75 serious adverse incidents reported - 21 suspected suicides

WHSCT staff also reported three serious incidents under the heading ‘serious assaults (including homicide and sexual assault) by a service user’ and on six occasions when incidents occurred deemed there had been ‘serious risk to a service user and/or staff member and/or member of the public.’

The incidents - revealed following a Sentinel Freedom of Information (FOI) request - refer to any events arising during the course of WHSCT business that led, or could have led, to serious unintended or unexpected harm, loss or damage.

The Department of Health, Social Services and Public Safety (DHSSPS) says Serious Adverse Incidents (SAI) may be deemed as such because they “involve a large number of patients, there is a question of poor clinical or management judgement, a service or piece of equipment has failed, a patient has died under unusual circumstances or there is the possibility or perception that any of these might have occurred.”

The Sentinel has learned that between April 2009 and March 2011 there were 75 SAIs reported by the WHSCT - including 17 ‘suspected suicides’ in Adult Mental Health and Disability Services (AMHDS), three ‘suspected suicides’ in Primary Care and Older People (PCOP) and one ‘suspected suicide’ in Women and Children.

The three SAIs categorised as ‘serious assaults (including homicide and sexual assault’ occurred in ADMHDS whilst ‘serious risk to a service user and/or staff member and/or member of hte public’ was identified twice in Acute Services, twice in PCOP, and once each in Finance & IT and AMHDS.

WHSCT staff also classed 18 SAIs as ‘Interface with Juvenile Justice Centre’ whilst 22 SAIs were put down alongside either ‘Public Concern,’ ‘Regional Learning,’ or a combination of both.

‘Unexpected death,’ ‘Serious self-harm,’ and ‘Public interest or concern, theft, fraud, information breaches or data losses’ were other SAIs reported to the regional health authority since it was formed in April 2009.

SAIs need to be reported within 72 hours of the incident being discovered or in the case of an unexpected/unexplained death, (where it is understood this poses a significant risk to service users, staff or the public) where possible within 24 hours.

The Trust was unable to provide the paper with specific detail on the incidents reported saying they would potentially contain patient/client identifiable information.