Investigation into matters relating to Jimmy Savile at Leeds General Infirmary

The organisational development programme should incorporate the following: • the safety of patients, staff, volunteers and visitors as a central priority (source: chapters six, seven and eight); • the promotion of enquiring leadership at all levels in the organisation. It should value a culture of curiosity and questioning, and behaviours that enable all staff and volunteers to have the courage to challenge any inappropriate behaviour witnessed in the Trust (source: chapters four, six, seven, eight and nine); • a review of existing policies, knowledge and understanding about how staff and volunteers can effectively raise concerns, and a new approach that empowers them to speak out (source: chapters seven, eight and nine); and • a review of the effectiveness of current approaches to the management of, and responses to, complaints from patients and visitors (source: chapters six, seven and eight).

The Executive Director with responsibility for safeguarding patients, and the Executive Director with responsibility for facilities and estates, should jointly assure the Board on how support services (including porters, security and mortuary services) contribute to safeguarding patients, particularly in the following areas: • that the Trust’s safeguarding policies extend explicitly to the care and transportation of deceased patients (source: chapters six and nine); • that there are policies and controls in place covering security at the mortuary, and that these are regularly audited (source: chapters six and nine); • on the quality of the Trust’s safeguarding compliance in respect of adult and child patients, and its duty to protect staff. Working with the Safeguarding Boards for Children and Adults in the city, an audit programme should include a review of the safeguarding of adults and children in in-patient areas; staff training; and employment checks (source: chapters four, six, seven, eight and nine); • that current Disclosure and Barring Service (DBS) checks are in place for all relevant employees, volunteers and, where appropriate, contractors as a matter of urgency, and that this position is reviewed to inform each Board meeting (source: chapters eight and nine); • on the quality of the complaints system; the Board should monitor full adherence to the recommendations of the 2013 Clwyd/Hart Review (source: chapters six, seven, eight and nine); and • on the robustness of the Trust’s processes for staff and others to raise concerns, and on how such matters are responded to and addressed. Particular attention should be given to allegations of sexual impropriety (source: chapters six, seven and eight).

There should be a Trust-wide campaign to raise awareness of the safeguarding duty to patients across all patient contact staff and volunteer groups (source: chapters six, seven and eight).

All safeguarding promotional material, educational material or information used in the Trust should be explicit in the inclusion of all patient contact and support services (source: chapters six and eight).

The quality of work carried out by porters should include reference to patient experience and safeguarding, in addition to the measurement of time to complete tasks (source: chapter six).

Porters should receive training and support about the transportation and handling of deceased patients. De-briefing and counselling should be available for porters who are adversely affected by carrying out this duty (source: chapters six and nine).

The Trust Quality Committee should commission a specific project on the care, transportation and storage of the bodies of deceased patients to give wider assurance that the matters raised by Savile’s association with the hospital mortuary could not happen again (source: chapter six).

Guidance and active support on interacting with VIP patients should be developed and issued to consultants and senior clinicians, and its use monitored through the appraisal process (source: chapters four, five and six).

A sanctioned visitor policy should be established and implemented across all sites of the Trust with some urgency. It should set clear boundaries regarding the role of celebrities, VIPs and media contractors in the Trust, including their access to hospital premises. This policy should include robust processes for Board assurance and information about the rules of engagement with media, celebrity visitors and other VIP or non-essential visitors to the hospital (source: chapters four, six, seven, eight and nine).

The Trust should conduct a review to ensure that the support, advice and care it provides to victims of sexual assault and statutory rape are consistent with current best practice (source: chapters six and seven).

The Trust should conduct an audit of placements of children and young people on adult in-patient areas to ensure that this no longer happens (source: chapters six, seven and eight).

The Trust should put in place a safe and confidential counselling service for all staff, patients, visitors and volunteers affected by the content of this report (source: chapter seven).

The Trust should establish a confidential helpline and referral service for victims of Savile, including those who have not yet come forward (source: chapter seven).

Development of strategies and actions should continue to improve the visibility of executive and non-executive directors across the organisation (source: chapters four, six, eight and nine).

As part of their Board responsibility, directors should foster a culture of curiosity, internal scrutiny and constructive challenge, particularly on matters that have a major impact on public confidence in Trust services (source: chapters eight and nine).

The Board should develop an understanding of how it feels to be a patient in the Trust and identify methods of communication to share good practice and celebrate success, in addition to ensuring that concerns are addressed promptly (source: chapters six, seven and eight).

The Trust should review security across all sites, including on-call residences and decommissioned areas in its estate, to develop a comprehensive strategic security plan. The Board should seek regular assurance that all restricted areas are secure, including high-risk areas (source: chapters six and eight).

A unified HR system should be established across the Trust that fulfils the recruitment and employment requirements for all employees, volunteers and contractors in a consistent manner (source: chapters eight, nine and ten).

The Trust should review its policy on gifts and hospitality and seek assurance that all staff (including volunteers and non-executive directors) are aware of their responsibilities and comply with the policy. Compliance should be reviewed at least annually by Internal Audit (source: chapters five and ten).

The Trust should develop with some urgency a volunteer policy. This should cover volunteers’ employment checks, induction, training, access to the Trust and clarity about the boundaries of their roles (source: chapters four, six, eight and nine).

The Trust should develop a major strategic plan for the management of potentially catastrophic issues where public confidence in the organisation may be at stake in the light of unprecedented events. This will enable greater clarity and consistency in matters of communication, accountability and action (source: chapters eight and nine).

The Trust should work with the Leeds Teaching Hospitals Charitable Trust to develop and implement a policy for the management of large financial donors, specifically setting out how to deal with requests for favours from them (source: chapter five).

The Trust Dignity at Work policy has been in place since 2011, but does not explicitly mention sexual harassment in its definition of what constitutes harassment or unwanted behaviour. This should be reviewed and sexual harassment clearly defined, with examples given. Following review, this policy should be audited: in particular, to gain assurance that staff who have line management responsibility for others are fully conversant with the required actions to take when faced with allegations of sexual harassment or unwanted behaviour (source: chapters six, seven, eight, nine and ten).

All policies should be reviewed to ensure that they comply with statutory obligations about the retention of records (source: chapters nine and ten).

All Trust policies should extend in their scope to the broader community, including volunteers, non-executive directors and, where appropriate, contractors; and, in time, to governors (source: chapters eight, nine and ten).

The Trust should review how it seeks the views of a wider range of stakeholders in developing policies, and should ensure that all policies are patient centred. In doing so, it should draw best practice from other organisations within and outside the NHS (source: chapter ten).

All policies should be succinct, clearly set out in plain language, and identify the points that people need to know in order to implement them safely (source: chapter ten).

There should be mandatory compliance with policies designed to protect patients and staff. The role of the Trust’s Internal Audit should be reviewed as part of this (source: chapters nine and ten).

A baseline review of the range of projects supported by the Leeds Teaching Hospitals Charitable Trust should be undertaken to assess consistency with the current priorities of the Trust (source: chapter five).

The Charitable Trustees should work closely with the Leeds Teaching Hospitals NHS Trust Executive Team to establish priority-setting and decision-making processes that reflect the needs of the patients of the hospital and the services provided to them (source: chapter five).

Assurance that charitable funds are channelled appropriately should be gathered on a systematic and ongoing basis and reported to both the Charitable Trustees and the Trust Board Audit Committee to ensure that the mechanisms in place to do this continue to be effective (source: chapter five).