Re: Request for information under the Freedom of Information Act 2000

Transcription

1 Pomona House Oak View Close Torquay Devon TQ2 7FF Tel: March 2016 Re: Request for information under the Freedom of Information Act 2000 Thank you for your request under the Freedom of Information Act 2000, which was received by NHS South Devon and Torbay Clinical Commissioning Group ( the CCG ) on 7 March I can confirm that the CCG holds the requested information, but I regret to inform you that the CCG will not release all of this to you because part(s) of the information is(are) exempt from release in accordance with one or more of the exemptions contained within the Freedom of Information Act For your information, the CCG is not the lead commissioner of the NHS 111 service in Devon, the lead commissioner is Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG) as such they are responsible for the incident management process and would notify us and seek our input only when the patient is registered with a practice in our CCG footprint. NEW Devon CCG is also responsible for the contract management although we take an active role in this. The answers provided are based on the one incident that occurred in the CCG s area and this is outlined below. With this in mind, the CCG cannot disclose any further information as it constitutes the personal information of the patient involved. 1. The South Western Ambulance Service Foundation Trust (SWAST) - which you commission to run the 111 out-of-hours service in your area - has admitted that there have been six serious incidents connected to its 111 service last year in 2015.

2 The Trust s Chief Executive Ken Wenman said in a statement to the Daily Mail: Last year the NHS 111 service answered 805,739 calls and unfortunately 6 of those resulted in serious incidents. None of these incidents has been publicly reported. However SWAST claim that information about serious incidents is shared with commissioners. Please can you confirm a) How many of these incidents have been reported to your Clinical Commissioning Group (CCG) if any; One Serious Incident Requiring Investigation (SIRI) has been reported to South Devon and Torbay CCG in relation to SWASFT as a provider of the 111 service. b) The nature of the serious incidents; The CCG is unable to respond because this information constitutes the personal data of the patient concerned and therefore disclosure of this information would contravene the Data Protection Act 1998, and is therefore exempt from disclosure under Section 40(2) and 40(3a) of the Freedom of Information Act c) Did any individuals die as a result of the incidents? If so, please give details. Of the incidents that have been reported to the CCG, the CCG is unaware of any incidents resulting in death. d) Did any individuals sustain adverse health effects as a result of the incidents? If so, please give details. Yes. e) The ages of the individuals involved The CCG is unable to respond because this information constitutes the personal data of the patient concerned and therefore disclosure of this information would contravene the Data Protection Act 1998, and is therefore exempt from disclosure under Section 40(2) and 40(3a) of the Freedom of Information Act f) What action was carried out by the CCG in response to these incidents, if any. Please refer to the response provided in question In 2014 disabled man in his 50s from Somerset died of a heart attack after he called the SWAST 111 service 20 times in a single weekend- but was never given an ambulance. The man had been asking for a district nurse to come and clean him up. But was in fact describing symptoms which should have alerted the 111 call advisors to a possible heart attack.

3 There was a potential Serious Incident Investigation carried out internally by the Trust in November 2014 and there are records which show call revi ews were carried out internally. These demonstrated repeated fai lures in the care provided by 111. For example the patient was declaring he had chest pain, upper back pain and shoulder pain - but was never categorised as a possible heart attack. It is thought the individual had been labelled a frequent caller and been viewed as a nuisance. b) If not, will the CCG now be investigating this? c) Despite the unusual circumstances of this man s death, and the apparent connection of his death to failures within the NHS, there was no inquest into the circumstances of his death. Can the CCG explain why this might have been? 3. A serious incident occurred during which a ten month old baby was wrongly given CPR, something which could have been fatal. This was because a 111 call handl er wrongly advised the ten-week-old baby should be resuscitated. The baby was breathing and therefore such a procedure is incredibly dangerous, placing the baby at risk of serious organ failure or even death. Throughout the call the baby was crying loudly and could be heard whimpering with the chest compressions. This incident involved the call advisor Anna-Lisa DeLuca. The details are on her individual Matrix profile as an under-compliant call involving resuscitation. Sarah Hayes, a whistle-blower who has now contacted the CQC to relay her concerns, was involved in reviewing the call. a) Was this incident ever reported by SWAST to your CCG? If so what action was taken? b) If not will the CCG be investigating this? 4. Last year the SWAST 111 service hired in a number of teenagers with no training in Pathways to act as call handlers.

4 These teenagers take 111 calls in their Devon and Dorset call centres (which also cover Cornwall). They are called Non Pathways Advisors and are paid less than normal call advisors, on a band 2 wage (c. 15,100p/a) as opposed to a Call Advisor s band 3 wage (c p/a). They have to make assessments about patients even though they have no training in - or access to - the pathways system. At least four of these NPAs working in Dorset were 17 years old when they started and had just completed GCSEs. After the hiring of these NPAs a serious incident subsequently occurred during which one of these teenaged call-handlers placed a person with a suspected stroke on hold for a number of minutes- when in fact they should have immediately been given an ambulance. She placed a patient who was reporting signs of a stroke (slumped to one side and not communicating as normal) in a queue to speak to a normal call advisor. If the call had been taken by a normal call advisor, the symptoms of stroke would have been recognised and an ambulance sent immediately. Because it was answered by an NPA, the person was placed in a queue, potentially placing their life at risk. The incident in question involved call handler Alex Banfield, who is the daughter of one of the managers at the service, Vicki Banfield, and was hired aged 17 to act as a Non-Pathways advisor. There is a record of this call within the Trust on Ms Banfield s individual Matrix profile as a non-compliant call, involving a suspected stroke. b) If not, will the CCG now be investigating this? 5. In the last two years, there was a serious incident review into a case where a 15 year old boy was left disfigured following the wrong advice being administered by the 111 service. Due to a problem with the 111 system, it was not identified- that the boy h ad a testicular torsion. As a result of that failing he lost a testicle. This went to the serious incident panel in Devon where it emerged that this was the second time this problem had arisen with 111. b) If not, will the CCG be investigating this?

5 This patient is a South Devon and Torbay CCG patient. In responding to the questions, we are not commenting on the veracity or otherwise of information already published. The CCG has been made aware of this incident and the subsequent investigation and associated learning. The CCG does not investigate serious incidents. This responsibility is held by the provider themselves including any actions as necessary. The responsibility of the CCG is to review the incident via a panel, which includes clinicians, so as to assure ourselves that the investigation held by the provider has been carried out to a thorough standard, and that causes and learning have been identified. The CCG is unable to disclose information from the investigation held by the provider. The disclosure of this information is also exempt under section 41(1)(a),(b) of the Freedom of Information Act This exemption applies where information was obtained from another person or organisation and the disclosure of that information to the public (otherwise than under this Act) by the public authority holding it would constitute a breach of confidence actionable by that or any other person or organisation. 6. In December 2014 a child called William Mead died after a string of NHS blunders. The circumstances of his death- including serious failures by 111 and other NHS services - became the subject of a major report by NHS England. a) On what date was William s death reported to your CCG by SWAST, if ever? b) If the death was not reported to the CCG, has the CCG subsequently asked SWAST why this was not reported given the findings of the NHS England review? This patient is not a South Devon & Torbay CCG patient and therefore the incident The CCG would not be asked to input into an investigation for a patient who is not in our area. NHS South Devon and Torbay Clinical Commissioning Group is committed to answering every request for information as fully as possible. I hope that you are happy with this response and that the information provided will be useful. If you have any further questions please do not hesitate to contact our Freedom of Information team on or foi.sdtccg@nhs.net. I recognise that you may be unhappy with the service you have received in relation to your request and that you may wish to make a complaint or request a review of our decision. If that is the case, please write to: The Director of Corporate Affairs and Medicines Optimisation, NHS South Devon and Torbay Clinical Commissioning Group, Pomona House, Oak View Close, Torbay, Devon, TQ2 7FF or foi.sdtccg@nhs.net. If you are still unhappy following our internal review, you may take your complaint to the Information Commissioner under the provisions of Section 50 of the Freedom of Information Act Chief Clinical Please Officer: note Dr that Nick the Roberts Information Commissioner will not investigate your case until the CCG s Clinical Chair: internal Dr Derek review Greatorex process has been completed. Further details of the role and powers of the Information Commissioner can be found on the Commissioner s website The Information Commissioner s address is: Information Commissioner s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF.