A concern means any complaint, claim or reported patient safety incident.

PUTTING THINGS RIGHT ANNUAL REPORT -2017 Introduction The Putting Things Right Annual Report provides information on the progress and performance of Powys Teaching Local Health Board (hereafter, the health board) in their management of concerns during -2017. Background The NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (hereafter, the Regulations ) that apply to all Welsh NHS bodies, primary care providers and independent providers in Wales, providing NHS funded care were introduced in April 2011. Since this time, work has progressed to put in place an integrated approach for people to raise concerns. A concern means any complaint, claim or reported patient safety incident. Arrangements in place for dealing with concerns Strategic oversight and arrangements for the handling and investigation of concerns The strategic oversight for concerns rests with Rhiannon Jones, Executive Director of Nursing. The arrangements for managing concerns is supported by a Senior Investigations Manager (Assistant Director of Quality & Safety) with responsibility for overseeing a team of two staff members, the Senior Manager Putting Things Right and Patient Experience/ Concerns Officer, who deal with concerns on a day-to-day basis. The Senior Manager Putting Things Right post was vacant from mid July 2015 until 3 October. As a result, the Health Board have operated with one staff member less for over half the period of -2017. Independent scrutiny, governance and reporting arrangements The Putting Things Right Redress Panel (hereafter known as the Panel ) provide independent scrutiny of the management of concerns, and remain accountable to the Executive Team. The Chair is required to provide quarterly reports to the Executive Team and assurance to the Quality and Safety Committee. Procedure for the Handling and Investigation of Concerns

Following the review and assessment of the management of concerns by the Welsh Risk Pool Services and Internal Audit earlier in the year, an improvement action plan was developed to strengthen existing processes for dealing with concerns. The main areas of improvement related to: Compliance with timescales. Detail provided in acknowledgement letters to include information about the terms of reference of the investigation. Improvement in holding letters and ongoing communication. Template letters should be used to ensure consistency and compliance with the content requirements. The detail and tone of the letters was noted as generally good but let down by the conclusions. The key area for improvement for the Health Board is to ensure that qualifying liability is clearly explained and is applied to the facts in all responses. It is very important when dealing with a Regulation 24 response (save for those where the financial value is likely to exceed the threshold) that all issues have been clarified as this is meant to be a final response. The L&RS template wording explaining qualifying liability should be used in all Regulation 24, 26 and 33 responses. There is a need to define informal and provide some appropriate guidance on management and recording of information and outcomes on Datix. It is important that everything is uploaded and recorded on Datix so that the concern raised and response outcome achieved are clear Given the issue with timeliness of receipt to conclusion, the Health Board may wish to consider increasing the timescales for responding to informal concerns, which albeit being outside guidance but maybe more realistic and in line with the Evans review. During the start of -2017, support was provided to the Concerns department by solicitors from NHS Wales Legal and Risk Services. Their expertise and experience informed more timely responses and reinforcement of the expected standards in accordance with the Regulations alongside improved compliance with the content requirements of responses. Since October the Senior Manager Putting Things Right post has been filled by a qualified solicitor adding support and expertise to the team. The main changes that have occurred as a result of the improvement plan and actions taken include: Clearance of the back log of concerns outside expected timeframes for responses Proactive management of all concerns, including regular review of all compensation claims A move to electronic reporting and recording of all concerns Increased knowledge and use of the Datix system Development of Intelligence Focused Online Reporting (IFOR) systems for tracking compliance with the regulations timeframes and number of concerns per month.

Templates for responses strengthened to take account of guidance and ensuring the content reflects the expected standard Improvements in the standard of investigations Investigation officers providing draft responses to concerns Structure for sharing of lessons via the Patient Experience Steering Group Training programme for staff on Datix, and their attendance recorded via Electronic Staff Records Putting Things Right Redress Panel Where the investigation of a concern concludes there has been a breach of duty the case is presented to the Putting Things Right Redress Panel. The Panel are required to consider whether redress applies in situations where a patient may have been harmed and the harm was caused during care provided by Powys Teaching Health Board or in relation to care commissioned from other providers on their behalf in other parts of the United Kingdom. Redress can be the giving of an explanation, a written apology, the offer of financial compensation and / or remedial treatment, on the understanding that the person will not pursue the same through civil proceedings. The redress panel met on 7 occasions during -2017. This in an increase on last year following the schedule of meeting dates being an identified area for improvement going forward to ensure proactive and timely management of concerns to conclusion for patients and their families. A total of 10 cases were considered resulting in: 1 case confirmed breach of duty but no causation 1 case confirmed breach of duty and resulting causation 2 cases confirmed breach of duty but causation requires further investigation 2 cases where external expert reports were obtained An apology was offered in 4 cases No cases resulted in remedial treatment 3 cases are ongoing Concerns Statistics Informal Concerns (Complaints) These are commonly termed on the spot concerns, and are normally resolved within 5 working days. A total of 80 informal concerns were raised in -2017, six were dealt with outside of the 5 working days. Review of these concerns indicated that one was an informal concern which transferred to a formal concern. Tracking of concerns moving from informal to formal will be strengthened in 2017-18. Two informal concerns were resolved by facilitation of a meeting with the clinician resulting in a delay in closure. One informal concern remained open to ascertain the scope of the concerns to respond to and one remained opened awaiting further contact from the complainant. Further work on the tracking of informal concerns will be prioritised in 2017-18. Formal Concerns (Complaints)

During -2017 the Health Board received 246 formal concerns; 190 relating to services provided by Powys Teaching Health Board, the remaining 56 relating to commissioned provider services. While this appears to be an increase in total concerns this is a reflection of the improvement in tracking concerns which are re-opened. The figures for previous years did not adequately reflect this. Concern s may be re-opened if a complainant returns to the health board following withdrawal of concern, if unsatisfied with improvements made to the service following an initial complaint or if an informal concern is re-opened as a formal matter at the complainant s request. Total number of Total Number of Total Informal Concerns Formal Concerns 2017 80 246 326 2015-67 154 221 2014-2015 51 131 182 Table 1: Services provided by Powys Teaching Health Board Timeframes for Responding to Formal Concerns Number /17 Number 2015/16 Number 2014/15 Total Concerns 246 154 131 No of concerns responded to within 30 working days of receipt Within a period exceeding 30 working days but within 6 months of receipt 157 105 42 77 48 42 A period exceeding 6 months of receipt 12 0 1 Withdrawn/ Not pursued 0 0 0 Table 2: Timeframes for responding to concerns. Please note some concerns remain ongoing. Significant work has been undertaken to improve the response times for formal concerns which will not be realised until the following year. During /17 extensive review of the data has taken place, the outcome of which cannot be compared with previous years reported progress. 94% of concerns were acknowledged within 2 working days 63% of concerns managed and responded to within 30 working days 37% of concerns managed and responded to within 30 working days and 6 months Less than 1% of concerns managed and responded to within 6 to 123

months Less than 1% of concerns managed and responded to over 12 months Some of the concerns in the three latter categories generally take longer due to the complexity of the cases. These are currently subject to further analysis to ensure they have been assessed accurately as capable of management outside of the 30 working days - 04-05 -06-07 -08-09 -10-11 -12 2017-01 2017-02 Total Concern s Open 69 59 48 46 44 45 36 32 32 35 31 Table 3: Concerns still open at end of each month by number of days waiting. Please note that some concerns are ongoing and data taken from IFOR includes informal concerns, redress and Public Service Ombudsman referrals. Referrals to the Public Services Ombudsman for Wales It was evident in reviewing the number of cases referred to the Public Services Ombudsman for Wales (PSOW) for 2015-, the data recording systems were inadequate and did not appear to capture all the referred cases. This has been strengthened during the year through the use of the Datix system, whereby all cases referred to the PSOW offices or cases where information is sought from the PSOW in response to a complaint they receive, is now recorded via the Datix system. In relation to complaints there has been 5 referrals to the PSOW of which only one was partially upheld. This related to dental services provided to children and it was recommended the dental practice use this case for learning and training in relation to preventative treatment for children. The practice has fully agreed with the findings by the PSOW. Themes, trends and any key issues emerging from Concerns The key areas of concerns reported are summarised below: Type of concern /17 2015/16 2014/15 Access, Admission, Transfer, Discharge 74 53 44

Clinical assessment (including diagnosis, scans, 2 tests, assessments) 7 6 Consent, confidentiality or communication 2 4 10 Discharge 8 Disruptive, aggressive behaviour (patient to patient) 1 1 Documentation (including records, identification) 2 2 Infection Control 0 0 Implementation of care or ongoing monitoring/review 5 19 24 Infrastructure or resources (staffing, facilities, 7 environment) 4 10 Medical device/equipment 1 0 Medication 1 1 3 Patient abuse (by staff / third party) 0 0 Patient accident 0 1 Treatment, procedure 51 2 22 Privacy and dignity 1 1 Attitude of Staff 16 13 19 Appointments (delay / cancellation) 0 0 4 Concerns handling 0 0 Other 9 6 Not coded No data 40 No data Lessons Learnt An area of improvement throughout -2017 was learning from concerns and the wider sharing of lessons. Although there has been an emphasis on learning, it is recognised further work is required to ensure that Powys has a robust infrastructure that supports and demonstrates learning has taken place and change has occurred. The Patient Experience Steering Group has a lessons learned report provided at each meeting identifying areas of good practice (locally and nationally), areas of deficit requiring action and any emerging themes, ensuring spread, learning and improvement. Our Patient Experience Strategy emphasises the importance of learning from concerns, recognised as a key source of patient feedback alongside patient surveys and experience, as a way of identifying areas for improvement and supporting lesson learning from areas that are performing well. Below are examples of learning from concerns: The purchase of additional privacy screens and identification of a cubicle for privacy to support dignified care for patients attending the leg club. Physiotherapy services have recruited permanent staffing to reduce reliance on locum staff. Learning from concerns and patient experience has also been used to improve the system for offering physiotherapist appointments.

Learning from concerns raised with regard to transport issues has included staff training to ensure all staff learn the importance of adopting a professional approach when dealing with people over the telephone and in person, for example communicating clearly the mobility status of a patient when booking ambulance transport. Employment of more staff who are trained to provide treatment for ear wax. District nurse team to use wound care charts to support them in their assessment and treatment of wounds, in addition to clear communication with relatives and carers. The introduction of a Carers clinic in the south locality with further support communication for carers. Proactive working with commissioners to ensure patients are seen within waiting times. Administration staff at Brecon War Memorial Hospital have introduced a system to ensure all telephone calls regarding confirmation of planned procedures are logged within the department and cross checked against current waiting lists. Conclusion and priorities for improvement During -2017 the Concerns Team worked with one less senior staff member for the majority of the year. The Team is now fully staffed and it is anticipated that the pace of change will improve. The processes and systems for managing concerns have improved and the back log of concerns has been cleared but not all the benefits have been realised in this year. However, moving forward there is a firm infrastructure, electronic working is the norm and the robustness of the strengthened systems and processes provides increased assurance in respect of the management of concerns. At the outset of the year the key areas of improvement going forward into -2017 were noted as: Improve the recording of grading for all concerns; Improve the recording of Public Services Ombudsman for Wales referrals All staff to focus on learning from concerns and contribute to improvement in organisation wide sharing of lessons; Development of a training programme for staff on dealing with concerns, to include investigation skills, drafting of responses, and others skills as needs dictate; Improve the timely management of informal concerns All concerns are now graded at the outset and in respect of concerns graded as moderate or severe harm patients are advised at the outset that the nature of the concern may require a more detailed investigation exceeding the 30 days concerns response time and kept up to date with the progress.

All Public Service Ombudsman for Wales referrals are logged and tracked on datix. A lessons learned report is provided to Patient Experience Steering Group to contribute to the sharing of lessons. A training programme is under development and the team has contributed to the investigation report writing training day provided by the Royal College of Nursing. The team has also contributed to a Pressure Ulcer Study Day setting out the lessons learned. Further improvements are underway in respect of timely responses to informal concerns and the Putting Things Right policy in this respect has been reviewed. Looking forward to 2017/18 the priority will be to build upon the work already undertaken and developed detailed grading, analysis and lessons learned from concerns raised.