Agenda and supporting papers - Plymouth Hospitals NHS Trust

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Item 15, Annex 1 • Include additional columns to show what evidence would need be provided to demonstrate assurance that risks were being adequately managed • Consider how complexity of resolving issues and associated risks can be incorporated • Diagnostic reporting to be included as a key risk • AJ asked that sharing of information reported on Datix and STEIS with Executive Directors is considered for inclusion Inclusion of medical staffing was discussed however, AM assured the Committee that this issue was being addressed with service line leads. The Chair explained that the overall risk assessment and assurance framework is due to be presented to SMT and the Board in July 2013 and once agreed this will determine the focus of the Committee. The Committee agreed to the content of the Assurance Framework subject to the suggestions listed above. 10. Serious Incident W33081 / W33105 – Action Plan Report KM presented the serious incident action plan to the Committee following an independent review of the case. The following key points were highlighted – • The external investigation looked into the process behind the internal investigation, access to relevant notes, IT support within the community and reporting mechanisms surrounding Glucose Tolerance Test (GTT) results • Of the 22 recommendations made, 20 have been implemented and the remaining 2 will take some time as they depend on IT support. 12 of the 33 areas in which care is provided within the Community have poor IT access therefore, if this cannot be improved the locations will be changed • Evidence of the recommendations implemented has been provided. The way in which this has been done will be used for all RCA reports completed within the Trust • The first RCA report that was completed focused on the delivery and resuscitation of the infant however, the key issues related to the reporting of GTT results • GP surgeries were found to be reporting GTT results differently therefore SS worked to have this standardised and the PCT have confirmed that set parameters are now in place • Two band 2 posts within maternity would provide the support required to manage GTT results within the Trust however, recent funding for this roles was removed but discussions to address this are ongoing • Considerable learning from the case has been highlighted and shared with the relevant teams • Terms of reference for investigations, including external, will be put in place to ensure all staff involved in the case receive the appropriate support • The case had been referred to the NMC and following a review they do not feel there are any additional issues that need to be followed-up • Case will be presented to the Child Death Panel and the initial RCA report, external investigation report and action plan report will be presented The Chair asked what the timeframes were surrounding this case. KM explained the incident occurred approximately two years ago. There were significant delays in finalising the investigation report and issues regarding GTT had not been identified. Lessons about how the investigation was set up and conducted had been learnt. SS added this investigation was completed outside of the specialty therefore a number of elements had to undergo an additional review. All incident and complaint investigations are now completed within the directorate by those who are independent of the specific case. AJ highlighted the importance of clarifying who will be responsible for completing an investigation, within what timeframe, with the involvement from whom and what the brief is. It is essential these elements are included within the Terms of Reference. S&Q Draft Minutes June 13 Page 5 of 7
Item 15, Annex 1 The Chair asked SS to ensure timeframes for looking for alternative solutions to the IT issues is agreed so that progress can be made if the initial recommendations cannot be implemented. Further update regarding these timeframes and evidence of imbedded actions to be discussed at the Safe Care Group in six months’ time. SS 11. RCOG Report on Patterns of Maternity Care in English Hospitals SS presented the RCOG report to the Committee and explained this is the first issue of the report. Although the first report for all Trusts has been anonomised this will be changed for future reports so that results can be compared and used for bench marking. The following key points were highlighted – • 11 areas of practice were chosen for the review and there were 19 relevant criteria • The Trust was performing above the mean in 17 of these criteria • Format of data clarified. Both lower and higher scores can be positive results • The key issues related to the disparity in management of a patient on the same care pathway. These pathways have been refined and clear standards have been put in place therefore improvements should be reflected within future reports • Areas of disparity that have been addressed will be audited to ensure the changes have been imbedded • The Trust’s caesarean section rate is consistently 4-5% lower than the national average however, research that is now available suggests that if a midwifery lead unit was available this could be improved even further as patients who deliver in an obstetric led unit are four times more likely to undergo a caesarean section AM asked how this information triangulates with other data that is available. SS explained that when the data is reviewed in line with best practice set by other organisations it helps clarify how the Trust should be performing. For example 2.1% of patients who deliver at Derriford Hospital suffer a third or fourth degree tear however, best practice suggests that a rate below 4% could demonstrate that these tears are not being identified and therefore patients are not receiving the adequate treatment. The Committee noted the content of the report. 12. Health Records Action Plan AB presented the Health Records Update Report to the Committee and highlighted the following key points – • Meeting held with AM and he has now been identified as the clinical lead for records • Letter sent to all service line leads explaining their responsibilities including the need for annual case note training and audits • A new working group has been established to discuss how improvements can be made to the paper records • A presentation regarding electronic notes was presented to the MEC and a significant amount of support has been offered. Currently awaiting approval of funding before this can be progressed any further • Significant progress has been made in relation to the transportation of notes. Maternity have not yet identified a space where blue boxes can be delivered and stored however, if this not agreed by the end of June 2013 all notes will be delivered to the level 3 storage room • MAU looking to use a fixed storage space for notes on the ward as opposed to lockable trolleys due to space issues. Lynher ward have also opted to store notes in lockable office S&Q Draft Minutes June 13 Page 6 of 7
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Trust Board Friday 5 July 2013, 9.0
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Members of Plymouth Hospitals NHS T
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Item 3 observer. The Chairman requi
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Item 3 Board oversight of contribut
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Item 3 the Board next month. • Th
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Item 3 been involved and there was
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Item 3 continuing to build. Mr Babe
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Item 3 to Norovirus, Professor Lewi
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Item 3 • Careful communication of
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Item 3 • Approved the writing off
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Updated: prior to July Board Item 4
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Updated: prior to July Board Item 4
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Item 8 Quality Impact Assessment Pa
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Item 8 3.2 Quarterly Summary Hospit
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Item 8 4.4 Monthly Proportion of Pa
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Item 8 Inpatient falls are currentl
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Item 8 REI signage PALS were contac
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Item 8 Complaints received listed b
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Item 8 The graphs below illustrate
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Item 8 5.5 Friends and Family Test
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Item 8 1. Pressure Ulcers (EoC) 2.
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Item 8 Observations The essence of
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Item 8a SUMMARY REPORT Trust Board
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Annex 2 Item 8a Summary of Serious
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Item 9 Key Recommendations The Trus
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Item 9 Effective Care (Section B2 o
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Item 9 Description 31 days from 'de
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Item 9 4.6 Non Elective Activity is
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Item 9 Summary of performance excep
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Item 9 Ensure that all patients adm
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Item 9 Forecast Significant progres
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Item 9 Update on previous actions C
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Contents EXECUTIVE SUMMARY D FINANC
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B1 Safe care Description Hospital S
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Response Rate Recommender Score B3
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B5 Other safety & quality metrics D
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C2 Non-Elective Activity Descriptio
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C4 Referral To Treatment (RTT) Desc
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C6 Other access & activity metrics
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D2 Cost improvement programme (CIP)
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Page 83 and 84: E1 Staffing numbers Description Est
Page 85 and 86: E3 Sickness absence PERFORMANCE IND
Page 87 and 88: Risk Rating F2 Monitor's Financial
Page 89 and 90: Item 10 DETAILED REPORT Trust Board
Page 91 and 92: Item 10 4. Key Issues for the Board
Page 93 and 94: Item 11 SUMMARY REPORT Trust Board
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Page 97 and 98: Item 11 • Challenge in respect of
Page 99 and 100: Item 11 Over the past two years, me
Page 101 and 102: Item 11 Getting it Right Charter An
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Page 107 and 108: Item 11 Peer Review 2.5 Peer Review
Page 109 and 110: Item 12 Next Steps 1. Conversation
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Page 113 and 114: Item 12 EDS Grades and E & D Object
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Page 117 and 118: Item 12 3.6 The workforce is suppor
Page 119 and 120: Item 13 Key Recommendations The Tru
Page 121 and 122: Item 13 Telephone conversations.
Page 123 and 124: Item 13 19. The Medical Director ha
Page 127 and 128: Item 15 incident investigations to
Page 129 and 130: Item 15, Annex 1 3. Review of Actio
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Page 135 and 136: Item 16 COMMITTEE MINUTES Finance,
Page 137 and 138: Item 16 pay and staffing, highlight
Page 139 and 140: Item 16 • PACS contract - likely
Page 141 and 142: Item 17 Terms and Conditions of Emp
Page 143 and 144: Item 17, Annex 1 29/2013 Minutes an
Page 145 and 146: Item 17, Annex 1 31/2013 Francis Re
Page 149 and 150: Item 18 Next Steps The Audit Commit
Page 151 and 152: Item 18, Annex 1 Matters arising 4/
Page 153 and 154: Item 18, Annex 1 time to embed and
Page 155 and 156: Item 18, Annex 1 Payroll & Expenses
Page 157 and 158: Item 18, Annex 1 The Committee note
Page 159 and 160: Item 18, Annex 1 Going Concern Revi
Page 161: Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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