Medical equipment fault and temporary IT unavailability posed ‘serious risk’

Last year’s 18,500 X-ray backlog at Altnagelvin was also one of 75 Serious Adverse Incidents (SAI) over the period that was classed as posing a serious risk to people.

The Western Trust said it could not give details of three other SAIs in the same category as they related to specific patients to whom confidentiality was owed.

Earlier this month the Sentinel reported how seventy-five ‘serious adverse incidents’ - including twenty-one suspected suicides - were reported by the Western Trust (WHSCT) to the Health and Social Care Board (HSCB) over the past two years.

The Sentinel subsequently asked the Trust if all the 21 suspected suicides referred to patients. A spokesperson confirmed that all 21 patients were known to the Trust but was unable to provide further details as it would jeopardise confidentiality owed to the patient and their family.

Concerning the aforementioned SAIs were ‘serious risk’ was posed the Trust advised that one “related to the back-log of unreported X-rays which has been widely reported in the media;” another “to the temporary unavailability of IT systems on a regional basis;” and another “to potential risks associated with a piece of medical equipment”

The spokesperson said: “All Health & Social Care Trusts within Northern Ireland are required to report SAIs to the Health & Social Care Board. The aim of reporting is to focus on providing service improvements for users by ensuring trends, best practice and learning is identified, disseminated and implemented in a timely manner, in order to prevent recurrence.”

Earlier this month the Sentinel revealed how WHSCT staff had 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 staff deemed there had been ‘serious risk to a service user and/or staff member and/or member of the public.’

The Department of Health, Social Services and Public Safety (DHSSPS) says SAIs 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.”

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.