints, inquests, and claims is communicated between teams
• what methods are being used for evaluating risk and identifying learning at all stages of legal processes, not just at the time of the incident, or in the event of an inquest
• how you monitor and evaluate ongoing risks, including the identification of themes
• how you support the engagement of staff through internal processes
• candour and how well you engage patients and family or carers, both in terms of sharing outcomes and learning from their experiences
• how you communicate areas of concern and learning outcomes with stakeholders, including coroners, the CQC, and NHS Resolution, to name but a few

Diagnostic reviews

At Hempsons, we are committed to capturing learning from all sources of available data, including learning from incidents. We work with organisations to improve patient safety through diagnostic reviews.

The purpose of a diagnostic review is to evaluate work processes, methods and culture around capturing and implementing learning from all data sources and incidents. Our approach to such a review is holistic.

We work with healthcare providers to understand and evaluate the risk profile of the organisation, and review the processes and procedures within the organisation to ensure that they support a culture of learning. Our reviews inform a diagnostic quality, safety and learning report addressing a range of risk and learning factors such as:

• risk profile of the organisation
• risk being carried by the organisation in terms of public confidence and accountability
• areas of good practice in relation to capturing and embedding learning
• areas where there are missed opportunities to capture and embed learning
• reasons for the missed opportunities to capture and embed learning

Using this analysis, we make recommendations for changes to policies and procedures to support improve the quantity and quality of learning. We also make recommendations for systemic and cultural changes all aimed at making positive and measurable changes to support patient safety.

PSIRF is the new framework for investigating patient safety incidents. It is “a new approach to responding to patient safety incidents” (NHSE).

Replacing the Serious Incident Framework (2015), those organisations delivering care under the NHS Standard Contract should now not only have implemented the new framework, but also overhauled their approach to investigating patient safety incidents (PSIs) in a way which represents a cultural shift. It is the objective of PSIRF to improve the qualitative approach to investigations and learning. The flexible approach seeks to balance investigative resource with implementing and embedding meaningful improvement.

With PSIRF representing a fundamental shift away from prescribed rules of investigation to a flexible system-based approach, relying on local data to support providers in establishing their own improvement priorities, never has it been more important for organisations transitioning to PSIRF to understand their risk profile and improvement priorities.

Our investigation and risk specialists work closely with providers and partners across the NHS on developing processes for harvesting and recording high quality data from incidents and disputes, such that we can subject the data to analysis, triangulation and thematic review to inform and support your organisation transition to PSIRF.

By combining skills in risk analysis and working practices within the NHS through our Risk Analysis Reports and Diagnostic Reviews, Hempsons can support organisations as they face the challenges of:

• understanding their risk profile
• setting improvement priorities
• developing a Patient Safety Incident Response Policy
• developing a Patient Safety Incident Response Plan
• making changes to working practices to sustain the flow of data for maximising patient safety improvements

Our lawyers undertaking clinical risk and investigation work regularly provide training for health and social care providers on a range of investigation and learning matters, including:

• duty of candour
• how to undertake an effective investigation
• report writing
• learning from deaths and adverse incidents
• PSIRF
• understanding risk
• CQC actions and learning
• fundamental standards of care