Government of Jersey

Health and Community Services Quality and Performance report - patient safety (FOI)

Produced by the Freedom of Information office
Authored by Government of Jersey and published on 20 January 2022.
Prepared internally, no external costs.

Request

The Government of Jersey Health and Community Services Quality and Performance Report dated June 2021 quotes data on Patient Safety on page 15.

This states that the number of patient safety incidents during the period June 2020 to June 2021 were 4,412 (four thousand four hundred and twelve) which is alarmingly high.

A
Please provide a breakdown of the nature of the incidents and the numbers involved in each type of incident.

B
How many of these incidents resulted in the death of the patient?

C
During that same time frame, there were 415 complaints received. How many of those related to situations where a patients life was put at risk?

Response

	Jun 2020	Jul	Aug	Sep	Oct	Nov	Dec	Jan 2021	Feb	Mar	Apr	May	Jun	Total
Contractor														8
Employees	47	48	64	45	67	44	64	55	48	48	56	51	56	693
Members of Public/Visitors														24
Organisation	25	33	21	21	24	26	20	10	11	18	13	8	30	260
Patient/Client/Service User	207	303	278	217	275	221	235	207	261	248	277	256	287	3427

Patient/Client Service User broken down by the nature of the incident	Jun 2020	Jul	Aug	Sep	Oct	Nov	Dec	Jan 2021	Feb	Mar	Apr	May	Jun	Total
Access, appointment, admission, transfer, discharge	9	24	25	16	24	27	14	19	35	35	30	26	39	323
Accident that may/did result in personal injury (e.g.- slips, trips, falls, etc..	44	45	47	46	48	29	46	28	46	42	33	44	44	542
Anaesthesia														10
Behaviour/Harassment/Violence/Abuse/Self harm	33	58	59	22	42	37	55	33	34	36	32	21	49	511
Blood Transfusion and Related Problems														54
Clinical Assessment (investigations, images and lab tests)	13	10	13	14	11	11	17	11	7	14	10	5	15	151
Consent, Confidentiality or Communication	15	8	6	9	10	11	6	17		7	14	5	9	117
Diagnosis Failed or Delayed														49
Implementation of Care or Ongoing Monitoring/Review	19		17	9	5	6	13	7	8	6	6	10	8	114
Infection Control Issue														27
Infrastructure or resources (Staffing, Facilities, Environment)	5	8	12	7	8	3	6	4	6	1	13	13	16	102
Maternity Triggers/Neonatal Triggers **	29	29	18	29	24	27	27	34	21	37	38	34	24	371
Medical Adhesive Related Skin Injury (MARSI)														11
Medical Devices/Equipment														32
Medication (this includes administration, advice, monitoring, preparation, prescribing and supply of over the counter medications)	25	34	25	15	26	26	10	22	21	19	23	22	20	289
Moisture Associated Skin Damage Developed in care Present prior to admission														21
														15
Other (please specify in description)														12
Patient/Client/Service User Information (records, docs, test results)	10	12	4	6	7	5	5	6	4	5	12	7	7	90
Pressure Ulcer developed during care deteriorated in care Present before admission	12		8	9	11	10	8	6	9	9	11	13	15	121
														49
	11	18	20	24	18	9	17	18	24	16	29	22	15	241
Security/Damage to property/Fire/Theft														44
Smoke free breach														10
Treatment, Procedure	4	17	15		11	10		6	8	13	11	14	13	121

There were no incidents that resulted in the death of a patient within the given timeframe.

The feedback management system does not classify complaints by whether or not a patient's life was put at risk. Each complaint would need to be manually reviewed and a subjective decision made on the incident the complaint relates to in order to answer this question. This process would exceed the 12.5 hour limit prescribed by Article 16 of the Freedom of Information (Jersey) Law 2011.

Article applied

Article 16 - A scheduled public authority may refuse to supply information if cost excessive

(1) A scheduled public authority that has been requested to supply information may refuse to supply the information if it estimates that the cost of doing so would exceed an amount determined in the manner prescribed by Regulations.