Gransha ‘near miss’ reporting criticised

The Western Trust has been told to urgently review its serious adverse incident (SAI) reporting regime at Gransha.

Friday, 26th July 2019, 6:55 pm

The Regulation & Quality Improvement Authority (RQIA) demanded action after inspectors found failings in how near misses were recorded.

Dr. Lourda Geoghegan, RQIA’s Director of Improvement, in a notice issued on Monday, said unannounced inspections in June at the Carrick and Evish Wards at Grangewood and at the Lime and Elm Wards at the Tyrone and Fermanagh Hospital found serious shortcomings.

“We identified incidents which had been incorrectly categorised in the Trust’s Datix system [internal reporting system] and this had not been appropriately escalated within the Trust,” she said.

Dr. Geoghegan said the RQIA discussed this with the Trust on July 10 but “received limited assurance regarding the actions in progress by the Trust with respect to recognition and management of adverse incidents and near misses”.

On July 15, the Trust confirmed “a number of additional adverse incidents were incorrectly categorised in the Trust’s Datix system and thus may not have been appropriately escalated”.

Dr. Geoghegan reported inspections in September 2017 and March 2019 had thrown up similar concerns but they still had not been addressed.

The Western Trust has been given until October 22 to “undertake an urgent review of information recorded in the Trust’s Datix system, to ensure that they understand the nature and extent of risks captured in the system as it operates across the Trust’s Directorate of Adult Mental Health & Disability Services.”