PATIENT SAFETY: Three patient deaths following serious incidents are being investigated at a south London trust.
HSJ understands the serious incidents at South West London and St Georges Mental Health Trust occurred over the last financial quarter. A root cause analysis has already been carried out for two and a third is ongoing.
Sutton Clinical Commissioning Group, one of the trust’s main commissioners, said in its May board papers: “Sutton has seen a number of serious incidents in recent months (three) resulting in deaths of patients known to the service. The CCG will look to the details of the root cause analysis for these cases to ensure that learning is captured.”
The trust is among those reporting the lowest number of serious incidents in the country.
Vanessa Ford, director of Nursing and Quality at SWLSTG said “We are proud to be an open and transparent organisation and have been commended by the CQC. We have very clear guidelines in line with national best practice for reviewing and learning from serious incidents. As part of our formal Trust Board agenda we hear directly from patients on areas that have worked well or where we need to improve.
“We work very closely with the family and all agencies involved in these cases. Our family liaison support service is unique and receives positive feedback. All serious incidents are reviewed internally and then externally scrutinised by the CCG and NHS England. Whilst we work very hard to protect our patients there may be very sad circumstances where individuals are determined to harm themselves. In these circumstance we take every opportunity learn where things could have been done differently.”
Sutton CCG said in a statement: “Sutton CCG is responsible for the quality of the health services we commission and we have rigorous processes in place to provide assurance that all serious incidents are investigated as appropriate using national guidance set by NHS England and the National Patient Safety Agency.
“We review completed serious incident investigations to ensure that recommendations and actions are identified to ensure learning, mitigate future risk and prevent the likelihood of reoccurrence.
“We work closely with South West London and St George’s Mental Health Trust to ensure they put sufficient controls in place to mitigate future risk and we are confident that the Trust has implemented strict processes to investigate all serious incidents thoroughly.”
CCG board papers and information provided to HSJ