Significant Clinical Incidents (SCIs)

12%70%

230%270%

0%

100%

200%

300%

Cancers &circulatory

systemdiseases

Suicides alcoholrelateddeaths

drug relatedpoisoning

Glasgow Effect : Excess mortality beyond deprivation compared to Liverpool & Manchester

SCIs The Process

• Write a briefing note• Commission an investigation • Invite the carer/relative to participate• Involve the GP• Arrange and action/learning plan• Send report to quality assurance group for

review• Offer to meet with carer/family and share report

Learning Themes

• Communication with carers/relatives• Communication at transition times• Risk assessment• Real time information• Medication issues (complex)• Communication- general • Documentation- general

Communication with carers

• A central theme across GG&C• Carer input is invaluable• Communication is a two way process• Concerns about confidentiality vs

managing risk.• Communication at transition points is very

important

We might not be able to explain the technical terms when

something isn’t right - but we often know something is going

wrong

Real Time Information

• It is easier to see patterns if you can have up to date information.

• Especially in people with multiple health issues.

• What may seem a small thing can be part of a bigger pattern.

• Future IT structures could play a sig part in improving access to real time information.

A Psychiatrist’s 10 year Perspective of Glasgow City