IHRD-31
Accepted
Hyponatraemia Inquiry
Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').
- The Department of Health NI reported that work to improve staff understanding of SAI processes and their purpose had been taken forward (IHRD Implementation …
HSC Trusts
IHRD-32
Accepted
Hyponatraemia Inquiry
Failure to report an SAI should be a disciplinary offence.
- The Department of Health NI reported that the SAI process had been redesigned to separate learning and improvement from disciplinary procedures (IHRD Implementation Programme, …
HSC Trusts
IHRD-33
Accepted
Hyponatraemia Inquiry
Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.
- The Department of Health NI reported that CEO accountability for SAI investigation quality and timeliness had been strengthened in revised SAI procedures (IHRD Implementation …
HSC Trusts
IHRD-34
Accepted in Part
Hyponatraemia Inquiry
The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.
- The Department of Health NI stated in March 2018 that independent investigation arrangements had been strengthened (IHRD Implementation Programme, Department of Health NI, March …
Department of Health NI
IHRD-35
Accepted
Hyponatraemia Inquiry
Failure to co-operate with investigation should be a disciplinary offence.
- The Department of Health NI reported that SAI investigation teams now include members with appropriate clinical expertise for the incident under review (IHRD Implementation …
HSC Trusts
IHRD-36
Accepted
Hyponatraemia Inquiry
Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.
- The Department of Health NI reported that SAI investigation training for panel members had been developed and delivered (IHRD Implementation Programme, Department of Health …
HSC Trusts
IHRD-37
Accepted
Hyponatraemia Inquiry
Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all …
- The Department of Health NI reported that standardised terms of reference for SAI investigations had been developed (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
IHRD-38
Accepted
Hyponatraemia Inquiry
Investigations should be subject to multi-disciplinary peer review.
- The Department of Health NI reported that timescales for completion of SAI investigations had been set and were being monitored (IHRD Implementation Programme, Department …
HSC Trusts
IHRD-39
Accepted
Hyponatraemia Inquiry
Investigation teams should reconvene after an agreed period to assess both investigation and response.
- The Department of Health NI reported that family engagement in the SAI process had been formalised through the SAI Engagement Platform (IHRD Implementation Programme, …
HSC Trusts
IHRD-40
Accepted
Hyponatraemia Inquiry
Learning and trends identified in SAI investigations should inform programmes of clinical audit.
- The Department of Health NI reported that SAI investigation reports are now shared with families in a timely manner (IHRD Implementation Programme, Department of …
HSC Trusts
IHRD-41
Accepted
Hyponatraemia Inquiry
Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.
- The Department of Health NI reported that arrangements for families to provide input to SAI investigations had been strengthened (IHRD Implementation Programme, Department of …
HSC Trusts
IHRD-42
Accepted
Hyponatraemia Inquiry
In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.
- The Department of Health NI reported that mechanisms for tracking implementation of SAI recommendations had been established (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
IHRD-62
Accepted
Hyponatraemia Inquiry
Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.
- HSC Trusts reported that training on clinical record-keeping standards had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …
HSC Trusts
IHRD-65
Accepted
Hyponatraemia Inquiry
Training in SAI investigation methods and procedures should be provided to those employed to investigate.
- HSC Trusts reported that training on complaints handling and family engagement had been enhanced (IHRD Implementation Programme, Department of Health NI, March 2018). - …
HSC Trusts
IHRD-66
Accepted
Hyponatraemia Inquiry
Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
- HSC Trusts reported that training on governance and accountability responsibilities for senior managers had been implemented (IHRD Implementation Programme, Department of Health NI, March …
HSC Trusts
IHRD-67
Accepted
Hyponatraemia Inquiry
Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.
- HSC Trusts reported that training on human factors and patient safety had been incorporated into staff development programmes (IHRD Implementation Programme, Department of Health …
HSC Trusts
IHRD-68
Accepted
Hyponatraemia Inquiry
Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.
- HSC Trusts reported that multidisciplinary team training for paediatric care had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …
HSC Trusts
IHRD-81
Accepted
Hyponatraemia Inquiry
Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.
- HSC Trusts reported that performance management frameworks had been updated to include patient safety objectives (IHRD Implementation Programme, Department of Health NI, March 2018). …
HSC Trusts
IHRD-82
Accepted
Hyponatraemia Inquiry
Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.
- HSC Trusts reported that whistleblowing and raising concerns policies had been reviewed and updated (IHRD Implementation Programme, Department of Health NI, March 2018). - …
HSC Trusts
IHRD-83
Accepted
Hyponatraemia Inquiry
Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.
- HSC Trusts reported that leadership development programmes for senior clinicians had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …
HSC Trusts
IHRD-86
Accepted
Hyponatraemia Inquiry
The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the SAI process (ii) be strengthened in its capacity …
- The Department of Health NI stated in March 2018 that RQIA's remit and resources were under review (IHRD Implementation Programme, Department of Health NI, …
Department of Health NI