Recommendation · source text
The Trust should ensure that all patients on a long-term follow-up pathway have a clear and documented plan for their ongoing care and that this plan is regularly reviewed and updated.
Source · Investigations in the NHS
This Independent Investigation into concerns and issues raised relating to Urology Services at University Hospitals Morecambe Bay NHS Foundation Trust was commissioned by NHS England and NHS Improvement in October 2019 and published in November 2021.
North West
Published 01 Nov 2021
Trust University Hospitals of Morecambe Bay NHS Foundation Trust
Index summary
The purpose of this important investigation is to gain a full understanding of clinical and patient outcomes as the result of care delivered by the Trust’s Urology Service. The Investigation has identified areas for learning, as well as the identification of good practice, to ensure that a recurrence of the same or similar issues will be avoided in the future. Final Independent Investigation Urology Report – University Hospitals of Morecambe Bay NHS Foundation Trust Final Independent Investigati
Recommendations
Recommendation · source text
The Trust should implement a robust system for tracking and managing all patients on a follow-up pathway, including those referred to tertiary centres, to ensure that no patient is lost to follow-up and that appointments are scheduled and attended in a timely manner.
Recommendation · source text
The Trust should review and update its policies and procedures for patient handover, particularly for patients with complex or long-term conditions, to ensure clear communication and continuity of care between different clinicians and teams.
Recommendation · source text
The Trust should ensure that all clinical documentation is comprehensive, accurate, and up-to-date, including details of discussions with patients, treatment plans, and any changes in patient condition.
Recommendation · source text
The Trust should review and strengthen its processes for multi-disciplinary team (MDT) meetings, ensuring consistent attendance, robust discussion of all relevant cases, and clear documentation of decisions and actions.
Recommendation · source text
The Trust should ensure that all staff involved in patient care receive appropriate training on the importance of accurate and timely record-keeping and the use of electronic patient record systems.
Recommendation · source text
The Trust should review its current arrangements for on-call services in Urology, particularly at Furness General Hospital, to ensure adequate staffing levels, timely access to theatre space, and safe working practices for all staff.
Recommendation · source text
The Trust should implement a clear and consistent approach to job planning for all Consultant Urologists, ensuring that job plans accurately reflect clinical responsibilities, administrative duties, and on-call commitments, and that they are regularly reviewed and agreed.
Recommendation · source text
The Trust should review the use of Additional Activity Sessions (AASs) in Urology to ensure that they are appropriately managed, effectively utilised to reduce patient backlogs, and do not inadvertently create disincentives for efficient working within core job plans.
Recommendation · source text
The Trust should strengthen its clinical leadership in Urology by providing dedicated support, training, and mentorship to the Clinical Lead, and by ensuring that the role has sufficient authority and resources to address departmental issues effectively.
Recommendation · source text
The Trust should review and update its policies and procedures for managing grievances and concerns raised by staff, ensuring that all concerns are investigated thoroughly, fairly, and in a timely manner, and that appropriate support is provided to all parties involved.
Recommendation · source text
The Trust should ensure that all staff are aware of and adhere to the Trust’s policies on incident reporting, raising concerns, and whistleblowing, and that a culture of openness and psychological safety is fostered where staff feel confident to speak up without fear of reprisal.
Recommendation · source text
The Trust should review its processes for managing referrals to tertiary centres, ensuring clear communication pathways, timely transfer of patient information, and robust follow-up arrangements to ensure continuity of care.
Recommendation · source text
The Trust should ensure that all Consultant Urologists have a named individual Consultant responsible for their patients, or if a pooled model of care is to continue, that robust systems are in place to ensure clear accountability, effective handover, and continuity of care.
Recommendation · source text
The Trust should review and strengthen its processes for managing and monitoring patients on active surveillance pathways, particularly for prostate cancer, to ensure timely review, appropriate investigations, and clear communication of results and next steps.
Recommendation · source text
The Trust should ensure that all staff involved in consenting patients for procedures receive appropriate training and adhere to national guidance and best practice, ensuring patients have a full understanding of the risks, benefits, and alternatives to treatment.
Recommendation · source text
The Trust should review its current administrative support for the Urology department, ensuring adequate staffing levels, appropriate training, and effective systems and processes to support clinical staff and patient pathways.
Recommendation · source text
The Trust should review and strengthen its processes for managing and monitoring the stent register, ensuring accurate and up-to-date records, timely follow-up, and clear accountability for patient safety.
Recommendation · source text
The Trust should review its current arrangements for paediatric Urology cases, ensuring clear pathways for referral, appropriate expertise for emergency and elective cases, and robust arrangements for follow-up and ongoing care.
Recommendation · source text
The Trust should ensure that all staff involved in the care of deteriorating patients receive appropriate training and adhere to national guidance and best practice, ensuring timely recognition, escalation, and management of acutely unwell patients.
Recommendation · source text
The Trust should review and strengthen its processes for managing and monitoring patients with suspected or confirmed bladder perforation, ensuring timely diagnosis, appropriate management, and robust follow-up arrangements.
Recommendation · source text
The Trust should ensure that all staff involved in the management of Never Events receive appropriate training and adhere to national guidance and best practice, ensuring robust investigation, learning, and implementation of preventative measures.
Recommendation · source text
The Trust should review and strengthen its processes for managing and monitoring patients who have undergone prostate biopsies, ensuring clear pathways for follow-up, timely communication of results, and appropriate management of complications.
Recommendation · source text
The Trust should review its current arrangements for private practice by Consultant Urologists, ensuring clear policies, transparency, and robust oversight to prevent any conflicts of interest or impact on NHS service delivery.
Recommendation · source text
The Trust should review and strengthen its engagement with primary care, ensuring clear communication pathways, timely sharing of patient information, and collaborative working to improve patient pathways and outcomes.
Recommendation · source text
The Trust Board should ensure that there is a clear and explicit recognition of the Responsible Officer (RO) role and its duties, and that the RO is formally appointed, supported, and held accountable for the effective implementation of medical revalidation and fitness to practice processes.
Recommendation · source text
The Trust Board should ensure that the RO reports directly to the Board on matters of medical revalidation, fitness to practice, and any significant concerns regarding the conduct or performance of doctors, and that the Board actively challenges the RO on these matters.
Recommendation · source text
The Trust Board should ensure that all Medical Directors and the RO receive appropriate and up-to-date training on their respective roles and responsibilities, particularly in relation to medical governance, revalidation, and managing concerns about doctors’ performance.
Recommendation · source text
The Trust Board should ensure that there is clear and effective communication and collaboration between the RO, Medical Directors, and the Director of HR and OD, to ensure a cohesive and comprehensive approach to managing medical staffing issues and concerns.
Recommendation · source text
The Trust Board should ensure that all external reports and reviews, including those from the PHSO, RCS, and CQC, are presented to the Board in full, with a detailed analysis of findings, recommendations, and a clear action plan for implementation and monitoring.
Recommendation · source text
The Trust Board should ensure that there is a robust and consistent process for learning from deaths, in line with national guidance, including detailed analysis of inpatient deaths by specialty/sub-specialty, and that this learning is regularly reported to the Board and used to drive service improvement.
Recommendation · source text
The Trust Board should ensure that there is a comprehensive and regular analysis of litigation and legal proceedings by specialty/sub-specialty, including trends, outcomes, and lessons learned, and that this information is regularly reported to the Board to inform risk management and service improvement.
Recommendation · source text
The Trust Board should ensure that there is robust and regular reporting on employee relations issues, including tribunals, whistleblowing, grievances, suspensions, restricted practice, and referrals to professional bodies, and that this information is triangulated with other service risk indicators to identify and address hotspots.
Recommendation · source text
The Trust Board should ensure that there is a clear and consistent approach to specialty-level performance monitoring and quality assurance, with dedicated management support and regular review of sub-specialty data to identify and address issues proactively.
Recommendation · source text
The Trust Board should ensure that all incident reports, complaints, claims, and other concerns are thoroughly and impartially investigated, with findings shared, lessons learned, and clear action plans implemented and monitored to prevent recurrence and drive service improvement.
Recommendation · source text
NHS England and NHS Improvement should review the current national guidance and support mechanisms for independent investigations, particularly in relation to ensuring the accuracy and reliability of information in the public domain, and the process for managing whistleblowing concerns to prevent their weaponisation.
Recommendation · source text
NHS England and NHS Improvement should consider establishing a fully independent national body or process for investigating significant and material whistleblowing concerns from the outset, to ensure impartiality, thoroughness, and timely resolution for all parties involved.
Recommendation · source text
The General Medical Council (GMC) should review its processes for investigating concerns about individual doctors, particularly in cases involving wider team dysfunction or systemic issues, to ensure that investigations are comprehensive, consider the broader context, and contribute to addressing underlying causes of poor performance.
Recommendation · source text
The Care Quality Commission (CQC) should review its processes for receiving and acting upon identifiable information relating to patient safety concerns, particularly in cases where anonymity is requested, to ensure that such information can be effectively used to trigger timely and appropriate regulatory action.
Recommendation · source text
The Royal College of Surgeons (RCS) should review its Invited Service Review process to ensure that the terms of reference are not unduly influenced by internal departmental dynamics, and that the review comprehensively addresses systemic issues and team conduct, rather than solely focusing on individual incidents.
Recommendation · source text
All NHS organisations should ensure that they have robust processes in place to manage emerging dysfunction within clinical teams, including early intervention strategies, conflict resolution training, and clear pathways for escalation and decisive leadership intervention.
Recommendation · source text
All NHS organisations should foster a culture of psychological safety and openness, where staff feel empowered to raise concerns without fear of reprisal, and where whistleblowing is seen as a last resort, supported by effective internal reporting and learning mechanisms.
Recommendation · source text
All NHS organisations should ensure that they have clear policies and training in place to address issues of race, discrimination, and inequality, and that concerns in these areas are investigated thoroughly, fairly, and with appropriate support for all parties.
Recommendation · source text
All NHS organisations should ensure that decisive leadership interventions are made when concerns about clinical performance or team dysfunction are identified, and that these interventions are timely, proportionate, and effectively monitored for impact.
Recommendation · source text
All NHS organisations should ensure that demand management and specialty development are proactively planned and managed, with clear strategies for workforce planning, skill mix, and the development of sub-specialties to meet the needs of the population.
Recommendation · source text
All NHS organisations should ensure that investigations and reviews are penetrating, impartial, and comprehensive, gaining deep insight into root causes and systemic issues, and that findings are used to drive sustainable service improvement.
Recommendation · source text
All NHS organisations should ensure that action planning, development, implementation, and governance assurance processes are robust, with clear accountability, measurable outcomes, and regular monitoring to ensure sustained improvement.
Recommendation · source text
All NHS organisations should ensure that they have robust processes in place for triangulating intelligence from various sources, including incident reports, complaints, claims, mortality reviews, and employee relations data, to gain a comprehensive understanding of service risks and performance.
Recommendation · source text
All NHS organisations should ensure that they have clear policies and training in place for managing media enquiries and messaging, particularly in sensitive cases involving patient harm or staff conduct, to ensure accuracy, transparency, and protection of individuals’ privacy.
Recommendation · source text
All NHS organisations should ensure that they have robust processes in place to manage the impact of serious incidents and investigations on patients and families, including clear communication, emotional support, and opportunities for involvement in learning and resolution.
Recommendation · source text
All NHS organisations should ensure that they have robust processes in place to manage the impact of serious incidents and investigations on staff, including psychological support, fair process, and opportunities for learning and rehabilitation.
Acceptance status
No Response Published
51
Total recommendations
51