Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators

NHS England and NHS Improvement should develop guidance for Trusts and NHS organisations more widely in relation to the following aspects of recommendation 5 (R26) above: • Statements to Coroners written in relation to whole episodes of care involving a … Read more NHS England and NHS Improvement should develop guidance for Trusts and NHS organisations more widely in relation to the following aspects of recommendation 5 (R26) above: • Statements to Coroners written in relation to whole episodes of care involving a team or a Trust service should be subject to validation and where a statement includes or implies failures in care all individuals named should be given a right of reply. This is distinct from an individual health care professional providing a witness statement solely in relation to their own input. • Where failures in care are identified as a result of the production of a statement and a new incident is reported, the Coroner should be informed to determine if an investigation report will be required for any further proceedings. • Trusts must assure themselves that their policies in relation to providing statements to the Coroner are being complied with. Statements should be based on fact rather than opinion and there should be a clear indication of how the statement has been compiled. Show less

NHS England and NHS Improvement should consider what relevant guidance could be developed for Trusts and NHS organisations more widely in relation to recommendations 1–8 made in this report and how these lessons might be shared. The learning from this … Read more NHS England and NHS Improvement should consider what relevant guidance could be developed for Trusts and NHS organisations more widely in relation to recommendations 1–8 made in this report and how these lessons might be shared. The learning from this report would be of benefit to the wider NHS community through an anonymised case study which will be developed from this case. Show less

NHS England and NHS Improvement should decide whether more guidance is needed in relation to the uses and retention of email correspondence (or other electronic communications) as part of health records and any regional or national implications of recommendation 9 … Read more NHS England and NHS Improvement should decide whether more guidance is needed in relation to the uses and retention of email correspondence (or other electronic communications) as part of health records and any regional or national implications of recommendation 9 above. Show less

As part of the work underway to establish system governance, commissioners should agree shared mechanisms to enable proactive commissioning and visibility of the Trust’s services at specialty/sub-specialty level.

Alternative mechanisms for specialty/sub-specialty level scrutiny as part of routine assurance processes should be examined, for example cyclical deep dives as part of an annual work plan led by commissioning managers for scrutiny by quality assurance forums. The heat map … Read more Alternative mechanisms for specialty/sub-specialty level scrutiny as part of routine assurance processes should be examined, for example cyclical deep dives as part of an annual work plan led by commissioning managers for scrutiny by quality assurance forums. The heat map approach (as in Appendix 16) developed by the CCG provides a useful model for this purpose. The CCG should add an analysis of complaints/concerns/incidents from GP practices at a specialty level on at least an annual basis as part of this scrutiny. Show less

A reporting template should be developed which brings together quality, activity and performance information at a specialty level. A programme of reporting at this level should be agreed with the Trust, with frequency of reporting for each specialty to reflect … Read more A reporting template should be developed which brings together quality, activity and performance information at a specialty level. A programme of reporting at this level should be agreed with the Trust, with frequency of reporting for each specialty to reflect jointly agreed priorities. This should provide a single source of reporting to all relevant governance groups. The Safe Today Report provides a sound basis for development. Show less

Terms of reference for all quality assurance forums should be explicit about specific areas of focus, reports to be considered and how issues should be monitored. Key Issues Reports should be used for escalation. An issues log should be maintained … Read more Terms of reference for all quality assurance forums should be explicit about specific areas of focus, reports to be considered and how issues should be monitored. Key Issues Reports should be used for escalation. An issues log should be maintained which identifies concerns with departments/specialties involved and this should be shared, populated and reviewed at key governance forums. Show less

Internal audit should test the efficacy of CCG assurance at a Trust specialty level as part of its annual work programme.

The CCG should ensure that its contractual requirements with the Trust relating to incident reporting, and as set out in the Quality Schedule to the latest contract (2021/22), are met.

Examine ways in which confidential patient information is appropriately anonymised for the purposes of employment tribunal hearings. Guidelines should include: • advice to healthcare professionals on the use of patient information in these proceedings in line with Good Medical Practice … Read more Examine ways in which confidential patient information is appropriately anonymised for the purposes of employment tribunal hearings. Guidelines should include: • advice to healthcare professionals on the use of patient information in these proceedings in line with Good Medical Practice guidance and GMC guidance on the use of personal information; • advice on the relevant GDPR and Data Protection regulations and the right to protect private information for both patients, their families and other individuals; • information relating to circumstances where patients do consent to the use of their personal information being used; and • the application of how Duty of Candour applies in such circumstances. Show less

Revisit the Never Events cases highlighted in this review and ensure that the Trust applies rigour to all possible Never Events reporting.

Consider a revision to the Learning from Deaths guidance to ensure that patient records on death are suitably managed in original form by professionals to reduce the risk of posthumous amendment.

NHS England and NHS Improvement and the CCG should seek stronger working relationships between the Trust and tertiary centres to support Consultants in facilitating the provision of sub-specialty services at the Trust.

A Urology strategy should be developed involving all key Urology medical staff and other relevant healthcare professionals to set the context for the following actions: • The Trust should undertake an equipment stocktake for Urology and plan into the capital … Read more A Urology strategy should be developed involving all key Urology medical staff and other relevant healthcare professionals to set the context for the following actions: • The Trust should undertake an equipment stocktake for Urology and plan into the capital replacement programme the need for cystoscopes, bipolar diathermy and suction equipment both in the short term and over the medium term or consider lease options. • Examine, with the Trust and CCG, the development of Urology sub-specialisms building on Andrology and stone services, the management of superficial bladder cancer, local anaesthetic transperinealbiopsy work and paediatrics. • Examine, through the provider collaborative network, the viability of Urology provision across two sites and its associated support services in the long term should be examined in respect of future provision at Furness General Hospital. Formal consideration of centralising inpatient and emergency Urology services on one site should be revisited. This should include options for dedicated ward-based facilities. Show less

• NHS England and NHS Improvement should discuss the lessons learned from this review with the Care Quality Commission and share them with the National Quality Board or similar regulatory oversight group, in respect of the failings to resolve the … Read more • NHS England and NHS Improvement should discuss the lessons learned from this review with the Care Quality Commission and share them with the National Quality Board or similar regulatory oversight group, in respect of the failings to resolve the long-standing dysfunction in this team. • NHS England and NHS Improvement should provide clear guidance about what external support might be available to Trusts from the regional medical directors’ teams and the advisory options when there is team dysfunction emerging. • Regulatory activity should review the effective functioning of the Responsible Officer role in regard to managing concerns where team dysfunction may be apparent. • Guidance should include ensuring Trusts are encouraged to seek early support where team dysfunction may put patient safety at risk. Show less

• NHS England and NHS Improvement should ensure that guidance to ROs is up to date and a final version is in force to include the 2013 RO regulation amendments and learning since the role was introduced. • Regional Medical … Read more • NHS England and NHS Improvement should ensure that guidance to ROs is up to date and a final version is in force to include the 2013 RO regulation amendments and learning since the role was introduced. • Regional Medical Directors should use this investigation as a case study to reinforce escalation processes for Responsible Officers who may be facing conduct difficulties within their medical workforce. • The North West Regional Medical Director should share this case study with other Regional Medical Directors to reinforce the importance of the RO role, appointment processes and the lessons learned from this investigation. • Good practice should be shared between Trusts to provide clarity on the best approaches for dealing with and escalating behavioural and conduct issues that are impacting on patient safety in line with Good Medical Practice. • The Trust Board should revisit its understanding of the role of the RO and assure itself that there is clarity of duties between the Medical Director (now as RO) and the wider team in exercising duties to meet the RO regulations. Show less

Guidance on setting up appropriate governance processes should be developed to support intractable whistleblowing cases. It should aim to provide resolution to concerns and facilitate learning in relation to patient safety.

NHS England and NHS Improvement should commission a Phase 5 review (Autumn 2022) in line with the Terms of Reference to include assurance on key elements such as: • continuity of care; • named Consultant; • MDT [multidisciplinary team] management; … Read more NHS England and NHS Improvement should commission a Phase 5 review (Autumn 2022) in line with the Terms of Reference to include assurance on key elements such as: • continuity of care; • named Consultant; • MDT [multidisciplinary team] management; • follow-up patient pathways; • the quality of incident reporting and investigations; • team development opportunities; and • mortality governance. to establish if implemented changes have become embedded and are sustainable. Show less

The GMC should reflect on this investigation. They should: • seek to understand how and if team dysfunction issues impact on fitness to practice investigations; • determine whether the role of medical managers and their fitness to practice (in relation … Read more The GMC should reflect on this investigation. They should: • seek to understand how and if team dysfunction issues impact on fitness to practice investigations; • determine whether the role of medical managers and their fitness to practice (in relation to their management function) have been sufficiently considered in this case; • ensure that GMC guidance in relation to the Responsible Officer (RO) regulations is up to date and considers the 2013 amendments to the regulations and learning since the role was introduced; • indicate to Trusts that the GMC Connect dashboard can be made accessible to Medical Directors as well as the RO team. Show less

Invited Service Reviews should include: • clear expectations for Royal College Invited Service Review Reports to be shared, in full, by the Trust with the relevant Trust Board; • expectations for when Royal College Invited Service Review Reports should be … Read more Invited Service Reviews should include: • clear expectations for Royal College Invited Service Review Reports to be shared, in full, by the Trust with the relevant Trust Board; • expectations for when Royal College Invited Service Review Reports should be shared, in full, by the Trust with regulators; and • clarity about the implementation of action plans arising from Invited Service Reviews to enable the Royal College to be satisfied that recommendations have been fully addressed to end their active involvement. Show less

The effectiveness and intention of the Emerging Concerns Protocol https://www.cqc.org.uk/what-we-do/how-we-work-people/emerging-concerns-protocolshould be revisited in the context of the findings of this case. The inclusion of additional signatories (e.g.Royal Colleges and NHS England) should be considered. This may be the most appropriate … Read more The effectiveness and intention of the Emerging Concerns Protocol https://www.cqc.org.uk/what-we-do/how-we-work-people/emerging-concerns-protocolshould be revisited in the context of the findings of this case. The inclusion of additional signatories (e.g.Royal Colleges and NHS England) should be considered. This may be the most appropriate process to improve information sharing. Show less

The role of the RO and its development since the introduction of this function in 2010 should form a regular and consistent part of examination as part of internal and external Well-Led and governance reviews.

NHS England and NHS Improvement should share the findings from the testicular implant recall exercise with relevant bodies and agree the next steps at a local or national level.