Inquiries · Recommendations

Recommendations: Hyponatraemia Inquiry

1,814 tracked recommendations 35 inquiries 96 match current filters Page 1 of 2

Recommendations issued by UK statutory and non-statutory inquiries, with their tracked government response and supporting evidence.

Recommendations

96 of 1,814 · page 1 of 2

Code	Recommendation	Inquiry	Response
IHRD-1	Statutory Duty of Candour A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-2	Criminal Liability for Candour Breach Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of …	Hyponatraemia Inquiry (2018)	Accepted in Part
IHRD-3	Guidance on Statutory Duty of Candour Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-4	Trust Awareness of Duty of Candour Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour …	Hyponatraemia Inquiry (2018)	Accepted in Part
IHRD-5	Employment Contracts and Duty of Candour Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-6	Support for Candour Compliance Support and protection should be given to those who properly fulfil their duty of candour.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-7	Monitoring Candour Compliance Trusts should monitor compliance and take disciplinary action against breach.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-8	RQIA Compliance Review Powers Regulation and Quality Improvement Authority ('RQIA') should review overall compliance and consideration should be given to granting it the power to prosecute …	Hyponatraemia Inquiry (2018)	Accepted in Part
IHRD-9	Leadership Development The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-10	Age-Appropriate Hospital Settings Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-11	Patient Transfer Protocol There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-12	Senior Paediatric Responsibility Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-13	Foundation Doctors in Children's Wards Foundation doctors should not be employed in children's wards.	Hyponatraemia Inquiry (2018)	Accepted in Part
IHRD-14	Clinician Competence Assessment The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-15	Consultant Notification on Admission A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-16	Bedside Display of Responsible Staff The names of both the consultant responsible and the accountable nurse should be prominently displayed at the bed in order that all …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-17	Recording Changes in Accountability Any change in clinical accountability should be recorded in the notes.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-18	On-Call Consultant Display The names of all on-call consultants should be prominently displayed in children's wards.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-19	Senior Lead Nurse in Children's Wards To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-20	Consultant-Led Ward Rounds Children's ward rounds should be led by a consultant and occur every morning and evening.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-21	Nurse Attendance at Clinical Interactions The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-22	Parental Knowledge in Care Plans Clinicians should respect parental knowledge and expertise in relation to a child's care needs and incorporate the same into their care plans.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-23	Care Plan Availability at Bedside The care plan should be available at the bed and the reasons for any change in treatment should be recorded.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-24	Blood Test Result Documentation All blood test results should state clearly when the sample was taken, when the test was performed and when the results were …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-25	Drug Prescription Documentation All instances of drug prescription and administration should be entered into the main clinical notes and paediatric pharmacists should monitor, query and, …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-26	Recording Clinical Discussions Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-27	Electronic Patient Information Systems Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-28	Informed Consent Documentation Consideration should be given to recording and/or emailing information and advices provided for the purpose of obtaining informed consent.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-29	Record Keeping Audit Record keeping should be subject to rigorous, routine and regular audit.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-30	Confidential Reporting of Clinical Concerns Confidential on-line opportunities for reporting clinical concerns should be developed, implemented and reviewed.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-31	SAI Reporting Understanding Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').	Hyponatraemia Inquiry (2018)	Accepted
IHRD-32	SAI Reporting as Disciplinary Offence Failure to report an SAI should be a disciplinary offence.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-33	CEO Responsibility for Investigations Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-34	Independent SAI Investigation The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with …	Hyponatraemia Inquiry (2018)	Accepted in Part
IHRD-35	Non-Cooperation as Disciplinary Offence Failure to co-operate with investigation should be a disciplinary offence.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-36	Separation of Investigation and Litigation Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-37	Family Involvement in SAI Investigations Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-38	Multi-Disciplinary Peer Review Investigations should be subject to multi-disciplinary peer review.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-39	Investigation Team Reconvening Investigation teams should reconvene after an agreed period to assess both investigation and response.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-40	SAI Learning Informing Clinical Audit Learning and trends identified in SAI investigations should inform programmes of clinical audit.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-41	Publication of External Investigation Reports Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-42	Sharing New Investigation Information In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-43	GP Notification of Death Circumstances A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-44	Post-Mortem Limitation Authorisation Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-45	Post-Mortem Documentation Checklist Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-46	Clinician Attendance at Post-Mortem Discussions Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-47	Post-Mortem Reporting Standards In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-48	Mortality Meeting Recording and Audit The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.	Hyponatraemia Inquiry (2018)	Accepted
IHRD-49	Multi-Trust Mortality Meeting Engagement Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should …	Hyponatraemia Inquiry (2018)	Accepted
IHRD-50	HSCB Notification of Inquests The Health and Social Care ('HSCB') should be notified promptly of all forthcoming healthcare related inquests by the Chief Executive of the …	Hyponatraemia Inquiry (2018)	Accepted

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