Rise in serious incident investigations at Shropshire hospitals is 'opportunity for learning'

By Lisa O'Brien | Shrewsbury | Health | Published:

Hospital bosses say they have “reviewed the threshold” at which serious incidents are investigated at their sites to allow the opportunity for staff to learn from them.

Dr Edwin Borman

Eight serious incidents were recorded by The Shrewsbury and Telford Hospital NHS Trust (SaTH) in December – one which involved an agency nurse being suspended following an 'unexpected death'.

It is understood an investigation is under way into what happened.

In December 2018, three serious incidents had been recorded by the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal Hospital.

Dr Edwin Borman, director for clinical effectiveness at SaTH, told a board meeting on Thursday that there had been a recent rise in the number of serious incident investigations for a reason.

He said: "It's related to the way we are exploring and investigating serious incidents."

Dr Borman said there had been "a review of the threshold for investigation".

He said a decision had been made that it is better to declare an investigation into a suspected serious incident so it can be fully scrutinised.

The choice is then made afterwards about whether an incident should be downgraded from 'serious' or not.



Dr Borman added: "It allows us to investigate in detail more cases, hence learn from more cases."

In his report to the trust board, Dr Borman said the rise in cases being reviewed by the patient safety team, combined with staff shortages within the team, had also brought about its own challenges.

These include assigning the appropriate investigating officers so that investigations are completed in a timely way.


He adds: "In addition, a number of complex cases have required particularly detailed investigation, with external expert engagement, further challenging the current resources of the team.

"A business case is being developed, in order to ensure that the team is appropriately resourced and the trust is able to focus on learning more fully from clinical incidents."

Other serious incidents recorded by the trust in December related to maternity services, a fall, delayed diagnosis and a treatment delay.

In another report to SaTH's board, Brian Newman, acting chair of the quality and safety committee, said an internal investigation into the death of a patient while receiving renal dialysis at Royal Shrewsbury Hospital in October had been completed by Dr Borman and the serious incident has been reported to the appropriate authorities.

An inquest is to be carried out at a later date.

It was previously reported that the man died through blood loss when a venous port became disconnected.

Lisa O'Brien

By Lisa O'Brien
Senior Reporter - @lisaobrien_Star

Senior reporter based at Shropshire Star's head office in Ketley. Covering the Telford area.


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