Action Taken
NHS Professionals has implemented measures including competency assessments for bank members, reviews with the Interim Director of Nursing, and a dedicated Clinical Governance Nurse Lead and Education Liaison Team to manage complaints and investigations. They also use a Complaints and Incidents Management System (CIMS) feedback form to address concerns raised by Client Trusts. (AI summary)
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Dear Mr Harris Regulation 28 Report to Prevent Future Deaths following inquest of Alex James Blake died at Lambeth Hospital, London; on 24 June 2018 (Case Ref: 04761-2018 who am writing to you to respond to the concerns raised by surrounding the tragic death of Alex James Blake. your investigation into the circumstances de4St Professionals takes very seriously its responsibility to act upon what it learns from rdeaths of patlents, Who were cared for by Bank Members Whlist in te cara of theaNHS unexpected In your report you Identified the following Matters of Concern: The evidence of the NHS Professionals Bank Members rise mandated observations gave to concerns that the were either not performed to the requisite standard or not performed at all; and
2. Shere was Inconslstency of account given by the three Bank Members as between their statements, the records and their oral evidence, raising the possibility of distoneety t written You asked NHS Professionals to consider whether there are wider implications for the recruitment and training processes_ organisation's Your report was sent to two organisations: NHS Professionals Ltd, Suites 1A &1B, Breakspear Park; Breakspear Hemel HP2 4TZ Hempstead The Nursing & Midwifery Council; Kemble Street; London; WC2 4AN: NHS Professionals I8 wholly owned by the Department of Health and Is the leading provider of managed flexible workforce into the NHS_ NHS Professionals is not a provider of services and Bank Members to NHS organisations only: We recruit Bank Members in line with NHS provides check standards and adhere to strict Clinical Governance guidelines when employment managing Bank Members. recruiting, and NSt Professionals has been working in partnership with South London & Maudsley NHS Foundation Trust since 2008, providing general and specialist nurses and healthcare workerss Registered in Erigland & Wales no. 6704614 Registered Office: NHS Professionals Ltd, Suites IA & 1B Breakspear Park; Breakspear Way, Hetel Hletupstezd ;1P24TZ Way the three Way, training
[HS ExplanationofNHS_Professionals role_Inthe provision of flexible stefing Professionals I order to respond to the matters raised in your report; it is helpful to set out the Professionals recruits and retaing staff; and ways in which NHS work in NHS arrangements upon which those staff are a8signed to organisations: We are committed to providing safe and reliable Bank Members to Client Trusts by partnership to support the effective of patient care to the population served working in work with: by Trusts we There Is a framework for governance and assurance within NHS Professlonals Nurse who is the Director of Clinical Governance and supported by the Chief represents clinical leadership on the Board, and the Medical Director who is also the Responslble Officer: Clinical Leadership is overseen by the Clinical Governance Committee, chaired by a clinical Non-Executive Director and is a sub-committee of NHS Professionals Board: NHS Professionals works in partnership with NHS Trusts to manage temporary staffing banks on their behalf We currently manage the temporary staff banks for 10 Mentai Health Trusts and 45 Acute Trusts. We have approximately 35,000 Bank Members actively working at one time_ Staff working NHS Professionals shifts in a Cllent Trust have been recruited through one of 3 recruitment processes: Substantive Registration Substantive Registration is primary registration route , which is available to applicants who hold substantive post within a Client Trust The substantive registration process allows substantive staff;, referred to as Multi Post Holder Bank Members, to work back at the Trust where are substantively employed and in an area of work that has been authorised by a Trust Manager. All training requirements for substantive staff are delivered by the Trust; Bank Registration Recruitment Standards The Bank Registration process is available to applicants who do not hold a substantive position In an NHS Professionals Client Trust or where the applicant wants to undertake shifts at a Trust other than where they hold their substantive position: Where this is the case, an applicant will undertake one Of two routes toirecruitment: Bank Exclusive: the applicants recruited through this route are known to the Client Trust; i.e. have previously worked substantively within the Trust or have worked in the Trust through a commercial agency and are therefore known to the Trust; Following recruitment by NHS Professionals, will only work in the one Trust in which are known; Bank Only: the applicants apply to work flexibly across the NHS Professionals client base in the areas where can demonstrate: 6 months experience in the previous 2 years Successiul completion of a Knowledge Based Assessment; where applicable linked to grade and speciality. Registered in England & Wales no. 6704614 Registered Qifice: NHS Professiorials Ldl, Suites IA & 1B Breakspear Park, Breakspear Way; Hercl Hempstead HP2 4TZ the delivery the the any the they they they they
[HS Evaluating Bank Members performance Professionals NHS Professionals uses an online performance review and monitoring system concerns informally at an early stage. It identifies Bank that helps to resolve highlights any lack of skills or Members who are performing well and also client TrusanV Hss /rofexitionakrwilliedge Development Performance assessment iS completed by the will in place improvement measures for Bank Members where performance or skill deficit has been identified by a Trust poor Dohen working an assignment in a Clent Trust; NHS Professionals staff work to individual Trust Policeg and guidelines and this is managed and monitored directly by Trus? staff, as NHS Professionals; Bank Members are required, along with all Trust statisto opposed to by to date records and this is monitored and maintain accurate and up bound The Code managed directly in the Trust AIl registered nurses are by (NMC) that is the professional standards of practice and behaviour for midivives and nursing associates Under 'Practise Effectively' section 40 onthe /aodo nurses, clear and accurate records relevant to your practice'_ it states, 'Keep Action taken by Irust and NHS Professionals _following Mr Blakes death Nfs Professionals was informed of Mr Blake's death on 6 July 2018, by the Ward informed that the Bank Members were not implicated in the events Manager: were manager wanted to ensure that surrounding Mr Blake's death. The we would be able to support the Bank Members with counselling if required: The Bank Members could continue to work bank shifts within Trust. We did Sl report, not receive the The Trusthlegal team included the three Bank Members in preparation for the inquest We aware at this time that the shift on 23/24 June 2018 was staffed exclusively were not by Bank Members_ Against the above background, have set out NHS Professionals' response below to the concern you have identified and the actions which should be taken, matters of Response to Concerns: As a result of the concerns YOU have asked NHS Professionals to take the following action: FrcidS Professionals to consider whether to conduct an Internal Investigation or a fitness to practise investigation For NHS Professionals to consider the wider impllcations for NHS Professionals recruitment training and For the avoidance of doubt; it is understood that the Coroner has made a referral to the NMC In of the staff members concerned. respect Orareceipt of the Prevention of Future Deaths Report on 2 August 2019 we obtained all the information relating to the case from South London & Maudsley NHS Foundation Trustehica ecluded ehe31 report: can confirm that the concerns raised were acted upon immediately and are currently the ongoing investigations. would therefore wish to assureoall concerneel hatactton ci betlakle leerecf any identified organisational or individual deficits arising from this to remedy safety. process in the interests of patient NHS Professionals Interim Clinical Governance Director and Senior Nurse/ Head of Risk met with the Trust Interim Director of to review the process undertaken in this case. There be learned for NHS Professionals, specifically around the are lessons to communication between two organisations and about a systematic approach to information sharing: A future meeting is planned to ensureiohs Rogistered iri England & Wales rio. 6704614 Registered Office: NHS Professionals Ltd, Suites 1A & 48 Breakspear Bruakspear Wlay; Helne:l Flemipnlead 14F2 412 put We the Nursing, the Paris,
[NHSI appropriate Iinks of the lead Glinicians in both Professionals categorised and managed effectively organisations are in place s0 that cases are accurately and where action is required it is undertaken promptiy. Wider Implications NHS Professionals Recruitment and Processes Asi outlned above NHS Professionals recruits to NHS strict Clinical Governance gyidelines when employment check standards and adheres to Protessionals' roaedazoce enfidelatertorheaineguitinglic and managing Bank members NHS provision is reviewed and updated aligned to the Core Skills Framework 'Training specialist consultant aregularly &8 part %i that process we are currently and all training provision both in practice wiih and online In addition to statutory and mandatory individual Client tralning requirements for bank staff who are proyidedi Trusts may have specific additional NHS Professionals works In partnership via NHS Professionals and, where this Is the case, The Trust Wblia Cllent Trust to support delivery of this additionai iraining; Ofcofnietencegeoformanhichsecvaton Verslon 6.1 (July 2017) includes & Nursing Verification feveoof obeecationfoThis Ighirkciecgkees at corrpetericy assessment prior fo areturse" undeVakifiga This is undertaken at ward level. any Evidencing %f successful completion and update of the competency meeting with the Interim Director of Nursing andewall foerc assessment was discussed at the systems review: part of the actions to be included in the whole In addition to the above should a Client Trust have concerns about by NHS Professionals, cah inform the competence of a worker provided us about this through the Complaints and Incidente System (CIMS) feedback form' CIMS is a bespoke complaints Manaigement case management; documentation and management syster which supports Trust: NHS Professionals has on-going review of concerns that have been raised by a Client Team of 8 Registered designated Clinical Governance Nurse Lead and Education Liaison Nurses and 2 Complaints Investigators Who manage complaintu The team also manage the remediation and continuing profeosionac investigation: the outcome of investigations for Bank Members. All development (CPD) action plans at discussed monthly with Client Trusts, concerns and complaints are reviewed and monitor steps taken; who receive a full report of all ongoing cases to enable them to that te information provided offers assurances that the findings of areas of concern you have highlighted have prompted action your investigation and the commitment to providing and and have been the focus for our continuing Trusts: improving provision of safe and effective Bank Members into our Client Ifyou require further information from NHS Professionals in relation to of do not hesitate to contact me. above matter; please