Duty of Candour events
Of the 4 events that triggered the DoC, 2 remain open at the time of reporting; these reviews are projected to breach timeframes, however effective communication will continue with those involved in the process.
In all of the DoC cases, relevant parties were advised a review was taking place. In both of the closed DoC events a copy of the final report with an offer made to meet to discuss the content of the report with the patient/family. This will also occur with the two that remain open, once reports are finalised.
Timescales for conducting and concluding SAERs has remained a challenge due to a number of factors and this has had an impact on the 90-day timescale for completion of DoC review. None of the 4 events reported during the reporting period have met the DoC process requirements including meeting the 90-day timescale for completion of the review process. It is acknowledged that meeting the timescales for DoC has been challenging during this period. The Clinical Governance team work closely with the Divisional Management Teams to improve compliance with timeframes and will monitor this throughout the year making necessary amendments where indicated.
Learning
Further to the review of the events that triggered the DoC, various learning points were identified.
Some of the learning that has been completed includes:
- Development of protocol for patients post-surgery – antiplatelets
- Standardised Surgical Handover
- Consideration of the falls assessment document
- Ensure consistent approach to documentation
- Consideration to be given to the utilisation of a sticker for patient handover which would clearly identify the type of prosthesis the patient has had.
Some of learning currently being implemented includes:
- Inclusion of patients type and duration of anticoagulant/antiplatelet on Clinical Information Systems (CIS-internal system used within critical care) Care Plan.
- Teams to be reminded that patient and family concerns should be taken on board at the time of discussion.
The implementation of learning from SAERs has also been a challenge. The Clinical Governance team has been working closely with the Division Management Teams and services to progress action points in a more timely manner.
Conclusion
This is the fifth year of the DoC being in operation. The organisation continues to learn and refine processes to ensure adherence to the DoC process. This report will be shared via the Clinical Governance reporting structure for internal information and will also be published on our public website as per the DoC legislation. The Scottish Government will be made aware of the publication of this report and we are aware that they may, for the purposes of compliance with the DoC provision, request information regarding the content of this report.
