Luton
Pilot run by: NHS Direct
No. of serious untoward incidents: 4
· Following an assessment through NHS Pathways, a health advisor advised a patient they should ‘speak to GP Practice within 6 hours'. As part of the regular call review process, our investigation concluded that a higher level of care would have been more appropriate. As with any incident like this the health advisor has undertaken a period of learning and development.
· A technical problem with the out of hours provider led to a delay in the NHS 111 service being able to book GP out of hours appointments for a number of patients. All patients were seen within an appropriate time frame.
· Following an assessment through NHS Pathways, a health advisor advised a patient to ‘make contact with their own GP the following morning'. As part of the regular call review process, our investigation concluded that that a higher level of care would have been more appropriate. As with any incident like this the health advisor has undertaken a period of learning and development.
· Following an assessment through NHS Pathways, a health advisor advised a patient they needed ‘tobe seen by GP Practice within 24 hours'. As part of the regular call review process, our investigation concluded that the call should have a higher level of care would have been more appropriate. As with any incident like this the health advisor has undertaken a period of learning and development.
Lincolnshire
Pilot run by: NHS Direct
No. of serious untoward incidents: 2
Information Governance issue
· A routine email reporting a system issue was sent from our clinical content suppliers to the technical team at NHS Direct. Patient identifiable data for a single patient which should have been removed was left in. NHS Direct notified the supplier immediately and the email was destroyed.
Issue with user practice
· Following an assessment through NHS Pathways, a health advisor advised a patient they should be ‘seen by GP Practice within 6 hours'. As part of the regular call review process, our investigation concluded that a higher level of care would have been more appropriate. As with any incident like this the health advisor has undertaken a period of learning and development.
Lancashire
Pilot run by: NHS Direct in partnership with ambulance service and OOH provider
No. of serious untoward incidents: 2
· Following an assessment through NHS Pathways, a nurse advised a patient they needed ‘to be referred to an Emergency Department within 1 hour'. As part of the regular call review process, our investigation concluded that a higher level of care would have been more appropriate. As with any incident like this the nurse has undertaken a period of learning and development
· A call handler was unable to automatically dispatch an ambulance for a patient who required a rapid response. The ambulance was organised verbally. This issue is being investigated by the Ambulance Service and contingency measures have been put in place.
Derbyshire
Pilot run by: Derbyshire Health United our-of-hours provider
No. of serious incidents: 1
· NHS Derbyshire said details are unavailable due to ‘ongoing investigation'.
