Litigation and inquest forum, Exeter - September 2016
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At our September forum we cover: • Hillsborough: lessons to be learnt - by Andrew Hopkin, Partner at Browne Jacobson - the involvement of Browne Jacobson in Hillsborough and lessons that trusts and providers can take from this seminal case • Learning lessons: identifying and communicating learning from complaints, claims and inquests - by Mark Barnett, Partner at Browne Jacobson - an interactive session giving tips and advice as to how trusts can ensure that learning is effectively disseminated to front line staff • Inquests: the beginning or the end? The impact of inquests upon disciplinary, regulatory and criminal proceedings - by Kate Brunner QC. This session includes: o the value of SUI's and their impact upon regulatory and employment issues o when to whistle blow - should CQC and NCAS be involved? o timing of internal investigations and the quality of the investigators o referrals to the Coroner and whether to pause until after the inquest. https://www.brownejacobson.com/health/services/inquests-and-investigations
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Litigation and inquest forum, Exeter - September 2016
- 1. Litigation and inquest forum September 2016, Exeter
- 2. Learning lessons from complaints, SIs, claims and inquests Mark Barnett Partner, Browne Jacobson
- 3. Overview • Opportunities for learning – complaints and SIs • Looking back (briefly!) • Momentum for change (with a focus on SIs) • Opportunities for learning - inquests and claims • Looking forward – drivers for change
- 4. Opportunities for learning – complaints and SIs • Complaints (NHS Constitution; The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009; duty of candour) • Serious Incidents (SI Framework (March 2015); duty of candour) – RCA – Incident Decision Tree
- 5. Looking back • An Organisation with a memory, 2000 “…there is evidence that some specific types of relatively infrequent but very serious adverse events happen time and again over a period of years. Inquiries and incident investigations determine that ‘the lessons must be learned’, but the evidence suggests that the NHS as a whole is not good at doing so.” Sir Liam Donaldson
- 6. Since then… • Bristol Children’s Hospital Inquiry, 2001 • The Francis Inquiry, 2013 • The Berwick Review, 2013 • The Keogh Review, 2013 • Kirkup Report, 2015
- 7. Momentum for change Each Baby Counts – June 2016 599 local reviews: • 48% used no specific tools or methodology • Only 7% used an external expert • 25% parents not aware of review • 47% parents aware but not invited to contribute • 39% contained no actions or recommendations or solely focused on an individual
- 8. Sam Morrish
- 9. “Learning from mistakes”, July 2016 ‘Across the NHS a fear of blame pervades that prevents individuals and organisations being open to the possibility that their initial view of what happened might not be the right one, and means they are not asking questions about what happened and why…’ Parliamentary and Health Service Ombudsman
- 10. CQC Briefing: Learning from serious incidents in NHS acute hospitals 5 opportunities of improvement: 1. Prioritising serious incidents that require full investigation and developing alternative methods for managing and learning from other types of incident. 2. Routinely involving patients and families in investigations.
- 11. CQC Briefing: Learning from serious incidents in NHS acute hospitals 3. Engaging and supporting the staff involved in the incident and investigation process. 4. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident. 5.Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.
- 12. Opportunities for learning - Inquests • Prevention of Future Deaths (Regulation 28) Report (“PFD”) • Promote safety and necessary change • Identification of themes
- 13. Opportunities for learning - Claims ‘The key to reducing the growing costs of claims is learning from what goes wrong and supporting changes to prevent harm in the first place” Helen Vernon, Chief Executive NHSLA • Thematic reviews of claims data • networking events to share outcomes of bid activity • ‘buddying’ arrangements with beacon organisations and those struggling with specific patient safety issues • promoting ‘ask’ and ‘offer’ work to share learning • facilitating bulk buying of maternity equipment
- 14. Looking Forward
- 15. Health Service Investigative Branch (HSIB) • National Health Service Trusts Development Authority (HSIB) Directions 2016 • “…a just an open culture across the whole of the healthcare system” • Not to apportion blame “Just culture” • “Safe Space”
- 16. Health Service Investigative Branch (HSIB) • Initial budget £3.6m • 30 investigations a year • ‘…encouraging the development of skills used to investigate local safety incidents in the health service and to learn from then, including suggesting standards which may be adopted in the context of such investigations’ (Section 5 of the National Health Service Trusts Development Authority (HSIB) Directions 2016)
- 17. Other drivers for change • Freedom to Speak Up Guardians • New medical examiners system • Impact of fixed costs? • AvMa proposal for “patient safety letter”
- 19. THE HILLSBOROUGH DISASTER: Lessons to be learnt Andrew Hopkin Partner, Browne Jacobson
- 20. A brief guide for the uninitiated On the day • 15 April 1989 semi-cup final between Liverpool FC v Nottingham Forest at Sheffield Wednesday FC • An exit gate was opened shortly before kick-off – fans poured into the already full Leppings Lane turnstiles • 96 Liverpool FC fans sustained fatal injuries • 766 fans were injured
- 21. Inquests and Inquiries • Taylor inquiry in August 1989 concluded that the cause of the disaster was “failure of police control” • First inquest concluded in 1991 returning “accidental death” verdicts • Judicial Scrutiny by Lord Justice Stuart-Smith reported in 1998 that amendments to police statements had no significant impact on the legal process or their outcomes – no new inquiry was necessary • Private prosecution of the Match Commander and his Deputy failed in 2000 • 2012 publication of the Hillsborough Independent Panel Report
- 22. The New Hillsborough Inquests • Original Inquest verdicts quashed by the High Court on 19 December 2012 • Lord Justice Goldring appointed as Coroner to oversee the new Inquests • Jury Inquest • Dedicated Court facility in Warrington
- 23. Who were the Interested Persons? Families of the deceased – 4 separate teams South Yorkshire Police South Yorkshire Metropolitan Ambulance Service Police Federation Police Match Commanders – 2 separate teams South Yorkshire Fire & Rescue Service IPCC CPS West Midlands Police Sheffield Wednesday Football club* Football Association* Peter Metcalfe* Anthony Edwards*
- 24. Evidence at the Inquest State of the art digital system Trial Director to review exhibits in Court In excess of ½ million documents Hundreds of witnesses called to give evidence
- 25. How long did the Inquest last? • 5 PIR hearings in London and Warrington • First sitting day 31 March 2014 • Conclusions returned on 26 April 2016 • Court sitting days – 319 • Jurors who started 11 – at the end 9!
- 26. What did it cost? Figures in, so far The total cost is yet to be announced but we do know the following interested persons incurred the following costs: South Yorkshire Police Crime Commissioner £24 million Police Federation £25 million Match Commanders £5.8 million Ambulance Service £1.5 million Sheffield Teaching Hospital £445,000 West Midlands Police £256,000 Sheffield City Council £1 million IPCC £321,000 South Yorkshire Fire £1.3 million Coroner £14 million (up to March 2015)
- 27. What conclusion did the Jury return: Unlawful Killing Question 6: Determination on Unlawful Killing issues Are you satisfied, so that you are sure, that those who died in the Disaster were unlawfully killed? Answer “yes” or “no” YES – by a majority of 7 to 2 Important Note: When answering this question, please refer to the section at the end of this questionnaire which is headed “Legal Directions on Question 6 (Unlawful Killing” (pages 30-31). That section contains important directions which you must follow carefully when answering this question. Note that, as with other questions, you should only give an answer to Question 6 if all of you agree upon the answer.
- 28. So what happens next? • SYP Chief constable was suspended and disciplinary proceedings are underway • The families also called for the Chief Ambulance Officer to be dismissed • The Chair of the Hillsborough Independent Panel review has been asked by the government to report on the “lessons to be learnt” from the disaster • IPCC investigation into police corruption • Operation Resolve – criminal investigation into individuals
- 29. Call for “Hillsborough Law” The Public Authority and Accountability Bill The draft bill sets out how public authorities, servants and officials can achieve this by:- i. Acting with proper expedition ii. Acting with transparency, candour and frankness; iii. Acting without favour to their own position; iv. Making full disclosure of relevant documents, material and facts; v. Setting out the core position on the relevant matters at the outset of proceedings, inquiries or investigations; and vi. Providing further information and clarification as ordered by a court of inquiry
- 30. Call for “Hillsborough Law” contd The Public Authority and Accountability Bill The draft bill also calls for a:- A Code of Ethics to be published to promote “Ethical behaviour, transparency and candour”. It also makes a failure to discharge a duty under the Act a criminal offence The draft bill also establishes criminal offences in the event that the public punishable by a term of imprisonment. How likely is it that this draft bill will ever become law?
- 31. Chief Coroner and Call for Equal Funding (8) Representation for families 201. In a small number of inquests the family of the deceased is unable to obtain legal aid funding for representation at the inquest, despite individuals or agencies of the state being funded for legal representation as “interested persons”. In some cases one or more agencies of the state such as the police, the prison service and ambulance service, may be separately represented. Individual agents of the state such as police officers or prison officers may also be separately represented in the same case. While all of these individuals and agencies may be legally represented with funding from the state, the state may provide no funding for representation for the
- 32. Call for Equal Funding contd 202. in some cases the inequality of arms may be unfair or may appear to be unfair to the family. It may also mean that the coroner has to give special assistance to the family which may itself give the appearance of being unfair to others. 203. The Chief Coroner therefore recommends that the Lord Chancellor gives consideration to amending his Exceptional Funding Guidance (Inquests) so as to provide exceptional funding for legal representation for the family where the state has agreed to provide separate representation for one or more interested parties.
- 33. On the horizon? • The tide does seem to be turning to provide equality of arms for families facing state represented parties • The Home Secretary is considering the application of the families of those affected by the Birmingham Pub Bombings in 1974 for funding a the new Inquests due to begin shortly • Orgreave Inquiry? Are there any more?
- 34. Contact us… Mark Barnett – mark.barnett@brownejacobson.com T: +44 (0)1392 45 8768 M: +44 (0)7920 713971 Andrew Hopkin – andrew.hopkin@brownejacobson.com T: +44 (0)115 976 6030 M: +44 (0)7879 885221
- 35. Albion Chambers Kate Brunner - Kate.BrunnerQC@albionchambers.co.uk T: +44 (0)117 927 2144 Alex West - alexander.west@albionchambers.co.uk T: +44 (0) 117 927 2144
Editor's Notes
- Look at opportunities for learning in NHS start by looking at SIs and complaints –concentrate on SIs because of the focus on these by a number of reports published over the summer which will undoubtedly shape and feed into how investigations are conducted in the future These reports focused on need to look forward but want to briefly go back and remind ourselves what Sir Liam D concluded in an Organisation with a memory
- Current framework…. Key documents which set out the core requirements for dealing with complaints and Sis Firstly complaints, This Constitution establishes the principles and values of the NHS in England and organisations must ‘have regard’ to it. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities, which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively It pledges the right to an open and transparent relationship with the organisation providing your care. You must be told about any safety incident relating to your care which, in the opinion of a healthcare professional, has caused, or could still cause, significant harm or death. You must be given the facts, an apology, and any reasonable support you need. Regulations provide legal framework. Drafted to allow health care providers to have flexibility to adopt a patient centered approach to complaints handling Duty of Candour As soon as is reasonably practicable after a notifiable patient safety incident occurs, the organisation must tell the patient (or their representative) about it in person. The organisation has to give the patient a full explanation of what is known at the time, including what further enquiries will be carried out. Organisations must also provide an apology and keep a written record of the notification to the patient. A notifiable patient safety incident has a specific statutory meaning: it applies to incidents where a patient suffered (or could suffer) unintended harm that results in death, severe harm, moderate harm or prolonged psychological harm. Severe and moderate harm definitions are derived from the NPSA's Seven Steps to Patient Safety. Prolonged psychological harm means that it must be experienced continuously for 28 days or more. There is a statutory duty to provide reasonable support to the patient. Reasonable support could be providing an interpreter to ensure discussions are understood, or giving emotional support to the patient following a notifiable patient safety incident. Once the patient has been told in person about the notifiable patient safety incident, the organisation must provide the patient with a written note of the discussion, and copies of correspondence must be kept. Framework for dealing with complaints in terms of the nuts and bolts of conducting the investigation/time frames etc set out in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 SI Framework first published 2010, updated in 2015 sets out what incidents should constitute serious incidents (there is not comprehensive list) but includes Unexpected or avoidable death or one or more people Unexpected or avoidable injury that has resulted in serious harm Thinking is that a list would lead to inconsistent/inappropriate management – tendency not to investigate things not on the list even where they should be investigated and equally a tendency to undertake a full investigation that may not be warranted simply because an incident fits the description of an incident on the list Highlights that care must be taken to ensure a balance of resources applied to reporting and investigating of individual incidents and the resources applied to implementing and embedding learning to prevent recurrence Former no good without the latter RCA – useful tool for thoroughly investigating reoccuring problems of a similar nature to identify the commen problems 9the what) contibuting factors (how) and the root causes (why) to enable a comprehensive action plan to be put in place and monitored Root Cause Analysis is an evidenced based, structured investigation process which utilises tools and techniques to identify the true causes of an incident or problem, by understanding what, why and how a system failed. Analysis of these system failures and true causes enables targeted and, where possible, failsafe actions to be developed and implemented which demonstrate significantly reduced likelihood of recurrence Incident Decision Tree to enable investigators to deal with staff fairly and consistently and ensure that appropriate action is taken
- Useful to go right back to an Organisation with a Memory It is some sixteen years ago since Liam Donaldson’s report into patient safety ‘An organisation with a memory’, was published. In this report, Sir Liam Donaldson was critical of an NHS that had no systemic way of identifying and learning from mistakes to reduce risk for future patients. This quote I think is particular pertinent when we come on to look at the latest criticisms of NHS investigations and the calls for change Made recommendations for change Since then a number of high profile reports/inquiries into various scandals all calling for similar changes in the system Identified similar themes including the need for a standardised investigation process and a change in culture whereby staff feel they can report errors and adverse incidents without fear of retribution.
- Most recently, number of reports published over the summer…… The RCOG’S report into the Each Baby Counts Programme was set up to look into the impact of intrapartum harm to babies – INCLUDING INTRAPARTUM STILLBIRTH, EARLY NEONATAL DEATH AND SEVERE BRAIN INJURY (DX WITHIN THE FIRST 7 DAYS OF LIFE). Often root cause is difficult to ascertain and effect on staff involved, financial costs to parents and wider NHS and years of uncertainty caused by possible litigation - wanted to know if this could be avoided Since Jan 2015 programme has been collecting and pooling the rersults of local risk management reviews to gain a national picture to understand what goes wrong better. 100% of maternity services signed up within the first 3 months. EARLY BRIEF REPORT ON 2015 DATA – out of almost 800,000 births 921 babies met criteria (last category higher than estimate of 500-800) Headline data Almost half of the reviews carried out using no specific tool/methodolgy Most common tool was RCA In just a quarter of reviews parents involved and asked to contribute Overall, the report echoes some of these themes, including the fact that although NHS England has recently issued a revised framework for Serious Incidents, there is no UK wide definition of what constitutes a Serious Incident. Furthermore, having identified an adverse outcome for local review, there is no consistency in the methodology used to conduct investigations. The report calls for a standardised national approach which allows clear causes of harm to be identified and lessons shared across the NHS.
- Parliamentary and Health Service Ombudsman in its report, ‘Learning from Mistakes’ (July 2016) which looked into how the NHS failed to properly investigate the tragic death of Sam Morrish, a three year old boy who sadly died from sepsis in December 2010. 2014 – phso published a report that found Sam would have survived had he received appropriate care and treatment. However, while the 2014 report confirmed the death was avoidable, it didn’t provide a satisfactory explanation as why it was that the local NHS failed to uncover what happened and therefore couldn’t ensure that necessary learning took place. At the request of Sam’s parents, the PHSO undertook a new investigation to look at why This concluded that the local investigation processes were not fit for purpose, not sufficiently independent inquisitive open or transparent and that the people carrying out the investigation were not sufficiently trained.
- stating ‘Across the NHS a fear of blame pervades that prevents individuals and organisations being open to the possibility that there initial view of what happened might not be the right one, and means they are not asking questions about what happened and why…’ Clear evidence base that there is an urgent need to change the way the NHS responds and learns from mistakes This report made specific recommendations on the need to establish an independent, learning focused patient safety investigation body that would investigate the most serious patient safety issues, and promote a just and learning culture across the healthcare system (more on that later)
- In June 2016, the CQC released a briefing note raising concerns about the quality of incident investigation and learning in the NHS and calling for a step change in the way that serious incidents are investigated and managed. The briefing is based on a review of 74 investigation reports (relating to incidents that had occurred over an 18 month period between April 2013 and October 2014) from 24 NHS acute hospital trusts. The review found that investigations are process driven and that acute Trusts often see the formal investigation process as the only available option for learning from incidents resulting in harm. It highlights that in some cases, an alternative approach would be more beneficial, using less complex but more efficient ways to address the needs to the patient(s) and identify any mitigating actions that could prevent the incidents happening again. There also remain concerns that investigation reports do not properly evidence the involvement of patients and/or family members. Similarly, that staff are not appropriately involved and that Trusts are not consistently and/or effectively applying the Serious Incident Framework guidance, the Incident Decision Tree tool (to promote fair and consistent staff treatment within and between healthcare organisations) or the recommended tools and templates provided by the National Patient Safety Agency (NPSA). In this respect, the CQC is critical of the structure and methodology behind the reports it reviewed with too many reports concluding that the cause of incidents was a failure by staff to follow trust policies and procedures. The report makes it clear that investigations should go further to identify and analyse key causal factors, for example, why the underlying system or environmental factors allowed things to go wrong. The briefing note identifies 5 “opportunities for learning and improvement”: The CQCs 5 areas of learning and improvement are endorsed by the Parliamentary and Health Service Ombudsman in its report, ‘Learning from Mistakes’ (July 2016) Prioritising serious incidents that require full investigation and developing alternative methods for managing and learning from other types of incident. Routinely involving patients and families in investigations. Engaging and supporting the staff involved in the incident and investigation process. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident. Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.
- Engaging and supporting the staff involved in the incident and investigation process. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident. Using human factors principles to develop solutions that reduce the risk of the same incidents happening again. These 3 reports illustrate that there is much appetite in the system for a re-think and implementation for change – come back to this but want to have a quick look at where do Inquests and Claims fit into all this?
- How does this tie in with Claims and Inquests? What is I think a huge challenge for the NHS is triangulating lessons learned from complaints and SIs with claims and Inquests Inquests The introduction of the Coroner’s Prevention of Future Deaths (Regulation 28) Report (“PFD”) – DUTY rather than discretion. You will appreciate that the coronial reforms a few years ago made it mandatory for coroners to consider whether, in spite of the healthcare provider’s response to the death in question, patient safety concerns still existed, and if (s)he was so concerned, to issue a report on this. PFDs are published, along with trusts’ responses, and organisations that fail to respond are “named and shamed”. In our experience these reports are rare, though there is much regional variation (by coroner). They are taken extremely seriously by the organisations we work for and providing a response to a PFD is a hefty task. Much effort also goes into preparing for the inquest in a way that will pre-empt the coroner (and family’s) concerns and head off any potential PFD. Whilst some PFDs miss the point, the majority reflect very real concerns about patient safety and it is alarming how often themes emerge. Therefore, the PFD process is a useful one, and it must be acknowledged that the possibility of adverse publicity is a powerful incentive for many trusts.
- NHS LA – resolve and learn Recognition that if the complaint/investigation process is done properly it may often result in resolution One of the motivations of bringing a claim – not being listened to, not getting answers and not having an apology. Although it is not always their preferred course of action patients and families can be left to pursue complaints or litigation as their only means of bringing problems to light and getting a full account of events Christine’s story illustrates this point
- A lot going on to improve learning Think back to the quote from Organisation with a memory ? Relevance now given time that has elapsed 16 years ago and yet criticism of system remain and calls for change based on similar concerns Sceptics may question whether the NHS will be capable of effecting the changes needed to improve patient safety, given that the themes arising from these recent reviews were identified by Sir Liam Donaldson as long ago as 2000. However, there is now more than ever a real impetus, at a number of different levels, to improve the way incidents are investigated so that learning outcomes can be identified and shared to prevent the same mistakes recurring.
- March 2015 Public Administration Select Committee Report recommended a national, independent and accountable investigative body to provide leadership and resource to “promote a just an open culture across the whole of the healthcare system” Governments response to the Public Administration Select Committee Report from March 2015 – agreed there should be a new Independent Patient Safety Investigation Service (IPSIS) ESTABLISHED BY April 2016 Operational this Autumn Keith Conradi – was head of UKs Air Accident Investigations Branch EAG established to advise the DH and Secretary of State for Health on purpose, role and operation of a new investigation function for healthcare EAG met between July, Aug and Sept 2015 and reported with its recommendations in May 2016 Number of recommendations: HSIB must be and be perceived to be independent in structure and operation – recommended that ultimately its independence and powers be established through primary legislation – to provide long term institutional stability although recognition that there will be a development phase to establish the function from April pending legislation Objective – LEARNING FOCUSED INVESTIGATIONS - to understand the causes of harm in order to improve the systems and prevent future harm – not to approtion blame or liability Patients, families and staff must be active participants in the process and must be engaged with a supported compassionately and respectfully recommended that the promotion of JUST culture should be a central principle in the operation of the new organisation Slightly different concept to ‘no blame’ which is still frequently referred to in healthcare but view is the just culture is preferable. No blame concept has 2 weakeneses: Ignored or at least failed to confront those individuals who willfully – or repeatedly – engage in dangerous behaviours that most observers would recogise as being likely to increase the risk of a bad outcome It does not address the business of distinguishing between culpable and non culpable unsafe acts Needs to be a balance and to ensure clear about where the line is drawn between unacceptable behaviours and blameless unsafe acts Concept of just culture is to treat healthcare professionals involved in error or incidents fairly consistently and transparently within understood boundaries So, how do the principles of a just culture align with the new HSIB? HSIB has introduced the concept of a safe space with investigations that focus on learning, not blame What does ‘safe space’ mean? – a principle defined in the Directions (section 6) – HSIB function of providing findings, alaysis and where appropriate recommendations is best informed by comprehensive and candid contributions from those whose actions come under consideration in the course of an investigation Contributions that are candid and comprehensive and more likely to be made where they may be made in the confidence that they will not be used for purposes of apportioning blame or establishing liability but for the purposess of identifying improvements or areas of improvement AND Unless there is an overriding public interest or legal compulsion that disclosures other than for the purposes other than making recommentsatoind should be avoided EAG recommendations were for a statutory protection of safety information provided to investigators solely for the purposes of safety investigatoon to ensure that information is not made available to other bodies e.g. that information given in an interview as part of a safety investigation could not be used as evidence in subsequent criminal or regulatory proceddings except if ovcerriden by court order/ Also protection from any FOI requests concern by patient groups may allow information to be hidden from patients and families of those harmed but Clear from EAG that safe space must never be allowed to negate duty of candour but allow healthcare staff and families incolved in safety investigations to disclose information knowing that it will only be used for learning
- The establishment of the new Healthcare Safety Investigations Branch (HSIB) in April 2016 is also a positive step forward to improving the quality of investigations. PHSO report into death of Sam Morrish welcomes the establishment of the HSIB but acknowledges that vast majority of healthcare investigations will continue to happen locally Hsib will carry out 30 investigations a year – focus on incidents and issues that provide the greatest potential for learning – likely ot be a focus on the most serious risks and patient safety issues that span the healthcare system and carrying out these investigations to an exemplary standard Questions have been raised about the limitations on the remit of the HSIB and its ability to effect change given that it is only expected to carry out about 30 expert safety investigations a year across the NHS. Section 5 sets out the functions of the HSIB – it is to act as an enabler, exemplar and catalyst for learning-orientated safety investigation However, it is envisaged that the greatest impact will come from ‘encouraging the development of skills used to investigate local safety incidents in the health service and to learn from then, including suggesting standards which may be adopted in the context of such investigations’ (Section 5 of the National Health Service Trusts Development Authority (HSIB) Directions 2016). SELECTION – HSIB to have the capacity to monitor and practively determine potential areas for invetigation as well as responding to triggers such as cluster events or empirically themed priorities or notifications from other system monitoring bodies Not direct referrals from patients/staff Jeremy Hunt pledged to review arrangements in 2 years to ensure organisation retains independence of judgment In the meantime, Patient Safety teams need to be fully resourced, well trained and organisations need to support and promote a just culture
- A number of initiatives have recently been announced to support learning in the NHS, including the reforms to the death certification system and proposed medical examiners process and the creation of a National Freedom to Speak Up Guardian. FTSU guardians have a key role in helping to raise the profile of raising concerns in their organisation and providing confidential advice and support to staff in relation to concerns they have about patient safety and/or the way their concern has been handled. They don't have a remit to assist staff who are employed outside of their trust. Guardians don't get involved in investigations or complaints, but help to facilitate the process where needed, ensuring organizational policies in relation to raising concerns are followed correctly. MEDICAL EXAMINERS SYSTEM – First proposed in 2005 following the Shipman Inquiry - subsequently legislated for in the Coroners and Justice Act 2009 but not implemented Subsequent reports (Francis and Kirkup) noted that medical examiners could play a vital role as a conduit for relatives concerns identufying problems earlier and with rregard to Mid Staffs acting as an agent for change and they called for the introduction of medical examiners to provide independent scrutiny of all deaths not just those referred to the coroner From April 2018 independent medical examiners will be in place for medical examiners part of a national network of specially trained independent senior doctors to scutinose deaths across a local area that do not fall under the coroner’s jurisdiction Robust and independent scrutiny of the circmstances and cause of deaths by natural causes Ensure right deaths referred to the coroner Opportunity for relatives to ask questions 7 pilot schemes which have demonstrated a number of benefits including helping to foster more openness in the NHS – health professionals who raised concerns felt supported knowing tht they were protected by the authority and independence of the medical examiner and medical examiners often able to discuss and defuse complaints so that in 1 pilot ther was a substantial fall in medical litigation costs FIXED COSTS - More C solicitors advising clients ‘behind scenes’ to exhaust complaints procedures to flush out information to assist with a claim and any funding decisions Avma Patient Safety Letter - to ensure patient safety lessons are learnt from litigation are laudable. However, there are a number of issues arising from the proposals which require further consideration and clarification in order to ensure that the current shortcomings in the systems are appropriately addressed and to ensure that any changes achieve the goal of enabling lessons to be learnt in the best way.
- Peter Metcalfe – Partner form Hammonds solicitor to SYP who oversaw review and amendment of Police statements Anthony Edwards – an ambulance officer critical of the ambulance service response to the disaster West Midlands Police investigate the role of SYP in the disaster and sent evidence to DPP insufficient evidence to prosecute and provided evidence to the original coroner’s inquest Those with a * only privately funded IP’s
- Jurors – 7 women and 4 men selected from more than 100 jurors. We lost one juror on the 2nd day of summing up. Could have lost 2 more to get to the finish line