Board Paper 21.1.16 Item 16/24 - Health in Wales Concerns... · 2016. 1. 14. · Board Paper...

Concerns Update Dec 15 (Final 110116) - 1 -

Board Paper 21.1.16 Item 16/24

To improve health and provide excellent care

Title: Concerns - Putting Things Right (PTR) 2014/15 Update Report

Author: Mrs Barbara Jackson, Deputy Director Corporate Services

Responsible Director:

Mr Chris Wright, Director of Corporate Services

Summary of Key Issues:

The purpose of the paper is to update the Board on work that is underway to manage Concerns within the Health Board. Significant work has been undertaken during 2015 to clear the backlog in complaints and further work is in progress to ensure continued improvement. Following a number of national high profile reviews, there has been a widespread agreement at an all Wales level to bring together patient experience and concerns teams to ensure the best use of resources and skills. The Service User Experience Assurance Framework was re-launched in June 2015 with a focus on ‘Listening and Learning Organisations’. This work is being taken forward nationally by the ‘Model Patient Experience and Concerns Team’ work stream of the National Quality and Safety Forum. The work stream will identify the key components of a model team and a proposed structure. A revised plan of actions to deliver improvement has been developed in relation to how it receives, responds to and learns from Concerns. This paper provides more detail in relation to the current position and future handling of all Concerns.

Action Required By Board:

To: Note Endorse � Ratify Approve

(Please provide a short summary against all that apply) Corporate Objective

To manage Concerns in an effective and timely manner and improve the quality of care provided


Key Impacts:

Finance Potential to reduce the finical consequences of Concerns

Quality Impact Assessment

Not yet completed

Health and Care Standards

Supports the delivery of Standard 6.3 – Listening and Learning from Feedback (previously standard 23)

Equalities, Diversity &Human Rights

Not applicable as this report is an updated and assurance position

Risk & Assurance

The management of Concerns is identified as a risk on the BCUHB Corporate Risk Register – CRR26

Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board Board Coversheet v6.0 May 2015


Concerns - Putting Things Right (PTR) 2014/15 Update Report 1. Purpose of report To provide an update report for the Board in relation to the work that is underway to transform the way BCUHB manages Concerns. 2. Introduction/Context Significant work has been undertaken during 2015 to clear the backlog in complaints and further work is in progress to ensure continued improvement. The revised operational management structures have resulted in significant changes to the way that the Corporate Concerns teams are structured (currently on an interim basis) and the operational structures are also in the process of being redeveloped to support the required functions moving forward. The period of ‘pause and reflect’ in relation to the structures has caused a degree of delay in finalising both structures. Work at a national level has identified the need to bring together patient experience and concerns within a single corporate team and further work is underway through the National Quality and Safety Forum to design a “model” team structure for implementation by all Health Boards A revised plan of actions to deliver improvement has been developed in relation to how it receives, responds to and learns from Concerns. This paper provides more detail in relation to the current position and future handling of all Concerns. 3. Current Position 3.1 National Context Following on from the review of complaints in 2014 ‘Using the Gift of Complaints’ led by Keith Evans, work is ongoing nationally and locally to respond to this report. Nationally work streams are considering a range of issues. Some groups are nearing completion of their work: • Potential revisions to the ‘Putting Things Right’ (PTR) guidance and legislation • Standardised data collection – a draft list of standard data to be collected is

currently being consulted on • Changes to legislation and Legal advice to PTR – draft recommendations being

finalised and will be considered by Welsh Government. • Technical support to PTR , monitoring and reporting – national website for

patients and staff being considered Other groups are about to commence work:


• Primary Care – this group will be chaired by Dr Chris Jones and will review the implementation of PTR in primary care

• Bereavement services – this group will consider how effective bereavement services can help bereaved families better cope and thus improve their experiences at this tragic time and potentially reduce their dissatisfaction and need to complain.

The Health Board is fully engaged in this work and local action plans incorporate early and emerging learning. 3.2 Local context The initial improvement plan agreed by the Quality, Safety and Experience Subcommittee earlier in the year aimed to provide stability during the transition from Clinical Programme Groups to the revised operational structures. The actions to continue to improve are aimed at building sustainable structures, accountabilities and processes to better manage concerns moving forward. The main areas for action are: • Strategic Planning – the revised concerns procedure has been out for

consultation widely across the Health Board. Comments are being considered and the final revised document, reflecting the operational structures and ways of working, will be issued early in the new year. The revised process includes a simplified and proportionate guide to conducting a robust investigation and provides standardised documentation.

• Being Open – the Health Board has worked to the principles of ‘Being Open’ for some time but has now developed a ‘Being Open’ procedure. The document has been to consultation across the Health Board and the implementation of this is now being led by the Office of the Medical Director. The procedure has been produced to assist the Health Board in meeting its obligations to patients, families and/or their carers by being open and honest about the causes of any unexpected harm that results from the way we care for and treat our patients. It explains the procedures that need to be followed to ensure that the NPSA’s ‘Being Open’ guidance (NPSA 2009) and Welsh Risk Pool’s Technical note 23 ‘Apologies and Explanations’ circular (WRP July 2001, updated 2009) are implemented consistently throughout the Health Board.

• Processes – to better manage the new cases received within 30 days, a further facilitated North Wales wide process mapping workshop is planned for 19th January involving both service and corporate leads.

• Revised structures – the revised structures are continuing to be developed both operationally and corporately to reflect ongoing national work and best meet the needs of the organisation. The revised structures if approved to move forward will provide dedicated teams for incidents, complaints and claims. The need to address overdue cases will require the staff to work in certain ways initially but once cases begin to be routinely managed to time the structures and relationships between corporate and the service and concerns and patient experience will be revisited to continue to make best use of resources to deliver the nationally agreed integrated agenda of patient feedback.


• Training - the Corporate Investigation team are offering extensive training to matrons, sisters and Heads of Department on a range of issues related to Concerns Management. The emphasis is on managing issues at the first point of contact and prevent escalation into formal complaints. Further training will be offered related to conducting an appropriate level of investigation and drafting complaints responses.

• Reporting and governance framework – the recent white paper ‘Listening and Learning to improve the Experience of Care’ brings together concerns and patient experience. In line with this a quarterly report is now been developed for the Quality, Safety and Experience Subcommittee on themes and trends emerging from patient feedback. The relevant report is also provided to the local Quality and Safety Committee where the information is considered and used to improve services. There is a weekly performance meeting in each geographic area including acute, area and MH teams, supported by the Corporate Concerns team to drive performance pick up themes and trends and coordinate immediate and identified lessons to be learnt.

• Concerns information – there is work on going to update the Concerns website to ensure all relevant information is available to allow patients/carers and the public to know how to complain and what to expect when they do and to support staff to manage Concerns effectively.

• Datix systems - Claims work has now been transferred onto the Datix on line system. The Datix support team have developed dashboards for each senior manager in acute and area teams to assist with performance management of concerns.

• The development of performance trajectories to support the management of concerns and to challenge poor performance;

• Development of a Patient Support and Advice Service (a PALS-style service) – the national model currently includes the development of an early resolution service aimed at preventing escalation of low level issues for patients by offering timely local resolution to their concerns. Development within Betsi Cadwaladr University Health Board is dependent on the identification of additional resources.

3.3 Performance 3.3.1 Complaints The processes for achieving the 2 day acknowledgement target are established however performance has been affected by short term absences and lack of administrative support. Additional resource has now been secured and performance has improved as a result. The small number that do not meet this target result from delays in the complaint being forwarded to the Concerns team when received by other sources. Significant work has been undertaken to deal with the historical ‘backlog’ of complaints (those received prior to March 1st 2015) and this has seen a reduction from 523 cases open in March 2015 to 35 in December. Plans are in place for each of the remaining pre-March 2015 complaints with an expectation all will be closed by the end of January 2016.

Concerns Update Dec 15 (Final 110116)

This focus on the historic cases, 2015 and an increase in the numbers of complaints receivedtotal number of complaints waiting over 30 daysunderway, including a workshop with operational teams, to look at sustainable improvement through revised processes within existing resources whilst final structures are resolved.


e historic cases, coupled to significant organisational2015 and an increase in the numbers of complaints received, has resulted in the total number of complaints waiting over 30 days increasing. Further work is

nderway, including a workshop with operational teams, to look at sustainable improvement through revised processes within existing resources whilst final

al change during has resulted in the

increasing. Further work is nderway, including a workshop with operational teams, to look at sustainable

improvement through revised processes within existing resources whilst final


294 272 256 286 270

459 435 445 445 435

Cases waiting over 30 days for a response

Cases open over 30 days

The PTR target is 30 working resolved within this target. Due to the complexity of some cases, resolution within 30 days is not deliverable or desirable if we are to ensure a robust investigation for the complainant.

The ‘Putting Things Right Guidance’ allows that where the case is complex the investigation may take longer but should still be completed within 6 months. For cases received which are clearly complex, acknowledgement letters now inform the complaint from the outset of the possibility that the investigation may not be concluded with 30 days. PTR requires all cases to be resolved within 6 months.

At the end of October 2015 2379% of cases were resolveddescribed in section 3.2 above are designed to deliver improvement towards the projected target for performance. against the 30 day target, cases cl6 month target internally. There are a number of issues that are having an impact on achievement of the 30 day target:

13%

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270 292 324 363 366 383 401 364 385 410435 461547 571 556 564 558 570 553

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Cases open over 30 days Total number of cases open

The PTR target is 30 working days. Currently approximately 23% of complaints are

Due to the complexity of some cases, resolution within 30 days is not deliverable or desirable if we are to ensure a robust investigation for the complainant.

The ‘Putting Things Right Guidance’ allows that where the case is complex the investigation may take longer but should still be completed within 6 months. For cases received which are clearly complex, acknowledgement letters now inform the

he outset of the possibility that the investigation may not be concluded with 30 days. PTR requires all cases to be resolved within 6 months.

At the end of October 2015 23% of cases were resolved in 30 days and i% of cases were resolved within 6 months. The measures being taken forward as

described in section 3.2 above are designed to deliver improvement towards the projected target for performance. Whilst efforts are being directed towards delivering against the 30 day target, cases classified as “complex” will be reported against the

There are a number of issues that are having an impact on achievement of the 30

18%23%19%

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% of Complaints Closed within 30

65%77%

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calendar months (inc 30 day responses)

402 430 433496

608 616 637 662


% of complaints are

Due to the complexity of some cases, resolution within 30 days is not deliverable or desirable if we are to ensure a robust investigation for the complainant.

The ‘Putting Things Right Guidance’ allows that where the case is complex the investigation may take longer but should still be completed within 6 months. For cases received which are clearly complex, acknowledgement letters now inform the

he outset of the possibility that the investigation may not be concluded with 30 days. PTR requires all cases to be resolved within 6 months.

% of cases were resolved in 30 days and in May 2015, measures being taken forward as

described in section 3.2 above are designed to deliver improvement towards the Whilst efforts are being directed towards delivering assified as “complex” will be reported against the

There are a number of issues that are having an impact on achievement of the 30

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% of Complaints closed within 6

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• An increase in formal complaints of approximately 18% over the previous year • Operational management structures still being implemented • The need to clarify and agree responsibilities and accountabilities between

corporate and operational teams in light of emerging guidance from Welsh Government before finalising structures

In terms of improvement actions, local trajectories are being developed to deliver an improvement with a target of 75% of all cases resolved within 30 days by March 2016. This target whilst reasonable is challenging. Delivery will be monitored through the Operational Management Accountability Meetings established by the Chief Operating Officer. The Corporate Concerns Team in June 2015, restructured on an interim basis to support the geographical operational structures for acute, community and mental health services. These arrangements are interim whilst awaiting the consultation on the formal structures, in line with OCP, for Corporate Concerns moving forward. This has provided initial challenges in reorganising cases to align to the appropriate area as cases were previously managed on a North Wales basis. However, as the structures are embedding, relationships have been established, working processes have improved and this will be further strengthened as part of the development of the substantive structures. The workshop referred to in section 3.2 will further strengthen processes and working practices on an area basis. A key element of all investigations and responses is to ensure the complainant/family are kept informed and involved as appropriate. It is the aim of the investigation manager to make direct contact with a complaint within the first week to ensure their expectations are clearly identified so that the issues can be adequately addressed and early meetings offered. Regular updates will then be provided throughout the process.

The corporate concerns function requires further strengthening to deliver sustainable improvement and this is dependent on reaching agreement with the operational structures in relation to roles and responsibilities and alignment to the “model” team structures emerging from the work at an all Wales level (see Section 3.9) for further details.

3.3.2 Public Services Ombudsman’s Office Wales (PSO W)

When a complaint is not resolved to the satisfaction of an individual there is the option for the complainant to refer the matter to the PSOW. During April-September 2015 the PSOW issued 10 reports to the Health Board, which were either upheld or partially upheld: • The highest number of the reports related to care provided in Glan Clwyd

Hospital (3), Wrexham Maelor Hospital (3) and 2 related to GPs • 6 out of the 10 reports related to complaints handling; these were either a poor

quality final response or delays in responding


• 4 cases related to poor communication with patients about treatment choices or ongoing care

• At least a third of these related to delay in receiving treatment; in one of the cases the patient waited 74 weeks to receive treatment (the guidance states the waiting time should be no longer than 26 weeks)

• There was 1 section 16 report published by the PSOW during the April-September period. This report found failings relating to communication, patient discharge, record keeping and complaints handling

Of the 48 open PSOW cases, 33 cases are with PSOW (no action required by BCUHB), whilst 15 cases are with the Health Board for action. Of the 15 cases which are currently with the Health Board :

The Corporate Concerns team has reviewed the process for managing these Cases and a Senior Concerns Manager has taken the role of Liaison Officer and established strong links with the office of the Ombudsman (and Coroner’s Offices). 3.3.2 Incidents Incident reporting is a key tool in the management and treatment of risk across the NHS. The reporting process enables any person to report an incident, hazard or near miss, which has given, or may give rise to, actual or possible personal injury, or resulted in or could have resulted in loss to the Health Board.

3.3.2.1 Locally Reported

Between January and November 2015 the Health Board had a total of 26,120 reported incidents on Datix. The accountability for incidents graded as negligible, minor or moderate sits with the relevant local manager to review, investigate and ensure lessons are learnt and improvements made. 69% of these incidents have been closed, the remainder are in the process of being reviewed. Those incidents graded as catastrophic are investigated by the appropriate Corporate Area Concerns Team in liaison with the service. Those graded as major

2

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New Case Enquiry PSOW requested

further info

Draft Report

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are investigated by senior managers with input from the corporate teams. Of these 54% have been closed. The Corporate Area Concerns Teams are supporting the service in the investigation and learning from these incidents. Of the cases reported, the majority (76%) are relating to patients.

*‘Risk management only’ -The BCUHB are required to upload all patient safety related incidents to the NRLS once they have been closed off in the Datix system. The use of this code acts as a safety net to ensure that any incident coded as Death has been reviewed by an investigation manager to ensure that the use of the result code, Death has been applied correctly.

The 10 main reasons for reporting these incidents are detailed below. This information is shared monthly with the current Hospital Management Teams and local Quality and Safety Groups and the Quality Assurance Executive (QAE).

All reported incidents are graded by severity of impact. The vast majority (71%) of incidents are graded as negligible – causing minimal or no harm. This grading system is used nationally across Wales.

19747

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Incidents affecting PatientIncidents affecting the StaffIncidents affecting visitors, contractors or the publicIncidents affecting the OrganisationRisk Management Use ONLY

Incidents by Type (Jan - Nov 2015)

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(A definition of each category can be found at http://howis.wales.nhs.uk/sitesplus/documents/861/PTR01a_concerns_procedure.pdf

Work is ongoing with all areas of the Health Board to ensure that staff are aware of their responsibilities in terms of reporting and investigating/ closing incidentsof work is also being taken forward to ensure the quality and accuracy of data sin Datix is accurate and complete. 3.3.2.2 Never Events Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Never Events are fully investigated by thunit at Welsh Government, that actions are completed and lessons shared across the organisation. The Health Board has reported a total of six Never Events to Welsh Government since April 2015. There are currently four Never Events open within the health board. The one Never Event reported in July 2015 was downgraded by Welsh Government but an internal investigation continues. 3.3.2.3 Welsh Government Report

For an agreed list of incidents there is a requirement Welsh Government (WG). Currently there are 290investigation process and of these 196 (68%)completion of 60 working daysto address this issue. For each case reported the Health Board provides a report to Welsh Government on competing the investigation. This closure report provides assurance that the case has been fully investigated and lessons learnt. followed up by Welsh Government incidents where further information was requested, timely manner. During the April-September 2015 serious incidents to Welsh Government


(A definition of each category can be found at http://howis.wales.nhs.uk/sitesplus/documents/861/PTR01a_concerns_procedure.pdf)

Work is ongoing with all areas of the Health Board to ensure that staff are aware of their responsibilities in terms of reporting and investigating/ closing incidentsof work is also being taken forward to ensure the quality and accuracy of data sin Datix is accurate and complete.

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.

Never Events are fully investigated by the health board with support from the delivery to ensure that robust investigations are undertaken and

that actions are completed and lessons shared across the organisation.

The Health Board has reported a total of six Never Events to Welsh Government since April 2015. There are currently four Never Events open within the health board.

The one Never Event reported in July 2015 was downgraded by Welsh Government al investigation continues.

Welsh Government Report able Incidents

For an agreed list of incidents there is a requirement for them to be reported nt (WG). Currently there are 290 cases that are still within the

and of these 196 (68%) are overdue against a target completion of 60 working days. The Investigation Teams are working with the service

For each case reported the Health Board provides a report to Welsh Government on investigation. This closure report provides assurance that the case

has been fully investigated and lessons learnt. 11 out of 196 closed cases by Welsh Government requesting further information. In each of these

formation was requested, the Health Board

September 2015 period, the Health Board reported serious incidents to Welsh Government.

Work is ongoing with all areas of the Health Board to ensure that staff are aware of their responsibilities in terms of reporting and investigating/ closing incidents. A piece of work is also being taken forward to ensure the quality and accuracy of data stored

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.

e health board with support from the delivery to ensure that robust investigations are undertaken and

that actions are completed and lessons shared across the organisation.

The Health Board has reported a total of six Never Events to Welsh Government since April 2015. There are currently four Never Events open within the health board.

The one Never Event reported in July 2015 was downgraded by Welsh Government

for them to be reported to the cases that are still within the

against a target The Investigation Teams are working with the service

For each case reported the Health Board provides a report to Welsh Government on investigation. This closure report provides assurance that the case

closed cases were requesting further information. In each of these

the Health Board responded in a

reported a total of 196


The table below provides a summary of theSerious Incidents reported:


The table below provides a summary of the Welsh Government categorSerious Incidents reported:

categories of


The previously identified historic position for WG reported incidents that are overdue is improving with a trajectory for all historic cases to be closed by the end of March 2016. The progress on closing the legacy of outstanding Serious Incidents is requiring focused management and Quality Assurance.

3.3.2.3 Serious Incident closures (December 2015) 2012-2013 Incidents 1 case remains open. This was a complex Safeguarding Multi-agency case with the final report expected January 2016 2013-2014 Incidents There are a total of 6 cases identified as still being open from 2013/14. There are a number of reasons for this: • Submitted to Welsh Government but not formally closed (3) • Complex multi-agency case (1) • Historic failure of service to implement outcomes (1) (escalated to Director of

Secondary Care) • Missing detail on closure submission (1) (in course of amendment) 2014-2015 Incidents 76 cases require closure from 2014/15. These are being actively managed by the Director of Nursing (Acute Site) supported by the Senior Investigation Managers with the aim of all being closed by the end of March 2016. 2015-2016 Incidents 203 cases require closure from 2015/16 of which 109 cases are overdue. Progress on these cases is being actively managed by the Senior Investigation Managers.

219 210187 170

147 130106

96 91 74

Backlog of WG cases pre 1st April 2015

Values Profile


Trajectories for improvement and the closure of all overdue serious incidents are being agreed and the position is being monitored through weekly operational accountability meetings and monthly corporate accountability meetings. Where necessary, issues will be escalated to the relevant Executive Director for action..

3.3.3 Claims Claims made against the Health Board are managed by the Corporate Concerns Team with the support of Welsh Health Legal and Risk Services. The Claims Managers form part of the revised geographic corporate area teams. This provides them with good support, local knowledge and relationships. However, each area has only one claims manager leading to challenges with capacity and cover for absences. Efforts are being made to increase the capacity available within the Claims Managers team; all Personal Injury Claims across the Health Board are now managed by a dedicated staff member (this is recommended good practice by L&R) and administration support has also been added to the teams. The recommended caseload for a claims manager is 150 cases, the average case load in the Health Board is 220 cases. Work has been undertaken to streamline the work carried out by the Claims managers and additional capacity is part of the ongoing discussions regarding structures. 3.3.3.1 Current position The Health Board currently has 790 claims open – 670 Clinical Negligence (CN) and 120 Personal Injury (PI) claims.

37

8 79 10

1416 16

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11 108

1815 15

22

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2523

1715

39

30

2124

26

19 19

31

22

14

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Claims opened by Month and Year

2013/14 2014/15 2015/16


3.3.3.2 Aggregated number and value of compensation claims NWSSP Legal and Risk Services (L&R) categorise all claims into 4 areas of Probability of Loss:-

• Certain 95% - 100% chance of settlement • Probable 50% - 94% chance of settlement • Possible 6% - 49% chance of settlement • Remote 0% - 5% chance of settlement

For the purposes of this report, only those claims classed as Certain or Probable have been considered as those categorised as possible or remote often do not progress. The figures below include settlement damages, claimant costs and defence costs. 3.3.3.3 Clinical Negligence Claims Of the 670 CN claims, 82 are classed as Certain , with an aggregated settlement value of £64,928,017.25. For these cases the projected settlement costs are likely to be very near at the time of settlement. 9 of these claims are valued at over £1million: • £7,800,000.00 – birth injury leading to cerebral palsy • £9,611,000.00 – brain injury due to delay in delivery • £9,230,000.00 – birth asphyxia causing cerebral palsy • £4,948,000.00 – birth injury leading to cerebral palsy • £1,943,000.00 – nerve damage leading to paraplegia • £4,320,000.00 – premature birth causing range of issues • £1,020,000.00 –erroneous diagnosis of small cell carcinoma • £8,447,000.00 – failure to recognise abnormalities during pregnancy • £4,323,000.00 – delay in delivery, child has cerebral palsy The anticipated settlement date of the above varies from 2015 – 2017. 37 claims are categorised as Probable , with an aggregated value of £24,994,355.79 (for these cases the projected costs may change during the course of the claim) : Central, East and West each have one claim projected as settling at over £1 million. • £8,797,000.00 – birth injury • £6,085,000.00 –hypoxic ischaemic encephalopathy • £4,430,000.00 – complications during labour leading to cerebral palsy If these claims settle for the anticipated sums of damages, the estimated dates of settlement vary between 2016 – 2018.


3.3.3.4 Personal Injury Claims Currently, 19 of the PI claims are classed as Certain with an aggregated settlement value of £1,075,103.19. The highest value is a Central claim, valued at £656,089.05; this claim is due to be heard at Trial in January 2016. There are 12 claims classed as Probable with an aggregated value of £310,725.81. Settlement on all of the above is anticipated as being no later than 2018. The Health Board’s liability is limited to £25,000 per individual case, all expenditure incurred above this level is reclaimabl e from the Welsh Risk Pool. 3.3.3.5 Remedial action arising out of compensation claims Case 1 – Clinical Negligence Claimant admitted to A&E following a fall at home. X-rays of knee showed no fracture or effusion although she was unable to weight bear due to the pain. Patient admitted to the ward for monitoring due to pre-existing co-morbidiites, including kidney failure. Four weeks later, due to ongoing pain, x-rays were taken of the hip and pelvis. The films revealed a displaced fracture of the right femoral neck. As a direct result of the above the A&E department took the following action: • Discussion at their departmental governance meeting • A clinical memo was circulated to all doctors in A&E reminding them that

examination of the hips is mandatory for all patients who fall and cannot subsequently weight bear, with x-rays being ordered if there is any doubt.

• An emphasis on the examination of the hip is now included in the department Junior Doctors teaching programme

Case 2 – Clinical Negligence Claimant underwent total knee replacement in 2009; still symptomatic four months later. Further examinations and radiology showed significant malpositioning of the prosthesis causing external rotation and leg shortening. Upon senior clinical review, it was established that there was a particular problem with this type of UKR (Stryker). BCUHB was one of the first units in the UK to use it. However, the instruments proved to be of very poor design, and this made inserting the prosthesis accurately very difficult. Following discussions with Stryker, a number of surgeons abandoned the device because of this; it is believed that Stryker have now redesigned the instruments


Case 3 – Personal Injury Claimant returning to car from A&E and tripped over a kerb that was proud of the pathway; the area was inadequately lit. Claimant sustained a ruptured nail bed to left thumb, soft tissue damage to right shoulder and grazed/bruised knees The claimant had been taking a short cut across the grassed area in front of the hospital; however, it was recognised that staff, patients and visitors frequently did the same. Estates therefore blocked the area so that this short cut could not be used Case 4 – Personal Injury The Claimant worked in cramped conditions and had reported this on several occasions to management. Claimant had been advised that shelving was due to be installed but this had not happened. Due to the arrangement of furniture and equipment, a set of drawers, which had previously been underneath her desk, were placed to the left of the desk. A fax machine was placed on top of the set of drawers and therefore the drawers were not flush against the wall; this caused them to overhang the edge of the Claimant’s desk by about 3 inches. The overhang meant that the Claimant would often catch the drawers with their feet leading to the drawers opening. On the day of the accident, the Claimant got up from the desk and caught the drawers with a foot, causing one of the drawers to open. The Claimant’s foot became caught underneath the drawer resulting in a fall and several fractures to bones in a hand. As a result of this incident, Health and Safety Guidance was updated:

http://howis.wales.nhs.uk/sitesplus/861/page/49504 3.3.4 Coroners cases There are many reasons why an inquest may be convened and the Health Board is responsible for providing all evidence required by the Coroner. This may include staff statements, full investigation and attendance of staff at the Inquest. Historically, the processes for providing the Coroner with requested information has been lacking resulting in delays to inquests (under new legislation these should be within 6 months of death) and significant criticism from the Coroner resulting in the potential for a Regulation 28 order for improvement. As a result, a senior manager within the Corporate Concerns Team has been allocated to act a central point for the cork related to coroner’s cases. The Senior Investigation Managers within each Corporate Area Concerns Team acts as a contact point and ensure all required information and actions are taken forward. Where the coroner has concern that further deaths could be avoided by the Health Board taking particular actions, he may issues a regulation 28 letter that must be responded to within 56 days.


The Coroner has issued 4 regulation 28 reports against the HB within the April-September 2015 period. There was no outlier theme or trend to the subject matter of these reports. The reports related to infection control, surgical, documentation and a patient fall.

Across Wales 17 regulation 28 reports have been issued for the same time period. They include a variety of subjects but some key themes include, 3 of which related to patient falls, 3 related to INR, 2 related to infection control, 2 related to pressure ulcers and 2 related to tracheostomy. 3.4 Meeting NHS Redress Requirements

Currently legal advice regarding redress is provided by the Legal and Risk Team within NHS Wales Shared Services. The lead times for assessing for redress often result in delays to final responses to complaints being issued. To improve the process the intention is to incorporate additional in house legal support within the Concerns Team as part of the developing structures. A senior Concerns Manager has been identified to lead on Redress cases. 3.5 Training & Education

The Investigation Managers have developed a training tool and will be creating time to deliver training on how to manage ‘On the spot’ concerns in the first instance. Training will be targeted initially at ward Sisters/ Charge Nurses, ward staff, managers, and senior nurses. Root Cause Analysis training sessions will also be provided as capacity allows. Each area and site are developing a register of trained investigation staff to better match skill levels to the complexity of the investigation. 3.6 Lessons Learned An explicit area of the Putting Things Right regulations is the requirement for concerns to be used for learning. Historically, this has not been systematic within the Health Board and annual Welsh Risk Pool Reviews have highlighted this. Moving forward the information and learning gained from the investigation of Concerns will be provided to the Area, Secondary and Site Teams, and to the Quality Improvement Faculty (when established) to systematise learning both with the services and across the Health Board. Currently the action plans form each serious incident and complaint investigation are shared with the relevant local Quality and Safety Group and a quarterly report on themes and trends is provided to the Quality, Safety and Experience Subcommittee.

3.7 Accountability & Responsibility • Performance Reviews

Delivery of timely responses to Concerns is a national target and the delivery of the 30 day/6 month target by the services requires management alongside all other national performance targets. Monthly Accountability Meetings now


incorporate a review of concerns performance monitoring data as do the quarterly Performance Reviews. The performance data is routinely included within the Integrated Performance Report.

• Governance and Assurance

Assurance regarding the overall BCU position against Concerns, both in terms of performance and learning will be via the Quality, Safety and Experience Sub Committee and the Quality Assurance Executive (QAE). As the Quality Improvement Faculty develops, information will also be shared and working relationships and practices developed as required. Local Quality and Safety Groups consider their local cases and performance.

A reporting schedule has been agreed by the Quality, Safety and Experience Sub Committee. In parallel, the Corporate Concerns Hub will provided information to the Area, Secondary Care and Site teams to support them to provide timely responses to complainants and ensure (working with the Faculty) the organisation identifies and learns lessons from concerns. Dashboard reports in Datix are currently being established to support senior managers in the services on a daily basis.

• Accountability

It is accepted within the Health Board and nationally that accountability and responsibility for Concerns sits with the relevant service. The Corporate teams provide the relevant support, expertise and processes to best manage Concerns. Responsibility for investigation of Concerns rests with the service. The Services are currently developing appropriate structures and processes to ensure the ownership and accountability for the management of concerns is embedded in the management structure and at site management level.

3.8 Technical Infrastructure The database in place across the Health Board to record and support the management of Concerns across the Health Board is Datix. The system allows for all information collected throughout the course of any complaint investigation to be recorded and stored including conclusions and lessons learned. It also produces statistical data on numbers and trends of complaints (and incidents). Currently there are gaps in the information being uploaded onto the system which hinders production of data sets and disseminating learning. A plan is currently being developed, to be implemented in liaison with the Area and site operational teams, to cleanse the data currently held on Datix and to improve the utilisation of Datix to fully support the management and lessons to be learnt processes across BCUHB. A national specification for an electronic management system is being taken forward at a national level by Welsh Government.


3.9 National Emerging Model Concerns Team As described above, work is being undertaken at an all Wales level to look at the implementation of the Evans Report and design a model structure for Health Boards and Trusts to adopt to ensure that the Regulations are appropriately applied. The following principles are underpinning this work: • Board level commitment is central to the effective implementation of a

successful structure for the management of patient experience and concerns. An Executive Director should have overarching accountability for the management of concerns in line with the principles of Putting Things Right and for assuring and improving the patient experience. This will include the integration and triangulation of patient feedback of all types including compliments and concerns and the actions taken to respond to these.

• Greater clinical engagement to ensure that responsibilities are promoted and owned. Structures must ensure that concerns relating to patient experience are escalated and managed.

• A Corporate Concerns Team (CCT) should be available to direct and support Divisional staff in the management of claims, complaints and clinical incidents, however, ownership must remain locally.

• A Patient Advice and Support Service (similar to the PALS service elsewhere in the UK) provides a central point of contact for patients and their families who need advice or support with a wide variety of issues that affect their overall care. Providing help in this way enhances their overall experience of care, but can also address “on-the-spot” concerns which may otherwise escalate into formal complaints. The role requires close collaborative working with the Directorates and Concerns Team and will include:

o advocacy o support and information o sign-posting service users or the general public to other

organisations and Third Sector Partners o ensure learning and improvements

• Whilst complaints and incidents are managed under the same legislation there

needs to be structures in place to adequately support both functions to prevent competing priorities for investigation.

The Health Board has already taken steps to align existing structures to the emerging model. Concerns and patient experience currently sit within the portfolio of the Director of Corporate Services. As previously reported the Corporate Concerns Team has in June been aligned into three geographical areas teams. All reports produced by the Corporate Concerns Teams now encompass information from both patient experience and concerns to provide a more balanced view of patient feedback. The proposed revised structures (see section 3.2 above) will begin to deliver the emerging national model but will require additional resources to deliver in entirety.


4. Assessment of risk The management of Concerns is identified as a risk on the BCUHB Corporate Risk Register – CRR26. 5. Equality Impact Assessment Not applicable as this report is an updated and assurance position 6. Conclusions / Next Steps Historically, there have been a number of barriers to sustained improvement in the handling of concerns. To enable the required step change in process and culture it will be necessary to: • Identify resources, both within the corporate team and within the developing

revised operational structures to support the timely management of Concerns and ensure learning and improvement to services as a result of lesson identified. This will need to be in line with the emerging national model concerns team, bringing together Concerns and patient experience;

• Included within this is the development of an early resolution “team” to manage low level issues and prevent escalation to the PTR formal process. This PALS-style function is recommended within the “model” team structure proposed by Welsh Government and its development is subject to the agreement of the proposed corporate structures

• Enhance clinical engagement; it is necessary for clinicians to welcome patient feedback to include concerns, recognise their role in their management and their key role in implementing change in line with lessons learnt - the implementation of ‘Being open’ Policy will significantly assist with this;

• Enhance timely delivery of Concerns management – Concerns are an important aspect of patient feedback and a valuable source of learning opportunities - Delivering timely responses must be prioritised and roles within the developing revised operational structures clearly defined;

• Provide ‘customer care’ and specific investigation and awareness training to all relevant staff regarding Concerns Management; resources to provide training are extremely low and this is a key platform to successful delivery of a customer focused service and to handling concerns on the spot to provide early resolution for the complainant;

• Improve available robust information across the Health Board to support opportunities to learn; the improvement plan includes work to cleanse the data held within Datix (the electronic system for the management of Concerns). Additional support and training is necessary to ensure Datix is systematically completed and used to its full potential. The Quality Improvement Faculty will be key to triangulating information and improving the quality and safety of care.

The actions identified to improve addresses these areas and, working with the operational structures, the aim is to ensure there is uniformity in relation to processes and standards across the Health Board and that all complaints, incidents and claims are thoroughly investigated and responded to promptly with lessons


being learnt and shared to improve the quality and safety of services and provide assurance to patients, families and carers. 7. Recommendations That the Board notes the current position and endorses the actions to be taken.

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