Serious incidents
The Trust saw a 400% increase in serious incidents declared in the 2021/22 financial year compared with the previous year. This was due to a huge increase in operational pressure in the health and social care system, leading to increased response times to our patients. The Trust developed an action plan to improve all elements which contributed to response delays within its control. 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.
The key themes of serious incident, with a comparison to the two previous years, are contained within the table below.
| 2019/20 | 2020/21 | 2021/22 | |
| Delay | 13 | 9 | 114 |
| ECAT / AOC | 8 | 1 | 8 |
| Patient injury | 4 | 7 | 8 |
| Clinical treatment | 9 | 5 | 11 |
| Non-conveyance | 13 | 18 | 17 |
| Equipment failure | 1 | 0 | 1 |
| Other | 3 | 0 | 2 |
| Total | 51 | 40 | 161 |
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. It provides staff with a standard of care to deliver to patients where previously there was none. The organisation developed an electronic auditing tool to sit alongside the care bundle which will allow continuous monitoring of its use and identify focused areas of improvement to further improve the safety and experience of patients not needing hospital treatment.
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