Independent Review of concerns raised around BCUHB Patient Safety

In general, there is a need to design and implement a systematic approach using data effectively alongside a set of agreed Key Lines of Enquiry (KLOEs) in relation to assurance of optimal patient safety, experience, and outcomes. To be able to undertake this effectively the handling and accessibility of data and information needs strengthening and positioning in order to support robust and accessible real-time data being available electronically as a dashboard holding one ‘single version of the truth’ to accurately inform and support staff with all aspects of quality work, alongside formal analytical support to provide trend analysis and the ability for staff to understand and benchmark at all levels, ward/IHC/Health Board and externally, both nationally/internationally. Additionally, the aligned support of the transformation team is needed to work alongside local leadership to embed this approach as business as usual proactively.

It is proposed that the implementation and embedding of the new quality framework would benefit from review, particularly around new clinical governance components coming together effectively as a collective organisational quality framework and system. This should include areas such as, but not limited to, safeguarding, health and safety, clinical effectiveness and research, audit, risk management, and education and training (both in relation to medical and non-medical learners). It is acknowledged that change will take some time to embed, however, it is proposed that this review could be commenced as soon as possible to evaluate simultaneously as its’ implementation progresses, and learning can also be fed in to ensure ongoing adaptation as required.

It is also suggested that by enabling the new quality strategy to be co-developed that this will strengthen it being co-owned by all and not ‘seen as’ potentially being imposed on staff.

In relation to the development and implementation of the new BCUHB operating model8: the scheme of delegation and structures between the executives and the senior IHC leadership teams require more clarity, and further detailing of ways of working, sharing of intelligence, risk, and opportunity. It is proposed that this information and any aligned Standard Operating Procedures should be disseminated to all staff, not just the leadership teams, so all staff fully understand ways of working and particularly in relation to understanding, implementing, and embedding quality monitoring, assurance and improvement in everyday practice, learning, and culture.

There is a need for the quality committees to have strong but respectful ‘challenge’ in addressing variations in patient safety practice, outcomes, and culture across the different sites; with a high standard of papers and note taking to trigger the relevant discussion and provide a robust recording of decision-making, actions, and evaluation. The cycles of all the BCUHB quality meetings across the organisation should be arranged to ensure that the calendar order of meetings taking place culminate in the pan-BCUHB assurance committees and Board receiving as near to contemporaneous data as possible by the time those meetings are being held. Governance should ensure that Board and Committee structures are in place; from a clinical perspective the Quality and Safety Committee needs to be strongly established with a clear rolling programme and key areas identified that need reporting, including for example how the process for “Duty of Candour” is to be adopted across the Health Board.

Ensuring that there is an effective procedure for learning from incidents and that preparations for inquests, and the HSE, are proactive, clear, and effective.

Review of how patient experience and involvement is being used to support and inform quality processes and develop services and provide assurance that the voice of the patient is being listened to and actioned.

Embedding the duty of candour and quality into ‘business as usual’ ways of working and all practice.

Review and consider the extent to which organisational learning is taking place and is being embedded.

A number of services/specialties were mentioned either in the discussions which took place, or meetings observed (Appendix two and Appendix four). They are in no specific order.
• Vascular
• Stroke
• Sepsis
• Dermatology
• Ophthalmology
• Primary Care
• Mental Health
• Urology
• Dental Access
• Gastroenterology
• Speech and Language Therapy
• Physiotherapy
• Crisis Response Team
• Emergency Care
• Children and Young People
It is recognised that both vascular and mental health services have additional assurance work currently in train. It is also acknowledged that the disclosures did not raise specific incidents or complaints and at times described concerns as more of a sense that assurance work was requiring to be undertaken. Therefore, it is suggested that there is more work to be undertaken to gain a more detailed assurance of ways of working and patient safety, experience, and outcomes.

In relation to safeguarding there is opportunity to include data such as that on training compliance as metrics in the design of a systematic approach alongside a set of agreed Key Lines of Enquiry (KLOEs) in relation to patient safety, experience, and outcomes.

Safeguarding training compliance data should also be triangulated with practice outcomes, for example, specific Deprivation of Liberty Safeguards training, where the safeguarding team had targeted areas of low compliance and/or where audit activity identified the need for greater awareness and improvement. It is reported that the compliance data does not always correlate with evidenced clinical practice, and this triangulated approach provides additional assurance.

Good safeguarding training compliance particularly in areas such as GP practices is clearly important. This was reported at times to fall below the expected compliance rate, and where a single presentation at a GP appointment might be the only opportunity a vulnerable patient has to access help, low compliance rates can escalate a risk of a safeguarding issue being missed. It is reported that there has been a number of requests from GP Clusters requesting bespoke safeguarding training for GP Practices and that this a matter being reviewed due to the demand. Additionally, attention is drawn to the reported variants of compliance levels within the Emergency Departments. It is also well recognised that ED staff should be particularly competent in safeguarding practice and knowledge, as this again might be the only chance vulnerable patients have to receive help if they present as an isolated case.

The need to link up safeguarding with wider work such as the work on estates was also identified. Risks aligned to this are such as that outdated estate which is potentially not fit for purpose or requires significant investment or modernisation, increases the likelihood of falls or poor observation of patients. In addition, work on legislation such as Martyn’s Law will aim to help further improve public safety and reduce the risk to the public from terrorism by the protection of public premises and events.

The need to consider the Disclosure and Barring Service (DBS) checks was also highlighted, it was currently recognised that the checks are only ‘as good as the day they are undertaken’. An exemplar identified was local authority working, where a rolling programme was in place for continuous updates to be made as were relevant.

In relation to Health and Safety there is opportunity to ensure that significant work has been undertaken to ensure that there is robust control of systems and processes, including policies, and training. Again, there is opportunity to include relevant data as metrics in the design of a systematic approach alongside a set of agreed Key Lines of Enquiry (KLOEs) in relation to patient safety, experience, and outcomes and for staff to understand that this area is central to delivering quality for both patients and staff.

There is opportunity to include relevant workforce data as metrics in the design of a systematic approach alongside a set of agreed Key Lines of Enquiry (KLOEs) in relation to patient safety, experience, and outcomes.

Reviewing staff capability and capacity in relation to understanding, implementing, and embedding quality monitoring, assurance and improvement in everyday practice, learning, and culture.