Patient safety incident response plan

This Patient Safety Incident Response Plan sets out how University Hospitals Plymouth NHS Trust (the Trust) intends to respond to patient safety incidents over a period of 12 to 18 months. The plan is not a permanent rule that cannot be changed. We will remain flexible and consider the specific circumstances in which patient safety issues and incidents occurred and the needs of those affected.

University Hospitals Plymouth NHS Trust is responsible for providing care across the widest of spectrums: from within people’s homes and working with our voluntary sector partners in local communities, to offering the most specialist hospital care available in our regional centre. 

The South West peninsula geography gives our Trust a secondary care catchment population of 475,000 with a wider peninsula population of almost 2,000,000 people who can access our specialist services. The population is characterised by its diversity – the rural and the urban, the wealthy and pockets of deprivation, and wide variance in health and life expectancy. 

University Hospitals Plymouth NHS Trust is a specialist teaching hospital in partnership with the University of Plymouth and working with Plymouth Marjon University. As host to the Joint Hospital Group South West (JHG(SW)) in a city with a strong military tradition, we have a tri-service staff of nearly 200 military doctors, nurses and allied health professionals who are fully integrated within our facilities.

University Hospitals Plymouth NHS Trust provide services for patients at the following main sites as well as through clinics at other hospitals and care centres. 

Derriford Hospital

Derriford Hospital is the largest specialist teaching hospital in the South West peninsula and the region’s major trauma centre. Our staff offer a range of specialist services including:

• Immunology

• Kidney transplant

• Pancreatic cancer surgery

• Neurosurgery

• Cardiothoracic surgery

• Bone marrow transplant

• Upper Gastro-intestinal surgery

• Hepatobiliary surgery

• Neonatal intensive care and high-risk obstetrics

• Plastic surgery

• Liver transplant evaluation

• Stereotactic radiosurgery

 

Royal Eye Infirmary

A dedicated specialist site for ophthalmology services.

 

Mount Gould Hospital

We have 30 beds for general rehabilitation plus 15 beds for stroke rehabilitation patients. Our Discharge Assessment Unit (opened on 03 April 2023) has 40 beds available.

 

South Hams Community Hospital

We have 15 beds here and began managing the site in 2021.
 

Tavistock Hospital

We have 13 beds here and began managing the site in 2021.
 

Urgent Treatment Centre and Minor Injuries Units

We run an Urgent Treatment Centre at the Cumberland Centre in Devonport, central Plymouth and minor injury units in Tavistock and Kingsbridge.
 

Child Development Centre

Developmental services for young children are provided at the Child Development Centre, Scott Business Park.
 

The Plymouth Dialysis Unit

Patients needing treatment for renal failure are cared for in state-of-the-art, purpose-built facilities in Estover.

 

Radiology Academy

The Plymouth Radiology Academy is the only purpose-built Radiology Academy in the world and provides an inspirational environment in which to learn radiology.

The Trust has a continuous commitment to learning from patient safety incidents. PSIRF sets no rules or thresholds to determine what needs to be learned from to inform improvement apart from the national requirements listed on Page 9. To fully implement the Framework, the Trust has completed a review of what types of patient safety incident occur to understand what needs to be learned from to improve. 

The Risk & Incident team engaged with key stakeholders, both internal and external and undertook a review of data from various sources to arrive at a safety profile. This process has also involved identification and specification of the methods used to maximise learning and improvement. This has led to the development of the local focus of our incident responses listed on Page 12. 

The Risk & Incident team commenced planning for PSIRF upon release of national documents in August 2022. We have consulted extensively with several PSIRF early adopters to enable us to understand the practicalities of planning for and implementation of PSIRF and their assistance has been invaluable. 

We are conscious that PSIRF requires a very different approach to the oversight of patient safety incidents. Therefore, the Trust have connected with those leading PSIRF implementation in the Integrated Care Board (ICB), Academic Health Science Network (AHSN) and Patient Safety Collaborative (PSC) and will continue to maintain these links to keep abreast of programme structure and support offered through the National Patient Safety Team.

An initial series of engagement meetings were held from August 2022 onwards with key stakeholders from various disciplines to outline the impact PSIRF may have and to begin to explore the nature of incidents reported, what processes are in place to currently manage and revise these and what such reviews might look like under PSIRF. 

A range of key stakeholders (including internal Care Groups, Corporate teams, Patient Safety Partner, Specialist Advisors and Quality & Safety team colleagues from NHS Devon ICB) attended a UHP PSIRF Planning Away Day on Thursday 11th May 2023, facilitated by the Southwest Academic Health Science Network (AHSN). The aim of the session was to set out how UHP will seek to learn from patient safety incidents reported by staff, patients, and their families/ carers as part of our work to continually improve the quality and safety of the care we provide.

Attendees were requested to undertake their own thematic analysis together and facilitated break-away sessions allowed the group to triangulate a range of data sources together with less ‘number-focussed’ sources of intelligence. Any Trust-wide improvement work already underway was also incorporated to make an assessment as to whether these programmes of works were demonstrating the necessary impact.

To define our patient safety response profile, we drew data from a variety of sources that had taken place over the period of 5 years (from 2018 onwards). We decided to look at these 5 years to minimise the possibility of any variation in data arising from the COVID-19 pandemic. 

The PSIRF Planning Away Day considered the feedback and information provided by key stakeholders as part of our data collation process. Data and information (both qualitative and quantitative) were received from the following sources:

• Patient Safety Incidents reported to Datix (the Trust’s Local Risk Management System)

• Learning Response Reports (formerly known as RCAs)

• Complaints and PALS contacts

• Patient survey data

• Inquests and Claims

• Learning from Deaths through Mortality data

• Safeguarding reviews

• Reports from external bodies (e.g. Care Quality Commission and Royal Colleges)

• Trust risk register

• Freedom to Speak Up reports

• Staff survey results

• Trust Corporate Risk profile

• Key themes identified from specialist Safety & Quality Committees. 

Where possible we considered what any elements of the data tell us about inequalities in patient safety. As part of our Away Day, we also considered any new and emergent risks relating to future service changes and changes in demand that the historical data does not reveal. The Away Day concluded with a list of local Trust safety priorities being proposed.   

University Hospitals Plymouth NHS Trust has a comprehensive programme of patient safety improvement, which is underpinned by our Quality and Safety Strategies and supported by an active Quality Improvement programme, led by our Quality Academy. We will also continue to draw on guidance and feedback from national and regional level NHS bodies, regulators, commissioners, partner providers and other key stakeholders to identify and define the quality improvement work we need to undertake.

Over a number of years, the Trust has developed its governance processes to ensure that improvement actions are grounded in evidence and impactful, and that improvements are embedded and sustained. 

We have drawn a listing of improvement work currently underway within the Trust. This can be found in Appendix B. This list is not exhaustive but is representative of the work commissioned through our existing Quality and safety Strategies. UHP encourages a culture where our staff are able to undertake improvement work when opportunities are identified and as such, there are many improvement projects being undertaken that are not captured here. 

We plan to focus our efforts going forward on development of safety improvement plans across our most significant incident types either those within national priorities, or those we have identified locally. We will remain flexible and consider improvement planning as required where a risk or patient safety issue emerges from our own ongoing internal or external insights. 

Some events in healthcare require a specific type of response as set out in policies or regulations. These responses include mandatory patient safety incident investigation (PSII – called Learning Responses within UHP) in some circumstances or review by, or referral to, another body or team depending on the nature of the event.

Incidents meeting the Never Event criteria (2018) or its replacement, and deaths thought more likely than not to have been due to problems in care require a locally led Learning Response.

The table below sets out the local or national mandated responses. AS UHP does not directly provide mental health or custodial services, it is more likely that the organisation will be a secondary participant rather than a lead for those incident types.

Event	Action required	Lead body for the response
Deaths thought more likely than not due to problems in care	Locally led Care Group investigation	UHP
Deaths of patients detained under the Mental Health Act (1983) or where the Mental Capacity Act (2005) applies where there is reason to think that the death may be linked to problems in care	Locally led Care Group investigation	UHP
Incidents meeting the Never Events criteria 2018	Locally led Care Group investigation	UHP
Mental health-related homicides	Referred to the NHS England Regional Independent Investigation Team (RIIT) for consideration for an independent Learning Response Locally led Learning Response may be required	As decided by RIIT
Maternity and neonatal incidents meeting Maternity & Newborn Safety Investigations (MNSI) criteria or Special Healthcare Authority (SpHA) criteria when in place	Refer to MNSI or SpHA for independent Learning Response	MNSI (or SpHA)
Child deaths	Refer for Child Death Overview Panel review Locally led Care Group Investigation (or other response) may be required alongside the panel review	Child Death Overview Panel
Deaths of persons with learning disabilities	Refer for Learning Disability Mortality Review (LeDeR) Locally led Care Group Investigation (or other response) may be required alongside the LeDeR	LeDeR programme
Safeguarding incidents in which: Babies, children, or young people are on a child protection plan; looked after plan or a victim of wilful neglect or domestic abuse/violence Adults (over 18 years old) are in receipt of care and support needs from their local authority The incident relates to FGM, Prevent (radicalisation to terrorism), moder slavery and human trafficking or domestic abuse/violence	Refer to Local Authority Safeguarding Lead via UHP named Safeguarding Children/Adults Lead UHP will contribute to domestic independent inquiries, joint targeted area inspections, child safeguarding practice reviews, domestic homicide reviews and any other safeguarding reviews (and inquiries) as required to do so by the local safeguarding partnership (for children) and the local safeguarding adults boards	Safeguarding team
Incidents in NHS screening programmes	Refer to local screening quality assurance service for consideration of locally led learning response	The organisation in which the event occurred
Deaths in custody	Any death in prison or police custody will be referred to the Prison and Probation Ombudsman (PPO) or the Independent Office for Policy Conduct (IOPC) to carry out the relevant investigations. UHP will fully support these investigations where required to do so.	PPO or IOPC
Domestic homicide	A domestic homicide is identified by the policy usually in partnership with the community safety partnership (CSP) with whom the overall responsibility lies for establishing a review of the case.	CSP

 

Beside the Incident types referred to MNSI, there will be various other known incident types, areas of risk or safety concerns within maternity services, as well as the potential for new and under-recognised issues to emerge. These incidents will be reviewed in line with the Trust’s PSIRF Process map (found within the Policy in Appendix A) and will be escalated to the Patient Safety Incident Response Group if necessary. Planning and implementation of PSIRF within maternity services has involved maternity governance teams.

PSIRF allows organisations to explore patient safety incidents relevant to their context and the populations served. Through our analysis of patient safety insights during our PSIRF Planning Away Day we have determined 10 patient safety priorities with 5 identified as requiring a Patient Safety Incident Investigation (PSII), known locally as a Learning Response. These are areas where patient safety risk is known to exist, and it is judged that a series of local targeted Learning Responses will deliver learning and improvement. 

A systems-based approach to learning will be taken, exploring the work systems and processes through reviewing reported incidents, engaging with subject experts, talking to those involved, observations and other quality pillars. Repeat responses will be avoided when sufficient learning is available to enable the development and implementation of a safety improvement plan. We will use the outcomes of Learning Responses to inform our patient safety improvement planning and work.

 

Patient safety improvement plan

Patient safety incident type or issue	Planned response	Anticipated improvement route	Update February 2025
Medicines safety - Incidents relating to missed doses of critical medications resulting in serious harm to the patient	Learning Response Learning Response applied because contributory factors are not well understood and local improvement work is minimal, providing the greatest potential for new learning and improvement.	Create local organisational recommendations and actions and feed these into the Quality Improvement strategy via the Care Delivery Group (CDG).	Learning Response commissioned and scope agreed 23/01/2025.
Discharges - Incidents of premature/ unsafe discharges whereby patients require unplanned readmissions and have led to increased morbidity and mortality.	Learning Response Learning Response applied because contributory factors are not well understood and local improvement work is minimal, providing the greatest potential for new learning and improvement.	Create local organisational recommendations and actions and feed these into the Quality Improvement strategy via the Care Delivery Group (CDG).	Appreciative Inquiry undertaken, presented to Trust Management Board (TMB) September 2024. Further review by Care Groups into discharge processes and safety, presented to TMB January 2025.  Further review undertaken January 2025 and presented to Clinical Quality Review Group.  Programmes initiated to support safe discharge as a result include: PAPER PSIRG and TMB will continue to keep under review with a particular focus on safety and experience.
Sub-speciality working - Incidents affecting inpatients where the care of the patient is being managed between two or more clinical specialities and the management of the care has resulted in the patient having an extended length of stay or requiring additional treatment/ surgery.	Learning Response Learning Response applied because contributory factors are not well understood and local improvement work is minimal, providing the greatest potential for new learning and improvement.	Create local organisational recommendations and actions and feed these into the Quality Improvement strategy via the Care Delivery Group (CDG).	Initial improvement of the number of incidents reported as a result of ongoing trust work.  Learning Response as yet to be undertaken, but this is kept under review under PSIRG to assess ongoing relevance.
Deteriorating patients - Incidents where the assessment of the patient was delayed and timely recognition of deterioration through effective monitoring and actions taken to escalate did not occur	Learning Response Learning Response applied because contributory factors are not well understood and local improvement work is minimal, providing the greatest potential for new learning and improvement.	Create local organisational recommendations and actions and feed these into the Quality Improvement strategy via the Care Delivery Group (CDG).	Learning Response commissioned and scope agreed 23/01/2025.
Capacity, flow, and resource implications - Incidents of system-wide failure causing crowding within the Emergency Department and delayed transfers from ambulances with consequential delays.	System-wide Learning Response	Create local organisational recommendations and actions and feed these into the Quality Improvement strategy via the Care Delivery Group (CDG).	Multiple workstreams initiated across the system. No additional learning anticipated through a Learning Response.
Falls - Inpatient falls resulting in a fractured neck of femur or haemorrhage.	Immediate Safety Review (ISR) Huddle It is acceptable not to undertake a further learning response to these incidents.  UHP and NHS Devon ICB are satisfied risks are being managed, improvement work is ongoing to address known contributory factors and efficacy of safety actions are being monitored.	Inform ongoing improvement efforts by Falls Steering Group	Improving position.
Pressure Ulcers - Hospital Acquired Pressure Ulcers Category 3 and 4.	Immediate Safety Review (ISR) Huddle It is acceptable not to undertake a further learning response to these incidents.  UHP and NHS Devon ICB are satisfied risks are being managed, improvement work is ongoing to address known contributory factors and efficacy of safety actions are being monitored.	Inform ongoing improvement efforts by Pressure Ulcer Steering Group	Initially improved position, this deteriorated following national changes in reporting. As a result further assurances sought through an Appreciative Inquiry requested February 2025.
Diagnostics - Incidents relating to diagnosis; specifically delay or failure to follow-up on abnormal scan/test results	Immediate Safety Review (ISR) Huddle It is acceptable not to undertake a further learning response to these incidents.  UHP and NHS Devon ICB are satisfied risks are being managed, improvement work is ongoing to address known contributory factors and efficacy of safety actions are being monitored.	Inform ongoing improvement efforts by Radiology Acknowledgement Improvement Programme	Radiology Acknowledgement programme progressing. Number of incidents and risk reducing as a result. Risk remains so will be kept under review.
IT Infrastructure – Incidents whereby a failure to synthesise all available clinical information has led to a delayed/ missed or incorrect diagnosis.	Immediate Safety Review (ISR) Huddle It is acceptable not to undertake a further learning response to these incidents.  UHP and NHS Devon ICB are satisfied risks are being managed, improvement work is ongoing to address known contributory factors and efficacy of safety actions are being monitored.	Inform ongoing improvement efforts by Electronic Patient Record Programme Board	EPR has been procured with implementation plan being led by D&I.
Delays/ Harm on waiting lists – Deterioration of patient condition due to prolonged waits.	Immediate Safety Review (ISR) Huddle It is acceptable not to undertake a further learning response to these incidents.  UHP and NHS Devon ICB are satisfied risks are being managed, improvement work is ongoing to address known contributory factors and efficacy of safety actions are being monitored.	Inform ongoing improvement efforts by Clinical Risk and Long Waits Group and Surgery Care Group Executive Performance Reviews	Kept under review with bi-monthly reports through the Integrated Performance Report to Trust Board.
A patient safety review will always be considered for Patient Safety Incidents that signify an unexpected level of risk and/ or potential for learning and improvement but fall outside the issues or specific incidents described in an organisation’s plan.	To be determined by the Patient Safety Incident Response Group (PSIRG).	Inform thematic analysis of ongoing patient safety risks and use to build case for a new improvement plan.	N/A

 

All local safety priority reviews will be undertaken with a view to remaining at all times patient focussed with the emphasis on quality, whilst being cognisant of operational efficiency and pressures, and ensuring we build on a just and restorative culture. 

For any incident not meeting Learning Response criteria, or any other incident to those listed above, we propose these will be managed at a local level with ongoing thematic analysis via our existing Trust assurance processes which may lead to new or supplement existing improvement work. 

Patient Safety Incident Response Framework (PSIRF) – Replaces the Serious Incident Framework (2015) and is a contractual requirement under the NHS Standard Contract.  PSIRF represents a significant shift in the way the NHS responds to patient safety incidents. The framework sets out the NHS’s approach to developing and maintaining effective system and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.  

Patient Safety Incident Response Plan (PSIRP) – Our local plan sets out how UHP intends to respond to patient safety incidents over a period of 12 to 18 months. Our local safety priorities have been developed through a co-production approach with key stakeholders across the Trust supported by analysis of local data. 

Learning Response Methods:

Immediate Safety Review (ISR) Huddle – Is designed to be initiated as soon as possible after an event and involves an MDT discussion. Staff ‘swarm’ to the site to gather information about what happened and why it happened as quickly as possible and decide what needs to be done to reduce the risk of the same thing happening in future.

Patient Safety Review (PSR) – A method of evaluation that is used when outcomes of an activity or event have been particularly successful or unsuccessful. It aims to capture learning from these to identify the opportunities to improve and increase the occasions where success occurs.
PSR is a structured facilitated discussion of an event, the outcome of which gives individuals involved in the event understanding of why the outcome differed from that expected and the learning to assist improvement. 

PSR generates insight from the various perspectives of the MDT and is based on four questions:

• What was the expected outcome / expected to happen?

• What was the actual outcome / what actually happened?

• What was the difference between the expected outcome and the event?

• What is the learning? 

Appreciative Inquiries – Used to understand key themes of concern, that are not included on the trust’s Patient Safety Incident Response Plan. Involves 3 steps, a data pull, a walk around and a team discussion. Will provide either assurance on the care delivered or identify improvement opportunities. 

Care Group Investigation – Conducted to identify underlying process that impacted an individual event. Used to review individual incidents. Findings are based on improving systems or processes in particular areas. 

Learning Response – Conducted to identify underlying system factors that are considered a high risk to patients.  These findings are then used to identify effective, sustainable improvements by combining learning across multiple events and other responses into a similar incident type. Recommendations and improvement plans are then designed to effectively and sustainably address those system factors and help deliver safer care for our patients.

UHP Improvement programmes

Improvement Programme	Focus
Healthcare Associated Infections	C. Diff to 86 per annum trust wide by 12 months
Falls	Reduction in all falls to 5.28 per 1000 bed days (rolling 12-month figure) or below, trust wide, by 12 months
Hospital Acquired Pressure Ulcers	Category 3 and 4 Hospital Acquired Pressure Ulcers to 1 or below per annum trust wide by 12 months
Mortality	Each service line to have an embedded and functioning Morbidity & Mortality process
	Agreed SJR Process
	Improved and consistent correct Consultant / Specialty identification & coding depth
	Improved oversight of coronial referrals and process
	Strengthening oversight and review of Child Death
	Improve experience for patients and family at end of life
Consent	Each service line to have implemented digital consent in top 3 risk procedures
Clinical Guidelines	Implementation of Health toolbox
	All guidelines accessible through health toolbox
	Guideline oversight process to be agreed
Radiology Acknowledgement	Agreed process for review, acknowledgment and action of radiology reports
	Implementation of a “Radiology Acknowledgment System”
Medication Safety	To reduce the number of medication incidents leading to Moderate or Severe harm by 15% within 12 months
Resuscitation	To develop and implement a Resuscitation improvement strategy to ensure that the provision of resuscitation training and care is in line with Resuscitation Council UK standards
Cellular Pathology	To reduce the number of harm events associated with missed or delayed actioning of significant cellular pathology results
Waiting List Safety	To reduce the number of harms caused by delays to accessing outpatient care
Violence and Aggression	To develop and implement staff and patient charters
	To reduce the use of “Static Security” on our wards
	To reduce the number of incidents where chemical restraint is used inappropriately