NHS Ayrshire & Arran Adverse Event Management: Review of Documentation Supplementary Information Requested by NHS Ayrshire & Arran April 2013
Background In February 2012, the Scottish Information Commissioner published a Decision tice (036/2012) that was critical of NHS Ayrshire & Arran s response to a Freedom of Information (Scotland) Act appeal. This decision focused on a request which Mr Wilson, an employee of NHS Ayrshire & Arran, had made for copies of Critical Incident Review Reports and Significant Adverse Event Review Reports completed since January 2005, together with the action plans arising from the reports. Decision tice 036/2012 required NHS Ayrshire & Arran to disclose the Critical Incident Reviews and Significant Adverse Event Reviews and their related action plans to Mr Wilson. Within the Information Commissioner s report from the investigation he describes At the very least, a significant failure of records management. Since the publication of this report allegations have been made of criminal behaviour by NHS Ayrshire and Arran. The allegations suggest that the NHS Board created adverse event documentation in response to the Information Commissioner s investigation and not contemporaneously as part of the local routine adverse review process. The Information Commissioner s report described a significant amount of confusion and poor records management around the creation and storage of adverse event files within the case documentation looked at. The report also highlighted the difficulty in locating files to be able to provide a clear auditable trail. Following the Information Commissioner s report, the then Cabinet Secretary for Health, Wellbeing and Cities Strategy instructed us to carry out a review of the approach taken by NHS Ayrshire & Arran in managing significant adverse events. Our review began in February 2012 and considered the current significant adverse event management system in considerable depth from January 2009 until March 2012. This time period covered 57 significant adverse events and differed slightly from the Information Commissioner s cohort of cases. This work resulted in the publication of our report: The Management of Significant Adverse Events in NHS Ayrshire & Arran, in June 2012. One aspect of our review methodology was to confirm that the detailed sample of seven cases had action plans that were produced within the same time period as the conclusion of the investigations. Our review team gathered the necessary evidence and confirmed that these action plans were in existence within these times frames. Since the publication of the Information Commissioner s and our report there has been continued attention, from a variety of sources, about the findings of these reports. A particular focus of this attention has been on the existing documentation of the critical incident review and significant adverse event review reports and action plans listed in Appendix 3 of our report. Due to the continued attention to this documentation, the Chief Executive of NHS Ayrshire & Arran asked us to undertake a supplementary review of all documentation (from 2002-2012) to seek assurance as to the timely creation of the action plans of the 89 cases listed in Appendix 3 of our report. 1
Method The primary objective was to confirm that there was an audit trail of the creation and subsequent development of critical incident review and significant adverse event review action plans following the incident occurrence, investigation and report. Healthcare Improvement Scotland was given access at the University Hospital Ayr to the electronic folders of the 89 cases. Additional papers were sent through by email to us over the subsequent days including governance papers and additional specific case information. Following a brief demonstration by an NHS Ayrshire & Arran staff member to help with navigating the various folders, we physically opened and reviewed electronic documents, for example, Datix reports, investigation and review reports, email correspondence, meeting minutes and papers, to ascertain if there was supporting evidence of the date documents were created, circulated and discussed. The Information Commissioner s and our report noted that there were local issues with document control and storage within the board, particularly with respect to older cases. Therefore, we expected that there would be limitations to the method we adopted and we would encounter gaps in the documentation trail. This is reflected in the findings below. Findings As stated above, we recognised on initiating this documentation review that there would be limitations to our approach, due to the previously noted historical document control issues in NHS Ayrshire & Arran. We have therefore approached the presentation of our findings by categorising the information we saw into four levels of assurance. 1. Adequate information The review of documentation confirms the around the timeframes of the incident. This included 52 cases with reports and action plans presented at governance committees. Thirteen cases were not presented at Committees, but showed documentary evidence of their development through a variety of dated documents, including emails and/or meeting minutes. One case is at the draft report stage and evidence confirms discussions taking place on the development of the action plan. 2. Partial information The review of documentation confirms that more than one version of an action plan exists however no version control/dates and no other documentation that would confirm the development around the timeframe of the incident. 3. Insufficient information The review of documentation confirms that an action plan exists however no version control/dates and no other documentation that would confirm the development around the timeframe of the incident. 4. Unable to determine The review of the documentation confirms that no action plan was found or an action plan template was present with recommendations from the report but no associated actions. For one case, no recommendations were made therefore no action plan was developed. 2
NB: Whilst there is documentation to support the timely development of the actions, we have made no judgement on their content and no verification on their progression or current position. Table 1 below provides an outline of the high level findings. A detailed list against each case reference is provided in Appendix 1. Table 1: High level findings Level of assurance Number and case percentage 1 Adequate information to support the timely development action plans 66 (74%) 2 Partial information to support the timely development of action plans 7 (8%) 3 Insufficient information to support the timely development of action plans 3 (4%) 4 Unable to determine 13 (14%) 3
Appendix 1 - Summary of case information for documentation review DB 32 2001 Full 1 Adequate information to support the timely 91 2003 Full Adequate information to support the timely 96 2003 Full Adequate information to support the timely 28 2003 Full Partial information to support the timely 31 2004 Full Adequate information to support the timely 36 2004 Full Adequate information to support the timely 52 2004 Full Unable to determine action plan found. 2 actions plans, one v 06 date. Summary and action plan documentation from v 2006. evidence of presentation. 3 action plans, Aug 03 and 2007 date on most recent. Summary report from Aug 2008. evidence presentation. 3 action plans, Aug 03 and 2007 date on most recent. te of review meeting shows report with actions discussed. evidence presentation. 2 actions plans, one dated June 07 (in report June 07) other has no date. evidence of presentation. 2 action plans, one dated April 06 updated Mar 2012 and one dated last review Mar 2012. 3 action plans but no dates. Suggested during 2004-2006. Mental Welfare Commission evident. Final report dated 2005. evidence of presentation. 37 2005 Full Partial information to support the timely Final report June 2005 no action plan included. Recommendations into action plan template 2005 (no date), actions added Aug 2005. Word document of text from an email in v 2007 asking for update on actions, updated plan with column noting this done retrospectively in Mar 2012. 63 2005 Full Unable to determine action plan found. 64 2005 Desktop 2 Insufficient information to support the timely 2 actions plans, no dates. Action plan on website last review dated 26/03/2012. 1 A full review is an in-depth review of the event, involving the establishment of a review team, the application of root cause analysis techniques, resulting in the production of a report with detailed recommendations/actions. 2 A desktop review involves a trained reviewer conducting an initial review of an event to identify whether there is a need to recommend full significant adverse event review. It includes recommendations from specialists when available. The report is presented to the requesting Executive Director who determines the next steps. 4
71 2005 Full Adequate information to support the timely 2 2006 Full Adequate information to support the timely 4 action plans dated v 05 - Jan 07. 2007 email discussing action plan and action plan update presented at a meeting in 2006. 3 action plans dated July 06-Sept 06. evidence of presentation. 3 2006 Full Adequate information to support the timely 27 2006 Full Adequate information to support the timely 34 2006 Full Partial information to support the timely 35 2006 Full Adequate information to support the timely 38 2006 Full Partial information to support the timely 39 2006 Full Adequate information to support the timely 42 2006 Full Adequate information to support the timely 55 2006 Full Adequate information to support the timely 29 2006 Full Adequate information to support the timely 3 action plans dated April 08 and June 08. Report June 2008 and other action plan with no date. evidence of presentation. 3 action plans one dated Aug 07. Action plan updated but no date, email Jan 2008 saying actions complete. 4 actions plans but no dates. presentation. 5 action plans dated Oct 06-Sep 07. Presented to Clinical Governance Committee (CGC) July 07. 2 actions plans first dated Oct 06 (with report) other with no date. evidence of presentation therefore unable to verify dates. 3 action plans one with May 07 date. Presented CGC v 07. 3 action plans dated June 06 - Aug 07. Revised action plan post report but no date. Clinical Governance action plan monitoring template (12/7/07/) & completed 17/8/07 6 action plans dated Sept 06-Feb 12. Presented CGC v 2006. Action plan present. Various reports and action plan with no date. Memo to Medical Director filename Jan 08. 5
33 2007 Desktop Adequate information to support the timely 26 2007 Full Partial information to support the timely 19 2008 Full Adequate information to support the timely 20 2008 Full Adequate information to support the timely 21 2008 Full Adequate information to support the timely 23 2008 Desktop Partial information to support the timely 24 2008 Full Unable to determine action plan found. CGC minute 04/07/07 supports case being presented report and action plan. 2 action plans one no date and Mar 2012. evidence of presentation therefore unable to verify dates. 4 action plans first dated Oct 08. Presented to CGC April 09. 3 action plans with no dates but presented to CGC v 08. 4 action plans dated Dec 08 - Aug 11 presented to CGC Feb 09. 3 actions plans but 2 with no dates and one within report from March 2008. evidence of presentation therefore unable to verify dates. 30 2008 Full Partial information to support the timely 70 2008 Full Adequate information to support the timely 48 2008 Full Adequate information to support the timely 47 2008 Full Adequate information to support the timely Report and action plan April 2008. other information therefore unable to verify dates. 7 action plans no dates - Feb 11. Presented CGC May 10. 2 action plans one dated Aug 08 one post report as updated on progress. 2 action plans Oct 08 and other no date. Presented CGC Feb 09. 68 2009 Full Unable to determine action plan found. 6
54 2009 Full Unable to determine recommendations were made therefore no action plan was developed. 51 2009 Full Unable to determine action plan found. 45 2009 Full Adequate information to support the timely 3 action plans one dated April 09 other 2 no dates. Presented to CGC Aug 09. 44 2009 Full Adequate information to support the timely 3 action plans one Dec 09 others no dates. Presented CGC Mar 10. 43 2009 Desktop Unable to determine action plan found. 41 2009 Full Adequate information to support the timely 40 2009 Full Adequate information to support the timely 18 2009 Full Adequate information to support the timely 17 2009 Full Adequate information to support the timely 16 2009 Desktop Adequate information to support the timely 15 2009 Full Adequate information to support the timely 14 2009 Full Adequate information to support the timely 13 2009 Full Adequate information to support the timely 16 action plans Feb 10 - Mar 12. Presented CGC Feb 10. 2 action plans dated Aug 09 and Feb 11. Presented to CGC Sept 10. 2 action plans dated Mar 09 other no date. Presented CGC June 09. 3 action plans one dated April 09 other 2 no dates. Post report updates evident (2nd report update 27/3/12). 7 action plans dated Aug 09 - Feb 11. Presented CGC Sept 10. 6 action plans dated Aug 09 - Feb 11. Presented CGC Jan 10. 6 action plans dated Oct 09-Oct 11. Update presented CGC Sept 10. 4 action plans dated Sept 09 - Jan 11. Presented Oct 09. 7
12 2009 Full Adequate information to support the timely 11 2009 Full Adequate information to support the timely 10 2009 Full Adequate information to support the timely 9 2009 Full Adequate information to support the timely 8 2009 Desktop Unable to determine action plan found. 5 2009 Full Adequate information to support the timely 4 2009 Full Adequate information to support the timely 97 2010 Desktop Adequate information to support the timely 94 2010 Full Adequate information to support the timely 93 2010 Desktop Unable to determine action plan found. 6 action plans dated Sept 09 - Feb 11. Presented CGC Mar 10. 5 action plans dated Dec 09 - Feb 11. Presented CGC May 10. 4 action plans 1st not date other dated Feb 11. Presented CGC May 10. 3 action plans Apr 10 other no date. Update presented CGC Sept 10 3 action plans dated Apr 10 - Feb 11. Update presented CGC Sept 10. 3 action plans dated April 10 - Feb 11. Update presented CGC Sept 10. 2 action plans dated March 12 and Oct 12. Presented CGC meeting June 12. 4 action plans dated Dec 10 - May 11. Presented to CGC Sept 11. 92 2010 Full Adequate information to support the timely 90 2010 Full Adequate information to support the timely 3 action plans dated July 11 - March 12. Presented CGC v 11. 3 action plans dated Aug 11 - v 11. Report presented CGC v 11 but not action plan. Version file name suggest presentation at CGC but CGC papers show action plan omitted. 3 versions with minor updates against status. 8
87 2010 Full Adequate information to support the timely 3 action plans dated July 2012 no other dates. Presented CGC Aug 2012. 86 2010 Full Unable to determine 3 action plans one date April 2012. Blank action plan in report. Blank action plan extracted and saved separately. 3rd action plan changes to recommendations. information to verify. 80 2010 Desktop Adequate information to support the timely 77 2010 Full Adequate information to support the timely 75 2010 Full Adequate information to support the timely 73 2010 Desktop Unable to determine action plan found. 1 action plan Oct 12. Blank action plan in report. Report with no action plan presented June 12. Action plan presented 1/11/12. 2 action plans Feb 12 and Oct 12. Presented CGC June 2012 3 action plans one dated Oct 10. Presented CGC v 10. 72 2010 Full Adequate information to support the timely 69 2010 Desktop Adequate information to support the timely 67 2010 Full Adequate information to support the timely 66 2010 Full Adequate information to support the timely 62 2010 Full Adequate information to support the timely 4 action plans dated Dec 10 - Feb 11. Presented CGC May 11. 3 action plans dated July 10 - Mar 12. Presented CGC v 10. 6 action plans latest dated v 11. Presented CGC June 11. 5 action plans dated Jun 11 - Jun 12. Presented CGC June 12. 3 action plans dated Feb 11 - Apr 11. Presented CGC v 11. 61 2010 Full Unable to determine action plan found. 9
60 2010 Desktop Adequate information to support the timely 59 2010 Full Adequate information to support the timely 58 2010 Full Adequate information to support the timely 57 2010 Full Insufficient information to support the timely 56 2010 Full Adequate information to support the timely 7 2010 Full Adequate information to support the timely 3 action plans dated v 10 - Mar 12. Presented CGC Jan 11. 5 action plans dated v 10 - v 11. Presented CGC Jan 11. 2 action plans dated Mar 12 - Aug 12. Presented CGC v 12. 3 action plans first no date one dated Oct 11 one date Sept 12. Report presented to CGC Feb 2012 but action plan not included. Subsequent action plans no evidence of presentation. 3 action plans one dated v 10, 2 no dates. Presented CGC Jan 11. 2 action plans one dated Oct 10 other no date. Presented CGC v 10. 6 2010 Full Adequate information to support the timely 4 action plans dated July 10 - May 11. Presented to CGC v 10. 74 2010 Desktop Unable to determine action plan found. 95 2011 Full Insufficient information to support the timely 89 2011 Full Adequate information to support the timely 88 2011 Full Adequate information to support the timely 85 2011 Full Adequate information to support the timely Draft report May 2012, incident 2011. presentation. 2 action plans dated Feb and 12 June 12. Report to CGC v 11 but no action plan so presented again June 2012. 3 actions plans one dated Oct 2012. Presented to CGC in report Aug 2012. 4 action plans dated Dec 11 - v 12. 1st report with action plan v 11, action plan agreed v 12. evidence of presentation. 10
84 2011 Full Adequate information to support the timely 83 2011 Full Adequate information to support the timely 82 2011 Full Adequate information to support the timely 81 2011 Desktop Adequate information to support the timely 79 2011 Full Adequate information to support the timely 78 2011 Full Adequate information to support the timely Draft report May 2012 with evidence of discussion re developing action plan. 2 action plans one July 2012. Presented to CGC Aug 2012. 4 action plans dated Oct 11-May 12. Presented to CGC Feb 2012. 2 action plans one dated Oct 2012 but not yet presented. 3 action plans dated Mar 12 - Sep 12. Presented to CGC v 2012 (date on action plan 22/10/2012). Various versions of reports with last report having 1 action plan Oct 12. presentation. 76 2011 Full Adequate information to support the timely Report and action plan still draft, separate action plan dated 18/9/12. Yet to be presented 11