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Executive Summary SI2020/21468 COVID-19 Outbreak

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Dear Sir/Madam responsible for Freedom of Information,
Under the Freedom of Information Act 2000, please let me know the following?
In a previous Freedom of Information request I made https://www.whatdotheyknow.com/request/s... you provided the document "Executive Summary of SI2020/21468 COVID-19 Outbreak".
You also provided information that there have been 21 Serious Incident investigations done for nosocomial deaths, 76 patient safety reviews done for nosocomial deaths, no Root Cause Analysis reports done for any nosocomial deaths, and 16 Serious Incident investigations done for nosocomial deaths ( you also said there were 21 Serious Incident investigations done for nosocomial deaths). You also said that the reports resulting from the investigations have not been made available to the families of the deceased patients, who developed nosocomial Covid-19 in Royal Berkshire Hospital.
Therefore, I have the questions:
Please let me know the date the "Executive Summary of SI2020/21468 COVID-19 Outbreak" was written.
Please let me know if that Executive Summary covers all cases of nosocomial deaths in Royal Berkshire Hospital or if there are additional summaries or investigation reports for each case.
Is the total of nosocomial deaths 21 + 76 + 16 = 113, if not, please will you explain why the breakdown in deaths and investigations is divided 21/76/16.
Please will you let me know why some deaths had one type of investigation done, but not another, for example, why were 76 deaths subject to a patient safety review and 21 subject to a Serious Incident investigation?
Please will you let me know how many deaths have been subject to a Structured Judgement Review?
What is the difference in investigation methodology between Serious Incident, Root Cause Analysis and patient safety reviews?
What is the hierarchy of investigation, for example does a patient safety review denote a less serious incident that what would warrant a  Serious Incident investigation?
Do all nosocomial deaths have an individual investigation, or are they grouped and reported as a group as with the Executive Summary you provided?
Please let me know why families of the deceased have not been given reports.
Thank you.
Yours faithfully,
Dwayne Donovan

FOI, Royal Berkshire NHS Foundation Trust

Dear Requester,

We acknowledge your enquiry under the Freedom of Information Act.  I will
look into your request and respond within 20 working days from receipt of
your request.

Yours sincerely,

Freedom Of Information Team
Royal Berkshire NHS Foundation Trust
Tel: 0118 322 6743/7405
Email: [Royal Berkshire NHS Foundation Trust request email]

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FOI, Royal Berkshire NHS Foundation Trust

Dear Dwayne,

In response to your Freedom of Information request, please see the below responses to your questions. We apologise for the delay in responding to your request.

Yours sincerely,

Freedom Of Information Team
Royal Berkshire NHS Foundation Trust
Tel: 0118 322 8514
Email: [Royal Berkshire NHS Foundation Trust request email]

1. Please let me know the date the "Executive Summary of SI2020/21468 COVID-19 Outbreak" was written.
January 2021

2. Please let me know if that Executive Summary covers all cases of nosocomial deaths in Royal Berkshire Hospital or if there are additional summaries or investigation reports for each case.
Yes

3. Is the total of nosocomial deaths 21 + 76 + 16 = 113, if not, please will you explain why the breakdown in deaths and investigations is divided 21/76/16.

The total number of deaths is 76.
21 Serious Incident investigations have been undertaken, the 16 previously stated was an error.

4. Please will you let me know why some deaths had one type of investigation done, but not another, for example, why were 76 deaths subject to a patient safety review and 21 subject to a Serious Incident investigation?

76 patients were reviewed at the weekly Patient Safety Case Review meeting, and were identified as being either Probable or Definite hospital onset and would require an serious incident investigation to be undertaken.
Single investigations can be undertaken where cases are linked i.e.; outbreaks
16 outbreaks were confirmed and therefore patients were linked to those individual outbreaks and investigations
5 individuals were confirmed as not part of an outbreak, and were deemed as an individual investigation

5. Please will you let me know how many deaths have been subject to a Structured Judgement Review?

22

6. What is the difference in investigation methodology between Serious Incident, Root Cause Analysis and patient safety reviews?

A serious incident is reported on a strategic information executive system, a root cause analysis in an investigation and a safety review determines the next steps

7. What is the hierarchy of investigation, for example does a patient safety review denote a less serious incident that what would warrant a Serious Incident investigation?
A safety review determines the next steps .

A serious Incident is an adverse event, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified

8. Do all nosocomial deaths have an individual investigation, or are they grouped and reported as a group as with the Executive Summary you provided?

In accordance with NHSE Reporting, reviewing and investigating hospital-onset COVID-19 cases and COVID-19 deaths October 2020 they were grouped together

9. Please let me know why families of the deceased have not been given reports.

As a number of patients were included in one serious incident report and that report would therefore include information that did not relate to their family member the full report was not provided on this occasion. An executive summary was provided to the families instead.

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Dear Sir/Madam responsible for Freedom of Information,
Thank you for your reply.
I would like to request an internal review as several areas require clarification.
To clarify, there is only one report on all nosocomial deaths and one executive summary of that report (the summary you previously supplied)?
Please let me know the full date, including the day, the "Executive Summary of SI2020/21468 COVID-19 Outbreak" was written.
I previously asked .. Please let me know if that Executive Summary covers all cases of nosocomial deaths in Royal Berkshire Hospital or if there are additional summaries or investigation reports for each case. You replied "Yes", does that mean "Yes" as in that report covers all cases of nosocomial deaths, so that one report covers all cases, irrespective of findings? Or "Yes" there are additional summaries or investigation reports for each case?
You reply 21 Serious Incident investigations have been undertaken, do those Serious Incident investigations have their own reports?
You reply 5 individuals were confirmed as not part of an outbreak, do those investigations have their own reports, what type of investigation were they? What what did families receive?
You reply there were 22 Structured Judgement Reviews, what specifically triggers a Structured Judgement Review?
The "Executive Summary of SI2020/21468 COVID-19 Outbreak" says "The investigation did not identify a root cause as each of the contributory factors could potentially have affected the hospital acquired transmission of COVID-19." Please confirm you never found a root cause of infection across 76 deaths or reasons for continued outbreaks and the spread between inpatients?
My previous Freedom of Information request I made https://www.whatdotheyknow.com/request/s... which I refer to in this Freedom of Information request, refers to 4 serious incidents (in the Internal Review document) please will you explain what that means?
In reply to my previous Freedom of Information request, you say that 16 families (you may now have changed that to 21) have been supplied with "Executive Summary of SI2020/21468 COVID-19 Outbreak", please will you say why the remaining families have not been supplied a report (at least 55 families)?
Please confirm of 76 nosocomial deaths - there were a total of 48 investigations (5 individual cases, 21 Serious Incident investigations, 22 Structured Judgement Reviews)?
Please confirm of 76 nosocomial deaths - with 16 outbreaks and 5 individual cases, 21 Serious Incident investigations, 22 Structured Judgement Reviews, no investigation found a root cause of infection across or reasons for continued outbreaks and the spread between inpatients?
You reply "As a number of patients were included in one serious incident report and that report would therefore include information that did not relate to their family member the full report was not provided on this occasion. An executive summary was provided to the families instead." Why not redact names and make the full report available to the families and the public? I believe they have the right to know the full events.
As you will not supply the full reports, please will you supply the method of investigation i.e what undertakings the investigations included, as you know the "Executive Summary of SI2020/21468 COVID-19 Outbreak" does not say.
Thank you.
Yours faithfully,
Dwayne Donovan

FOI, Royal Berkshire NHS Foundation Trust

Dear Dwayne,

Thank you for your email, we confirm that we are now progressing your internal review and will come back to you with the response as soon as this is ready.

Yours sincerely,

Freedom Of Information Team
Royal Berkshire NHS Foundation Trust
Tel: 0118 322 8514
Email: [Royal Berkshire NHS Foundation Trust request email]

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Dear Sir/Madam responsible for Freedom of Information,
It has been more than a month since I requested an internal review.
Please will you say when I will receive the internal review report?

Thank you.
Yours faithfully,
Dwayne Donovan

FOI, Royal Berkshire NHS Foundation Trust

Dear Dwayne,

We apologise for the delay in responding. Our staff are very busy caring for patients. We will respond as soon as we have received the required information internally.

Yours sincerely,

Freedom Of Information Team
Royal Berkshire NHS Foundation Trust
Tel: 0118 322 8514
Email: [Royal Berkshire NHS Foundation Trust request email]

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Dear Sir/Madam responsible for Freedom of Information,
I am concerned that your Freedom of Information staff are busy caring for patients as I assumed clinical staff would be better placed to do that.
20 working days after the date of the request for review is when the internal report should have been delivered.
Please tell me when I will receive the internal review report.

Thank you.
Yours faithfully,
Dwayne Donovan

FOI, Royal Berkshire NHS Foundation Trust

Dear Dwayne,

Freedom of Information staff are not caring for patients, however the Freedom of Information team have to request the information you require from internal departments. We apologise for the delay, we are not able to say with accuracy when we can respond to you, as we need to receive the information internally before we can respond.

Yours sincerely,

Freedom Of Information Team
Royal Berkshire NHS Foundation Trust
Tel: 0118 322 8514
Email: [Royal Berkshire NHS Foundation Trust request email]

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Dear Sir/Madam responsible for Freedom of Information,
As it has now been well over 40 working days and you have not replied to me with the internal review, I assume you are not going to, so will escalate this.

Thank you.
Yours faithfully,
Dwayne Donovan

FOI, Royal Berkshire NHS Foundation Trust

 
Dear Dwayne Donovan,
 
Further to you request for information please see the Trust's response
below.
These have been highlighted in red.
Please accept our sincere apologies for the late response.
 
Kind regards,
 
Natasha Tucker
Freedom of Information and Policy Officer
Corporate Governance Team
Royal BerkshireNHS Foundation Trust
 
 
 

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We don't know whether the most recent response to this request contains information or not – if you are Dwayne Donovan please sign in and let everyone know.