Serious incidents
The Trust saw a 72% increase in serious incidents declared in the 2022/23 financial year compared with the previous year. This was due to another year with huge operational pressures on the health and social care system, leading to increased response times to our patients.
The Trust continued to use the action plan to improve all elements which contributed to response delays within its control. This action plan has been reviewed several times to ensure appropriate actions remain in place. A key aspect of the action plan was to continue the close working relationship between EEAST and its system partners. One product of this collaborative approach was the development of a framework for each local system to investigate incidents together where treatment delays have caused harm, allowing for an end-to-end review of a patient’s care. Four Integrated Care Boards are working with EEAST to review system serious incidents.
The key themes of serious incidents, with a comparison to the three previous years, are contained within the table below.
| 2019/20 | 2020/21 | 2021/22 | 2022/23 | |
| Delay | 13 | 9 | 114 | 214 |
| ECAT / AOC | 8 | 1 | 8 | 12 |
| Patient injury | 4 | 7 | 8 | 3 |
| Clinical treatment | 9 | 5 | 11 | 18 |
| Non-conveyance | 13 | 18 | 17 | 21 |
| Equipment failure | 1 | 0 | 1 | 1 |
| Other | 3 | 0 | 2 | 8 |
| Total | 51 | 40 | 161 | 277 |
With the commitments to treat more patients in the community, an important piece of learning from a thematic review of non-conveyance serious incidents, was the introduction of a non-conveyance care bundle. This is designed to improve the safety of patients who are discharged from EEAST’s care to another part of the healthcare system.
The organisation developed an electronic auditing tool to sit alongside the care bundle which has allowed continuous monitoring of its use and identify focused areas of improvement to further improve the safety and experience of patients not needing hospital treatment. This piece of work is continuing to be developed and monitored by the Patient Safety Team into 2023/24 with further training planned to be rolled out.
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