Identifying notifiable safety incidents

An occupational therapist completed an assessment with a care home resident whose mobility was deteriorating. They advised that grab rails were needed in his bathroom before it was safe for him to use the bath, and that in the meantime staff should assist him with a wash each morning.

The manager failed to update the resident’s care plan or inform the care staff of this change. Staff then supported him to take a bath the following morning as usual. He slipped when getting out of the bath and broke his arm. The arm was put in a plaster cast and the man needed full assistance for all aspects of his care for six weeks until the cast was removed. He made a full recovery. 

1. Was the incident unexpected or unintended? Yes. The incident may not be unexpected, but it was unintended. 

2. Did it occur during provision of a regulated activity? Yes. The incident occurred during the provision of the regulated activity 'accommodation for persons who require nursing or personal care'. 

3. Has it resulted in death or severe or moderate harm? Yes. The injury in this case is a broken arm and would fall under Regulation 20 as if the injury was left untreated the person using the service could experience one or more of the scenarios referred to in Regulation 20

The answers to all three questions are 'yes'. So this qualifies as a notifiable safety incident. And all steps outlined in the duty of candour (Regulation 20) should be carried out.  

A prescribing error on a mental health ward resulted in a detained patient being given double her normal dose of lithium for several days. She developed lithium toxicity, which required inpatient admission. She made a full recovery.  

1. Was the incident unexpected or unintended? Yes. The incident was both unexpected and unintended.

2. Did it occur during provision of a regulated activity? Yes. It occurred during provision of the regulated activity 'assessment or medical treatment for persons detained under the Mental Health Act 1983'.

3. Has it resulted in death or severe or moderate harm? Yes. The incident resulted in moderate harm as defined in 20(7) (significant, but not permanent, harm, and a moderate increase in treatment). The patient was receiving care in an NHS trust so the definitions in Regulation 20(8) apply.

The answers to all three questions are 'yes'. So this qualifies as a notifiable safety incident. And all steps outlined in the duty of candour (Regulation 20) should be carried out.   

A young man fell over while playing badminton and goes to his GP the next day with a swollen and painful foot and ankle. 

His GP decides not to order an x-ray and sends him home with advice to rest, ice, compress and elevate the leg. He tells the man he can weight-bear fully. 

Over the following week, the pain and swelling does not improve, and the man goes back to the GP surgery and sees a different doctor who sends him for an x-ray. 

He is found to have a fracture of the base of fifth metatarsal that should have been put into a plaster cast and should have been non-weight bearing. 

Due to this mismanagement, the patient develops a nonunion* over the following six weeks which causes him ongoing pain and eventually requires surgical intervention in hospital.

*A nonunion is a permanent failure of healing following a broken bone

1. Was the incident unexpected or unintended? Yes. The incident was both unexpected and unintended.

2. Did it occur during provision of a regulated activity? Yes. It occurred during provision of the regulated activity 'treatment of disease, disorder or injury'.

3. Has it resulted in death or severe or moderate harm? Yes. The incident resulted in prolonged pain, impairment of motor functions, and the need for surgical intervention. The patient was receiving care in a GP surgery so the definitions in Regulation 20 apply.

The answers to all three questions are 'yes'. So this qualifies as a notifiable safety incident. And all steps outlined in the duty of candour (Regulation 20) should be carried out.