PERFORMANCE: The community trust recorded five serious untoward incidents in January, against a target of zero, its latest performance report states.
The report notes that Bridgewater also recorded five SUIs in the previous month.
One of the serious incidents recorded in January was an unexpected death. The report states that the patient “deteriorated after over-administration of [a] controlled drug by [a] carer”, and that a root cause analysis is underway.
The other four incidents were pressure ulcers.
“Four of the five SUIs occurred in the patient’s home and RCA evidence would indicate a high ratio of patients and/or carers are non-compliant with advice given that would avoid Pressure Ulcers,” the report states.
“The risk of developing a Pressure Ulcer may be further increased, as in at least four of these five cases, by the symptoms of an existing medical condition i.e. cancer or palliative state that reduces their mobility.”
7 March 2013