Emergency Preparedness, Resilience & Response (EPRR) 2016/17 Annual Report Public Board 28th September 2017

Agenda item 14.4 BLUE BOX Emergency Preparedness, Resilience & Response (EPRR) 2016/17 Annual Report Public Board 28th September 2017 Presented for: Presented by: Author: Previous Committees: Assurance Professor Suzanne Hinchliffe CBE, Chief Nurse / Deputy Chief Executive Sharon Scott, Resilience Manager Vicky Taylor, Emergency Planning Officer Emergency Preparedness Coordinating Group - 23rd August 2017 Risk Management Committee - 7th September 2017 Trust Goals The best for patient safety, quality and experience The best place to work A centre for excellence for research, education and innovation Seamless integrated care across organisational boundaries Financial sustainability Key points 1. The 2016/17 EPRR Annual Report provides Trust Board with assurance that Leeds Teaching Hospitals NHS Trust (LTHT) has met its statutory duties and national standards. 2. The EPRR Annual Report details learning from incidents and events, achievements and improvements made to existing emergency response arrangements between 1st April 2016 and 31st March 2017. To provide a continuous cycle of improvement, the Annual Report sets out the key EPRR priorities for 2017/18. 3. Trust Board is asked to receive the assurance within the EPRR Annual Report. Assurance Assurance Assurance

PUBLIC BOARD 28th SEPTEMBER 2017 EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE 2016/17 ANNUAL REPORT (FOR BLUE BOX) Forward Resilience planning in a large complex acute Trust requires a strong focus on preparedness, collaboration, teamwork and a recognition that at times unexpected incidents occur which can affect the efficient running of services within our hospitals. This can be as a result of external or internal influences. Plans and training must therefore be robust and flexible in nature to respond to a wide variety of situations where patient care could be compromised. One such incident occurred on Friday 16th September 2016 when the Pathology Telepath IT system failed resulting in an unprecedented business continuity incident for our hospitals with wide-scale impact on patients requiring access to Pathology services across Leeds and Bradford. The incident required a robust sustained response and recovery period. Many departments, teams and colleagues internally and across the local health care system worked hard to keep patients safe and to ensure the continuous delivery of emergency and critical services. Regrettably, it was necessary to reschedule some non-urgent appointments and GP services across Leeds and Bradford were impacted. I would like to sincerely thank all those who participated in the response and reflect upon the high level of commitment made to keep patients safe throughout the incident response. In addition to the above during the period that this report covers, the Trust has responded to a number of events which had the potential to disrupt hospital services and required additional special measures to be put in place. These include international sporting events in and around Leeds city centre, numerous large scale sporting and community events and maintaining key and critical services during periods of national coordinated industrial action by our junior doctor workforce. The hospital has also undertaken a live multi-agency decontamination exercise and tested response arrangements alongside partner agencies during a number of local and regional mass casualty exercises. Whilst outside the time scale of this report, I have been especially saddened by the terrible atrocities and number of deaths in the UK as a result of terrorism. This together with the terrible loss of life during the Grenfell Tower major incident serves to remind us of the importance of emergency preparedness, resilience and response (EPRR) and how vital it is to ensure lessons are learnt and plans are strengthened as a result. The learning from these terrible events, together with learning following the national cyber-attack on the NHS and other incidents that have occurred outside of this report will be incorporated into resilience plans and response arrangements during 2017/18. The Trust Board supports the work of the Emergency Preparedness Team to continue to drive improvement within its EPRR agenda. Professor Suzanne Hinchliffe CBE, Chief Nurse/Deputy Chief Executive 2

Contents Forward... 2 1. Introduction... 4 2. Purpose... 4 3. Statutory Framework & National Policy Drivers... 4 3.1. NHS England EPRR Assurance Process... 5 4. Responsibility and Accountability... 5 5. Trust Groups... 6 6. External Groups... 7 7. Resilience Plans... 8 7.1. CSU Bronze Command Checklist... 8 7.2. Business Continuity Planning... 9 7.3. Cyber Security... 9 8. Training Programme... 10 9. Exercise Programme... 10 9.1. Communications Exercises... 10 9.2. Table Top Exercises... 11 9.3. Live Exercise... 12 10. Mass Casualty Exercises... 12 10.1. Exercise Day Hawk... 13 10.2. Exercise Spiral... 13 10.3. Exercise Elsa... 13 11. Pathology Telepath IT System Failure... 13 12. Industrial Action... 14 13. Event Briefings... 14 14. Influenza... 15 15. Conclusion & Key Priorities for 2017/18... 15 16. Recommendations... 16 Appendix 1 - NHS England EPRR Statement of Compliance Yorkshire and the Humber Emergency Preparedness, Resilience and Response (EPRR) Assurance 2016-17... 17 3

1. Introduction This report summarises the Leeds Teaching Hospitals NHS Trust (LTHT) EPRR activities from 2016/17 and key priorities for 2017/18. The annual report describes the Trust duties in relation to the statutory framework and national guidance for EPRR including those responsible for ensuring that LTHT is compliant with the duties. This report identifies the Trust compliance level against the NHS England Core Standards for EPRR following the 2016/17 assurance process. The Emergency Preparedness Team benefited from the expertise shared by two interim Resilience Managers from Public Health England and Yorkshire Ambulance Service (YAS) whilst the permanent Resilience Manager and Emergency Planning Officer were on shortterm secondments to Acute Medicine CSU and NHS England (North). The knowledge and experience gained from the secondments has and will continue to enhance the EPRR arrangements within the Trust. A number of exercises and training sessions have taken place throughout the year in collaboration with multi-agency partners and internally to ensure preparedness for an incident involving mass casualties. Learning from these events has been incorporated within the Trust Mass Casualty Plan to improve the Trust preparedness for a mass casualty incident. A live decontamination exercise was held at the Leeds General Infirmary (LGI) in July 2016 in collaboration with West Yorkshire Fire and Rescue Service, West Yorkshire Police, Leeds City Council, YAS and with the help of 53 volunteers who pretended to be contaminated casualties. This was a valuable and worthwhile exercise for LTHT and partner agencies. Pre-planned arrangements were tested and special measures were put in place during nationally coordinated industrial action by the British Medical Association to ensure safe patient care was maintained. Later on in the year, plans were activated in response to a failure of the Pathology Telepath IT system. Incident management arrangements were in place over a number of weeks with a strong focus on ensuring patient safety. Valuable lessons were identified in 2016/17 which will enhance business continuity arrangements across the Trust. 2. Purpose The purpose of this report is to provide the Trust Board with assurance that the Trust has met the required EPRR statutory duties and obligations during the period 1st April 2016 to 31st March 2017. The report provides an overview of EPRR activities and sets out EPRR priorities for 2017/18. The Trust Board is asked to receive this assurance. 3. Statutory Framework & National Policy Drivers Under the Civil Contingencies Act 2004, NHS organisations and providers of NHS funded care must show that they can plan for and deal with a wide range of incidents and emergencies that could affect health or patient care. This programme of work is referred to as Emergency Preparedness, Resilience and Response (EPRR). LTHT is classed as a Category One responder under Schedule 1 of Chapter 36 and is obliged to respond in the event of a civil emergency, which threatens serious damage to human welfare in a place in the United Kingdom. LTHT as a Category One responder is subject to the following civil protection duties: 4

Assess the risk of emergencies occurring and use this knowledge to inform contingency planning. Ensure emergency plans and business continuity management arrangements are in place. Communicate with the public to ensure they are warned, informed and advised in the event of an emergency. Share information and cooperate with other local responders to enhance coordination and efficiency. These duties are accompanied by other legislation and national guidance such as the Health and Social Care Act (2012), NHS standard contract, NHS England Core Standards for EPRR, NHS England Framework and NHS England Business Continuity Management Framework. The EPRR framework and core standards for emergency preparedness enable the Trust to ensure effective arrangements are in place to deliver appropriate care to patients affected during an emergency. 3.1. NHS England EPRR Assurance Process NHS funded organisations are required to undertake an annual self-assessment against the NHS England Core Standards for EPRR and submit a compliance level which is either full, substantial, partial or non-compliant. A key priority in 2016/17 was to achieve substantial compliance or above against the core standards and have a work programme in place to address the requirements. LTHT assessed the EPRR arrangements against the 2016/17 NHS England Core Standards that related to acute healthcare providers and the Trust were at a substantial compliance level (see Appendix 1). Four out of 57 core standards required improvement and development. These standards related to mass casualties, evacuation and business continuity planning. This work has been incorporated within an improvement plan and embedded into the EPRR work programme. The Quality Assurance Committee signed off the statement of compliance (see Appendix 1) and improvement plan on behalf of Trust Board on 15th September 2016. The compliance was noted as part of the Chief Executive's update report at Trust Board on 29th September 2016 and included in the minutes. A key priority for 2017/18 is to improve and develop the areas in the EPRR core standards which relate to mass casualty, evacuation and business continuity plans. Continue to ensure the Trust achieves substantial compliance against the EPRR core standards. The 2017/18 statement of compliance will be submitted to the Trust Board on 28th September 2017. 4. Responsibility and Accountability The Chief Executive has the responsibility for ensuring that LTHT is compliant with the Civil Contingencies Act (2004), other supporting statutory legislation and national guidance. The responsibility of Accountable Emergency Officer is assigned to the Chief Nurse/Deputy Chief Executive and responsibilities are delegated to the Resilience Manager. During 2016/17, the Resilience Manager went on secondment to Acute Medicine CSU and the Emergency Planning Officer was seconded to NHS England (North) to focus on winter 5

resilience. Whilst the Resilience Manager and Emergency Planning Officer were on secondment, interim Resilience Managers were seconded to the Trust. A member of staff from Public Health England (PHE) worked full-time and an employee from YAS worked parttime for the Trust specifically focusing on business continuity. A Secretary from the Trust Safeguarding Team was contracted part-time to provide administration assistance to the Emergency Preparedness Team (see Table 1 for a timeline). Emergency Preparedness Team Staff 2016 2017 Oct Nov Dec Jan Feb Mar Apr Resilience Manager Full-time Emergency Planning Officer Full-time Resilience Manager (seconded from PHE) Full-time Resilience Manager (seconded from YAS) Part-time Secretary Part-time Key Seconded away from the Emergency Preparedness Team Seconded to the Emergency Preparedness Team Table 1.Emergency Preparedness Team Secondment Arrangements Knowledge and experience gained by the Resilience Manager and Emergency Planning Officer from operational management and winter resilience has benefited the LTHT EPRR portfolio. Furthermore the work provided by the interim Resilience Managers has benefited the Trust, for example, a new business continuity plan template has been created for the Trust which will be distributed to CSUs and corporate services to enhance business continuity plans. 5. Trust Groups The Accountable Emergency Officer chaired the Emergency Preparedness Coordinating Group which met on a quarterly basis throughout 2016/17. This group ensured that the Trust remained compliant with EPRR statutory legislation and NHS England requirements. This group was supported by the Chemical, Biological, Radiological, Nuclear (CBRN)/Hazmat Subgroup, Emergency Department Major Incident Steering Group and Industrial Action Management Group (see Table 2 for internal EPRR groups). Subgroups continue to benefit from the support of senior medical consultants and nursing team colleagues to clinically drive the promotion of resilience planning. Internal EPRR Group Emergency Preparedness Coordinating Group Subgroups CBRN/Hazmat Subgroup Ebola Virus Disease Steering Group Purpose To ensure the Trust remains compliant with EPRR statutory legislation and NHS England requirements. To oversee the CBRN/Hazmat preparedness and response arrangements within the Trust. To oversee coordination and management of operational readiness in anticipation of a patient(s) attending LTHT with suspected or confirmed Ebola Meeting Frequency Quarterly Quarterly Reconvened when required. No meetings during Chair Chief Nurse/Deputy Chief Executive (Accountable Emergency Officer) Intensive Care Consultant Intensive Care Consultant 6

Internal EPRR Group Emergency Blood Management Group Emergency Department Major Incident Steering Group Industrial Action Management Group Purpose Meeting Frequency Virus Disease. 2016/17. To provide overall direction and Reconvened set priorities for Emergency Blood when Management Arrangements required. within the Trust. No meetings during To provide overall direction and set priorities for emergency preparedness activities within the Emergency Department. To provide overall direction and set priorities for staff side negotiation, Trust-wide contingency planning and stakeholder engagement in response to national coordinated industrial action. 2016/17. Quarterly Reconvened when required. Chair Deputy Chief Medical Officer/Medical Director Operations Consultant in Emergency Medicine/Emergency Department Major Incident Clinical Lead Deputy Chief Medical Officer/Medical Director Operations Table 2. Internal EPRR Groups Information The Emergency Preparedness Team provided status reports to the Trust Risk Management Committee throughout 2016/17 to provide the group with assurance that all EPRR threats and hazards had been risk assessed, mitigated and proportionate plans had been put in place. The Trust risk assessment was considered against the national planning assumptions, national risk assessment guidance, community risk register, knowledge and experience of risk in the local area. A key priority during 2017/18 is to continue to ensure that EPRR threats and hazards are monitored to ensure patient safety is maintained as well as ensuring statutory and non-statutory EPRR duties are fulfilled by the Trust. 6. External Groups During 2016/17, the Trust was represented by the Accountable Emergency Officer and Emergency Preparedness Team at a number of local and regional EPRR groups (see Table 3). These meetings facilitated information sharing and collaboration with other responding organisations; which is one of the Trust s key duties under the Civil Contingencies Act (2004). Group Type Area Citywide EPRR / Escalation Workshop Health Local Leeds Health and Social Care Resilience Group Health Local Leeds Pandemic Influenza Group Health Local Leeds Resilience Group Multi-agency Local Strategic Safety Advisory Group Multi-agency Local System Resilience Assurance Board Health Local West Yorkshire Health and Social Care Resilience Subgroup Health Regional West Yorkshire Local Health Resilience Partnership Health Regional West Yorkshire Resilience Forum Mass Fatalities Subgroup Multi-agency Regional 7

Group Type Area West Yorkshire Interoperability Subgroup Multi-agency Regional Table 3. Local and regional EPRR groups A key priority for LTHT in 2017/18 is to ensure that the Trust continues to be represented by the Accountable Emergency Officer and Emergency Preparedness Team at local and regional EPRR groups. This engagement will seek to improve patient care and services through integration and collaboration across networks and partner agencies. 7. Resilience Plans Throughout 2016/17, the Emergency Preparedness Team developed and improved Trustwide resilience plans following learning from incidents, events and exercises. Table four below provides a summary of Trust-wide resilience plans and when they were last updated. Trust-wide Resilience Plan Last Updated CBRN/Hazmat Plan July 2016 Ebola Virus Disease Plan June 2016 Emergency Blood Management Arrangements Plan May 2016 Emergency Fuel Plan March 2016 Friends and Relatives Centre Plan October 2016 Heatwave Plan May 2016 Industrial Action Management Plan April 2016 Major Incident Plan November 2016 Mass Casualties Plan Draft - November 2016 Multiple Minor Trauma Injuries Plan March 2017 Operational Plan January 2016 Pandemic Influenza Plan November 2015 Public Interest/Media Incident Response Plan May 2016 Switchboard Major Incident Procedure November 2016 VIP Patient Management Protocol March 2016 Table 4. Trust-wide resilience plan status as at 31st March 2017. Emergency Preparedness Team staff engaged with CSUs and corporate services throughout 2016/17 to ensure CSU level major incident and business continuity plans were up to date and include learning from exercises, events and incidents. The Trust currently has 49 CSU/Corporate business continuity plans in place and 19 major incident plans in place. Plan statuses were reviewed on a monthly basis by the team with performance reports taken to the Emergency Preparedness Coordinating Group. Any areas of non-compliance were raised with key staff to ensure that timely action was taken to ensure up to date plans were in place to maintain patient safety in the event of an incident. The Emergency Preparedness Team will continue to assess risk and develop plans at a Trust-wide and CSU/Corporate level throughout 2017/18. 7.1. CSU Bronze Command Checklist 8

Internal Audit undertook an audit of emergency preparedness within the Trust during November and December 2015. The audit report (Major Incident - Report No 2015/34) was shared in April 2016 and a compliance level was chosen out of either full, significant, limited or no assurance. A significant level of assurance was provided. A recommendation to develop a process for receiving assurance and monitoring CSU Bronze Command room facilities and equipment was put forward in the report. The Emergency Preparedness Team developed a CSU Bronze Command Checklist which was included within the updated EPRR Policy in November 2016. The CSU Bronze Command Checklist provides a list of key requirements for a CSU Bronze Command including plan requirements, equipment and recommendations when updating the Bronze Command (Operational) room. CSU General Managers were asked to complete the checklist and provide a statement of compliance endorsed by the CSU Clinical Director following governance meetings to the Resilience Manager. This assurance process will be undertaken annually to confirm that all CSUs have access to appropriate facilities and their secure cabinet is reviewed to ensure that the relevant information is up to date for in the event of an incident. 7.2. Business Continuity Planning A key priority for 2016/17 was to embed learning from business continuity disruptions to further develop business continuity strategy and response plans at organisational and service level across all sites. An experienced Business Continuity Manager from YAS joined LTHT on a part-time secondment to the role of Resilience Manager (Business Continuity). Her remit was to assess the maturity of the organisation s Business Continuity Management System against the International Standards for Business Continuity and Societal Security (ISO 22301). A recommendations report was submitted to the Deputy Chief Executive/Chief Nurse for consideration to improve business continuity management within the Trust. Meetings were held with a number of CSU senior management teams to review and provide advice on CSU business continuity plans and arrangements. She provided the Trust with a new business continuity plan template and key information which will improve how the Trust writes business continuity plans. A key priority for 2017/18 is to begin implementing the new CSU business continuity impact analysis and business continuity plan template across the Trust. 7.3. Cyber Security The Trust is committed to ensuring the safety and integrity of personal information held on Trust Information Systems. The 2016 review of security tools and practises identified areas of potential weakness. Work has been undertaken in 2017 to address these weaknesses. A report documented the Trust s compliance with the Ten steps to cyber security as well as making recommendations to achieve compliance. Work is underway to implement these recommendations including advanced anti-virus and malware, breach detection, advanced backup and data security. Further elements will be implemented including network access control, and advanced intrusion detection and prevention. A series of in-depth cyber penetration tests have also been undertaken in conjunction with the Trust audit department and Mersey Internal Audit Agency who specialise in commissioning audits of this type. The work covered the following areas: 9

Internet attack - replicating the malicious attack available to any of the internet three billion plus users. Based upon nine internet facing IP addresses. N3 - replicating a malicious attack by any of the circa 1.3 million N3 connected users. Based upon 27 N3 facing IP addresses. On-site (internal) - replicating an attack by an unauthenticated user directly connecting to the network from within the premises. Based upon a vulnerability assessment of 20 systems. Firewall - A review of external facing firewall rules. WiFi - replicating an attack by an unauthenticated user directly connecting to the wireless network from within the premises. Social Engineering - replicating an email phishing attack on the Trust. The tests resulted in a series of reports highlighting areas of weakness and detailed recommendations. The Trust has acted upon these recommendations tightening existing security as well as feeding the learning into the wider proposals for increased security tools. 8. Training Programme The Trust s EPRR training programme includes Level One Major Incident Plan Awareness Training, Level Two Command and Control Training and Leeds Hospitals Crisis Communication Training. Level One Major Incident Plan Awareness Training was provided as part of mandatory fire training and encourages staff to seek out their roles and responsibilities in response to an incident. Level Two Command and Control Training was aimed at staff with managerial on call commitments and for staff who would be directly involved in an incident. Training includes how to access and set up the command and control rooms utilised for Gold (Strategic) and Silver (Tactical) Command. The CSU General Manager has the responsibility to ensure staff know how to access and establish the Bronze (Operational) Command rooms. The Emergency Preparedness Team administers the Leeds Hospital Crisis Communication system. This system allows the Trust to simultaneously contact multiple groups via different communication paths such as email, text message and voice message. Ward and department phones on every hospital site are accessible on the system. Training was provided by the Emergency Planning Officer to staff across the Trust involved in an incident response including Clinical Site Managers, Estates, Facilities, Switchboard, Communications and Emergency Department staff. 9. Exercise Programme The NHS England EPRR Framework and NHS England Core Standards places a requirement on acute trusts that a communications exercise should be undertaken every six months, table top exercise annually and a live exercise at least every three years. The following describe how the Trust has met these requirements. 9.1. Communications Exercises A Switchboard major incident communication test was undertaken every three months during 2016/17. The key contact details within the Trust Major Incident Plan were tested every six months. CSUs were required to undertake a six monthly test of the CSU 10

communication cascade which will be formally reported during 2017/18 as part of the CSU Bronze Command assurance process. 9.2. Table Top Exercises The Trust has business continuity plans in place to maintain continuity of key services in the face of unexpected disruption. On Friday 16th October 2015 and Saturday 27th February 2016, Clarendon Wing at the LGI which holds some of the Trust s theatres, paediatric intensive care, and is home to the Children s Hospital, experienced two serious power failures. The first power failure in 2015 was caused by a fault found during routine testing of the emergency generator which supplied power to Clarendon Wing. The subsequent power failure in 2016 was caused by a water leak from corroding pipes above the low voltage switch room. During both incidents, contingency plans were put in place until the Trust was assured that the electrical supply was stable and patients were safe. For instance, a number of inpatients were transferred to other areas of the hospital and some non-urgent appointments were rescheduled. Patient safety was not compromised and business as usual resumed promptly following the power failures. Following learning from these two incidents, the Associate Director of Estates and the Resilience Manager continued to engage throughout 2016/17 with CSUs to improve understanding of the Trust electrical infrastructure at a local level. In April 2016, a business continuity table top exercise was held with the theatres team. The key objectives were to improve the knowledge and understanding of interruptible and uninterruptable power supply, agree an action plan for theatre evacuation, test communication pathways and identify gaps in planning. In May 2016, table top exercises were provided to Clinical Site Managers. Prior to the exercise, the Emergency Preparedness Team delivered Level Two Command and Control Training and Leeds Hospitals Crisis Communication System Training. The North East Counter Terrorist Unit presented Stay Safe Training and the Clinical Site Managers were taken through a table top exercise involving a shooting scenario. A similar session was provided to General Managers in September 2016 which in addition included a presentation from Leeds City Council on the support and resources which the council can provide including reception centres and transport. Later in the year in November 2016, Clinical Site Managers attended table top exercises based on a bomb threat scenario in the hospital. The first exercise was delivered by the Emergency Preparedness Team with a North East Counter Terrorist Unit presentation and involved a review of the LTHT Bomb Threat Policy. The subsequent exercise was delivered by the North East Counter Terrorist Unit. This involved an interactive media simulation involving a suspect package brought into a hospital. The Clinical Site Managers were given the opportunity to consider the context and determine the response. This was reviewed in the context of the Trust plans, policies and procedures. After the Pathology Telepath IT system failure, a Pathology business continuity table top exercise was delivered in March 2017 by the Emergency Preparedness Team to key staff within Pathology. The presentation explained business continuity and the staff were provided with a loss of IT systems scenario. During 2016/17, the Trust Fire Safety Team carried out 27 joint exercises with West Yorkshire Fire Service. They also provided 31 table top exercises to CSUs based on fire 11

scenarios that reflect a large scale evacuation of their areas and the resultant business continuity impact. The Fire Safety Team continually review the Trust s operational response to fire incidents, fire information boxes, information available to the fire service and Trust Fire Response Team tasks. Appropriate training has been reviewed and delivered to all staff and in particular those with specific responsibilities in response to fires. 9.3. Live Exercise A key priority in 2016/17 was to repeat the St. James s Hospital live multi-agency decontamination exercise (Operation Molly) at the LGI site in order to test the LGI response, apply learning from Operation Molly and further engage with partner agencies and stakeholders. Members of the Trust CBRN/Hazmat Subgroup led by an Intensive Care Consultant and Consultant in Emergency Medicine/Emergency Department Major Incident Clinical Lead planned and delivered the live decontamination exercise on the LGI site. The exercise known as Operation Jenny took place on Saturday 16th July 2016. This was the Trust s fourth live decontamination exercise undertaken in close collaboration with West Yorkshire Fire and Rescue Service, West Yorkshire Police, Leeds City Council and YAS with the help of 53 volunteers who pretended to be contaminated casualties. The Emergency Department and West Yorkshire Fire and Rescue Service set up their decontamination equipment outside the Emergency Department. A Police Documentation Team was available within the Emergency Department to obtain casualty details after decontamination. Leeds City Council provided volunteer casualties with a presentation on casualty welfare arrangements following an incident. A multi-agency hot debrief and cold debrief were held after the exercise to gather learning. Unfortunately, the Emergency Department submersible pump which is used to pump water through the Trust decontamination unit failed during the exercise. This experience highlighted the importance of working in partnership with the fire service in response to a major CBRN/Hazmat incident. Since the exercise, the Emergency Department submersible pump has been repaired, a backup pump is accessible and Estates undertake a regular schedule of testing. A key priority in 2017/18 is to run an internal live decontamination training exercise focusing on the LTHT decontamination equipment and process to improve the hospitals response to a contamination incident. 10. Mass Casualty Exercises A key priority in 2016/17 was to strengthen the Trust's Mass Casualties Plan by using external specialist advice and collaborating with key clinical leads to oversee the development of a joint CSU operational plan in response to a mass casualty terrorist incident. The Consultant in Emergency Medicine/Emergency Department Major Incident Clinical Lead developed a mass casualty incident appendix which has been added to the Emergency Department Major Incident Plan and supports the Trust s Mass Casualties Plan. The LTHT Mass Casualties Plan has been updated to incorporate learning from several exercises which the Trust participated in throughout 2016/17. Whilst it falls outside the scope of this annual report, clinical learning from a number of terrorist atrocities in the UK will be embedded into mass casualty arrangements. 12

10.1. Exercise Day Hawk On 11th October 2016, West Yorkshire Police and Leeds City Council hosted Exercise Day Hawk, a multi-agency table top exercise with a scenario involving a terrorist attack in Leeds. The aim was to test the Leeds City Council emergency management plans. The exercise allowed partners to discuss how each organisation would respond to such an incident. Clinical leads from LTHT Major Trauma Centre and the Emergency Preparedness Team representatives attended the exercise. This exercise was beneficial for the Trust as it tested assumptions in the mass casualty response plan and strengthened engagement with partner agencies. 10.2. Exercise Spiral LTHT hosted Exercise Spiral on 9th November 2016 which was a West Yorkshire Major Trauma Network Emergo exercise delivered by Public Health England. The Emergo Train System was used to facilitate the exercise. This system involved the use of large magnetic whiteboards to represent hospital departments. Magnetic puppets and symbols represented casualties, staff, equipment and resources. This allowed visual representation of hospital staff and resources available at the time during the incident. The aim of the exercise was to focus on the response of the West Yorkshire Major Trauma Network to a mass casualty incident resulting in a large number of seriously injured casualties. Medical and nursing teams were represented from the West Yorkshire Major Trauma Centre and Trauma Units. Separate control teams were in place for the Major Trauma Centre, each Major Trauma Unit and the ambulance service. Since the exercise, local and regional plans for the management of mass casualties are being further developed and refined following the lessons identified from the exercise. 10.3. Exercise Elsa The Trust was represented at Exercise Elsa on 22nd March 2017 which was delivered in Manchester supported by NHS England and Public Health England. The exercise coincided with the terrorist attack on Westminster in London which further emphasised the importance of planning, exercising and learning in order to improve the preparedness and response to a terrorist incident. The exercise explored the challenges that incidents resulting in large numbers of casualties could present to health providers in the NHS in the North region. A number of valuable learning points were identified which will benefit the collaborative working during the response to a mass casualty incident. A key priority in 2017/18 is to embed learning from exercises and recent terrorist incidents in the UK to continue to strengthen the Trust's mass casualty preparedness arrangements. 11. Pathology Telepath IT System Failure On 16th September 2016, the Pathology Telepath IT system failed resulting in a significant business continuity incident for the Trust with wide-scale impact on patients requiring access to Pathology services from within LTHT, across Bradford Teaching Hospitals NHS Foundation Trust and primary care services across Leeds and Bradford. Due to the potential risk to patient safety and impact on service delivery, the Trust activated internal business continuity arrangements on Sunday 18th September 2016. Regrettably, 13

many non-urgent elective and outpatients appointments were rescheduled in order to maintain the safe delivery of urgent and acute care to inpatients. Similarly many patients attending primary care appointments for pathology tests were unfortunately rescheduled. The incident response lasted many weeks, requiring a strong focus and the support of many colleagues and external partners to ensure patient safety and business continuity. The incident response was stood down on 10th October 2016 and a Recovery Working Group was established to monitor and report on the work to fully restore Pathology IT systems, restore and reconcile data, and ensure future system resilience. In parallel to the working group, an independent investigation was undertaken to establish the root cause of the Telepath IT system failure. Internal staff and multi-agency colleagues involved in or affected by the incident were invited to submit feedback. A multi-agency formal debrief took place on 13th December 2016. Lessons identified were transformed into recommendations and actions to enable lessons to be learned. A wider audit of IT system resilience was taken forward as a work programme beyond the remit of the Recovery Working Group. A key priority for 2017/18 is to improve business continuity and disaster recovery within Pathology. Plans will be developed at departmental level with a focus on stakeholder communications, formalising mutual aid arrangements with Sheffield Teaching Hospitals NHS Foundation Trust and ensuring a robust local training and exercising plan in place. 12. Industrial Action Junior doctor members of the British Medical Association took part in a number of nationally coordinated industrial action during 2015/16. This action continued in April 2016 after ongoing concerns about the new contract and the Government s decision to impose this contract from August 2016. The Industrial Action Management Group chaired by the Deputy Chief Medical Officer/Medical Director (Operations) led planning to minimise disruption to patient care and ensure the hospitals ran safely and effectively during periods of industrial action. A Hospital Control Team (Silver Command) was set up during the periods of industrial action to respond to any unexpected event or operational pressures and to collate information for NHS England. Staff maintained safe patient care during the industrial action. Unfortunately, it was necessary to reschedule some non-urgent appointments, although staff worked hard to keep the number as low as possible. The British Medical Association announced further periods of industrial action with a full withdrawal of labour. Extensive planning was undertaken by the Industrial Action Management Group in order to prepare for the possible action in April, September, October, November and December 2016. Regular information was formally submitted to NHS England. The British Medical Association subsequently called off planned industrial action. Due to the extensive work undertaken throughout the junior doctor contract dispute, LTHT has a robust Industrial Action Management Plan in place which can be utilised for future periods of industrial action. 13. Event Briefings During 2016/17, Leeds hosted a number of international and large scale sporting, music and community events such as the Columbia Threadneedle World Triathlon, Leeds 10k, Sky Ride, Leeds Festival, West Indian Carnival, Leeds Light Night and Leeds Marathon. 14

Events which had the potential to cause direct risk to access or service delivery were identified and business continuity arrangements were put in place. Event briefings were prepared in close collaboration with Leeds City Council to advise staff of the disruption and key contact details of event and medical provision. In 2017/18, a key priority will be to horizon scan, risk assess and work with partner agencies to review and develop contingency plans in light of international and large scale events that may compromise patient safety. 14. Influenza Influenza can easily spread from person to person and cause health complications. Those who work in healthcare have a greater risk of receiving influenza compared to the general population due to the nature of their work. They can transmit influenza to patients who may be particularly vulnerable to health complications. The influenza vaccine can protect staff, patients and the public. During the 2016/17 flu season, the Occupational Health Team worked alongside 99 peer vaccinators from wards and departments across Leeds Hospitals to vaccinate frontline healthcare workers as part of the annual flu immunisation programme. A total of 9,796 (79.9%) vaccines were given to frontline healthcare workers in 2016/17. The Occupational Health Team provided 6,662 (68%) and peer vaccinators administered 3,134 (32%) vaccines to frontline healthcare workers. The Department of Health target of 75% of all healthcare workers vaccinated was reached on 30th November 2016 and the percentage of frontline staff vaccinated was improved by 4.5% in comparison to 2015/16. Overall 12,231 (76.7%) of LTHT staff were vaccinated which was an increase of 603 vaccinations in comparison to the previous year. These achievements have contributed to reducing serious illness and death caused by the influenza virus. Leeds Hospitals will continue to encourage the uptake of the flu vaccination among staff in 2017/18, promote the clinical response to the influenza virus, review and strengthen the influenza strategy. 15. Conclusion & Key Priorities for 2017/18 Throughout 2016/17, the risk of emergencies has been assessed, emergency and business continuity plans have been improved. The Trust has been represented at multi-agency meetings and exercises to facilitate information sharing. A number of mass casualty exercises have been undertaken internally and externally to strengthen the multi-agency response to a mass casualty incident. Business continuity arrangements were enacted in response to the Pathology Telepath IT system failure, nationally coordinated industrial action by the British Medical Association and numerous large scale events in Leeds. Learning from training, exercises, incidents, events and best practice has informed a number of key priorities for 2017/18: 1. Further improve and develop the areas in the EPRR core standards which relate to mass casualty, evacuation and business continuity plans. Continue to ensure the Trust achieves substantial compliance against the EPRR core standards. 2. Continue to ensure that EPRR threats and hazards are monitored to ensure patient safety is maintained as well as ensuring statutory and non-statutory EPRR duties are fulfilled by the Trust. 15

3. Ensure that the Trust continues to be represented by the Accountable Emergency Officer and Emergency Preparedness Team at local and regional EPRR forums. 4. Continue to risk assess and develop plans at a Trust-wide and CSU/corporate level throughout 2017/18. 5. Begin implementing the new CSU business continuity impact analysis and business continuity plan template across the Trust. 6. Run an internal live decontamination training exercise focusing on the LGI decontamination equipment and process to improve the hospitals response to a contamination incident. 7. Embed learning from exercises and recent terrorist incidents in the UK to continue to strengthen the Trust's mass casualty preparedness arrangements. 8. Improve business continuity and disaster recovery within Pathology. 9. Horizon scan, risk assess and work with partner agencies to review and develop contingency plans in light of international and large scale events that may compromise patient safety. 10. Continue to encourage the uptake of the flu vaccination among staff, promote the clinical response to the influenza virus, review and strengthen the influenza strategy to protect patients, public and staff from the influenza virus. 16. Recommendations Trust Board is asked to: Receive and note this EPRR annual report and the assurance it provides to support the ongoing work of the EPCG its subgroups and the Emergency Preparedness Team. Sharon Scott Resilience Manager Vicky Taylor Emergency Planning Officer August 2017 16

Appendix 1 NHS England EPRR Statement of Compliance Yorkshire and the Humber Emergency Preparedness, Resilience and Response (EPRR) assurance 2016-17 STATEMENT OF COMPLIANCE Leeds Teaching Hospitals NHS Trust has undertaken a self-assessment against required areas of the NHS England Core Standards for EPRR v4.0 Following assessment, the organisation has been self-assessed as demonstrating Substantial Compliance (from the four options in the table below) against the core standards. Compliance Level Evaluation and Testing Conclusion Full Arrangements are in place that appropriately address all the core standards that the organization is expected to achieve. The Board or Governing Body has agreed with this position statement. Substantial Arrangements are in place however they do not appropriately address one to five of the core standards that the organization is expected to achieve. A work plan is in place that the Board or Governing Body has agreed. Partial Arrangements are in place, however they do not appropriately address six to ten of the core standards that the organization is expected to achieve. A work plan is in place that the Board or Governing Body has agreed. Non-compliant Arrangements in place do not appropriately address 11 or more core standards that the organization is expected to achieve. A work plan has been agreed by the Board or Governing Body and will be monitored on a quarterly basis in order to demonstrate future compliance. Where areas require further action, this is detailed in the attached core standards improvement plan and will be reviewed in line with the organisation s EPRR governance arrangements. I confirm that the organisation has undertaken the following exercises on the dates shown below: A live exercise (required at least every three years) 16 July 2016 A desktop exercise (required at least annually) 19 April 2016 A communications exercise (required at least every six months) 16 July 2016 I confirm that the above level of compliance with the core standards has been confirmed by the organisation s board / governing body. Signed by the organisation s Accountable Emergency Officer Date of board / governing body meeting 15 September 2016 Date signed 15 September 2016 17