QUALITY AND PATIENT SAFETY COMMITTEE Minutes of the meeting held on 10 th April 2014 Welsh Health Specialised Services Committee Offices Unit 3a, Van Road Caerphilly Business Park Caerphilly CF83 3ED Present Professor Simon Smail Chair Mr Robert Dutt Community Health Council Representative Mrs Andrea Gristock Clinical Director Representative Cwm Taf UHB Mr Andrew Phillips Clinical Director Representative, Abertawe Bro Morgannwg UHB Dr Christopher Roseblade Clinical Director Representative, Betsi Cadwaladr UHB Dr Graham Shortland Medical Director Representative, Cardiff and Vale UHB Mrs Cathie Steele Corporate Governance Manager, WHSSC Mr David Wilmott Head of Nursing and Quality, WHSSC In attendance Mrs Lisa Cooper Dr Jean Matthes Mrs Karen Stapleton Corporate Services Manager, WHSSC Clinical Lead for the Neonatal Network and Consultant Neonatologist, Abertawe Bro Morgannwg UHB Neonatal Network Manager QPS14/01 WELCOME AND INTRODUCTIONS The Chair, Professor Simon Smail welcomed and thanked all for attending the Quality Patient Safety meeting. Version: Confirmed Page 1 of 14 Quality Patient Safety meeting
QPS14/02 QPS14/03 APOLOGIES FOR ABSENCE Apologies for absence were RECEIVED from: Mr Michael Williams, Non Officer Member, Abertawe Bro Morgannwg UHB; Dr Geoffrey Carroll, Medical Director, WHSSC; and Dr Ashraf Mikhail, Clinical Governance Lead for the Renal Network. DECLARATIONS OF INTEREST There were no declarations of interest. Mrs Cathie Steele reminded Members that the WHSSC Declaration of Interest form will circulated soon as they are required for completion to coincide with the start of the new financial year 2014/15 so that declarations of any personal or business interests that may affect, or be perceived to affect the conduct of their role as a Member of the QPS Committee can be declared. QPS14/04 MINUTES OF THE MEETING HELD 13 th February 2014 The minutes of the last meeting were AGREED as a true and accurate record Dr Graham Shortland thanked the Chair for the improvements made on the content of the Minutes of the last meeting stating that they better reflected the robust discussions that were held. QPS14/05 ACTION LOG Members NOTED the progress on the actions from the last meeting and briefly discussed the following actions: QPS/13/92: WHSSC Appointments and Staffing Resources The Chair updated Members of the commencement date of 28 th April 2014 for the new WHSSC Director of Specialised Services, Mr John Palmer. The Chair reported that he updated the Version: Confirmed Page 2 of 14 Quality Patient Safety meeting
Members of the Joint Committee at the last meeting in March 2014, in relation to the additional resources required in WHSSC to provide Members with providing assurance that satisfactory standards are being met and that robust reporting mechanisms are in place. The Chair reported Members that he would discuss the additional WHSSC resources with the new Director of Specialised and Tertiary Services. Mr David Wilmott reported that three members of the WHSSC staff had tendered their resignation from the Patient Care Team. He reported that he planned to discuss this and potential solutions with the new Director of Specialised and Tertiary Services. Dr Shortland recommended that Members share the updated vacancy discussion with their respective Health Board as a means of assisting with future planning of Health Board and WHSSC quality and safety functions. The Chair thanked Members for the helpful discussion and AGREED to arrange a meeting with the new Director of Specialised and Tertiary Services. QPS/13/97: Update report from the Cardiothoracic Programme Team Mr Wilmott reported that work is ongoing with regards to concerns on the cardiac surgery waiting times. It was AGREED that this will be a substantive agenda item for the next meeting. Mr Wilmott advised Members that the Medical Directorate are leading the work of the TAVI working group and it was AGREED that a report will be provided at a future Quality and Safety Committee. Chair Head of Nursing and Quality Medical Director Members discussed the potential of introducing penalties to providers that do not Version: Confirmed Page 3 of 14 Quality Patient Safety meeting
comply with the agreed arrangements for day to day commissioning and contracting procedures. Mrs Steele reported that similar discussions had been held in the Management group meeting. The Chair noted that the role of the clinical lead in each programme team is crucial in the way forward. Members discussed the potential impact of penalties and outcomes for areas such as serious untoward incidents (SUI) and specific audits. Mrs Steele advised Members of the ongoing discussions in relation to penalties and clauses being added to specialised contracts. She noted that their introduction would not be added in current contracts as notice to providers must be given. Therefore would be included at the start of the new financial year. Mr Wilmott reported that the current arrangements for data storage is resource intensive and WHSSC is not able to respond with up to date modern health care, as NHS Wales Informatics Service (NWIS) are currently unable to provide support at this time. Dr Shortland asked for clarification of the briefing report for assessment of PCI treatment. The Chair confirmed that PCI treatment formed part of the agenda of the next Joint Committee meeting and has subsequently been added to the WHSSC Risk Register and the Cardiothoracic programme team risk register. The Chair advised Members that the minutes of the last Joint Committee would be available to update the current position in relation to concerns raised and potential of further networking for risks raised. In response to Mr Andrew Phillips, Mrs Steele explained the Membership of the committee and also confirmed that WHSSC had appointed an interim Chair, Mr John Hill-Tout for a period of 3-6 months. Version: Confirmed Page 4 of 14 Quality Patient Safety meeting
There were no further matters arising. Members RESOLVED to: NOTE the Action Log QPS14/06 CHAIRS REPORT Members received a verbal report from the Chair. He noted that the purpose of his report was to provide an update on key issues that were considered at the last two meetings of the committee in December 2013 and February 14. Mrs Steele reported that the Integrated Governance Committee had agreed discussed the suggested modifications to the self assessment against the Standards for Health Services in Wales and had agreed that the amended suggested Standard 8 should be made. Members RESOLVED to: NOTE the content of the report. QPS14/07 NEONATAL NETWORK UPDATE Members received a verbal update report from Dr Jean Matthes, Clinical Lead for the Neonatal Network and Mrs Karen Stapleton Neonatal Network Manager on key issues and ongoing development of patient care activity within the Neonatal Network. Dr Matthes briefly explained to Members the function of the Badgernet data base noting that it is used as a clinical tool to provide up to date information for all Neonatal units across Wales in relation to cot availability. She advised Members that a detailed report of a recent audit has been presented to a recent Joint Committee meeting. Members briefly discussed the availability of cots across Wales. Dr Matthes explained that many of the Neonatal Units across Wales cope regularly with peeks and troughs caused by factors that are usually outside of their Version: Confirmed Page 5 of 14 Quality Patient Safety meeting
control, for example pre term babies requiring acute care. Members had a brief discussion on Health Board contingency plans in relation these pressures and potential for planning in their own areas of responsibility. Dr Matthes reported that the Neonatal Units at Cardiff, Newport and Swansea participate in the Vermont Oxford Network data collection which looks at and compares the care and outcomes of high-risk newborn infants. This database is recognised across the UK and Europe and allows units to benchmark with each other. Dr Matthes advised Members that the smaller Neonatal units across South Wales and North Wales do not at this time participate in the Vermont Oxford process. In response to a question from the Chair on assurance, Mrs Stapleton reported that the Neonatal National Audit programme and the introduction of a Neonatal steering group will assist with provision of this information. In response to a point from Mr Wilmott it was AGREED that the Neonatal Network and their Quality and Safety Committee would in future provide regular reports to the WHSSC Quality and Safety Committee. It was also AGREED that the future dates of the committee would be shared with Dr Matthes and Mrs Stapleton. Neonatal Network Manager Corporate Services Manager Members RESOLVED to: NOTE the content of the verbal report QPS14/08 QUALITY and PATIENT SAFETY UPDATE REPORT Members received an update report from Mr David Wilmott, Head of Nursing and Quality WHSSC on key issues and ongoing development of patient care and safety within WHSSC. Mr Wilmott reported that he had tendered his resignation and will be taking up a post in Version: Confirmed Page 6 of 14 Quality Patient Safety meeting
London. He noted that he needed to confirm his exact leaving date with the new Director of Specialised and Tertiary Services. Mr Wilmott also reported that Mrs Lisa Cooper had resigned from her post of Corporate Services Manager and will be taking up a position in Powys Teaching Health Board. Mr Wilmott thanked Mrs Cooper for all her support and hard work whilst working in WHSSC and in particular in facilitating the QPS committee. The Chair and Dr Shortland thanked Mr Wilmott for his support and hard work whilst working at WHSSC. In response to Dr Shortland, Mr Wilmott reported that he had reviewed the structure of the Patient Care Team and planned to dsicuss this draft structure with the new Director of Specialised and Tertiary Services. The Chair reported that he would share his concerns in relation to WHSSC staffing arrangements with the Interim Chair, Mr John Hill Tout. Mr Wilmott explained to Members that the report presented sets out some of the key issues that the Patient Care team are engaged in relation to quality dashboards. He confirmed that several dashboards are almost complete and noted that the Gender Dysphoria dashboard will be nearing completion soon. Mr Wilmott explained to Members some of the patient experience issues within gender dysphoria services. The Chair advised Members that he is aware that there are similar problems experienced by English patients. Mr Wilmott updated Members of key areas of risk for WHSSC in relation to receiving complex information from provider organisations. Mr Wilmott suggested that in order to accurately receive, analyse and interpret data, a dedicated IT system is required and he described a system currently Version: Confirmed Page 7 of 14 Quality Patient Safety meeting
in use at University Hospital, Birmingham that would be beneficial to WHSSC. Mr Wilmott advised Members that he would seek support from the new Director of Specialised and Tertiary Services in relation to this. Mr Wilmott reminded Members of recent media reports of CQC assessment that had taken place at Alder Hey Foundation NHS Trust in Liverpool. He advised Members that there is an ongoing dispute with Alder Hey and CQC in relation to how the assessment was carried out and confirmed that an update position and future action plan has been received from the Nurse Director at Alder Hey. It was AGREED that a full report will be brought to the next meeting. Members discussed the appropriateness of receiving similar reports and the information to be received as part of the contract arrangements which would enable them to give assurance to the Joint Committee. Head of Nursing and Quality Members RESOLVED to: NOTE the content of the report; and SUPPORT the ongoing work around quality and safety. QPS14/09 TO RECEIVE AN UPDATE REPORT ON THE INDIVIDUIAL PATIENT CARE (IPC) TEAM REPORT Members received an update report on the All Wales Individual Patient Funding Request (IPFR) panel from Mr David Wilmott, Head of Nursing and Quality, WHSSC. Mr Wilmott provided Members with a summary of the cases presented to and decisions made by the All Wales IPFR Panel from April 2013 to March 2014. Mr Wilmott reported that attendance at the All Wales IPFR panel is not consistent and the same representative is not always available at consecutive meetings which may result in inconsistent decisions being made. The Chair confirmed that he had written to the Mrs Version: Confirmed Page 8 of 14 Quality Patient Safety meeting
Allison Williams to alert her to the situation. Mr Wilmott reported that Internal Audit are currently reviewing the WHSSC IPFR process. He reported that currently approximately 200 requests for funding of specialised treatments are received per month. Members had a brief discussion in relation to type of requests received and the mechanism used for each cohort of patients. Members discussed the increase demand of high cost drugs and the need for appropriate planning for appropriate health care delivery. Dr Christopher Roseblade noted that this is a pressure faced by all Health Boards. Mr Wilmott advised Members that, in view of some high cost drugs being supported by NHS England, there areas which are difficult for WHSSC. It was AGREED that the Medical Directorate would be asked to provide further information in regards to high cost drugs and AWMSG at a future meeting. Medical Director Members RESOLVED to: NOTE the content of the update report QPS14/10 TO RECEIVE AN UPDATE REPORT ON THE WHSSC RISK REGISTER Members received an update report on the WHSSC Risk register from Mrs Cathie Steele, Corporate Governance Manager WHSSC. Mrs Steele noted that the purpose of the report is to provide Members with an overview of the top risks for WHSSC and to confirm what actions are being taken to minimise the risk. Members discussed the ongoing issues experienced by Welsh Renal Clinical Networks (WRCN) Water treatment plants. Dr Roseblade advised Members that he is aware of water treatment issues at Wrexham Maelor hospital however did not recall seeing the detail on the WHSSC risk register. Mrs Steele Version: Confirmed Page 9 of 14 Quality Patient Safety meeting
confirmed that WHSSC had not been notified of the issues at Wrexham Maelor Hospital from the WRCN network and therefore the detail of the risk has not been added to the risk register. She further explained to Members that the WRCN risk register is in a different format to the organisational register. Work is underway to resolve this. Members RESOLVED to : NOTE the content of the report QPS14/11 TO RECEIVE A SUMMARY REPORT ON THE PUBLIC SERVICE OMBUDSMAN FOR WALES (PSOW) REPORTS BY WHSSC Members received a summary report on the PSOW reports received by WHSSC from Mrs Cathie Steele, Corporate Governance Manager WHSSC. Mrs Steele provided Members with an overview of the issues faced by WHSSC with regards to the PSOW, for example the fact that WHSSC is not a statutory body. Mrs Steele drew Members attention to the table (Figure 1) within the paper. She noted that the table does not currently reflect an accurate position as the information within Datix is not currently up to date, for example the need to generate closed dates for some concerns. Mrs Steele highlighted to Members some of the concerns investigated by the PSOW since 1 April 2013 as detailed within the report. Members RESOLVED to : NOTE the content of the report. QPS14/12 TO RECEIVE REPORTS FROM THE CANCER and BLOOD, AND CARDIOTHORACIC PROGRAMME TEAMS Members received reports from the Cancer Version: Confirmed Page 10 of 14 Quality Patient Safety meeting
and Blood and Cardiothoracic programme teams from Mr David Wilmott, Head of Nursing and Quality. Mr David Wilmott highlighted to Members some of the issues at the Bone Marrow Transplant (BMT) unit based in Cardiff and Vale University Health Board (UHB). He reported that Cardiff and Vale UHB have submitted information to the Joint Accreditation Committee (JACIE) and that there is no timescale set for a response from them. Mr Wilmott advised Members that he had undertaken a site visit at the unit and was able to identify the issues for patients in terms of privacy and dignity. He has responded by formally writing to the Nurse Director at Cardiff and Vale UHB. Dr Shortland AGREED to discuss the issues further with the Mrs Ruth Walker, Director of Nursing at Cardiff and Vale UHB and update Mr Wilmott. Medical Director, C&V Members RESOLVED to : NOTE the content of the report. QPS14/13 TO RECEIVE A VERBAL UPDATE REPORT ON RISK REFERENCE 050/16 The Chair updated Members on the issues and concerns reported in relation to referral to treatment (RTT) for Cardiac patients. Mr Wilmott highlighted to Members a recent patient story where the patient, who required Cardiac Surgery and who clinicians at the referring hospital had deemed appropriate for cardiology surgery was subsequently offered treatment at the Queen Elizabeth (QE) Hospital in Birmingham, however upon arrival at QE Hospital was faced with a difference of clinical opinion on her condition and resulted in the patient returning to Wales without having her operation. Members had a detailed discussion on the issues explained by Version: Confirmed Page 11 of 14 Quality Patient Safety meeting
Mr Wilmott and agreed that this kind of situation is to be expected if a robust referral process is not put in place before patients are accepted for treatment. Members RESOLVED to : NOTE the content of the report and; SUPPORT the actions to be taken. QPS14/14 TO RECEIVE A VERBAL UPDATE REPORT ON SERIOUS INCIDENT WHSSC Ref NO: 12/10/42970 Mr David Wilmott reported that the incident is finally drawing to a conclusion. He explained that there are robust action plans in place to meet and discuss any further issues with the relatives of the patients involved. Mr Wilmott advised Members that a closure meeting is arranged with the provider for 28 April 2014. Mr Wilmott reported that the Royal College of Surgeons report had been concluded and that many of the recommended actions have been achieved. Mr Wilmott advised that the Putting Things Right process is being used by some of the relatives and that this therefore is action for the the Health Board. Dr Shortland reported that the provider have learned lessons from a number of important safety issues in terms of recruitment, discipline, and transparency. He also assured Members that new processes and mechanisms are now in place to assist with future plans. Members RESOLVED to : NOTE the content of the verbal report. QPS14/15 TO RECEIVE A VERBAL REPORT ON POTENTIAL SERIOUS INCIDENT NEURO REHABILITATION Members received verbal update on the Version: Confirmed Page 12 of 14 Quality Patient Safety meeting
potential serious incident within neuro rehabilitation from Mr David Wilmott, Head of Nursing and Quality. Mr Wilmott explained to Members that the NHS Whistle blowing process had been implemented following a text received about serious issues within the service. Mr Wilmott confirmed that he had met with the Medical Director of the provider organisation to discuss the key factors in the concerns raised and a response following the investigation is awaited. Members RESOLVED to: NOTE the content of the verbal report. QPS14/16 TO RECEIVE A VERBAL REPORT ON NEW CONCERNS QPS14/16 Members received a verbal update on new concerns from Mr David Wilmott, Head of Nursing and Quality. Mr Wilmott reported on a potential issue of delayed transfer of patients from North Wales to Liverpool Heart and Chest NHS Hospital NHS Foundation Trust in Liverpool. Mr Wilmott confirmed to Members that a meeting has been arranged with the Head of Nursing of Liverpool Heart and Chest NHS Hospital NHS Foundation Trust to discuss procedures currently in place for transferring patients. Mr Wilmott AGREED to provide an update at the next meeting. Members RESOLVED to: NOTE the content of the verbal report. IMPROVEMENT NEWSLETTERS Members received the following newsletters for information: 1,000 Lives Plus Newsletter March Head of Nursing and Quality Version: Confirmed Page 13 of 14 Quality Patient Safety meeting
2014; 1,000 Lives Plus Newsletter April 2014; and All Wales Neonatal Network Newsletter March 2014 QPS14/16 ANY OTHER BUSINESS There were no other items for discussion. QPS14/17 DATE OF NEXT MEETING The date of the next meeting was confirmed as: Thursday 9 October 2014 at 2pm Signed. Insert Name (Chair) Date.. Version: Confirmed Page 14 of 14 Quality Patient Safety meeting