Appendix I: Risk Summit Attendees
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A Risk Summit was held on 21 June 2013 to discuss the priority findings and actions of the Rapid Responsive Review (“RRR”) of Burton Hospitals NHS Foundation Trust.
This report provides a summary of the discussion held, including the Trust response to the findings, any support required from the risk summit attending organisations, including the regulatory bodies and the agreed actions and next steps.
Overview of review process
On 6 February 2013, the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the basis that they have been outliers for the last two consecutive years on either the Summary Hospital Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio
(HSMR)
1
.
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
1)
Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the patients in each of the hospitals, and this is reflected in the reports. The Panel also considered independent feedback from stakeholders related to the Trust, received through the Keogh review website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the interest of patients first at all times.
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Definitions of SHMI and HSMR are included at Appendix I of the full Rapid Responsive Review report published here http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
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Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid responsive reviews and risk summits. The process was designed to:

Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.

Identify: i. Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken. ii. Any additional external support that should be made available to these Trusts to help them improve. iii. Any areas that may require regulatory action in order to protect patients.
The review followed a three stage process and this report documents the conclusions of Stage 3:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review stage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/publishedreports.aspx

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators, following training, visited each of the 14 hospitals and observed the hospital in action. This involved walking the wards and interviewing patients, trainees, staff and the senior executive team.
The two day announced RRR visit took place at the Trust’s main site on Thursday 23 and Friday 24 May 2013 and the unannounced visit was held on the evening of Monday
3 June 2013. A variety of methods were used to investigate the Key Lines of Enquiry (KLOEs) to enable the panel to analyse evidence from multiple sources and follow up any trends present in the Trust’s data pack. The KLOEs and methods of investigation are documented in the Rapid Responsiveness Review Report (RRR) for Burton
Hospitals NHS Foundation Trust. A full copy of the report was published on 16 July 2013 and is available online: http://www.nhs.uk/NHSEngland/bruce-keoghreview/Pages/published-reports.aspx

Stage 3 – Risk summit .
This stage brought together a separate group of experts from across health organisations, including the regulatory bodies. The risk summit considered the report from the
RRR, alongside other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to the hospitals concerned. (Please see Appendix I for a list of attendees).
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The Burton Hospitals NHS Foundation Trust Risk Summit was held on 21 June 2013. The meeting was Chaired by Paul Watson (Regional Director - Midlands and East, NHS
England) and focussed on supporting the Trust in addressing the urgent actions identified to improve the quality of care and treatment. The opening remarks of the Risk
Summit Chair and presentation of the RRR key findings were recorded and are available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/publishedreports.aspx
This report documents the Trust response to the priority RRR findings and summarises the discussions and actions arising.
Conclusion and Priority Actions
Whilst the Trust has not identified all the causes behind its excess mortality in the review period, the panel did not find direct evidence that there were quality failings that were causing excess mortality. However, there were a number of urgent issues that increased the risk in the Trust and impacted on the organisation’s ability to provide consistently high quality and safe care and treatment to patients.
The review team identified concerns at the Trust which may impact on the quality of care and treatment being provided to patients, including:

A lack of trust wide understanding of its quality objectives;

Inadequate staffing levels;

Issues with escalation, delegation and clinical supervision;

Shortfalls in learning from serious incidents and complaints including poor communication with patients and staff;

Support for junior doctors; and

Consistent reviews of medical equipment.
The Trust has responded positively to the review process, accepting the findings of the Review Panel and welcomed the support of risk summit members to increase the pace and focus of improvement. It was acknowledged that the Trust was on an improvement journey and some of these actions would take longer to address in their entirety.
Next Steps
As the risk summit focussed on urgent priority actions, the Trust provided a detailed action plan to all outstanding concerns and recommended actions included in the RRR report by 11 July 2013 . Progress against this will be monitored by the local Quality Surveillance Group and a follow up review will be undertaken in November 2013 to review the actions taken by the Trust.
Follow up of the RRR and risk summit action plan will utilise other sources within the system, including CQC and GMC visits. Formal follow up may consist of:

A desktop review – to be discussed with the Trust and timing to be confirmed

A targeted site visit – to be discussed along with number of days of the visit, timing and scope

A report of follow up findings will be issued to risk summit attendees

Consideration, if there are significant remaining concerns, if there is a need to convene a further risk summit.
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Introduction
The following section provides a summary of the Review Panel’s findings and the Trust’s response to the risks identified. The detailed findings are contained in Burton
Hospitals NHS Foundation Trust RRR Report.
Overview of Trust’s response
The Trust’s response was presented by Helen Ashley, Chief Executive, who was also supported by the Medical Director and Director of Nursing. The Trust thanked the panel for their review and reflected that the findings recognised that the organisation was on a development journey . The Trust’s Board and Executive Team had already identified many of the issues found by the panel and was already making improvements. The Trust was committed to providing high quality services for its patients and would continue to progress on its journey and provide ongoing assurance that the issues identified by the review were being addressed.
Summary of Review Findings
1. There was a lack of understanding of th e Trust’s quality objectives, governance structures and processes for quality and patient safety amongst staff in the organisation
The panel saw and heard evidence from frontline staff, including senior clinicians, that there was confusion about the governance processes for quality and patient safety. This included a lack of clarity of divisional and Trust level governance arrangements and feedback mechanisms for complaints and reported incidents.
Staff in a number of focus groups, interviews and ward observations were unable to describe a cross-trust, systematic approach to the collection and reporting of data, its use by the Board to assure itself of quality and patient safety and the feedback mechanisms to support learning and service improvement.
Recommendation
The Board should ensure that there is a systematic approach in place for the collection, reporting and acting upon information on the quality of services
Trust response
The Trust has recently introduced a new ward assurance tool as the foundation for Ward to Board reporting and a new Integrated Performance Report is now in place at
Trust Board, providing Trust Wide and Directorate Level Performance. A Quarterly report on quality objectives along with thematic analysis is now in place at Trust
Board.
The Trust will formally consider feedback from External Quality Governance Review (report received 12 June 2013) in line with review team recommendations and develop a Trust wide Quality Dashboard (Quality at a glance). Further investment to support divisional structures and quality structures (supported by the CCG) will be investigated and the Trust will self assess against Foundation Trust Quality Governance Framework in 6 months time. This will be supplemented by further external / independent assessment as appropriate.
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2. The Trust’s Board needs to improve communication with its front line staff and with patients
A number of communication issues were identified during the review, these were summarised into three main headings:

Communication with patients

Communication with staff

Complaints
Patients reported:
 having to ask the same doctor/nurse the same question several times due to the doctor/nurse not understanding what the patient wanted;
 being moved several times between different wards without being told why by staff members;
 a lack of continuity of clinical staff which meant that situations had to be explained to several staff. The communication between staff members was not thought to be good; and
 communication regarding appointment bookings was thought to be poor.
The panel also noted that some patient notice boards were too cluttered and had the potential to be confusing for patients.
During focus groups, many staff groups felt that Board Exec and Non-Exec Members did not make themselves available on a regular basis to see the quality of services for themselves and heavy reliance was placed on the intranet.
The Director of Nursing and the patient and public listening event both identified that there were many instances where complaints had not been dealt with to the satisfaction of the complainant and that the complaints process was not feeding adequately into the wider governance of assurance for trend analyses, early warnings and feedback to staff.
Recommendation
The Trust should review how it communicates with its staff to ensure that it is using the correct methods of communication and is effectively sharing learning from incidents and complaints reporting with its staff.
Trust response
The Trust has already implemented a weekly review of serious incidents led by DON and MD with Senior Nursing Team. It has committed to invest in the complaints department to enable appropriate and timely responses. The Trust has established a Patient Safety and Patient Experience Committee. A Governance monitoring group has been established focusing on review of SI and complaints trends and themes.
The Trust will now implement and electronic reporting mechanism upgrade to include feedback to reporter and it will conduct an annual review/triangulation of complaints, serious incidents, and quality metrics by ward and department
The Trust will consider a development programme for Ward Managers in line with supervisory status focusing on local resolution of issues and introduce a board to ward programme. Practically, the Trust will relocate its complaints and PALS department onto the main hospital site.
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3. Junior Doctors fed back a number of concerns related to a lack of support from the Trust
Junior doctors highlighted an undermining culture and a lack of senior support both through the Deanery Report and their focus group. There was an observation from the medical team that the ‘bleep goes down the chain, not up’. Most concerning was the culture of junior doctors being asked to certify deaths for patients they had not previously treated or seen.
In addition, there was an allegation that the Bereavement Office was instructing junior doctors to change death certificates so that it did not identify certain causes, such as COPD or pneumonia. The panel formally escalated this to the CQC during the announced visit. CQC visited the Trust on 31 May 2013 to perform an inspection into medical record keeping at the Trust. Following the inspection, the Trust was found to be compliant with the standards and was reported as having an effective system in place to ensure patient's records were appropriately completed.
The Junior Doctors did not feel able to raise their concerns about death certification issues within the organisation prior to our visit.
From a surgical perspective, there is only a first year junior doctor (FY1) and Specialist Registrar (6 Staff grades and 2 Training grades). This means if the senior doctor is in theatre, then the FY1 is expected to look after the wards as well as see new patients in A&E. The rota has recently been adapted to ensure that there are now 2
FY1’s to do this at the weekend, but it means that if the senior doctor is in theatres there is no one able to make decisions about admitting and discharging patients.
Recommendation
The Trust should consider carefully the support that Junior Doctors receive as part of their training and ensure that delegation and escalation are appropriate.
Trust response
The Trust has put in place a junior doctors ’ forum that will take place every 2 months plus access to 1:1s with Post Graduate Tutor, a patient safety forum will now take place every month to which junior doctors will be invited. The foundation doctors have an educational supervisor for the year who for at least 8 months of the year is not their direct clinical supervisor – this will provide an escalation channel for the junior doctors if necessary.
The Trust will establish a pre-meet to existing forums in order that Junior Doctors can discuss their concerns without the presence of Trust representatives, before feeding them back anonymously, if required. In addition the Trust will seek to understand from other Trusts and the Deanery as to further actions and arrangements that could be put in place in order to support Junior Doctors.
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4. There was a concern over medical and nursing staffing levels and skills mix, in particular related to medical middle grades
Our observations, interviews and focus groups during the visit identified a number of issues in relation to medical staffing and skills mix which are summarized as follows:
 A lack of middle grade medical staff and qualified nursing staff, especially out of hours, leaving staff very stretched with many working shifts of 14 hours.

Healthcare Assistants (HCAs) performing tasks that should be performed by a qualified nurse e.g. blood observations.
 Consultant Medical staffing cover at the two Community Hospitals is limited to one day per week, in addition to specialty level cover.
 Ward 44 is only covered by 1 staff grade. Up until recently there was no designated consultant cover which can still be ad-hoc. There is no formal cover for sickness or annual leave. In addition, doctors are expected to travel to the other site if the doctor there is absent.

The Trust needs to undertake further work to affirm its Triage processes. Whilst patients access the Emergency department receptionist as a first point of entry, the policy for triage on admission is through a registered nurse within the department. The existing policy for triage access requires upgrading to make this explicit, and to ensure this reflects service provision.
As a result of a suboptimal staff mix, the panel observed clinical decisions being delegated to an inappropriate level. The lack of medical staffing means that there are no decision makers present at the Trust out of hours. The symptoms of this could be inappropriate admission decisions and lack of discharge out of hours. In addition, since August 2012 there had been a small number of instances where the Trust had been unable to ensure registrar cover at night.
Recommendation
The Trust should consider urgently the staffing levels and mix throughout the Trust (including the Community hospitals), particularly at the middle grades, to address concerns about inappropriate delegation, escalation and lack of decision making.
Trust response
The Trust has reviewed all existing rotas and vacancies, and provided this to the CCG for further assurance. Emergency and Urgent Care Intensive Support Team
(ECIST) has performed a review of the Trust’s Urgent Care Pathway and a decision has been taken to make investment into frontline assessment areas. The Trust has also sought clarity on its medical staffing model at its Community Hospitals and the nursing staff template has been reviewed to ensure equity across 7 day service. The leadership model has been reviewed and further enhanced.
The Trust will complete the recruitment process for both nursing and medical staff into emergency, assessment and specialty areas and finalise rotas for Junior Medical
Staff for August rotation.
The Trust will re-emphasise escalation process for out of hours advice and clinical input.
The Trust will make an application for further Emergency Department middle grade funding from Aug 2014.
The admission criteria for the Community Hospitals are currently under review by a multi disciplinary team, with changes to be agreed within next month. There will also be targeted local nurse recruitment to remove need for temporary staffing.
In addition, the Trust will benchmark its clinical staffing model against other community hospital providers.
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5. The e-rostering system is causing a number of problems for staff, in particular, some nurses are having to work very long shifts
The Trust has implemented an e-rostering system which has received mixed feedback from staff. Some feedback is very negative and some staff ignore the e-rostering system completely as they do not believe that it delivers the right level of patient care.
The change to the shift times and reduction in hand over time has resulted in staff struggling to meet their required hours and can sometimes result in staff working a 14 hour shift to make up these hours. In addition, nursing staff are often working 12 days in a row.
Ward sisters do not retain ownership of the rotas, instead this is done by HR.
Recommendation
The Trust should ensure that the working practices of its staff are safe and sustainable and prevent long shifts or a high number of consecutive working days where possible. It should also review the e-rostering system currently in place and make changes so that it better meets staff and clinical requirements.
Trust response
The Ward establishments were reviewed in February 2013 and the Trust has undertaken focused Registered Nurse recruitment events. The Trust has implemented immediate cessation of ‘long stretches’ as identified by the review team.
The Trust will now undertake an immediate review of current shift pattern and consider overseas’ nurse recruitment. Ward Managers will be released to work in a supervisory status.
Ward managers will start to manage their own e-roster. The Trust will use the AUKUH acuity and dependency programme to identify optimal staffing levels
.
6. Equipment safety checks were not complete on a number of observations
Some areas of the Trust visited were found not to be fully completing relevant safety and equipment checks. In particular, the following examples were noted:

Resuscitation equipment in A&E and paediatrics had not been checked on a number of occasions at the start of May.

Resuscitation trolleys in A&E checked on our unannounced visit (3 June 2013), identified out of date bags of Gelofusine, something that was escalated to the
Charge Nurse immediately. It should be noted that these had an expiry date of April 2013 therefore the robustness of the checks is also in question as these trolleys had been signed off subsequent to this date.
Recommendation
The Trust should review all resuscitation trolleys to ensure they are fully stocked, organised and there are no out of date drugs or fluids. Staff should be reminded of the importance of regular resuscitation equipment checking.
Trust response
A reminder has been sent to all staff of requirement to making clear responsibilities for ensuring resuscitation trolleys are checked. Independent checking of resuscitation trolleys has been added to the internal regulation process in place at all sites.
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Introduction
All attendees agreed the report accurately reflects the current position of the Trust and there was no new information raised. The following section provides a summary of the discussion and actions agreed at the Risk Summit. The discussion and action plan focused on six key areas the Trust should urgently prioritise to improve patient safety and these are documented in more detail in the following table:
Action Plan
Key issue Agreed actions and support required Owner Timescales
1. The Board should ensure that there is a systematic approach in place for the collection, reporting and acting upon information on the quality of services
There was a lack of understanding of the Trust’s quality objectives, governance structures and processes for quality and patient safety amongst staff in the organisation.
2. The Trust should review how it communicates with its staff to ensure that it is using the correct methods of communication and is effectively
Complete actions set out in the Trust presentation and replicated in the ‘Trust
Respo nse’ above (e.g Ward assurance) including triangulation approach.
Increase Trust Board visibility through the following actions:
 Reinvigorate the ‘back to the floor’ programme
 Implementation of the ‘Board to Ward’ programme

Consideration of relocation of the Executive team to the main hospital site
Trust 2 weeks
2 weeks
Updating of the Quality Strategy in conjunction with staff consultation and engagement, putting the patient at the heart of everything the Trust does.
3 months to engage with staff and stakeholders and agree revised strategy
6 months to implementation
The Trust should engage strategically with Healthwatch to understand better how it can communicate with and listen to patients.
.
Trust With immediate effect
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Key issue Agreed actions and support required Owner Timescales sharing learning from incidents and complaints reporting with its staff
The Trust’s Board needs to improve communication with its front line staff and with patients
3. The Trust should consider carefully the support that Junior Doctors receive as part of their training and ensure that delegation and escalation are appropriate
Junior Doctors fed back a number of concerns related to a lack of support from the Trust
4. The Trust should consider urgently the staffing levels and mix throughout the Trust (including the
Community hospitals), particularly at the middle grades, to address concerns about inappropriate delegation, escalation and lack of decision making
There was a concern over medical and nursing staffing levels and skills mix, in particular related to medical middle grades
The Trust should engage with multidisciplinary teams, moving away from ‘staff groups’.
The Trust executive should get out and meet people rather than inviting groups to come and see them.
The Trust should undertake a root and branch review of the complaints system. This should encompass hardwiring of clinical ownership of complaints and executive team involvement.
The Trust should consider the physical location of the complaints team and PALs and the support infrastructure associated with complaints.
With immediate effect
3 months
With immediate effect
The Trust should develop a tactical approach to ensure that junior doctors are appropriate supported within the Trust. This could include building junior doctor support into middle grade job planning to offer an attractive career development package. This may not be universal across all specialities.
Trust 3 weeks
By Sept 2013 The Trust should consider its strategic options to support of junior doctors. This will be included within the Trust wide sustainability review currently being undertaken in conjunction with the CCGs.
The Trust should ensure that other arrangements at put in place to ensure the bleep goes up the chain, not down. This may include asking consultants to stay on site and should be factored into their job planning.
Plan in 4 - 6 weeks
Active in 3 months
The Director of Nursing should review the levels of nurse staffing and take an action plan to the Trust Board in due course.
Trust
(DoN)
Sept 2013
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Key issue Agreed actions and support required Owner Timescales
5. The Trust should ensure that the working practices of its staff are safe and sustainable and prevent long shifts or a high number of consecutive working days where possible. It should also review the e-rostering system currently in place and make changes so that it better meets staff and clinical requirements.
The e-rostering system is causing a number of problems for staff, in particular, some nurses are having to work very long shifts.
The Trust has already ended long shift patterns and implemented workarounds at ward level.
The Trust has put in place arrangements to ensure that Ward Managers become supervisory to prevent this from happening in the future.
The CCG has led an assurance programme to confirm that this has already taken place.
Trust With immediate effect
6. The Trust should review all resuscitation trolleys to ensure they are fully stocked, organised and there are no out of date drugs or fluids. Staff should be reminded of the importance of regular resuscitation equipment checking.
Equipment safety checks were not complete on a number of observations, including A&E and paediatrics.
The Trust should implement a robust checking process including unannounced spot checks to ensure that safety equipment is appropriately checked
The CCG will also factor this into their programme of announced and unannounced visits
Trust A&E by 24
June 2013
Rest of Trust by
28 June 2013
CCG Ongoing
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Organisation
NHS England
NHS England
NHS England
NHS England
NHS England
NHS England
NHS England
NHS England
NHS England
Burton Hospitals NHS Foundation Trust
Burton Hospitals NHS Foundation Trust
Burton Hospitals NHS Foundation Trust
South East Staffordshire & Seisdon Peninsula CCG
South East Staffordshire & Seisdon Peninsula CCG
CQC
CQC
Monitor
Healthwatch
Role
Summit Chair and Regional Director
Regional Dir Ops and Delivery
Regional Medical Director
Regional Deputy MD
RRR Chair & Reg Chief Nurse
Regional Deputy Chief Nurse
Senior Regional Support
Area Team – Director of Nursing
Area Team – Medical Director
Chief Executive
Director of Nursing
Medical Director
Chief Nurse
Accountable Office
CQC Regional Director
CQC
Monitor Representative
Healthwatch Representative
Name
Paul Watson
Sarah Pinto-Duschinsky
David Levy
Alistair Lipp
Ruth May
Sylvia Knight
Gareth Harry
Brigid Stacey
Ken Deacon
Helen Ashley
Brendan Brown
Craig Stenhouse
Heather Johnstone
Rita Symmonds
Andrea Gordon
Mandy Walker
Deepa Nair
Jan Sensier
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Organisation
Health Education England (HEE)
General Medical Council (GMC)
RRR Panel
RRR Panel
PwC
RRR Panel
RRR Panel
Observer
PwC
Role
HEE Representative
GMC Representative
RRR panel rep 1
RRR panel rep 2
RRR panel rep 3
RRR panel lay rep
Obeserver
Moderator
Recorder
Name
Russell Smith
Jill Williams
Mike Lambert
Bethan Graf
Tonia Dawson
Leon Pollock
Professor Sir Mike Richards
Charlotte Kennedy
Alkay Masuwa
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