manchester newborn screening laboratory quarterly blood ... · 1 aisha rahman & everly hird...
TRANSCRIPT
1 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Manchester Newborn Screening Laboratory Quarterly Blood Spot
Screening Report: Quarter 4 2019-20
Manchester Newborn Screening Laboratory, which serves babies born in Greater
Manchester, Lancashire and South Cumbria, received 13143 blood spot samples between 1st
January and 31st March 2020. This report describes performance against the NHS Newborn
Blood Spot Screening Programme Standards. Full details of the standards including
definitions and exclusions can be found at https://www.gov.uk/government/publications/
standards-for-nhs-newborn-blood-spot-screening. The appendix of this document contains
the data for standards 3-7 in table form.
The data for the laboratory reportable standards is presented by maternity unit/NHS trust of the sample taker. For accurate figures, please ensure the trust code is written/stamped on the blood spot card (in the PCT field). The proportion of samples with a missing maternity unit/trust code is presented in figure 1 by CCG. Overall the maternity/ trust code was missing from 115 sample cards (0.9%).
Declines In quarter 4 the laboratory received 56 notifications of declined blood spot screening. Figure 2 shows the trends in declined screens over the past year, by place of birth (born in UK or born outside of UK). The laboratory should be notified of all declines, including those for babies screened elsewhere, rather than directly notifying Child Health.
2 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
3 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Key to colour coding
Met achievable threshold
Met acceptable threshold
Within 10% of acceptable threshold
More than 10% below acceptable threshold
Standard 3 – The proportion of blood spot cards received by the laboratory with the
baby’s NHS number on a barcoded label
Acceptable: ≥ 90.0% of blood spot cards are received by the laboratory with the baby’s NHS number on a barcoded label. Achievable: ≥ 95.0% of blood spot cards are received by the laboratory with the baby’s NHS
number on a barcoded label.
Figure 3 displays performance against standard 3.
Overall, 83.7% of samples received January and 31st March 2020 had a barcoded NHS
number label, which is slightly higher than quarter 3 (82.7%). Of 11 maternity units, 4 met
the standard, including two reaching the achievable threshold (East Lancashire and
Lancashire Teaching).
Standard 4 - The proportion of first blood spot samples taken on day 5
Acceptable: ≥ 90.0% of first blood spot samples are taken on day 5. Achievable: ≥ 95.0% of first blood spot samples are taken on day 5. Figure 4 displays performance against standard 4. Overall, 92.0% of samples received January and 31st March 2020 were collected on day 5. Of 11 maternity units, 10 met standard 4, which is similar to quarter 3 (91.5%; 10 units met the standard). Manchester FT and Blackpool met the achievable threshold.
4 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
5 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
6 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Standard 5 - The proportion of blood spot samples received less than or equal to 3
working days of sample collection
Acceptable: ≥ 95.0% of all samples received less than or equal to 3 working days of sample collection.
Achievable: ≥ 99.0% of all samples received less than or equal to 3 working days of sample collection.
Performance against the transport standard (figure 5) was good. Overall 98.1% samples
were received within 3 working days. 9 Trusts met the standard, including 6 reaching the
achievable threshold. Performance was very similar to the last quarter (98.6% samples
received within 3 working days).
Standard 6 - The proportion of first blood spot samples that require repeating due to an
avoidable failure in the sampling process
Acceptable: Avoidable repeat rate is ≤ 2.0%
Achievable: Avoidable repeat rate is ≤ 1% The avoidable repeat rate for quarter 4 was 2.1%, compared with 2.5% in quarter 3. The
performance for each trust is displayed in figure 6. Five Trusts met the standard. Tameside
met the achievable standard. Figure 7 compares the avoidable repeat rate for samples
collected from in-patients with sample collected from babies at home/ in the community.
The rate was 1.7% for babies at home (similar to quarter 3; 1.8%) and 5.2% for samples
collected from in-patients (7.1% in quarter 3).
Please note that from 23rd March 2020, the national COVID-19 temporary acceptance
criteria was applied. Using the standard acceptance criteria, the avoidable repeat rate for
this quarter would have been 2.5% as an additional 44 samples would have been rejected.
When processing samples we have noticed a definite deterioration in sample quality
presumably as a result of pressures due to the pandemic and awareness of the less stringent
sample acceptance criteria. Please see the Appendix for additional tables displaying what
the rejection rates would have been (by Trust and for in-patients) using the established
criteria.
7 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
8 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
9 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
There were no avoidable repeats for Blackburn in-patients.
10 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Trust STD 3 STD 4 STD 5 STD 6
Blackpool Teaching Hospitals NHS FT 91.1% 95.7% 99.1% 1.2%
Bolton NHS FT 82.1% 92.3% 99.5% 2.4%
East Lancashire Hospitals NHS Trust 95.2% 92.3% 99.5% 2.0%
Lancashire Teaching Hospitals NHS FT 97.2% 93.7% 99.6% 1.1%
Manchester University NHS FT 93.4% 95.3% 99.8% 2.2%
Pennine Acute Hospitals NHS Trust 82.4% 89.1% 97.0% 2.2%
Southport & Ormskirk Hospital NHS
Trust76.6% 93.6% 80.3% 3.8%
Stockport NHS FT 83.7% 92.8% 99.7% 2.4%
Tameside And Glossop Integrated Care
NHS FT89.1% 93.2% 97.8% 0.6%
University Hospitals of Morecambe Bay
NHS FT89.2% 94.5% 96.8% 2.0%
Wrightington, Wigan and Leigh NHS FT 21.9% 93.0% 94.1% 3.0%
Q4 19-20 Table 1 - Summary of performance
11 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Standard 7a - The proportion of second blood spots for raised IRT taken on day 21 to day
24
Acceptable: ≥ 95% of second blood spot samples taken on day 21 to day 24 Achievable: ≥ 70% of second blood spot samples taken on day 21
The acceptable threshold was met for Standard 7a. During quarter 4 there were 6 repeats
for raised IRT (CF inconclusive). Of these, 67% (4) were collected on day 21 and 100% (6) on
day 21-24. CF inconclusive repeats are performed by Screening Link Health Visitors. The data
is presented in figure 7 and by local Child Health Records Department, in table 2.
21 22 23
Blackpool 1 1 2 50% 100%Lancaster 1 1 0% 100%Manchester 1 1 100% 100%
Rochdale 1 1 100% 100%Salford 1 1 100% 100%
Grand Total 4 1 1 6 67% 100%
% collected
day 21-24
Child Health Records
DepartmentGrand Total
%
collected
day 21
Age at Collection of CF Inconclusive
Repeat (days)
Q4 Table 2 - Standard 7a
12 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Standard 7b - The proportion of second blood spot samples for borderline TSH taken
between 7 and 10 calendar days after the initial borderline sample
Acceptable: ≥ 95.0% of second blood spot samples taken as defined Achievable: ≥ 99.0% of second blood spot samples taken as defined Standard 7b was not met. Figure 8 displays the proportion collected 7-10 days after the initial sample and table 3 displays the information by Trust.
7 8 9 10 11 12
Blackpool Teaching Hospitals NHS FT 1 1 100%
Bolton NHS FT 1 1 100%East Lancashire Hospitals NHS Trust 1 1 100%Lancashire Teaching Hospitals NHS FT 1 1 2 50%Manchester University NHS FT - SMH & RMCH 1 1 2 4 100%Manchester University NHS FT - Wythenshawe 1 3 1 5 80%Not Stated 1 1 100%Pennine Acute Hospitals NHS Trust 1 2 2 2 8 63%Southport & Ormskirk Hospital NHS Trust 2 2 100%Tameside And Glossop Integrated Care NHS FT 1 1 100%University Hospitals of Morecambe Bay NHS FT 2 2 100%Wrightington, Wigan and Leigh NHS FT 1 1 0%Grand Total 1 5 8 9 3 2 29 79%
Trust
% collected 7-10
days after
original sample
Grand Total
Number of days between original sample
and collection of repeat sample
Q4 Table 3: Standard 7b
13 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Standard 7c - The proportion of CHT pre-term repeats collected on day 28 or at discharge
Acceptable: ≥ 95.0% of second blood spot samples taken as defined
Achievable: ≥ 99.0% of second blood spot samples taken as defined
Standard 7c was not met. During quarter 3, 116 CHT pre-term repeats (second samples only,
avoidable repeats excluded) were received. Performance by trust is displayed in figure 9.
78% were collected on day 28 or at discharge. 5% were collected too early and required a
further repeat. 16% were collected after day 28.
Of note, 10 out of 19 babies with samples collected after day 28 had transfusions on days
25-28, which would account for the delayed sampling.
Standard 9 - Timely processing of CHT and IMD (excluding HCU) screen positive samples
Acceptable: 100% of babies with a positive screening result (excluding HCU) have a clinical
referral initiated within 3 working days of sample receipt
8 samples screened positive for CHT during quarter 4. 100% of babies were referred within 3
working days.
There were 6 IMD positives (excluding HCU) and all were referred within 3 working days.
Standard 11 - Timely entry into clinical care
Data for standard 11 is displayed in table 4.
14 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Condition Criteria Thresholds
Number of
babies seen by
specialist
services by
condition
specific
standard
Number of
babies
referred
Percentage
seen by
specialist
services by
condition
specific
standard
Comments
IMDs (excluding HCU)
Attend first clinical
appointment by 14 days of
age
Acceptable: 100% 6 6 100%
CHT (suspected on first
sample)
Attend first clinical
appointment by 14 days of
age
Acceptable: 100% 3 3 100%
CHT (suspected on repeat
following borderline TSH)
Attend first clinical
appointment by 21 days of
age
Acceptable: 100% 5 5 100%
CF (2 CFTR mutations
detected)
Attend first clinical
appointment by 28 days of
age
Acceptable: ≥ 95.0%
Achievable: 100%4 4 100%
HCU
Attend first clinical
appointment by 28 days of
age
Acceptable: ≥ 95.0%
Achievable: 100%0 0 N/A
CF (1 or no CFTR mutation
detected)
Attend first clinical
appointment by 35 days of
age
Attend first clinical
appointment by 35
days of age
2 4 50%
1 baby died at 2.5 months prior to being seen by
CF team. One extremely pre-term baby seen on
day 84.
SCD
Attend first clinical
appointment by 90 days of
age
Attend first clinical
appointment by 90
days of age
5 6 83%1 baby not 90 days yet (88 days old at the time of
this report)
Table 4: Standard 11
15 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Incidents
Figure 10 displays blood spot screening incidents identified by the lab or notified to the lab. A summary table of incidents is included in the
appendix.
16 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Appendix
TrustNumber of all samples
(including repeats)
Number of blood spot
cards including baby's
NHS number
Number of blood spot
cards including ISB
label barcoded baby's
NHS number
Percentage of all blood
spot cards including
babies' NHS number
Percentage of all blood
spot cards including ISB
bar-coded babies' NHS
number
Blackpool Teaching Hospitals NHS FT 666 666 607 100.00% 91.14%
Bolton NHS FT 1590 1588 1305 99.87% 82.08%
East Lancashire Hospitals NHS Trust 1623 1620 1545 99.82% 95.19%
Health Visitor 126 119 1 94.44% 0.79%
Lancashire Teaching Hospitals NHS FT 963 963 936 100.00% 97.20%
Manchester University NHS FT - SMH & RMCH 2393 2387 2234 99.75% 93.36%
Not Stated 115 113 84 98.26% 73.04%
Pennine Acute Hospitals NHS Trust 2544 2537 2095 99.72% 82.35%
Southport & Ormskirk Hospital NHS Trust 248 248 190 100.00% 76.61%
Stockport NHS FT 790 790 661 100.00% 83.67%
Tameside And Glossop Integrated Care NHS FT 634 634 565 100.00% 89.12%
University Hospitals of Morecambe Bay NHS FT 687 685 613 99.71% 89.23%
Wrightington, Wigan and Leigh NHS FT 764 759 167 99.35% 21.86%
Grand Total 13143 13109 11003 99.74% 83.72%
Quarter 4 2019-20: Standard 3
17 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Trust
Number of first
samples taken
on or before
day 4
5 6 7 8 9+ 4 or earlier 5 6 7 8 9 or later
Blackpool Teaching Hospitals NHS FT 1 619 19 2 1 5 0.15% 95.67% 2.94% 0.31% 0.15% 0.77%
Bolton NHS FT 1 1330 78 19 5 8 0.07% 92.30% 5.41% 1.32% 0.35% 0.56%
East Lancashire Hospitals NHS Trust 2 1368 90 12 2 8 0.13% 92.31% 6.07% 0.81% 0.13% 0.54%
Health Visitor 0 0 0 0 0 104 0.00% 0.00% 0.00% 0.00% 0.00% 100.00%
Lancashire Teaching Hospitals NHS FT 2 865 34 3 7 12 0.22% 93.72% 3.68% 0.33% 0.76% 1.30%
Manchester University NHS FT 1 2043 72 12 7 8 0.05% 95.33% 3.36% 0.56% 0.33% 0.37%
Not Stated 0 74 3 0 1 0 0.00% 94.87% 3.85% 0.00% 1.28% 0.00%
Pennine Acute Hospitals NHS Trust 5 2144 204 21 13 20 0.21% 89.07% 8.48% 0.87% 0.54% 0.83%
Southport & Ormskirk Hospital NHS Trust 1 221 8 3 2 1 0.42% 93.64% 3.39% 1.27% 0.85% 0.42%
Stockport NHS FT 0 706 43 6 1 5 0.00% 92.77% 5.65% 0.79% 0.13% 0.66%
Tameside And Glossop Integrated Care NHS FT 1 578 35 2 2 2 0.16% 93.23% 5.65% 0.32% 0.32% 0.32%
University Hospitals of Morecambe Bay NHS FT 1 623 22 3 2 8 0.15% 94.54% 3.34% 0.46% 0.30% 1.21%
Wrightington, Wigan and Leigh NHS FT 1 674 41 5 0 4 0.14% 92.97% 5.66% 0.69% 0.00% 0.55%
Grand Total 16 11245 649 88 43 185 0.13% 91.98% 5.31% 0.72% 0.35% 1.51%
Quarter 4 2018-19: Standard 4
Excludes samples with missing dates
18 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Maternity Unit
Number of samples
received in 3 or fewer
working days of
sample being taken
Total number of
samples received
Percentage of
samples received by
laboratories in 3 or
fewer working days
of sample being
taken
Blackpool Teaching Hospitals NHS FT 658 664 99.1%
Bolton NHS FT 1502 1510 99.5%
East Lancashire Hospitals NHS Trust 1535 1542 99.5%
Health Visitor 104 110 94.5%
Lancashire Teaching Hospitals NHS FT 951 955 99.6%
Manchester University NHS FT 2267 2271 99.8%
Not Stated 86 88 97.7%
Pennine Acute Hospitals NHS Trust 2444 2520 97.0%
Southport & Ormskirk Hospital NHS Trust 196 244 80.3%
Stockport NHS FT 788 790 99.7%
Tameside And Glossop Integrated Care NHS FT 618 632 97.8%
University Hospitals of Morecambe Bay NHS FT 660 682 96.8%
Wrightington, Wigan and Leigh NHS FT 718 763 94.1%
Grand Total 12527 12771 98.1%
Quarter 4 2019-20: Standard 5
19 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Status code and description of avoidable
repeat
Blackpool
Teaching
Hospitals
NHS FT
Bolton NHS
FT
East
Lancashire
Hospitals
NHS Trust
Lancashire
Teaching
Hospitals
NHS FT
Manchester
University
NHS FT
Not StatedHealth
Visitor
Pennine
Acute
Hospitals
NHS Trust
Southport &
Ormskirk
Hospital NHS
Trust
Stockport
NHS FT
Tameside
And Glossop
Integrated
Care NHS FT
University
Hospitals of
Morecambe
Bay NHS FT
Wrightington,
Wigan and Leigh
NHS FT
Grand
Total
0301: too young for reliable screening (≤ 4
days)0 0 3 1 0 0 0 4 0 0 1 1 1 11
0302: too soon after transfusion (<72 hours) 0 6 8 2 7 1 0 3 0 2 0 0 0 29
0303: insufficent sample 6 14 10 3 8 1 0 7 0 4 1 3 4 61
0304: unsuitable sample (blood quality):
incorrect blood application2 15 4 5 22 2 2 16 3 14 1 3 10 99
0305: unsuitable sample (blood quality):
compressed/damaged 0 0 0 0 2 0 0 5 1 0 1 1 0 10
0306: Unsuitable sample: day 0 and day 5 on
same card0 0 0 0 0 0 0 0 0 0 0 0 0 0
0307: unsuitable sample for CF: possible
faecal contamination0 5 0 0 4 0 0 4 1 0 0 1 2 17
0308: unsuitable sample: NHS number
missing/not accurately recorded0 0 2 0 4 2 4 7 0 0 0 2 4 25
0309: unsuitable sample: date of sample
missing/not accurately recorded0 0 11 1 7 1 0 9 4 0 0 2 1 36
0310: unsuitable sample: date of birth not
accurately matched0 0 0 0 0 0 0 0 0 0 0 0 0 0
0311: unsuitable sample: expired card used 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0312: unsuitable sample: >14 days in transit,
too old for analysis0 0 0 0 0 0 0 1 0 0 0 0 0 1
0313: unsuitable sample: damaged in transit 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of Avoidable Repeat Requests 8 34 30 10 47 6 6 53 9 18 4 13 22 260
Number of first samples received/
babies tested647 1442 1495 925 2151 96 120 2420 240 761 620 663 726 12306
Avoidable Repeat Requests Rate 1.2% 2.4% 2.0% 1.1% 2.2% 6.3% 5.0% 2.2% 3.8% 2.4% 0.6% 2.0% 3.0% 2.1%
Transfusion Reapeats are not included in the Avoidable Repeat calculation
Quarter 4 2019-20: Standard 6 by Trust
20 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Status code and description of avoidable repeat
Blackpool Victoria Hospital
Burnley General Hospital
Furness General Hospital
North Manchester
General Hospital
Not in hospital
Ormskirk & District General
Royal Albert
Edward Infirmary
Royal Blackburn Hospital
Royal Bolton
Hospital
Royal Lancaster Infirmary
Royal Manchester
Childrens Hospital
Royal Oldham Hospital
Royal Preston Hospital
St Mary's Hospital,
Manchester
Stepping Hill
Hospital
Wythenshawe Hospital
Tameside General Hospital
Grand Total
0301: too young for reliable screening (≤ 4 days)
0 1 0 0 9 0 1 0 0 0 0 0 0 0 0 0 0 11
0302: too soon after transfusion (<72 hours)
0 8 0 0 1 0 0 0 6 0 0 3 2 7 2 0 0 29
0303: insufficent sample 1 3 1 1 45 0 0 0 1 1 1 3 0 1 1 2 0 61
0304: unsuitable sample (blood quality): incorrect blood application
0 3 0 4 59 2 4 0 5 0 1 2 1 9 3 6 0 99
0305: unsuitable sample (blood quality): compressed/damaged
0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 1 1 10
0306: Unsuitable sample: day 0 and day 5 on same card
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0307: unsuitable sample for CF: possible faecal contamination
0 0 0 0 15 0 0 0 1 0 0 1 0 0 0 0 0 17
0308: unsuitable sample: NHS number missing/not accurately recorded
0 0 0 1 20 0 3 0 0 0 0 1 0 0 0 0 0 25
0309: unsuitable sample: date of sample missing/not accurately recorded
0 2 0 0 29 1 0 0 0 0 0 1 0 2 0 1 0 36
0310: unsuitable sample: date of birth not accurately matched
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0311: unsuitable sample: expired card used
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0312: unsuitable sample: >14 days in transit, too old for analysis
0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1
0313: unsuitable sample: damaged in transit
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of Avoidable Repeat Requests 1 9 1 6 185 3 8 0 7 1 2 9 1 12 4 10 1 260
Number of first samples received/ babies tested
70 169 17 93 10859 18 61 3 164 42 12 175 110 282 68 110 53 12306
Avoidable Repeat Requests Rate 1.4% 5.3% 5.9% 6.5% 1.7% 16.7% 13.1% 0.0% 4.3% 2.4% 16.7% 5.1% 0.9% 4.3% 5.9% 9.1% 1.9% 2.1%
Transfusion Reapeats are not included in the Avoidable Repeat calculation
Quarter 4 2019-20: Standard 6 by Current Hospital
21 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Projection of avoidable repeat rate by Trust for Q4 2020 had the standard acceptance criteria been used
Status code and description of avoidable
repeat
Blackpool
Teaching
Hospitals NHS
FT
Bolton
NHS FT
East Lancashire
Hospitals NHS
Trust
Lancashire
Teaching
Hospitals NHS
FT
Manchester
University NHS
FT
Not
Stated
Health
Visitor
Pennine
Acute
Hospitals
NHS Trust
Southport &
Ormskirk
Hospital NHS
Trust
Stockport
NHS FT
Tameside And
Glossop
Integrated Care
NHS FT
University
Hospitals of
Morecambe
Bay NHS FT
Wrightington,
Wigan and
Leigh NHS FT
Grand
Total
0301: too young for reliable screening (≤ 4
days)1 0 3 2 0 0 0 4 1 0 1 1 1 14
0302: too soon after transfusion (<72 hours) 0 6 8 2 7 1 0 3 0 2 0 0 0 29
0303: insufficent sample 6 21 15 5 9 4 0 12 0 4 1 4 4 85
0304: unsuitable sample (blood quality):
incorrect blood application4 18 4 7 23 2 2 22 3 15 1 3 11 115
0305: unsuitable sample (blood quality):
compressed/damaged 0 0 0 0 2 0 0 5 1 0 1 1 0 10
0306: Unsuitable sample: day 0 and day 5 on
same card0 0 0 0 0 0 0 0 0 0 0 0 0 0
0307: unsuitable sample for CF: possible
faecal contamination0 5 0 0 4 0 0 4 1 0 0 1 2 17
0308: unsuitable sample: NHS number
missing/not accurately recorded0 0 2 0 4 2 4 7 0 0 0 2 4 25
0309: unsuitable sample: date of sample
missing/not accurately recorded0 0 11 1 8 1 0 9 4 0 0 2 1 37
0310: unsuitable sample: date of birth not
accurately matched0 0 0 0 0 0 0 0 0 0 0 0 0 0
0311: unsuitable sample: expired card used 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0312: unsuitable sample: >14 days in transit,
too old for analysis0 0 0 0 0 0 0 1 0 0 0 0 0 1
0313: unsuitable sample: damaged in transit 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of Avoidable Repeat Requests 11 44 35 15 50 9 6 64 10 19 4 14 23 304
Number of first samples received/
babies tested647 1442 1495 925 2151 96 120 2420 240 761 620 663 726 12306
Avoidable Repeat Requests Rate 1.7% 3.1% 2.3% 1.6% 2.3% 9.4% 5.0% 2.6% 4.2% 2.5% 0.6% 2.1% 3.2% 2.5%
Transfusion Reapeats are not included in the Avoidable Repeat calculation
Quarter 4 2019-20: Standard 6 by Trust - using the standard acceptance criteria
22 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Projection of avoidable repeat rate by current hospital (in-patients) for Q4 2020 had the standard acceptance criteria been used
Status code and description of avoidable repeat
Blackpool Victoria Hospital
Burnley General Hospital
Furness General Hospital
North Manchester
General Hospital
Not in hospital
Ormskirk & District General
Royal Albert Edward
Infirmary
Royal Blackburn Hospital
Royal Bolton
Hospital
Royal Lancaster Infirmary
Royal Manchester
Childrens Hospital
Royal Oldham Hospital
Royal Preston Hospital
St Mary's Hospital,
Manchester
Stepping Hill
Hospital
Tameside General Hospital
Wythenshawe Hospital
Grand Total
0301: too young for reliable screening (≤ 4 days)
1 1 0 0 11 0 1 0 0 0 0 0 0 0 0 0 0 14
0302: too soon after transfusion (<72 hours)
0 8 0 0 1 0 0 0 6 0 0 3 2 7 2 0 0 29
0303: insufficent sample 1 4 1 1 64 0 0 0 4 1 1 4 0 1 1 0 2 85
0304: unsuitable sample (blood quality): incorrect blood application
0 3 0 7 68 2 4 0 6 0 1 4 1 10 3 0 6 115
0305: unsuitable sample (blood quality): compressed/damaged
0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 1 1 10
0306: Unsuitable sample: day 0 and day 5 on same card
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0307: unsuitable sample for CF: possible faecal contamination
0 0 0 0 15 0 0 0 1 0 0 1 0 0 0 0 0 17
0308: unsuitable sample: NHS number missing/not accurately recorded
0 0 0 1 20 0 3 0 0 0 0 1 0 0 0 0 0 25
0309: unsuitable sample: date of sample missing/not accurately recorded
0 2 0 0 30 1 0 0 0 0 0 1 0 2 0 0 1 37
0310: unsuitable sample: date of birth not accurately matched
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0311: unsuitable sample: expired card used
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0312: unsuitable sample: >14 days in transit, too old for analysis
0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1
0313: unsuitable sample: damaged in transit
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of Avoidable Repeat Requests 2 10 1 9 216 3 8 0 11 1 2 12 1 13 4 1 10 304
Number of first samples received/ babies tested
70 169 17 93 10859 18 61 3 164 42 12 175 110 282 68 53 110 12306
Avoidable Repeat Requests Rate 2.9% 5.9% 5.9% 9.7% 2.0% 16.7% 13.1% 0.0% 6.7% 2.4% 16.7% 6.9% 0.9% 4.6% 5.9% 1.9% 9.1% 2.5%
Transfusion Reapeats are not included in the Avoidable Repeat calculation
Quarter 4 2019-20: Standard 6 by Current Hospital - using the standard acceptance criteria
23 Aisha Rahman & Beverly Hird 05/06/2020 CB-REP-REP-10
Early On time Late Total
Blackpool Teaching Hospitals NHS FT 0 1 1 2 50% 50%
Bolton NHS FT 1 5 4 10 50% 60%
East Lancashire Hospitals NHS Trust 1 10 2 13 77% 85%
Lancashire Teaching Hospitals NHS FT 0 14 2 16 88% 88%
Manchester FT 0 22 5 27 81% 81%
Pennine Acute Hospitals NHS Trust 4 19 3 26 73% 88%
Stockport NHS FT 0 5 0 5 100% 100%
Tameside And Glossop Integrated Care NHS FT 0 3 0 3 100% 100%
University Hospitals of Morecambe Bay NHS FT 0 5 1 6 83% 83%
Wrightington, Wigan and Leigh NHS FT 0 7 1 8 88% 88%
Grand Total 6 91 19 116 78% 84%
Quarter 4 2019-20: Standard 7c
Trust
Number of Pre-term CHT second samples collected: % Prem repeats
collected on day 28
or at discharge
% Prem repeats
collected on day 28
or earlier
Incident
Number
Incident
Date
Incident
Severity
Incident
HarmSummary of incident Further details
Lab/ Ward/
Maternity Unit
2107782 04/01/20 2 - minor 1 - no harmBlood spot collection error: delay/
failure to collect screening sample
Delayed postnatal care.
Sample collected day 12.
SMH Community
Midwives
2101378 20/11/19 4 - major 1 - no harm
Blood spot labelling error: another
baby's bar-coded demographic
sticker, detected prior to reporting
Mismatch of handwritten
mother's details with
details on barcode.
Lancaster Community
Midwives
2109211 08/01/20 1 - low 1 - no harm
Blood spot transport issue: sample(s)
delayed/ lost in transit or not
dispatched, resulting in retesting of
baby
SMH Community
Midwives
2109785 12/01/20 1 - low 1 - no harmBlood spot collection error: delay/
failure to collect screening sample
Patient expected visit on
day 5. Sample collected
day 6.
Wythenshawe
Community Midwives
2109813 15/01/20 2 - minor 1 - no harm
Blood spot labelling error: unlabelled/
inadequately labelled sample found
on ward
Disposed off Ward 68, SMH (NICU)
2112433 30/01/20 1 - low 1 - no harm
Blood spot transport issue: sample(s)
delayed/ lost in transit or not
dispatched, resulting in retesting of
baby
First sample not recorded
as received in clerk' s
office or lab. Repeat
collected day 15.
Ward C2,
Wythenshawe
2113111 03/02/20 4 - major 6-external
Blood spot labelling error: manually
labelled with another baby's
demographic details
Blood spot card
contained a mixture of
demographic details from
two different babies.
Bolton Community
Midwives
2113584 05/02/20 1 - low 1 - no harmBlood spot collection error: delay/
failure to collect screening samplePostnatal visit missed
SMH Community
Midwives
2114152 08/02/20 2 - minor 1 - no harmBlood spot collection error: delay/
failure to collect screening sample
Assumed baby in-patient
with mother (under
gynaecology) but baby
was at home. Sample
collected day 7
SMH Community
Midwives
2115783 14/02/20 3 - moderate 2 - slight
Blood spot labelling error:
handwritten NHS number belonging
to another baby (other demographic
details correct)
Pennine Community
Midwives
2118329 27/02/20 1 - low 1 - no harmBlood spot collection error: delay/
failure to collect screening sample
Postnatal visit missed,
then no access. Collected
day 8.
SMH Community
Midwives
2120295 14/03/20 1 - low 1 - no harm
Blood spot labelling error: unlabelled/
inadequately labelled sample found
on ward
Ward 68, SMH (NICU)
2121043 13/03/20 3 - moderate 2 - slight
Blood spot labelling error:
demographic sticker contained errors
e.g. another baby's NHS number
(some details correct)
Twins. Rank and birth
weight swapped. 2nd
sticker underneath on
each sample with details
of the opposite.
East Lancs Community
Midwives
2124409 23/03/20 1 - low 2 - slight
Blood spot transport issue: sample(s)
delayed/ lost in transit or not
dispatched, resulting in retesting of
baby
First sample not recorded
as received in clerk' s
office or lab. Repeat
collected day 13.
Ward C2,
Wythenshawe