5. Incidents review

Incidents Review: Sharing and

Learning from Common Themes

London Local Screening Coordinators & Heads of Midwifery

Forum

1 July 2016

Michelle Onslow

Senior QA Advisor, London Screening Quality Assurance Service.

Contents:

• Overview of incidents across London

in the last 6 months

• Review of the main themes and

lessons

2 Incidents Review: Themes and Learning LCO & HoM forum - 1 July 2016

3

NCL 37

NEL 49

NWL 13

SEL 21

SWL 16

Total London ANNB Incidents 1.12.2015 - 31.5.2016

NCL

NEL

NWL

SEL

SWL

Total = 136

Incidents Review: Themes and Learning LCO & HoM forum - 1 July 2016

London incidents by programme

11

11

8

2

102

2

FASP

IDP

SCT

NHSP

NBS

NIPE

4


Serious Incidents • 6 serious incidents reported in the

timeframe

• 3 NBS, 1 FASP and 2 IDS incidents

• Incomplete antenatal screening bloods

for 50 women found at KPI data

collection

• Missed down’s syndrome screening –

affected baby


Serious Incidents

• Diagnosis of SCD at 10 years of age –

unknown screening status

• Lab – discrepant reporting of HIV & Hep B

positive ANNB screening result

• Lab – delayed repeat request for CF

inconclusive result – delayed entry into care


Themes – Infectious diseases

• Missed/delayed Screens: Lack of failsafe

Failsafe in place but not monitored

Lack of escalation

• Delayed referral into treatment

• Delay or missed vaccination or HBIG Late bookers, transfer in labour, baby on HDU with

Mum

Incidents Review: Themes and Learning LCO & HoM forum - 1 July 2016 7

Themes: SCT

• Missed/delayed screening – some

resulting in delayed diagnosis of at risk

couples

• Lab – delayed reporting of results,

ambiguous wording of results – national

standards not followed.


Themes: FASP

• Missed screens – more on this later!

• Of the 11 FASP incidents reported for this

time frame 9 of them are missed

screening incidents affecting at least 20

women


Themes: NBS • Delayed screening due to no receipt of discharge

paperwork

• Midwives repeating NBS samples without knowing the

reason why

• Family visited for a repeat NBS screen after the baby

had passed away

• Incorrect entry at birth notifications not corrected

appropriately

• Northgate ping pong


Themes: NHSP

• Audiology referral was cancelled as a record was

deactivated in error

• Premature baby was screened and diagnosed

with a PCHI but was too young to be screened

• No incidents reported in London where families of

deceased babies were contacted – huge

success!

11


Themes - NIPE • Missed or delayed screens – reduction in the

numbers reported as incidents

• One late diagnosis of congenital dislocation of

the hips – met the screening criteria for a hip

ultrasound but not organised before discharge,

picked up by GP at second NIPE that took place

at 12 week.


Key Messages 1) Failsafe’s – essential to reduce the risk of missed screens; they only work if

they are monitored regularly and missing results are escalated

2) They must also be in place to ensure that women and babies are referred

into care and/or receive the treatment they require – it’s the point of

screening

3) Screening incidents in labs should be reported too – please let us know if

you know. Don’t recall women before seeking QA advice!

4) NBS samples shouldn’t be repeated without knowing the reason – ideally

write the reason on the card

5) Discharge details – important to know they reached the receiving hospital

6) Bereavement checklists – is updating Northgate included?


Thank you

Healthcare

5. Incidents review