Standard 22 Managing Risk and Health & Safety

Transcription

1 Betsi Cadwaladr University Health Board Board Paper Item 14/84 Subject: Summary or Issues of Significance Corporate Risk Register This paper provides an overview of the current risks on the Corporate Risk Register as at March It brings together the high level risks which if they were not addressed would compromise the Board s ability to achieve its corporate objectives. No amendments or new risks have been made since March The Board s strategic approach to board assurance and the development of the corporate risk register will be reviewed and revised as part of the externally commissioned programme of work to strengthen the Board s governance arrangements. Strategic Theme / Priority / Values / Francis Report recommendations addressed by this paper Relevant legislation or Standard for Health Services: Evidence base or other relevant information to inform decision (e.g risk assessment, consultation with others) This section is mandatory due to legal requirements Equality Impact Assessment (EqIA) Doing well, Doing Better Standards for Health Services in Wales addresses all strategic themes. Standard 22 Managing Risk and Health N/A The Board and its Committees may reject papers/proposals that do not appear to satisfy the equality duty. See 1.Has EqIA screening been undertaken? N (If yes, please supply a copy) 2.Has a full EqIA been undertaken? (If yes, please supply a copy) N 3.Please state how this paper supports the Strategic Equality Plan Objectives:

2 N/A 4.Please include a justification if no EqIA has been carried out: The Corporate Risk Register provides a position statement regarding current LHB high level risks, actions required and progress to date including timescales. No Policy decision is required. Recommendations That the Board review the corporate risks and mitigating actions Author(s) Presented by Executive Team Grace Lewis Parry, Governance Communications Date of report Date of meeting Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

3 Ref No (Link to Assurance Framework) Risk Register Ref No Date Entered onto BCUHB Risk Register Risk/Issue (Including Impact) AF3 CRR1 Mar-12 Failure to control healthcare associated infection leading to increased morbidity and mortality, increased length of stay, increased treatment costs, reputational damage and loss of public confidence in the Health Boards ability to provide a safe environment for patients. Existing Controls 1) Integrated Infection Prevention Improvement Plan in place, approved by the Board. 2) Key responsibilities and actions for CPGs and sites clearly identified within the plan. 3) Assistant Nursing Infection Prevention appointed to improve expert leadership. 4) Surveillance systems in place for C difficile, MRSA and MSSA bacteraemia, with reporting to Committee and to the Board. 5) Some BCU-wide core infection prevention policies in place. Some legacy policies remain. 6) Programme of monthly hand hygiene audit in place, plus monthly monitoring of 10 key standards. 7) Infection Prevention Team input rapidly to cases of key infections, to ensure correct management of the patient. 8) Clostridium difficile ward rounds in place on each acute site to ensure patients are managed effectively to minimize mortality. 9) BCU antimicrobial policy in place, monitoring of antimicrobial prescribing in place in key areas, and routine monthly audit being rolled out at present. 10) Strengthened RCA process is in place for all deaths where C difficile is identified on the death certificate. 11) Weekly agenda item for Executive Director meetings, and Nursing meeting. 12) Standing agenda item on QS Committee and Board. Current Risk Impact / Consequence Likelihood Score Adequacy Existing Controls Summary of Additional Controls 1) Robust monitoring of improvement plan to ensure actions are achieved by identified deadlines - in place. 2) Restructure of the Infection Prevention Team to increase expertise and capacity - in progress. 3) In the absence of applicants for the role, implement an interim solution to deliver the role of the Lead Infection Prevention Control Doctor to strengthen medical leadership - in progress. 4) Implement a BCU programme of policy development and review - in progress. 5) Implement a co-ordinated audit programme to ensure all key practice standards are routinely monitored - in progress. 6) Develop surveillance systems to routinely monitor other infections; implement ICNet system across BCU to achieve this - in development. 7) Further develop antimicrobial monitoring programme, and available treatment guidelines, and ensure compliance with newly launched Antimicrobial Policy - in progress. 8) Continue to develop the quality of RCA for infection, and routinely share learning identified in RCAs via the HCAI lessons learned summary reprot implemented Jan Ensure robust monitoring of RCA action plans to provide assurance that action has been taken. 9) Develop the quality, range and depth of information in reports to provide wider assurance on infection-related issues, from Board to Ward. Target Risk Impact / Consequence Likelihood Score Date of Last Review Executive Lead Board Committee to review risk AF14 CRR3 Mar-12 Failure to have effective financial planning and control to deliver statutory financial duties in 2014 and in the future. 1) Detailed plans included as part of Operational Plan for 2013/ ) Delivery Board established to monitor performance against savings plans of CPG and CSFs on behalf of Board. 3) Finance Committee. 4) Board of Directors has routine oversight of financial position. 5) Finance reported to the Board as a standing agenda item. 6) External support in place for turnaround (Surgery/Dental CPG and Primary Care Specialist Medicine CPG). 7) External support and review from Deloittes. 1) Financial planning and reporting is well established to provide timely information for planning and control. 2) Additional funding has been provided by the Welsh Government, but currently the expenditure trend indicates that the Health Board is not going to achieve its breakeven duty for 2013/14. s to mitigate the financial position remain under a iterative review process. 3) The continued focus on the delivery of savings is being maintained in order to secure the ongoing sustainability of services. The themes from the recent Deloitte report provide information which will be used to guide future savings activity. 4) Work is ongoing with other Executives to ensure that the balance between activity, performance, patient safety and finance is maintained for overall organisational effectiveness and delivery Mar-14 Finance Finance AF8 CRR4 Mar-12 Failure to deliver appropriate access to planned care within a reasonable time including the management of the follow up backlog. 1) Weekly monitoring of progress against action plan, referrals, waiting list, activity and productivity. 2) Close links with WG for delivery support. 3) Establishment of the Delivery Board within BCUHB including all related CPG and Corporate Functions. 4) Financial assurance processes, and auditable controls. 5) Strong clinical engagement and project management support. 6) Performance management and holding to account for delivery. 7) Increased validation of waiting lists. 8) Additional Orthopaedic activity outsourced to COCH and RJAH. 9) Capacity planning reflecting 7% reduction in demand. 10) Micromanagement of Cancer access targets 11) Follow up backlog: prioritisation of patients at clinical risk 1) Allocate financial resources in line with the criteria approved by Finance Committee. 2) Continue to monitor referral pathways to ensure they are aligned with new care pathways. 3) Outsource high risk urology patients where clinical skills are limited. 4) Improve risk management arrangements with CPGs in relation to RTT. 5) Improve clinical engagement and clinical validation of waiting lists, 6) Follow up backlog: local enhanced services to be put in place. WECs to be used to support Ophthalmology Mar-14 Chief Operating Officer AF1 AF2 12 CRR5 CRR10 CRR 19 Mar 12 Oct 13 Inability to attract, recruit and train 1) In partnership with staff organisations ensure effective operation of policies and qualified staff with the appropriate procedures e.g. recruitment, OCP, appraisal. skills and competencies, therefore 2) Workforce Recruitment Strategy to be further developed. hampering their ability to deliver the 3) Comprehensive delivery of appraisal/padr across all work areas. Health Boards' agenda in a 4) Workforce Plans incorporated within 2013/14 operational planning process. sustainable way. 5) High level scrutiny of rosters by managers, to ensure appropriate challenge around rosters. 6) Implement Welsh guidelines for safe staffing of acute hospital medical and surgical wards (CNO 2012) and midwifery (Birthrate plus). Align additional resources from Welsh Government in line with identified priorities. 7) Work to guidelines in other specialist areas. 8) CPGs to undertake an annual review of staffing, skill mix, dependency and acuity. 9) Regular Birthrate Plus compliance review. 10) CPG and ward level reporting and monitoring. 11) Systems in place for escalation of staffing concerns. 12) Nursing and sign off of nursing and midwifery workforce plans. 13) Clinical engagement in the development of service reviews. 14) Partnership working with Universities and Postgraduate Deanery ) Regular reporting to Workforce OD Committee and to CPGs/CSFs via Workforce intelligence report 2) Continue to develop the Board's Recruitment Strategy and recruitment campaigns. 3) Organisational focus on PADR and mandatory training compliance. 4) OCP Group continues to meet and monitor progress. 5) Monitor and report compliance with CNO Guidance for Acute and Surgical ward staffing. 6) Continue to contribute to the All Wales development of acuity tools. 7) Reduce delays in recruitment pathways 8) Analyse incident reporting relating to staffing ) Consider new models of service delivery as part of service reviews. 10) Support Bangor University in bidding for funding to sustain the academic and organisational component of the North Wales Clinical School. 11) Continue to work with Wales Post Graduate Deanery to ensure its reconfiguration plans do not disadvantage North Wales and lead to improved recruitment. Mar-14 Director/ Workforce and OD/Director of Nursing and Workforce OD/ Z:\Corporate Team\Meetings\BCUHB_Formal\2014\Board\ \Corporate Risk Register V16 Page 1 of 5 - Date printed - 24/04/2014

4 AF13 CRR6 Mar-12 Failure to manage and respond to unscheduled care demand in a safe and appropriate way. 1) Senior Leadership Team monitor and review unscheduled care performance weekly. 2) Service improvement model being implemented by Emergency Departments. 3) Emergency Department clinical leadership team developed. 4) Clinical Decision Units established on all three major hospital sites. 5) Choose Well Campaign. 6) Development of whole system approach with primary, community, WAST, LA and voluntary sector partners. 1) Implement detailed Seasonal Plan with partner organisations and resource appropriately. 2) Coordinate multi-agency debrief May 2014 and cotninue to plan for winter Mar-14 Chief Operating Officer AF11 CRR7 Mar-12 Failure to manage concerns effectively and learn lessons to improve patient safety. 1) Lead responsibility for Concerns with Nursing and from 1st August ) External review commissioned to review the current arrangements for Concerns.The external review report has been considered formally by QAE and QS and the action plan in response to that report presented at both Committee's. Work has commenced from that action plan, the resource implications require further consideration by the Executive team and a business case was submitted in January 2014 to Nursing. 3) Redress Panel in place and external reviews have made recommendations about how this process can be improved. This is subject to the Business case being approved and a centralised approach being resourced and in place. 4) Interim objectives established for the Health Board to improve the responsiveness of the CPG's and to ensure corporate approach to learning lessons. Board updates have been provided on the progress being made to eliminate any overdue complaints, PSOW cases and SI's. Monthly updates provided for PSOW office and Welsh Government. CHC have been kept briefed on position and involved in performance meetings to support clarity and assurance on progress. Weekly concerns performance meetings held with CPG ACoS nursing to support progress. QAE formally reviewing progress being made with each CPG on Interim objectives. 5) QIS in draft stage where new processes are being outlined to support lessons learned and bringing together soft and hard intelligence from patient experience and formal concerns ) Formally review the outcomes and recommendations made by the external reviews (December 2013)and develop an action plan. 2) Ensure interim and substantive resources are identified to develop capacity and capability of the service. 3) Develop and implement an action plan to irradicate backlog. 4)Provide weekly performance data to CPGs. 5) Brief external partners on action and progress. 6) Identify a systematic process for sharing lessons learned which can be effectively evidenced and tracked through at a CPG and corporate level. AF3 CRR9 Sep-12 Potential exposure to asbestos fibres and a loss of clinical service as a result of asbestos contamination across all sites. 1) Organisation wide Asbestos Policy and Management Plan in place. 2) Completion of a self assessment questionnaire relating to the Control of Asbestos Regulations. 3) Site visit undertaken by the NWSSP - Facilities Services Unit in August 2013 and LHB Asbestos Management Compliance Report received and action plan developed. 4) A central Asbestos register of all sites and is used to prioritise and co-ordinate actions. 5) Asbestos Management Group in place. 6) Asbestos Survey Reports in place. 7) Regular reports to the Risk Management Sub Committee 8) Ysbyty Glan Clwyd Project and implementation plan in place. 9) Routine safety inspections in place. 10) Location plans available. 11) Robust procedures in place. 12) Ysbyty Glan Clwyd Project and implementation plan in place. 13) Asbestos Consultant advice sought. 14) Some areas have been quarantined. 15) Comprehensive ceiling access procedures in place by permits to work. 16) Appointed licensed asbestos removal contractors on site providing 24/7 cover. 17) Asbestos analyst and licensed contractor on 24/7 30 minute call-out response time. 18) Agreed and funded removal programme over 7-8 years for the Glan Clwyd Project ) Ongoing implementation of the Asbestos Policy and Asbestos Management Plan. 2) Implementation of the self assessment questionnaire relating to the Control of Asbestos Regulations action plan. 3) Ongoing - YGC Redevelopment Board with responsibility for project delivery. 4) Ongoing background air monitoring in place within original building H block, Ysbyty Glan Clwyd, including ground and first floors, regular audit and inspection by appointed asbestos consultant. Planning AF1 CRR12 Mar-13 Failure to develop a clear strategic plan for clinical services. 1) Develop 3 Year Strategic Plan. 2) Clinical symposium to ensure engagement and delivery. 3) Wide and ongoing engagement on the integrated Services Strategy. 4) Implementation of the 'Healthcare in North Wales is Changing' recommendations. 5) Work to establish acute intervention teams on all 3 main hospital sites. 1) Update the BCU three year plan in line with planning guidance and feedback from WG 2) Facilitate additional stakeholder events 3) Broaden the scope of the clinical services strategy to reflect a whole system approach to care. 4) Continue to implement, monitor and report the impact of changes made Mar-14 Planning AF8 CCR13 Mar-13 Failure to create a climate and culture that puts the patient first. 1) Implement the National Governance Framework 'Safe Care, Compassionate Care'. 2) Develop and implement a programme of work in line with the themes from the Francis recommendations. 3) Deliver "Dignity in Care" agreed actions. 4) Develop continued effective systems for listening to patients and staff. 5) Refine and promote organisational values. 6) Monitor and respond to breaches in the fundamentals of care. 7) Improve the opportunities for clinical engagement. 1) s plans in response to the Staff Survey to be implemented. 2) Following the 'Shaping our Future' events promote the revised strategic aims and values of BCUHB. 3) Revisit mechanisms to improve arrangements for whistleblowing. 4) engagement: targeted events and ongoing support. 5) Older People's Commissioner to review Health Board plans March/April 2014, and attend Health Board meeting Mar-14 Z:\Corporate Team\Meetings\BCUHB_Formal\2014\Board\ \Corporate Risk Register V16 Page 2 of 5 - Date printed - 24/04/2014

5 AF10 CCR14 15 Mar-13 Failure to provide information which supports effective governance, quality assurance and decision making for LHB and commissioned services. 1) Integrated Quality and Report. 2) Develop and publish the Annual Quality Statement. 3) Publish mortality data. 4) Implement the Board Level Improving Quality Together programme. 5) Support the delivery of a formal Board Development Programme and Leadership walkrounds. 6) A review is being undertaken regarding the structure of Board and Committee agendas and papers to allow for effective scrutiny. 7) Identify and make explicit limitations created by separate IT systems and absence of real time data. 8) Quality Standards are built into all Service Agreements for externally commissioned secondary care services. 9) Continue to develop and monitor commissioning and contractual arrangements. 10) Clear lines of communication to identify and address issues of concern. 11) Contracts review group established to oversee external secondary care contract management and changes to patient pathways. 12) Monitoring reports via the Assistant Finance. Key issues and actions discussed with Executive Team and Board of Directors. 1) Integrated Quality and Report implemented and to be revised further following review of Executive portfolios. 2) Annual Quality Statement: peer review of the AQS undertaken which will inform future development. 3) Continue to role out the IQT programme. 4) Leadership walkaround programme to be refined and on going. 5) Strengthen clinical input into contracting arrangements specifically for specialist services and responding to Francis /commissioning for quality. Chief Operating Officer AF1 AF3 CCR16 17 Feb-14 Failure to locate, provide and modernise patient medical records and corporate records to underpin the delivery of safe patient care. 1) Corporate and Health Records Management Policies and Procedures developed and implemented across BCUHB. 2) Work with NWIS to develop local plans to match National programme. 3) Policies Library set up on Sharepoint to ensure they are reviewed and updated regularly. 4) Records Management included in Information Governance training. Health Records training provided across BCU. 5) Health Records tracked to ensure current location is known. 6) KPI's relating to Acute Health record availability are monitored and reported in a variety of forums for assurance these include Health Records Group and Committee. 7) Case note availably for outpatient clinics has been assigned as an lead area of work to increase focus and remove barriers to availability. 8) Escalation of concerns and breaches to plans to the Health Informatics Group, Information Governance Committee and NWIS. 9) Continued engagement with NWIS ) Maintain record audits and reporting mechanisms. 2) Clarity sought on National timescales. 3) Local tactical solutions being evaluated e.g. Digital medical record and document repository. 4) Secure additional storage space to enable management of records, safe storage and minimise risks to staff safety (through the management of records in inadequate space). 5) Submission of bid for funding/an innovation to assist with the location of case notes/records with pin point accuracy on and off site. 6) Submission for funding for alternative sources such as Health Technology Fund and WG SBRI funding. Mar-14 Director Information Governance AF1 CRR18 Oct-13 Failure to provide safe patient care in obstetrics and gynaecology in YGC negatively influencing c- section rates; induction of labour, surgical site infection rates, inpatient reviews and the training experience of junior doctors. 1) Plan monitored by CPG Board and Site Management Team (Programme Team) / Consultant body with Director lead. 2) Weekly compliance checks. 3) Staff relocation. 4) Focus team. 5) External reports. 6) Levels of monitoring in place Unit / CPG / QS Committee and Board. 7) Implementation of recommendations arising from Reports from: Deanery 2011/ RCOG / HIW / WG. 8) Executive leadership by the Director and Nursing and. 9) Implementation of agreed action plan including relocation of staff; changes in clinical leadership; consultant job planning; appropriate support and clinical supervision; consultant ward rounds; robust management and accountability arrangements. 10) Feedback from local supervising authority (HIW) on provided significant assurance in relation to midwifery services. 1) A further review and report by the Royal College of Obstetrics and Gynaecology to be considered by Health Board ) Work with the Deanery and the Consultant Body directly to address the experiences on site for doctors in training. 3) Job Planning with Consultant body continues. AF1 CRR20 Oct-13 Failure to provide safe and 1) Implementation of the Hergest improvement plan which brings together the effective patient care at the Hergest recommendations arising from internal and external reports. Unit leading to poor outcomes for patients 2) Levels of monitoring in place at Unit, CPG and QS Committee. 3) Raise awareness of dignity and respect requirements. 4) Improve the physical inpatient environment in line with the facilities plan Revision of existing plans to reflect findings of Royal College Psych and HIW reviews. 2. Amend bed capacity to reflect safe staffing levels and patient need. 3. Provide external capacity to support implementation of revised actions. 4. Recruit additional Executive leadership. 5. Implement weekly quality and safety monitoring. ActingChief Executive AF3 CRR21 Nov-13 Failure to have robust arrangements in place for the decontamination of medical devices thus increasing the risk of avoidable infection 1) Strategic Decontamination Group now chaired by the Assistant Nursing - Infection Prevention. Attendance and participation by CPGs is inconsistent, and there is some evidence of non-progression of agreed actions between meetings. Fundamental review of terms of reference and membership commenced. Strategic decontamination action plan to be produced. 2) Limited evidence of action plans in place to mitigate some of the risks currently identified. Major focus on this and production of decontamination risk register at next meeting is arranged. 3) Of the 4 Sterile Service Units, 3 are fully accredited with a Notified Body, indicating they meet all required standards. The fourth is awaiting final confirmation of accreditation following a visit by the Notified Body. 4) Most endoscopy decontamination has been centralised on 2 of the 3 main sites, reducing the amount of local decontamination that is required and reducing the risk of variation from safe practice standards. 1) Additional controls are required, and the detail of this is being worked up currently, with implementation via the Strategic Decontamination Group. A recommendations paper will be brought to the Executive Team. 2) The previous chair of the Strategic Decontamination Group has followed-up with CPG leads, to identify the key risk issues so that clear mitigation plans can be confirmed Mar-14 Z:\Corporate Team\Meetings\BCUHB_Formal\2014\Board\ \Corporate Risk Register V16 Page 3 of 5 - Date printed - 24/04/2014

6 AF1 CRR23 Feb-14 Failure to reduce mortality and harm for patients and the implementation of early recognition and timely response to the deteriorating patient. 1) Nursing Metrics compliance data for the 'care bundles'. 2) Rapid Response to the Acutely Ill Learning set (RRAILs) Audit ) BCUHB Acutely Ill Patient Steering Group in place. 4) Acute Intervention Team on each site to improve the response to the acutely ill patient. 5) BCUHB RRAILs and Sepsis management implementation plan. 6) RRAILs reporting to CPG's facilitated by service improvement team. 7) RAILs, NEWS, principles of ALERT and sepsis training. 8) Sepsis Leads (Nursing) secured from each CPG. 9) Clinical Observation audit conducted in January ) Operational feedback to CPG's given via Sepsis Steering Board and CPG's reporting framework. 11) Review of system of internal transfers in relation to NEWS scoring for patient transfer from acute admission wards to other wards and other departments undertaken. 12) Ward improvement programmes are incorporating Briefings as a key objective. 1) Multi-disciplinary education, standardised documentation and system prompts under review. 2) Work ongoing with CS/Acute Illness Team (AIT). 3) Clinical Leads to determine medical training provision. 4) BCUHN graded response flowchart under development. 5) Core information sheet under development which will be incorporated into CPG Induction packs for Nurses. 6) AIT Clinical Leads to discuss Sepsis and AIT at Induction. 7) Definitions, measures and data collection methods are being discussed and agreed with CPG's. 8) Work ongoing regarding RAMI data and correct documentation within medical notes. 9) BCUHB clinical observation chart designed and being trialled Mar-14 AF1 CRR24 Feb-14 Failure to provide the resources required to respond to increasing demand for Safeguarding Services and as a consequence increase potential risk or harm to vulnerable people. 1) Expert leadership from the Deputy Nursing. 2) Integration of key governance risks with work relating to DoLS and MCA. 3) Engagement of clinical medical leads within Serious Case Reviews, Homicide Reviews. 4) Safeguarding Children Liaison Posts support in ED. 5) Business case under development to increase the capacity. 6) Independent review of the function and governance arrangements. 7) Development of an e-learning package. 8) Additional Safeguarding Children Team members have been appointed, awaiting 1 further post. 9) Business case prepared to support the request for additional administrative and secretarial support. 10) Mechanisms to identify priorities have been agreed. 11) Task and Finish Groups with multi -agency membership to challenge activities and membership at forums and statutory Safeguarding Children/conferences. 12) Activities have been identified to support greater numbers of clinicians within group settings, although this is not always practical or appropriate. 13) E-learning package for Level 2 Safeguarding Training has been secured and implemented across the organisation ) Additional resources are required to increase the number of Specialist Safeguarding Adult Practitioners to support Named Doctor for Safeguarding Adults role and the strategic agenda. 2) Review the governance and reporting framework and accountability of Deprivation of Liberty Safeguards (DoLS). 4) Additional resources are required to increase the number of specialist Safeguarding Adult Practitioners. 5) Additional controls are currently under review. 6) Multi-agency engagement within task and Finish Groups are to be convened to support and identify agreed strategies and priority activities Mar-14 AF1 CRR25 Feb-14 Failure to reduce cardiac mortality and harm to patients attending Ysbyty Gwynedd. 1) Risk adjusted Mortality Index (RAMI) data monitored and published. 2) North Wales Cardiac Network and Board in place. 3) Cardiac Network development plan in development 1) Improve the correct coding within the current clinical assessment documentation. 2) Further analysis to be undertaken of 2013 data for mortality and access times. Plan for the development of the Catheter Laboratory service should include a risk assessment and a quality assurance plan. 3) Secure clinical and board level agreement on the development of and implementation of primary PCI. Executive Director AF1 CRR26 Feb-14 Failure to attain cancer access targets potentially causing ham to patients. 1) Escalation tracking procedure and sustainability pathway plans 2) Implementation of action plan for Urology, Colo-rectal pathway change, endoscopy and 1st OPD ring fenced capacity enable patients to be managed to agreed 62 day milestones. 3) Cancer Delivery Group 4) Cancer Performance Delivery Board 5) Performance reports to Quality and Committee and the Board. 1) Increased focus on Cancer delivery with greater scrutiny and holding to account. 2) Where required undertake a pathway review. Executive Director AF1 CRR27 Feb-14 Failure to provide sufficient resources to ensure effective Continuing Health Care processes resulting in the lack of capacity to meet increasing demands. 1) Additional staff recruited to improve capacity. 2) Robust escalation systems in place. 3) Work with the regional hub on contract monitoring and nationally with Welsh Government lead. 1) Work with Powys LHB to map backlog of retrospective claims and identify potential solutions. 2) Develop more robust and sustainable plans Mar-14 Diector of Z:\Corporate Team\Meetings\BCUHB_Formal\2014\Board\ \Corporate Risk Register V16 Page 4 of 5 - Date printed - 24/04/2014

7 Risk Matrix Likelihood Consequence Rare Unlikely Possible Likely Almost certain 5 Maximum Impact Major Moderate Minor Negligible to 3 Low risk 4 to 6 Moderate risk 8 to 12 High risk 15 to 25 Extreme risk