PUBLIC SERVICES OMBUDSMAN WALES PROGRESS WITH CORRECTIVE ACTION PLANS. Assistant Director of Patient Safety & Quality

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1 PUBLIC SERVICES OMBUDSMAN WALES PROGRESS WITH CORRECTIVE ACTION PLANS AGENDA ITEM June 2011 Report of Paper prepared by Nurse Director Assistant Director of Patient Safety & Quality Executive Summary Ensuring arrangements are in place monitor the outcome from serious concerns is a key requirement of the Committee and outlined within its agreed terms of reference. As part of the public sector complaints process, patients or their representatives who raise concerns about services provided by the UHB, can if they choose ask the Public Services Ombudsman Wales (PSOW) to investigate their concerns on their behalf. The Ombudsman looks to see whether people have been treated unfairly or inconsiderably, or have received a bad service through some fault on the part of the public body providing it. In February 2011, the Committee considered progress against the action plans of two published Section 16 reports relating to care and services provided by the UHB. Case 1 in August 2010 and Case 2 in January Public Services Ombudsman Wales Page 1 of 13 Quality and Safety Committee

2 Action/Decision required Link to other Board Committee (s) and subcommittees Link to Standards for Health Services in Wales Link to Public Health Agenda Link to UHB Strategic Direction and Corporate Objectives / Legislative and Regulatory Framework Link to relevant evidence base The paper outlines a summary of the PSOW s findings, the recommendations made and an update on progress in relation to the corrective action plans developed by the UHB to respond to the concerns raised. To NOTE the attached report. This work aligns to the work of the Complaints/Claim Panel which is Chaired by the Chair of the UHB. Standard 23, Dealing with concerns and managing incidents. N/A Supports and strengthens systems in place to improve the quality and safety of patient care NHS Complaints Policy Public Services Ombudsman Wales Regulations Public Services Ombudsman Wales Page 2 of 13 Quality and Safety Committee

3 INTRODUCTION FOR INFORMATION PUBLIC SERVICES OMBUDSMAN WALES PROGRESS WITH CORRECTIVE ACTION PLANS Ensuring arrangements are in place to deal with concerns and manage incidents is a key requirement of the Committee and outlined within its agreed terms of reference. As part of the public sector complaints process, patients or their representatives who raise concerns about services provided by the UHB, can if they choose ask the Public Services Ombudsman Wales (PSOW) to investigate their concerns on their behalf. The Ombudsman looks to see whether people have been treated unfairly or inconsiderably, or have received a bad service through some fault on the part of the public body providing it. The Ombudsman will normally have expected any complainant to have first raised their concern with the body being complained about and afforded them the opportunity to respond. In February s Committee meeting, two published section 16 PSOW reports and their related action plans were considered; Case 1, published in August 2010 and Case 2 published in January In total, over the last year, 62 complaints have been referred to the PSOW, 21 of these are currently open and at various stages of the PSOW investigation process. During the year 18 (including the 2 cases above) were partially upheld; 21 remain under investigation; 1 was not upheld and 4 did not proceed to investigation. General themes identified from the PSOW cases where there is full or partial upholding of the issues relate to Communication and poor complaints handling, End of life care, lack of robust decision making processes and poor multi disciplinary documentation. Some of the cases are very specific and the individual points in these cases are addressed in the action plan. Where complaints are upheld or partially upheld a detailed action plan and letter of apology from the Chief Executive is compiled. Public Services Ombudsman Wales Page 3 of 13 Quality and Safety Committee

4 CASE 1 MRS P RE THE CARE PROVIDED TO HER SON MR P Mrs P complained that her adult son (Mr P), who had advanced Huntington s disease, had been in hospital unnecessarily for two years having been admitted for what she had understood would be a two week period of rehabilitation. Mrs P was concerned about the proposed plans for her son s discharge and future care as although he had previously expressed a wish to stay at home, the NHS services with responsibility for Mr P felt that it was not possible to care for him safely at home with the resources then available. Mrs P also disputed an assertion that Mr P needed 24 hour care and complained that the reasons she was given for Mr P being admitted to hospital were not accurate. Turning to Mrs P s complaints about the length of time her son was in hospital and the arrangements for his future care, the Ombudsman found that there had been a failure to carry out adequate assessments, a failure to take into account all the relevant facts of the case, and that there had been excessive delay. Had comprehensive assessments been done within a reasonable time, and had all the relevant facts been adequately considered, then it was possible that Mr P would have been able to return home sooner than he did. The Ombudsman upheld this part of the complaint. He recommended that Cardiff & Vale University Local Health Board (as it now is) should apologise to Mrs P for the failings identified in the report and pay her 1,500 in recognition of the time and trouble she was put to in pursuing the complaint and the inconvenience she was put to in visiting Mr P every day to feed him (as the hospital staff were unable to do this). The Ombudsman also recommended that the Health Board remind staff of the need to carry out full assessments, take specialist advice where necessary, and consider, where appropriate, assisting carers to access relevant training. The UHB agreed to implement the recommendations. The Ombudsman found that there had been some confusion about the reasons for Mr P s admission, but the evidence did not suggest that Mrs P was misled. He therefore did not uphold this part of the complaint. Public Services Ombudsman Wales Page 4 of 13 Quality and Safety Committee

5 Following receipt of this report, the Chief Executive wrote to Mrs P and offered unreserved apologies of the UHB and included an action plan to address the recommendation made by the Ombudsman See Appendix 1. In addition, the Chair, Nurse Director and Assistant Director of Patient Safety & Quality, went to Mrs Ps home to apologise and also discuss the action being taken by the UHB to learn from the report. CASE 2 MRS F RE THE CARE PROVIDED TO HER LATE SON MR X Mrs F complained about the standard of care afforded to her late son, X, by the former Trust s Mental Health Services, before his death in October 2008 (when he took his own life). During his care period he had expressed a suicidal intent, taken an overdose, and had, whilst away with Mrs F, further self harmed. She complained that X had been discharged from the Trust s Crisis Home Treatment Team s ( Crisis Team ) care too soon, after 2 ½ weeks, when he went away with her. Further, when he attended a Trust hospital immediately from the airport on his return, seeking admission, he was denied. The Trust had, Mrs F complained, failed to admit him to hospital throughout because of a shortage of beds. Following advice from the Ombudsman s clinical advisers, the complaint was mostly upheld. The investigation found that: The threshold for admission to a hospital bed (such admission being governed solely by the Crisis Team) appeared to be at a high level given there was no clear policy guidance or definition as to what constituted a severe case warranting admission; The high bar coloured the way in which X was dealt with, given he had not previously been known to the Trust s services. This was particularly evident immediately following his return from the trip with Mrs F, when he had self harmed; There was no clear guidance in place as to what should happen when patients recently discharged from the Crisis Team s care self presented at a hospital front desk, out of hours, requesting admission; The Ombudsman did not uphold the complaint that any shortage of beds had influenced the decision not to admit X, as he was satisfied that a bed could have been sourced elsewhere if required. Public Services Ombudsman Wales Page 5 of 13 Quality and Safety Committee

6 Rather, the reason was the high threshold for admission. He could not either find that X would not have ended his life when he did had he actually been admitted as hospital admission is not the solution for many patients. As a matter of good practice, the Ombudsman also found that the Trust should have undertaken a more thorough and objective investigation into X s death (a Root Cause Analysis RCA)1, as opposed to the Multi Disciplinary meeting involving those who had treated him that took place. This would have resulted in identifying the lack of guidance about presenting out of hours, which the Trust agreed was required. The Ombudsman recommended that the UHB apologise to Mrs F for the failures identified and offer her redress for the need to pursue the investigation (which might have been avoided had a RCA been undertaken). Further recommendations included a review of the threshold and criteria for admission to hospital, a written procedure for a patient s out of hours presentation at hospital, and a reminder to senior staff within Mental Health Services about the need for an RCA investigation particularly where the death of a patient occurs. The UHB agreed to implement the recommendations. Following receipt of this report, the Chief Executive wrote to Mrs F and offered unreserved apologies of the UHB and included an action plan to address the recommendation made by the Ombudsman See Appendix 2. In addition, the Chair and Chief Executive have offered to meet with Mrs F and discuss the action being taken by the UHB to learn from the report. Copies of both reports have already been made available to Board Members and are available on the UHB s internet site if required. CONCLUSION Ensuring corrective action results from any PSOW report is a key requirement for the UHB. In both the Section 16 cases, which have been published, detailed action plans have been developed by the respective Divisions, shared with the complainants and progress monitored through the appropriate Division. Public Services Ombudsman Wales Page 6 of 13 Quality and Safety Committee

7 The same process is in place for Section 21 (not in the public domain) investigation reports. During the year 15 such reports were received, partially upholding the complaints made against the UHB. More detail relating to these is being considered and discussed by the Complaints/ Claims Panel. 21 cases are currently still under ongoing investigation, 1 was not upheld and 4 did not proceed to investigation after initial screening. RECOMMENDATION The Committee is asked to; NOTE the PSOW publications and consider and review the Action Plans in place to respond to both reports. Public Services Ombudsman Wales Page 7 of 13 Quality and Safety Committee

8 PUBLIC SERVICES OMBUDSMAN FOR WALES COMPLAINT BY MRS P IN RESPECT OF MR P UNIVERSITY HEALTH BOARD ACTION PLAN NO. RECOMMENDATION UHB RESPONSE / PROPOSED ACTION RESPONSIBLE PERSON 1. That the University Health The UHB Chief Executive will issue a written Chief Executive Board (UHB) provides a full apology to Mrs P and as part of this apology written apology to Mrs P for has offered Mrs P the opportunity to meet with the failures identified by the the Chief Executive and Chairman to discuss Ombudsman the report further. Completed 2. Pays Mrs P the sum of 1,500, of which 500 is in recognition of the time and trouble she has been put to pursuing the complaint and 1,000 is in recognition of the inconvenience she was put to visiting Mr P at Rookwood. 3. Ensures that where relevant, appropriate specialist advice about Huntington s disease is obtained when a patient with that condition is admitted. The UHB will arrange the payment of 1,500. Completed The Huntington s specialist nurse is routinely involved in advising and guiding the care of patient s with this condition when in hospital. The UHB will ensure that their input continues fully in discussions relating to discharge planning and the related comprehensive assessment process. Completed Assistant Director of Patient Safety & Quality Director, Acute Hospital Services / Director of Primary Community & Mental Health Services DATE August 2010 August 2010 August 2010 Public Services Ombudsman Wales Page 8 of 13 Quality and Safety Committee

9 NO. RECOMMENDATION UHB RESPONSE / PROPOSED ACTION RESPONSIBLE PERSON 4. Reminds staff of the need to Whilst the unified assessment process was Director, carry out full and undertaken for Mr P whilst in hospital, Acute Hospital comprehensive assessments, integrated hospital and community liaison to Services / including all relevant support the ongoing assessment process was Director of Primary information, when deciding not in place. The Divisional Nurse, Primary, Community & Mental how best to care for patients in Community and Intermediate Care has Health Services future. established a task and finish group to consider these issues in the context of Continuing healthcare packages of care available within the community, the neurosciences department are also fully involved in this work. 5. Gives consideration, where appropriate, to assisting carers to receive relevant training to provide them with skills to help them best care for their friend/family member. Completed The District Nursing service actively engages families and carers so that they are fully involved in providing direct care and this is captured within the District Nursing leaflet which is provided to families / carers. Where appropriate, consideration and support with training is also considered and provided, this will be captured within the District Nursing Leaflet. Completed Director, Primary Community and Mental Health Services DATE September 2010 September 2010 Action Plan as at 8 June 2011 Public Services Ombudsman Wales Page 9 of 13 Quality and Safety Committee

10 PUBLIC SERVICES OMBUDSMAN FOR WALES COMPLAINT BY MRS F IN RESPECT OF MR X UNIVERSITY HEALTH BOARD ACTION PLAN NO. RECOMMENDATION UHB RESPONSE / PROPOSED ACTION RESPONSIBLE PERSON 1. The UHB offers Mrs F redress in the The UHB Chief Executive will issue a Chief Executive form of a written apology for the written apology to Mrs X and as part of this shortcomings in the treatment of X, as apology has offered Mrs X the opportunity identified in this report, together with to meet with the Chief Executive and further redress in the sum of 500 in Chairman to discuss the report further. recognition solely of the time and effort she has had to expend in pursuing this The UHB will also ensure the sum of 500 complaint. Both should be is paid to Mrs F. implemented within 28 days of the Completed issue of this report 2. A Senior Officer at the UHB reviews the Policy document for the Crisis Team and the working practice of the Crisis Team in relation to both its criteria (and threshold) for hospital admission and its interface with Whitchurch Hospital when individuals attend there out of hours. Such reviews should take place within 2 months of the issue of this report. The UHB will review the findings of the Ombudsman s investigation and consider this in the context of the recommendation made. Guidance Completed May 2011 Policy Review Completed May 2011 (Equality Impact Assessment being completed June 2011). To be circulated to GPs in June Lead Nurse, Adult Mental Health Services DATE January 2011 March 2011 Public Services Ombudsman Wales Page 10 of 13 Quality and Safety Committee

11 NO. RECOMMENDATION UHB RESPONSE / PROPOSED ACTION RESPONSIBLE PERSON 3. Within 2 months of completion of the The UHB will provide the Ombudsman with Director, above review, the UHB should provide a copy of any Policy/Protocol relating to Acute Hospital me with a copy of any policy/protocol mental health patients attending hospital Services / introduced to deal specifically with a locations/departments within the UHB and Director of Primary situation where mental health patients confirm the dissemination of the document Community & Mental attend hospital locations/departments to staff as required. Health Services within the UHB area without prior Completed appointment (or assessment). It should further disseminate the protocol information document to staff within 28 days of the document s completion. DATE May I recommend that the Executive Director of Primary, Community & Mental Health Services should remind senior staff within the Mental Health Service about the NRLS Guidance and the need for root cause investigations in particular where serious injury or the death of a patient occurs. The UHB follows guidance recently issued by Welsh Assembly Government, which follows the best practice outlined by the National Patient Safety Agency. Completed. Director of Primary Community & Mental Health Services Complete Action Plan as at 8 th June Public Services Ombudsman Wales Page 11 of 13 Quality and Safety Committee

12 IMPACT ASSESSMENT [Please identify the impact on the following areas and what further action is required as a result of the assessment] Health Improvement Ensuring arrangements are in place to learn from reported concerns will have a positive impact on health improvement. Workforce Ensuring the workforce is appropriately supported to ensure the recommendations from PSOW reports are taken forward. Education and Education and Training plays a key part in Training ensuring staff are skilled in concerns avoidance in the first instance or where staff or systems failures are identified. Financial Strengthening the organisations arrangements for quality improvement and patient safety and reducing waste, variation and harm will improve effectiveness and resource utilisation. Legal Failure to implement and embed quality and safety initiatives within the UHB has a high legal risk attached. Equality Ensuring the delivery of safer services including the learning from PSOW publications will impact positively on all citizens accessing services. Environmental Ensuring learning from incidents, complaints and claims will impact positively on the environment. RISK ASSESSMENT [Please undertake a risk assessment against the following domains and detail whether the recommendations in the report are designed to address a known risk] Clinical/Service Financial Ensuring the learning is implemented following a PSOW report will reduce the risks to patients and staff and improve service delivery. Implementing quality and safety improvement initiatives will reduce financial risk. Reputational Reduction in the reputational risk to UHB if learning results from complaints, claims and incident reporting and corrective action is taken. Public Services Ombudsman Wales Page 12 of 13 Quality and Safety Committee

13 Acronyms and abbreviations UHB University Health Board UHL University Hospital Llandough PSOW Public Services Ombudsman Wales RCA Root Cause Analysis CONSULTATION AND ENGAGEMENT Divisions as appropriate; Mental Health; Older Persons and Intermediate Care Directorate SOURCES OF INFORMATION NHS Complaints Policy Public Services Ombudsman Wales, Regulations Public Services Ombudsman Wales Page 13 of 13 Quality and Safety Committee