NHS Board Meeting
28 March 2012 Paper 15
NHS Board Meeting
Wednesday 28 March 2012
Subject
Minutes of the Clinical Governance Committee
Purpose
To report to the Board
Recommendation
To receive the draft Clinical Governance
Committee minutes of 29 February 2012
1.
Background
1.1
Committees of the Board should submit approved and draft minutes to the Board.
2.
Current situation
2.1
Attached are the draft minutes of 29 February 2012.
3.
Conclusion
3.1
The Board is asked to receive the minutes.
Dr David Price
Chair – Clinical Governance Committee
7 March 2012
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Ayr Hospital
Ayr KA6 6DX
Telephone 01292 614510
Clinical Governance Committee
Wednesday 29th February 2012 at 9am
Board Room, Ayr Hospital
Present:
Dr David Price, Non Executive Board Member (Chair)
Mrs Gillian Watson, Non Executive Board Member
Mr David O‟Neill, Non Executive Board Member
Mrs Kirsty Darwent, Non Executive Board Member
Mrs Janet McKay, Area Clinical Forum
In attendance:
Prof Robert Masterton, Executive Medical Director
Mrs Fiona McQueen, Executive Nurse Director
Prof Craig White, Assistant Director
Mrs Diane Murray, Assistant Director
Dr Grant McHattie, Associate Medical Director (For item 1.1)
Dr John Taylor, Associate Medical Director (For items 1.2 and 1.3)
Mr Eddie Docherty, Nurse Consultant(For item 7.2)
Mr Andrew Moore, Assistant Director for Nursing (PF&PI) (For item 7.3)
Audrey Christie, PA to Assistant Director and AMD (minutes)
1.
PROPOSED NEW MODEL FOR THE INVESTIGATION AND RESOLUTION OF
PERFORMANCE ISSUES IN PRIMARY CARE
Dr Grant McHattie, Associate Medical Director, Primary Care Development was
in attendance to present the proposed new model for the investigation and
resolution of performance issues in primary care.
Independent contractors in primary care provide services to NHS Ayrshire &
Arran on a contractual basis. The contracts are nationally defined and cover
General Medical Services, General Dental Services, Pharmaceutical Services
and Optometric Services. The contractors are not employed by NHS Ayrshire &
Arran and, as such, Human Resource policies for performance and discipline do
not apply. There is a need to establish a transparent, robust and formal structure
to identify, investigate and resolve performance issues in Primary Care.
In January 2010, the National Clinical Assessment Service (NCAS) and the
National Patient Safety Agency (NPSA) published two documents – “Handling
performance concerns in primary care” and “How to conduct a local performance
investigation”. These two documents effectively set out a gold standard
framework for policies and procedures in this area.
At the moment when performance issues within the independent contractor
community are identified by or are reported to NHS Ayrshire & Arran, these are
addressed at the Primary Care Delivery Group. This group comprises of the
Director of Primary Care and Mental Health Services, the Associate Medical
Director for Primary Care Development and the Head of Primary Care. The group
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invites other individuals with relevant expertise to attend meetings when their
advice is required to address a performance issue. These would include the
Dental Advisor, the Optometric Advisor or the Pharmaceutical Advisor. The group
currently investigates or where appropriate asks others to undertake investigation
and then decides upon a course of action for each individual event.
It is proposed that NHS Ayrshire & Arran should move to implement the
recommendations of the NCAS reports. This scheme relates only to registered
health care professionals providing services within primary care. In doing so, the
current Primary Care Delivery Group should be restructured as a screening
group to decide upon the need to instigate an investigation into performance
issues. Membership of this group would be:
The Community Health Partnership (CHP) Clinical Leads;
The Dental Practice Advisor
The Optometry Advisor
The Lead Pharmacist – Public Health and Community; and
The Head of Primary Care
In addition the relevant professional advisor would be in attendance to provide
expert advice.
It is also proposed that NHS Ayrshire & Arran should establish a Primary Care
Decision Making Group (PCDMG). The PCDMG would have no investigative
function but would hear performance issues brought to it by the Primary Care
Delivery Group. The PCDMG would consist of:
A Non Executive Director of NHS Ayrshire & Arran (Chair)
The Director of Primary Care and Mental Health Services
The Associate Nurse Director for Primary Care Development
The Associate Medical Director for Primary Care Development
The Chair of the relevant Area Professional Committee
In the event that the Chair of the Area Dental Professional Committee is not a
General Dental Practitioner then the Committee will appoint a suitable
representative.
In the event the PCDMG felt that further investigation was appropriate, it would
establish an appropriate panel of experts to consider each performance issue
within each directorate. Each of these Professional Assessment and Support
Groups (PASG) would undertake the investigation and make its report and
recommendations available to the PCDMG who would endorse and take action
on the recommendations from the PASG.
The Clinical Governance Committee were concerned that there would be a lack
of external objectivity. Prof Masterton informed that Dr McHattie would be sitting
on the Group but would be representing him and will report directly to him on a
regular basis. It was agreed that Prof Craig White would also become a member
of the PCDMG.
Mrs Watson asked what the cost of clinical representation on a PASG would be
and whether a cost benefit analysis could be carried out. Dr McHattie advised
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that clinical representation on the Dental, Optometry and Pharmacy PASG is not
currently routinely used as part of the investigative process and would therefore
require an additional resource. Based on the number of issues experienced
within each professional group in the last 12 months, this additional coat would
be in the region of £28,700. It would be very difficult to calculate what is being
prevented and this is our statutory duty to protect the public.
Dr McHattie advised that Union representation has been removed from the
membership of the PASG for General Medical Services.
The Clinical Governance Committee was happy to approve the document.
2.
HEALTHCARE ASSOCIATED INFECTION
Mr Robert Wilson, Infection Control Manager and Dr John Taylor, Associate
Medical Director Mental Health Services were in attendance to present on
Healthcare Associated Infection.
Since April 2005 there has been a 6.9% year on year reduction in the Scottish
SAB rate. This has been driven almost exclusively by MRSA. In that time MSSA
reduction has been non-significant. The last verified NHS Ayrshire & Arran
quarterly rate for period ending September 2011 was 0.33. The Scottish average
for the same period was 0.3. The local pattern is reflective of the national picture.
MRSA as a proportion of all SABs have fallen from 25% to 11%. The differences
in epidemiology are poorly understood.
Areas of intervention for 2012 – 13 are:
Focus remains on vascular access related SABs
Multidisciplinary Renal SAB Working Group established to review all SAB
related issues
Renal and Oncology Clinical Teams, supported by Infection Control Team,
to undertake review of all SAB case to ensure learning and promote
changes in practice
PVC insertion bundle spread throughout organisation by Infection Control
Team and Clinical Improvement Unit
Hickman and Peripherally Inserted Central Catheter (PICC) Line Training
and Competency programme being developed and rolled out to
Crosshouse and Ayr Hospital
Blood culture Learn-pro package introduced
Blood culture Care Bundle to be incorporated into Sepsis 6 work
programme
Enhanced surveillance of all community related SABs to identify potential
areas of intervention
Liaison with Health Protection Scotland re community Interventions
All antibiotics increase the risk of developing CDI. The four groups considered to
present the highest risk are known collectively as them “4Cs”. These are:
Cephalosporins
Co-amoxiclav
Fluroquinolones (Ciprofloxacin)
Clindamycin
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Actions taken to reduce the increased risk of developing CDI are:
Revised Surgical Prophylaxis Policy
Antibiotic Bundle Project in Care of the Elderly using Improvement
Methodology
Promote compliance with prescribing policies
Engage with clinical teams to agree further reduction in policy indications
for 4C antibiotics
Additional AMT resource
Further work that is being undertaken is:
Sepsis 6
Clinically led by Mr Eddie Docherty, Nurse Consultant
It was agreed that a proposal to implement root cause analysis will commence on
all SABs.
An HAI action plan will be tabled at the next Committee meeting.
RW
It was agreed that process measures to support the „big dot‟ outcome measures
for infection rates would be developed and reported to CCIB.
3.
DM
MENTAL HEALTH SERVICES CLINICAL GOVERNANCE ANNUAL REPORT
2010 / 11
Dr John Taylor, Associate Medical Director for Mental Health Services (MHS)
was in attendance.
This is the third MHS Clinical Governance annual report which provides a brief
overview of the activities, achievements and outcomes relating to healthcare
quality, clinical governance and risk management within the Mental Health
Directorate during 2010 – 2011. The report provides assurance to the Clinical
Governance Committee that all elements of healthcare quality, clinical
governance and risk management within the MHS Directorate are operating
effectively and complying with local objectives and national guidelines.
The Committee was concerned with the last sentence in the last paragraph on
page 9 which read “The reason for this decline is that there were further high
risks added to the register however no action plans were created”. Dr Taylor
advised that he would investigate this and will report back with an update on why
no action plans were created and provide assurance that action plans would be
in place for these risks.
Mrs Darwent asked how it was decided what information should be included into
the report as she was aware there was an issue to access psychology but this
was not reported. It was agreed that Dr Taylor would discuss this with the Mental
Health Governance & Development Group and report the access to adult
psychology services and what impact this has and will report back to the next
Clinical Governance Committee meeting.
JT
JT
The committee stated that it expected that access data should be reported
through Health and Performance Governance Committee, with specific quality
and safety data that are linked to these being reflected in the Clinical
Governance Committee report.
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Mrs Watson commented that the current annual reporting cycle was not helpful(ie
this one is almost 1 year out of date), and that the structure of each annual report
differs. It was agreed that annual reports for Integrated Care and Emergency
Services, Integrated Care and Partner Services and Mental Health Services
would all be presented at the June Clinical Governance Committee meeting and
Prof Masterton advised that he would be happy to prepare the agenda on that
RGM /
basis. It was agreed that Prof White would liaise with Non-Executive Directors on CW
the Committee in the first instance to prepare a standardised annual report
template. This will be sent to Committee members for approval before the next
meeting.. It was also agreed that these reports should come under the name of
the Associate Medical Director within the Directorate reporting.
4.
APOLOGIES
Apologies were noted from Mr Jim Welsh, Mr John Burns and Mr Martin Cheyne.
Dr Price noted his thanks to Mr Bill Stevely as recently retired Chairman of the
Board and to Dr Wai Yin Hatton, recently retired Chief Executive for their
attendance at and contribution to the Clinical Governance Committee meetings.
Their attendance sent out a strong message as to the importance of clinical
governance.
5.
DECLARATION OF ANY CONFLICT OF INTERESTS
Prof Masterton advised of a possible conflict of interest in relation to Paper 10,
Price Waterhouse Coopers review of the process for the reporting and follow up
of Significant Adverse Event Review, in accordance with NHS Ayrshire & Arran‟s
adverse events policy and associated procedures.
Mrs Darwent advised of a possible conflict of interest in relation to Paper 9, Royal
College of Obstetrics & Gynaecology Update as she is a member of the Nursing
and Midwifery Council (NMC).
6.
DRAFT MINUTES OF THE MEETING HELD ON 16TH NOVEMBER 2011
The minutes were approved as an accurate record of events pending the
following amendments:
7.3 should read – The current HAI position has reached a plateau and new
interventions require to be further discussed with key stakeholders.
AC
9.1 should include – Concerns were expressed about the current position. Prof
Masterton advised that 90% of doctors had currently completed their appraisal
for this year. As of 2013 the Responsible Officer role will be introduced and work
is currently underway to prepare for this.
AC
Prof White informed the Committee that sections 7.5 to 7.8 had been left blank
as written consent was required from the families. He advised that informed
verbal consent was in place, and that families had indicated that they were
sending in written consent for summary information to be documented in future
minutes. .
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7.
SHORT TERM ACTIONS
SAER 2844
Prof White advised that there had been feedback through this committee
previously that care planning did not seem as robust as it might have been. He
advised that he had initially met with Dr Grant McHattie, Associate Medical
Director Primary Care Services, and had discussed this with the Associate Nurse
Director in Mental Health Services who will be factoring this into ongoing
improvement work.
Continuous Clinical Improvement
This is agenda item 6.
Royal College of Obstetrics & Gynaecology Update
This is agenda item 7.5.
Healthcare Acquired Infection (HAI) Position Report
This is agenda item 7.8.
SAER 4976
This is agenda item 7.3.
SAER 1009C32
This is now complete.
SAER 10648
Prof White advised that there was still work ongoing to incorporate measure of
implementation and measures of effectiveness and this will be tabled at the next
meeting in April.
Corporate Risks Relating to the Clinical Governance Committee as at 19 th
October 2011
This will be tabled at the April 2012 meeting.
CW
AC
Trend Analysis Adverse Events and Complaints 1st April – 30th June 2011
This has been actioned.
Internal Audit Report – Significant Adverse Events Reviews
This is agenda item 7.6.
LONG TERM ACTIONS
Healthcare Associated Infection
This is agenda item 1.2.
Integrated Care and Partner Services Annual Report 2010 / 11
Paper to be submitted to April 2012 meeting.
AC
SAER 8865
Paper to be submitted to April 2012 meeting.
AC
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Corporate Risks Relating to the Clinical Governance Committee as at 19/10/11
Paper to be submitted to April 2012 meeting.
8.
AC
CONTINUOUS CLINICAL IMPROVEMENT
The Adverse Events work stream has commenced work to reduce adverse
events at ward level. This was initially agreed as a reduction of falls within the inpatient settings and a reduction in hospital acquired pressure ulcers. Based on
the learning identified from the wards testing improvement interventions in
relation to falls and pressure ulcers, it was agreed at CCIB that a different
approach should be explored. The new approach would integrate the learning
from testing of falls and pressure ulcer prevention programmes with other
essential elements of care; in particular nutritional care needs, cognitive
impairment / dementia care and patient experience. The new approach has been
introduced within two pilot wards and early indications suggest a positive impact
with staff reporting an immediate effect, for example; the use of patient buzzers
to attract attention of staff has reduced significantly because staff are anticipating
and meeting patient needs more effectively and are visible and available. Nursing
documentation has been completely reviewed and ward staff have been actively
involved in designing documentation which is fit for purpose; meets all
professional requirements; enhances professional decision making; and allows
documentation of the implementation. This work now needs to be spread to a
ward which doesn‟t have as much clinical leadership.
The Patient and Community Relations Team (PCR Team) have developed a
number of “small dot” measures to capture the patient experience. The PCR
Team have also been rolling out the use of the CARE measure across all
professions, with a view to establishing an organisational baseline. To date the
CARE measure is being used routinely by the following professions on a planned
basis (at least annually):
Specialist Nursing
District Nursing
Health Visiting
Allied Health Professions
A more limited implementation has been achieved across medical specialities. A
number of individual Consultants have agreed to pilot the use of the CARE
measure with a view to peer led roll out on a wider basis. The following
specialities are participating:
Orthopaedics
General Surgery
Ophthalmology
Medicine
Vascular Surgery
Emergency Medicine
The overall mean score across all valid CARE measure surveys submitted to
date (sample of 1073 patients since May 2011) is 45.8. The “target” score is 43.0
based on the mean score taken from the normative data available nationally.
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To ensure medical engagement, it was agreed by CCIB members that Mr
Andrew Moore, Assistant Director of Nursing (PF&PI) would attend the next
Clinical Directors Forum to discuss and engage doctors through the revalidation
process using an early adopters approach. Under this new revalidation process
doctors are required every 5 years to affirm to the General Medical Council that
they are “fit to practice”. One area of the revalidation process is “Communication,
Partnership and Teamwork” which requires doctors to provide evidence of how
they have established and maintained partnerships with patients.
The PCR Team have developed a Patient‟s Story Toolkit to support clinicians
with the collection of patients‟ stories and this is available to download on
Athena. One example of this is the story of a mother whose son was admitted to
paediatrics for a surgical procedure. The patient and carer experience was
captured and shared with clinical staff. There is still a lot of work ongoing.
During 2010 Customer Care Commitments were developed and agreed in
partnership with patients, the public, clinicians and staff side representatives. An
organisational change plan was also developed and approved by the Area
Partnership Forum to support implementation. The Customer Care Commitments
have been implemented during 2011 with the following Year 1 targets being met
or exceeded:
5% (35%) reduction in customer service related complaints
2000 staff completed customer care awareness session or on-line learnpro module
100% of all new staff
Each team / ward / department is currently undertaking a self-assessment audit
against the Customer Care Commitment standards. The results of this audit are
currently being analysed and will be available for review by CCIB members at the
meeting on 31st March 2012.
A virtual Improving Patient Experience Group was established in early 2011 to
drive the improvement work arising from the in-patient survey results.
Improvement work has concentrated on the “bottom” five results highlighted in
the 2010 and 2011 in-patients surveys. Considerable improvement has been
noted in reducing noise levels on wards taking part in a pilot noise reduction
programme. A slight improvement has been demonstrated in patients being told
how long they have to wait in the emergency department. The PCR Team have
supported the introduction of ward volunteers in several wards to support
patients with various aspects of care including nutrition, socialisation and spiritual
care. Several positive qualitative benefits have been realised for patients and
staff. There is a requirement to develop a quantitative measure for nutritional
intake. Development of a quantitative measure will be included in the Patient
Experience work plan for 2012.
The PCR Team held a stakeholder event on 2nd December 2011, which was
attended by more than 50 stakeholders. The outcomes from this event will be
tabled at the CCIB meeting in March for review and agreement and will then
come to the April Clinical Governance Committee meeting for final approval.
DM
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Considerable work has been undertaken in relation to understanding and
improving patient experience with slow progress in some key areas. Focussed
attention will be applied during 2012 to increase medical engagement and to
improve customer care results.
Mrs Darwent asked how often the CARE measure was being used. Mrs Murray
advised that it was on average 50 patients.
Dr Price queried how effective the booklet on informing patients of danger signals
to watch for when they go home was, given the range of symptoms. Mrs
McQueen advised that this was used more as a prompt as it would not cover
every condition.
Mrs Watson asked if the details tabled were the bottom ten results of the
customer care survey or if this was the whole survey. Mrs Murray confirmed that
this was just the bottom ten.
9.
QUALITY STRATEGY SAFE
9.1
New and Updated Adverse Events
Prof White advised that there are 15 SAER reviews in progress, 3 of which are
on target to report to the April meeting. There was one new reviewed
commissioned by Prof Masterton:
A lady attended the Medical Assessment Unit in 2010 for a chest X-ray
and a CT scan. The X-ray was filed in the notes and not signed off. The
lady later represented and lung cancer was detected. There is currently
another review under way looking at a follow up on positive radiological
findings. The Chair of that review has been asked to review this incident to
see if there are similar issues and inform further decision making about
the need for additional review.
9.2
Significant Adverse Event Review (SAER) Datix Reference 8934
Mr Eddie Docherty was in attendance as the Chair of the review for any
questions. Prof White provided the Committee with a brief summary of the
review.
On 14th December 2010, Ms X was admitted for a planned induction of labour at
40+3 weeks gestation of pregnancy. A plan of management was recorded by the
Consultant Obstetrician. The labour did not progress as expected and following
examination a decision to deliver by emergency caesarean section was made.
There was difficulty in locating the fetal heart and a decision to proceed to
category 1 (immediate) caesarean section under general anaesthetic was made.
During the procedure, uterine rupture was identified. The baby was delivered at
22.15 hrs and was handed to the waiting paediatric team. The baby was
subsequently transferred to the Neonatal Unit and was ventilated. He
unfortunately died in May 2011.
The SAER team have made the following recommendations to reflect potential
learning from the adverse event which can be implemented to improve services
for the future:
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When considering the use of syntocinon in women considering Vaginal
Birth after Caesarean section (VBAC), there should be an individualised
management plan documented in the patient‟s case record.
There needs to be an immediate review of the existing induction of labour
protocol and development of a specific care bundle for the use of
syntocinon. This should include guidance for communication with patients.
There needs to be an urgent review of how the Labour Suite is covered by
the Consultant obstetric team and specifically increasing continuity of care
by minimising the amount of handovers during any 12 hour period.
There needs to be a named Consultant Obstetrician taking over the full
caseload of a retiring Consultant Obstetrician.
There should be increased reliability of communication process
organisationally in relation to the escalation of internal reviews to full
SAERs.
Mr Docherty advised that this had been a challenging review. Both he and Prof
White had been in regular contact with the family, including visits to the family
home.
Mrs Darwent asked if there was assurance that best practice is followed when
the decision is made to induce. Mr Docherty advised that this was something that
the midwifery team were looking into. It was noted that the clinical decision to
induce did not fit the standard guideline and more details are needed to explain
why guidelines were not adhered to as potentially the entire process may have
been different. The Committee asked Prof Masterton to investigate the reason for
the induction and also the audit of current practice.
Mrs Darwent also highlighted that there was need to ensure that when
commissioning reviews that all elements in the care pathway preceding the
occurrence of the adverse event were included in scope of the review. Professor
White confirmed that this would be factored into the Terms of Reference for
future Significant Adverse Event Reviews.
RGM
CW
Prof Masterton advised that members of the investigation team, staff at the
maternity unit, the Consultant involved and Prof White had been the target of
high levels of aggression and threats from a family member. This included verbal
threats of physical violence and he also advised that items were sent to a
clinician at their home address. The Clinical Governance Committee noted the
significant threats (which has required police advice and involvement) to the
investigation team and clinical staff. This was noted that this was the most
extreme case of threats to date and staff were understandably very anxious
about their names being released. Professor White stated that these events
would be taken into account as part of decision-making in the future about
requests for release of this report. Prof White emphasised that the committee
needs to be aware of the significant risks that were identified and experienced by
staff during this review.
9.3
Significant Adverse Event Review (SAER) Datix Reference 13525
Mr Andrew Moore was in attendance as the Chair of the review for any
questions. Prof White provided the Committee with a brief summary of the
review.
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The patient is a frail 87 year old female with a past medical history of Chronic
Obstructive Pulmonary Disease (COPD), osteoarthritis, osteoporosis, peripheral
vascular disease and anxiety. The lady was admitted to Ayr Hospital on 12 th
February 2011 following a fall at home. She was later transferred to McMillan
Ward at Biggart Hospital on 16th February 2011 for a period of assessment and
rehabilitation. During this admission the patient fell and sustained a minor injury
on 18th March 2011. The patient subsequently sustained further facial injury on
4th April 2011 as a result of a fall or an alleged assault.
The SAER team identified a number of areas of clinical practice that require
improvement. Recommendations relate to fundamental elements of registered
nurse practice, including the requirement for greater understanding and
acceptance of personal and professional accountability and the need for
accurate, timely recording of basic physiology information. Other
recommendations refer to current clinical processes which are clearly not fit for
purpose. The review team did not find conclusive evidence that supported the
allegation of patient assault by a member of staff, however, the review team did
find evidence of issues relating to the capability of an individual staff member that
fell outside the terms of reference of this review.
Mrs Watson asked if it was noted in the medical notes that the lady required oneto-one care and also if the notes were transferred with the lady when she went to
the Biggart Hospital. Mrs McQueen confirmed that it was but no-one had
apparently read the notes and it was not noted on the internal transfer form.
Mr Moore advised that in this report the decision had been made not to name
staff involved.
Mrs Darwent raised concerns that staff members may be working to only just
over the required standard. The Committee were advised that Mrs Angela
O‟Neill, Associate Nurse Director, was in the process of reviewing the current
processes in place within the Biggart Hospital and Mrs McQueen was confident
that improvements will be made.
The Committee asked that care standards within the Biggart Hospital be added
as a standard agenda item so that a regular report can be provided to the
Committee, providing assurance of the required improvements.
9.4
AC
Royal College of Obstetrics & Gynaecology Update
This paper was provided to update the Committee on the work of the Executive
Nurse Director and Continuous Clinical Improvement Board (CCIB) in relation to
progress with the Royal College of Obstetrics & Gynaecology (RCOG)
recommendations for Maternity services, particularly work on culture as
commissioned by Pascal Metrics. Staff engagement and involvement is key to
successful implementation of sustainable improvement, and it was clear that
involvement in staff at all levels is taking place.
The Committee were advised that two Clinical Directors have been appointed, Dr
David Rae for Gynaecology and Dr Jane Ramsay for Obstetrics. Both Clinical
Directors took part in a recent Good to Great programme and both were very
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focused on their issues and will take forward an action plan.
Dr Price commented that this was a very useful document and that it was good
have a summary of what was on-going, and requested a regular update.
It was agreed that Maternity Services should be added as a standard item to the
agenda and regular report should be submitted to provide the Committee with an
update on ongoing work. It was agreed that Dr Jane Ramsay and Mrs Angela
Cunningham, Head of Midwifery and Children‟s Nursing to attend a future
meeting to provide an update.
AC
It was noted that page one should read “2 Significant Adverse Events occurred in
maternity services that resulted in neonatal deaths” and not 4.
9.5
Price Waterhouse Coopers review of the process for the reporting and
follow up of Significant Adverse Event Review, in accordance with NHS
Ayrshire & Arran’s adverse events policy and associated procedures
Prof Masterton advised that this paper had been overtaken by recent events and
the release of the Scottish Information Commissioners (SIC) report. He stated
that he would provide an update on the current position to date and comment on
proposals and would then be happy to leave the meeting for the Committee to
have further discussions if they felt appropriate.
The SIC issued a Decision Notice on 21st February 2012, the content of which
related to issues that had previously been highlighted within the PWC report.
From 2006 to 2009 systems and processes to support document control were
deficient.
Mr John Burns, Chief Executive, has commissioned four streams of work to start
looking at issues highlighted by the PWC report and an overarching action plan
has been created to incorporate actions from this report and also issues from the
SIC report.
The Committee advised Prof Masterton that they did not require him to leave the
room.
Dr Price advised that he had not been happy hearing of the situation through the
media and asked whether all Board members had received the briefing on the
SIC Decision Notice. Professor Masterton explained that the report had been
released to the BBC before it had been issued to the Board‟s Communications
Department.
Professor White agreed to speak with the Corporate Office.
The overarching action plan will be tabled at the next Clinical Governance
Committee and it will be clearly defined what are Clinical Governance and what
are FOI issues. The Committee noted that this is consistent with the reporting on
information governance through this Committee.
9.6
CW
Action Plan re Price Waterhouse Cooper report into risk management
The review of the process for risk management was undertaken as part of the
2011 / 12 internal audit plan, which was approved by the Audit Committee on 11 th
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May 2011. The overall objective of this review was to assess the arrangements in
place for the management of risk within NHS Ayrshire & Arran.
The report details a number of recommendations for progression. These confirm
the issues that the Clinical Governance Committee previously identified as
requiring action. An action plan will be developed from the recommendations,
tabled at the next committee and will be regularly reviewed until all actions are
complete.
9.7
CW
Healthcare Acquired Infection Position Report
This was covered by Dr Taylor‟s report at 1.2.
9.8
Litigation Report : Quarter 1 2011 / 12
This is to come to the next meeting.
9.9
AC
Trend Analysis Adverse Events and Complaints 1st July – 31st December
2011
The Committee were happy with the report as it provided helpful feedback and
started to show some evidence on where actions were focused.
Mrs Watson noted the detailed content in the „Conclusion‟ section and proposed
that this would be better placed elsewhere in the document.
CW
Mrs Darwent found the report very useful and felt that it really drilled down to the
issues. It was also reassuring compared to where we were a few years ago. It
was very helpful to see data from December 2010 in February.
9.10
Scottish Public Service Ombudsman report number 201005047
The Ombudsman issued its report to NHS Ayrshire & Arran on 21st December
2011. At the same time the report was made public. The report relates to a
patient treated within Crosshouse Hospital following an attempted suicide in his
mother‟s home. The complaint stated five distinct issues, four of which were
upheld by the Ombudsman. One issue was not upheld. The Ombudsman did
however make a recommendation in relation to this as there are potential
improvement actions required in other wards.
Mrs McQueen advised that she had convened two meetings to consider the need
for integrated learning and improvement actions across Integrated Care and
Emergency Services and Mental Health Services Directorates. The Associate
Nurse Directors are leading the implementation of agreed actions. This will be
monitored through the ICES Clinical Governance structures.
10.
FOR INFORMATION
10.1
Chief Scientist Office Research Nurse Activity Report
This was tabled for information.
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10.2
Organ Donation Team
This was tabled for information.
10.3
Minutes of the Meeting of the Information Governance Steering Group 23rd
March 2011
This was tabled for information.
10.4
Minutes of the Meeting of the Information Governance Steering Group 15th
June 2011
This was tabled for information.
10.5
Minutes of the Meeting of the Information Governance Steering Group 14 th
September 2011
This was tabled for information.
11.
AOCB
11.1
Letter from Dr Stevenson
Dr Price advised that he had received a letter from Mr James Stevenson
welcoming the change to more information being shared in relation to SAER‟s
but that he was worried that giving too much information on personal details
would be breaching Caldicott guidelines. He asked that his letter was not
distributed. Dr Price had discussed this letter with Prof Masterton and Prof White
and wrote back to Mr Stevenson, describing the current SAER consent
procedure and assuring him that necessary consent was in place and agreeing to
raise his concerns with the Clinical Governance Committee. Professor White
reported that he had offered to arrange to contribute to the Consultant‟s
professional development events on the issues raised if this would be helpful.
Patient Story
Mrs Murray advised that she had been approached by a complainant who would
like to share her story with the organisation about the care of her husband and
how her recommendations have helped to change processes. It was agreed that
as previous people had been denied an invitation to attend a meeting that this
should be discussed fully and a proposal should come to the next meeting.
Retirements
Dr Price advised that this would be his and also Mrs Darwent‟s last meeting. He
thanked everyone for their regular attendance, constructive comments and help
and support during his Chairmanship. He advised that he had very much enjoyed
working on the Committee and was sad to be leaving.
Prof Masterton thanked Dr Price on behalf of the Committee for his leadership
and contribution as it was very much appreciated, and also thanked Mrs Darwent
for her contribution.
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12.
DATE AND TIME OF NEXT MEETING
Wednesday 25th April 2012 at 10.00am in the Board Room, Ayr Hospital.
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