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NHS Direct's 111 - details of SUIs

A Pulse investigation has uncovered a series of safety alerts across the Government’s NHS 111 pilots and concerns GP commissioners are being excluded from the rollout, which have prompted the GPC to demand the programme be put on hold.

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'.

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