Serious incidents and deaths of patients with a learning disability

The request was successful.

Dear Gateshead Health NHS Foundation Trust,

Please could you provide the following information:

1a) total number of deaths that have occurred at the Trust in each of the the last five years (please provide data broken down by year)
1b) the number of these deaths that were classified as unexpected

2a) total number of deaths that have been referred to the Coroner by the Trust in each of the last five years
2b) of these, the number of deaths of patients with a learning disability referred to the Coroner

3a) total number of deaths of patients with a learning disability that have occurred at the Trust in each of the last five years (please provide total number and indicate whether they were inpatients at the time of their deaths)
3b) of these, the number of these deaths of patients with a learning disability that were classified as unexpected

4a) total number of deaths at the Trust reported as an incident on the National Reporting and Learning System (NRLS) in each of the last five years
4b) total number of deaths at the Trust reported on Strategic Executive Information System (STEIS) in each of the last five years
4c) if possible, please indicate the number of these that relate to patients with a learning disability

5a) total number of initial 72-hour reviews into deaths (as defined by the NHS Serious Incident Framework) in each of the last five years
5b) total number of investigations into deaths (as defined by the NHS SI Framework) in each of the last five years - please provide data broken down by severity, Level 1 internal investigations, Level 2 comprehensive internal investigations, Level 3 independent investigations. Please also indicate whether the numbers refer to investigations opened or completed.

Many thanks for your time.

Yours faithfully,
Dr George Julian

Freedom of Information Enquiries (RR7) Gateshead Health,

3 Attachments

Dear Dr Julian

 

Our reference: FoI 2016-17.562

 

Thank you for your request for information held by Gateshead Health NHS
Foundation Trust.  Your query is being considered under the terms of the
Freedom of Information Act 2000 (FOIA). 

 

You have requested:

 

Please could you provide the following information:

 

1a) total number of deaths that have occurred at the Trust in each of the
last five years (please provide data broken down by year)

1b) the number of these deaths that were classified as unexpected

 

2a) total number of deaths that have been referred to the Coroner by the
Trust in each of the last five years

2b) of these, the number of deaths of patients with a learning disability
referred to the Coroner

 

3a) total number of deaths of patients with a learning disability that
have occurred at the Trust in each of the last five years (please provide
total number and indicate whether they were inpatients at the time of
their deaths)

3b) of these, the number of these deaths of patients with a learning
disability that were classified as unexpected

 

4a) total number of deaths at the Trust reported as an incident on the
National Reporting and Learning System (NRLS) in each of the last five
years

4b) total number of deaths at the Trust reported on Strategic Executive
Information System (STEIS) in each of the last five years

4c) if possible, please indicate the number of these that relate to
patients with a learning disability

 

5a) total number of initial 72-hour reviews into deaths (as defined by the
NHS Serious Incident Framework) in each of the last five years

5b) total number of investigations into deaths (as defined by the NHS SI
Framework) in each of the last five years - please provide data broken
down by severity, Level 1 internal investigations, Level 2 comprehensive
internal investigations, Level 3 independent investigations. Please also
indicate whether the numbers refer to investigations opened or completed.

 

Your request was received on 30^th January, therefore you can expect a
reply by close of business on 27^th February unless we need to contact you
to clarify your request or the balance of the public interest test needs
to be considered.

 

Please find attached a leaflet giving guidance on our procedure for
managing requests covered by FOIA.

 

Yours sincerely

 

FOI Officer

The Information Governance Team

Gateshead Health NHS Foundation Trust

Information Department | Bensham Hospital

Saltwell Road | Gateshead | NE8 4YL

Telephone: 0191 445 3465

 

 

Freedom of Information Enquiries (RR7) Gateshead Health,

Dear Dr Julian

 

Our reference: FoI 2016-17.562

 

We write further to your email of 30^th January 2017 where you requested
information held by Gateshead Health NHS Foundation Trust.

The Freedom of Information Act 2000 states that where an authority
receives a request with more than one possible meaning, it must go back to
the requester to ask them to clarify which interpretation is correct.

In addition, it shall be the duty of a public authority to provide advice
and assistance, so far as it would be reasonable to expect the authority
to do so, to persons who propose to make, or have made, requests for
information to it.

We require further information in order to identify and locate the data
you asked for.  In particular, we need to know if you can define what you
would determine as ‘classified as unexpected’.

Once you have clarified your request, we will be able to begin to process
it accordingly.  Please note that until the clarification is received,
your request will be on hold and you will be notified of the new statutory
deadline once that information is provided.

 

If we do not receive clarification within 20 working days your request
will be considered to have lapsed. Under section 1(3) of the Freedom of
Information Act, a public authority need not comply with a request unless
any further information reasonably required to locate the information is
supplied.

 

Please remember to quote the reference number above in any future
communications.

 

Yours sincerely

FOI Officer

The Information Governance Team

Gateshead Health NHS Foundation Trust

Information Department | Bensham Hospital

Saltwell Road | Gateshead | NE8 4YL

Telephone: 0191 445 3465

 

 

Dear Freedom of Information Enquiries (RR7) Gateshead Health,

Thanks for getting in touch to seek clarification. Personally, I would consider an unexpected death to be one that could not reasonably have been anticipated, or occuring as a direct result of the natural course of the patient’s illness or underlying condition where this was managed in accordance with best practice.

That said I would rather that Gateshead Health defined unexpected and provided the data - because I am interested in what happens locally. I notice that your Non-Medical Care of the Dying and Deceased Patient (Adults and Children) Policy v3 provides a definition of unexpected,

Yours sincerely,
Dr George Julian

Freedom of Information Enquiries (RR7) Gateshead Health,

Dear Dr Julian

 

Our reference: FoI 2016-17.562

 

Thank you for your request for information of 30^th January 2017, as
copied below. Your request has been considered under the terms of the
Freedom of Information Act 2000 (FOIA). We will answer each of your points
in turn. 

 

Your request and our response:

 

Please could you provide the following information:

1a) total number of deaths that have occurred at the Trust in each of the
last five years (please provide data broken down by year)

2012 – 1194

2013 – 1094

2014-1067

2015 – 1137

2016-1103

1b) the number of these deaths that were classified as unexpected

In response to this question we are providing figures for all deaths that
were referred to the coroner for either a post mortem, or inquest not
requiring post mortem.

The figures provided do not include cases where telephone conversations
have taken place prior to the trust issuing the Medical Certificate of
Cause of Death

2012 - 114

2013 - 112

2014 - 91

2015 - 110

2016 - 103

2a) total number of deaths that have been referred to the Coroner by the
Trust in each of the last five years

As above

2b) of these, the number of deaths of patients with a learning disability
referred to the Coroner

2012 – 1

2013 - 1

2014 - 0

2015 - 4

2016 - 1

3a) total number of deaths of patients with a learning disability that
have occurred at the Trust in each of the last five years (please provide
total number and indicate whether they were inpatients at the time of
their deaths)

3b) of these, the number of these deaths of patients with a learning
disability that were classified as unexpected

These patients were all inpatients at the time of death

2012 - 9

2013 - 7

2014 - 8

2015 - 4

2016 - 7

4a) total number of deaths at the Trust reported as an incident on the
National Reporting and Learning System (NRLS) in each of the last five
years

2012 -0

2013 - 1

2014 - 0

2015 - 2

2016 - 1

4b) total number of deaths at the Trust reported on Strategic Executive
Information System (STEIS) in each of the last five years

2012 -0

2013 - 1

2014 - 0

2015 - 2

2016 - 1

4c) if possible, please indicate the number of these that relate to
patients with a learning disability

None

5a) total number of initial 72-hour reviews into deaths (as defined by the
NHS Serious Incident Framework) in each of the last five years

4

5b) total number of investigations into deaths (as defined by the NHS SI
Framework) in each of the last five years - please provide data broken
down by severity, Level 1 internal investigations, Level 2 comprehensive
internal investigations, Level 3 independent investigations. Please also
indicate whether the numbers refer to investigations opened or completed. 

Total
number Total Number Number
of number that refer of
deaths of to a initial
at the deaths patient 72 - Severity / Level of Opened /
trust at the with a hour investigation Completed
reported trust learning reviews
as an reported disability into
incident to STEIS deaths
on NRLS
2012 0 0 - - - -
 1 complete
2013  Death/Comprehensive no
Level 2 outstanding
1 1 0 1 Investigation actions
2014 0 0 - - - -
 2 x
2015 Death/Comprehensive  2 complete 1
Level 2 with open
2 2 0 2 Investigation actions
 Death/Comprehensive  1
2016 Level 2 investigation
1 1 0 1 Investigation underway

 

We hope that you will find this response helpful. If you have any queries
about this email please contact us quoting the reference number above.

 

Your appeal rights

 

If you are not happy with the handling of your request, you have the right
to ask us to review our original decision. You can contact us by email at
[Gateshead Health NHS Foundation Trust request email], or post to Information Governance, QE
Gateshead, Information Department, Bensham Hospital, Saltwell Road,
Gateshead, NE8 4YL. Any complaint should be submitted within two months of
the date of this response. Please remember to quote the reference number
above in any future communications.

 

If you are not content with the outcome of your complaint, you have the
right to apply directly to the Information Commissioner for a decision.
The Information Commissioner can be contacted by email at
[email address], or post to: Information Commissioner’s Office,
Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF.

 

Yours sincerely

 

FOI Officer

The Information Governance Team

Gateshead Health NHS Foundation Trust

Information Department | Bensham Hospital

Saltwell Road | Gateshead | NE8 4YL

Telephone: 0191 445 3465