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Serious Untoward Incident investigations

Dwayne Donovan made this Freedom of Information request to Bolton NHS Foundation Trust

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Dear Sir/Madam responsible for Freedom of Information,
Under the Freedom of Information Act 2000, please let me know how many Serious Incident investigations/ Serious Untoward Incident investigations have been undertaken relating to nosocomial Covid-19 acquired in Royal Bolton Hospital resulting in death.
Please let me know how many Patient Safety Reviews have been undertaken relating to nosocomial Covid-19 acquired in Royal Bolton Hospital resulting in death.
Please let me know how many Root Cause Analysis investigations have been undertaken relating to nosocomial Covid-19 acquired in Royal Bolton Hospital resulting in death.
Please supply full copies of all reports from Serious Incident Investigations/ Serious Untoward Incident Investigations, Patient Safety Reviews and Root Cause Analysis investigations related to nosocomial Covid-19 acquired in Royal Bolton Hospital resulting in death.
Thank you.
Yours faithfully,
Dwayne Donovan

Freedom of Information, Bolton NHS Foundation Trust

Dear Sir/Madam,

 

 

Please accept this as acknowledgement of receipt of your request for
information under the Freedom of Information Act 2000. No further
acknowledgment will be sent.

 

Valid Freedom of Information Requests will receive a response within 20
working days. Please note:

 

- 20 working days will commence from the next working day following
receipt of your request

- Public holidays, Saturdays and Sundays are not classed as working days

 

 

 

Yours sincerely,

 

Information Governance Department

Informatics

Informatics Building

Opposite N Block

Royal Bolton Hospital

' 01204 390390 Ext 3982

8 [1][email address]

 

 

Our Bolton NHS Foundation Trust values
V O I C E
Vision Openess Integrity Compassion Excellence

 

References

Visible links
1. mailto:[email address]

Freedom of Information, Bolton NHS Foundation Trust

 

 

 

Dear Sir/Madam,

 

 

Please accept this as acknowledgement of receipt of your request for
information under the Freedom of Information Act 2000. No further
acknowledgment will be sent.

 

Valid Freedom of Information Requests will receive a response within 20
working days.  Please note:

 

- 20 working days will commence from the next working day following
receipt of your request

- Public holidays, Saturdays and Sundays are not classed as working days

 

Please consider if your request for information is absolutely necessary at
this time.

 

 

Any request that can be deferred or delayed will allow staff time to be
focussed on other areas.  

 

Submitted requests for information may be delayed due to urgent
operational needs dealing with Public Health priorities. The Trust
apologises for any inconvenience this may cause. The Trust does remain
committed to responding to your request and will reply as soon as
possible.

 

Should the Trust’s response to your request breach the statutory timeframe
and you remain unhappy with our response you have the right to complain to
the Information Commissioner’s Office.

 

 

 

They can be contacted at the following address:

 

The Information Commissioner’s Office

Wycliffe House

Water Lane

Wilmslow

Cheshire

SK9 5AF

 

Tel: 0303 123 1113

Website: [1]www.ico.gov.uk

 

 

 

Please find the link to the ICO’s COVID-19 response

 

 

Yours sincerely,

 

Information Governance Department

Informatics Building

Royal Bolton Hospital

' 01204 390861

8  [2][email address]

 

 

show quoted sections

Freedom of Information, Bolton NHS Foundation Trust

FREEDOM OF INFORMATION

 

 

REF: 2021-460          

Subject: Serious Incident Investigations      

 

 

Dear Sir/Madam,

 

Thank you for your email dated 28^th July 2021 where you requested
information about Serious Incident Investigations.

The information you requested is enclosed.  

 

Please let me know how many Serious
Incident investigations/ Serious
Untoward Incident investigations have 1
been undertaken relating to
nosocomial Covid-19 acquired in Royal
Bolton Hospital resulting in death.
Nosocomial covid-19 deaths have been
reviewed using the trust standard
learning from deaths process –
Please let me know how many Patient structured judgement review
Safety Reviews have been undertaken methodology:
relating to nosocomial Covid-19
acquired in Royal Bolton Hospital  
resulting in death.
To date 143 patients who have died
with or from nosocomial COVID-19
infection have been reviewed using
this methodology
Please let me know how many Root
Cause Analysis investigations have See above answers, as these are a
been undertaken relating to form of RCA as is SI.
nosocomial Covid-19 acquired in Royal
Bolton Hospital resulting in death.
Please supply full copies of all
reports from Serious Incident We cannot disclose this information,
Investigations/ Serious Untoward as disclosure of this level of
Incident Investigations, Patient detail could lead to the
Safety Reviews and Root Cause identification of individuals.
Analysis investigations related to Refused under section 40 of the
nosocomial Covid-19 acquired in Royal Freedom of Information Act.
Bolton Hospital resulting in death.

 

If you have any queries or concerns please do not hesitate to contact the
Freedom of Information Department. It would be helpful to quote the above
reference number in any future communication.

 

If you are unhappy with the service you have received in relation to your
request and wish to make a complaint or request a review of our decision,
you should write to The Chief Executive, Bolton NHS Foundation Trust, The
Royal Bolton Hospital, Minerva Road, Farnworth, Bolton. BL4 0JR.

 

If you are not content with the outcome of your complaint you may apply
directly to the Information Commissioner. Generally the Information
Commissioner cannot make a decision unless you have exhausted the
complaints procedure provided by Bolton NHS Foundation Trust. The
Information Commissioner can be contacted at The Information
Commissioner's Office, Wycliffe House, Water Lane, Wilmslow, Cheshire. SK9
5AF.

 

The information supplied to you continues to be protected by the Copyright
Design and Patents Act 1998. You are free to use it for your own purposes,
including any non-commercial research you are doing and for the purposes
of news reporting. Any other reuse, for example commercial publication
requires the permission of the Trust. You must ensure you gain the Trust
permission before reproducing any third party information.

 

 

Yours sincerely,

 

Information Governance Department

Informatics Building

Opposite N Block

Royal Bolton Hospital

' 01204 390861

8  [1][email address]

 

Our Bolton NHS Foundation Trust values
V O I C E
Vision Openess Integrity Compassion Excellence

 

 

 

 

 

show quoted sections

Dear Sir/Madam responsible for Freedom of Information,

Thank you for your reply,

I am requesting an internal review.

Firstly, unfortunately, I am unable to read your responses properly as the formatting in your reply is corrupt - please see here:
https://www.whatdotheyknow.com/request/s...

From what I can make out, I think your response is as follows, please confirm I have understood your answers correctly:

Question: Please let me know how many Serious Incident investigations/ Serious Untoward Incident investigations have been undertaken relating to nosocomial Covid-19 acquired in Royal Bolton Hospital resulting in death.

Your Answer: 1

Question: Please let me know how many Patient Safety Reviews have been undertaken relating to nosocomial Covid-19 acquired in Royal Bolton Hospital resulting in death.

Your Answer: Nosocomial covid-19 deaths have been reviewed using the trust standard learning from deaths process –Patient structured judgement review methodology:relating to nosocomial Covid-19 To date 143 patients who have died with or from nosocomial COVID-19infection have been reviewed using this methodology

Question: Please let me know how many Root Cause Analysis investigations have been undertaken relating to nosocomial Covid-19 acquired in Royal Bolton Hospital resulting in death.

Your Answer: See above answers,

Question: Please supply full copies of all reports from Serious Incident Investigations/ Serious Untoward Incident Investigations, Patient Safety Reviews and Root Cause Analysis investigations related to nosocomial Covid-19 acquired in Royal Bolton Hospital resulting in death.

Your Answer: We cannot disclose this information,Investigations/ as disclosure of this level of Incident Investigations, Patient detail could lead to the identification of individuals.
Refused under section 40

Secondly, Section 40 exemption of the FoI Act does not apply in this case as, the NHS Serious Incident Framework, states:
"4.4. Final report and action plan"
"Serious incident investigation reports must be shared with key interested bodies including patients, victims and their families. It is recommended that reports are drafted on the basis that they may become public, so issues concerning anonymity and consent for disclosure of personal information are important and should be considered at an early stage in the investigation process.”

If the Serious Incident report(s) must be redacted to remove confidential information such as patient names, that is understandable and correct, but the public does have a right to see the full reports (redactions aside), so please supply them.

Thank you.

Yours faithfully,

Dwayne Donovan

Freedom of Information, Bolton NHS Foundation Trust

Good afternoon,

 

Thank you for your email. I’d like to apologise for the format of the
email not being correct and difficult to read, and would like to assure
you that our next response will be in a readable format. This email is to
confirm that we have received your request for an internal review and this
is now being processed. Once this has been reviewed we will return the
response to you as quickly as we can.

 

Yours sincerely,

 

Information Governance Department

Informatics Building

Opposite N Block

Royal Bolton Hospital

' 01204 390861

8  [1][email address]

 

Our Bolton NHS Foundation Trust values
V O I C E
Vision Openess Integrity Compassion Excellence

 

show quoted sections

Freedom of Information, Bolton NHS Foundation Trust

2 Attachments

Good Afternoon,

 

Please find attached the original response, and the internal review in the
format of a PDF. When our responses are sent to a whatdotheyknow account,
it appears that the website does not support the format in the same way
that it is sent, so the PDF should be easier to read.

 

Yours sincerely,

 

Information Governance Department

Informatics Building

Opposite N Block

Royal Bolton Hospital

' 01204 390861

8  [1][email address]

 

Our Bolton NHS Foundation Trust values
V O I C E
Vision Openess Integrity Compassion Excellence

 

 

show quoted sections

Dear Sir/Madam responsible for Freedom of Information,

Your reply stating that you refuse to supply a Serious Incident report because:

"We are not prepared to share Serious Incident Investigations with a member of the public because whilst a copy could be redacted in terms of patient/staff identifiers (and are indeed written to safeguard) identity. It is the actual circumstances and events of a Serious Incident that can make it unique and thus identifiable and it is this which could lead to the identification of the patient or staff. To redact a Serious Incident report to the point that the details of the incident become opaque in order to protect the identities of persons the report loses its inherent value for learning. There is a risk that the identity of the patient could be deduced due to the type of incident and that would be a breach of UK GDPR and is refused under section 40 of the FOI Act 2000."

1. Your Internal Review was completed within a few hours of me requesting it, I a do not consider that due care has been applied to consideration of the review.
2. You have not offered a summary of the factors which contributed to the 143 deaths contained in the Serious Incident investigation report.
3. You are referring to 143 nosocomial deaths. Your position is you are saying that 143 patients could be identified as well as staff, even if their names were redacted, because the incident itself could allow a member of the public to identify those names, by the release of the report. This is unreasonable.
4. Given the point  above, you are therefore indicating that only one incident, lead to 143 nosocomial deaths. This does not seem likely.  Surely more than one incident occurred leading to the nosocomial deaths. Or are you saying there are many instances, but only one investigation?
5. Given the point above, please explain why there is only one SI investigation.
6. Have the families of the 143 patents who died with hospital acquired Covid-19 each been supplied with a copy of the Serious Incident investigation report?
7. .."inherent value for learning" is an internal discourse for staff not the public, the impact on opacity of the report is not a consideration under Section 40.
8. Which subsection of Section 40 you aim to invoke?
9. I do not believe you have applied Section 40 exemption correctly, including the overriding aspect of public interest.
10. From the ICO Section 40(2) – Personal information "This exemption can only apply to information about people who are living; you cannot use it to protect information about people who have died."

I have therefore made a complaint to the Information Commissioner's Office  and request, pending their involvement, you release the Serious Incident Investigation report.

Thank you.
Yours faithfully,
Dwayne Donovan

Dear Sir/Madam responsible for Freedom of Information,

Please reply to my message of 16 August 2021.

Thank you.
Yours faithfully,
Dwayne Donovan

Dear Sir/Madam responsible for Freedom of Information,
I ask again, please reply to my message of 16 August 2021.
Thank you.
Yours faithfully,
Dwayne Donovan

Freedom of Information, Bolton NHS Foundation Trust

 

 

FREEDOM OF INFORMATION

 

 

REF:            2021-460

Subject:        Serious Untoward Incident investigations

 

 

Dear Sir/Madam,

 

Thank you for your email dated 16^th August 2021 where you requested an
internal review for your request.

The information you requested is enclosed.  

 

The report that you requested last year has been published now, The report was presented to the Board od
Director 27^th January 2022.

 

[1]https://www.boltonft.nhs.uk/wp-content/u...

 

You can find the information in page 24-45.

 

 

If you have any queries or concerns please do not hesitate to contact the
Freedom of Information Department. It would be helpful to quote the above
reference number in any future communication.

 

If you are unhappy with the service you have received in relation to your
request and wish to make a complaint or request a review of our decision,
you should write to The Chief Executive, Bolton NHS Foundation Trust, The
Royal Bolton Hospital, Minerva Road, Farnworth, Bolton. BL4 0JR.

 

If you are not content with the outcome of your complaint you may apply
directly to the Information Commissioner. Generally the Information
Commissioner cannot make a decision unless you have exhausted the
complaints procedure provided by Bolton NHS Foundation Trust. The
Information Commissioner can be contacted at The Information
Commissioner's Office, Wycliffe House, Water Lane, Wilmslow, Cheshire. SK9
5AF.

 

The information supplied to you continues to be protected by the Copyright
Design and Patents Act 1998. You are free to use it for your own purposes,
including any non-commercial research you are doing and for the purposes
of news reporting. Any other reuse, for example commercial publication
requires the permission of the Trust. You must ensure you gain the Trust
permission before reproducing any third party information.

 

 

Yours sincerely,

 

Information Governance Department

Informatics Building

Opposite N Block

Royal Bolton Hospital

' 01204 390861

8  [2][email address]

 

Our Bolton NHS Foundation Trust values
V O I C E
Vision Openess Integrity Compassion Excellence

 

 

 

 

From: Fletcher-Wilde Shannon On Behalf Of Freedom of Information
Sent: 16 August 2021 15:12
To: 'Dwayne Donovan' <[FOI #777958 email]>
Subject: RE: Internal review of Freedom of Information request - Serious
Untoward Incident investigations

 

Good Afternoon,

 

Please find attached the original response, and the internal review in the
format of a PDF. When our responses are sent to a whatdotheyknow account,
it appears that the website does not support the format in the same way
that it is sent, so the PDF should be easier to read.

 

Yours sincerely,

 

Information Governance Department

Informatics Building

Opposite N Block

Royal Bolton Hospital

' 01204 390861

8 [3][email address]

 

Our Bolton NHS Foundation Trust values
V O I C E
Vision Openess Integrity Compassion Excellence

 

 

show quoted sections

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.