Colchester Hospital University NHS Foundation Trust
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
KEY FINDINGS AND ACTION PLAN FOLLOWING RISK SUMMIT
July 2013
Contents
1.
Overview
3
2.
Summary of Review Findings and Trust response
6
3.
Risk Summit Action Plan
Appendices
Appendix I:
14
18
Risk Summit Attendees
19
2
1. Overview
A risk summit was held on 2 July 2013 to discuss the findings and actions of the Rapid Responsive Review (RRR) of Colchester Hospital University NHS Foundation Trust
(“the Trust”). This report provides a summary of the risk summit including the Trust response to the findings and an action plan for the urgent priority actions from the RRR
discussed at risk summit. The action plan includes any agreed support required from health organisations, including the regulatory bodies.
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
1
(HSMR) .
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.
1
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
3
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.
ii.
iii.
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.
Any additional external support that should be made available to these Trusts to help them improve.
Any areas that may require regulatory action in order to protect patients.
The review followed a three stage process:

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 the Trust is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.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. This report contains a summary of the findings from this stage of the review in
section 2.
The two day announced RRR visit took place at the Trust’s main site on Tuesday 4 and Wednesday 5 June 2013 and the unannounced visit was held on the evening of
Tuesday 11 June 2013. A variety of methods were used to investigate the Key Lines of Enquiry (KLoEs) and enable the panel to analyse evidence from multiple sources and
follow up any trends identified in the Trust’s data pack. The KLoEs and methods of investigation are documented in the RRR report for Colchester Hospital University 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-keogh-review/Pages/publishedreports.aspx

Stage 3 – Risk summit.
This stage brought together a separate group of experts from across health organisations, including the regulatory bodies (Please see Appendix I for a list of attendees). 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.
4
The Risk Summit was held on 2 July 2013. The meeting was Chaired by Paul Watson, NHS England Regional Director (Midlands and East), 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/published-reports.aspx
Conclusions and priority actions
The RRR Panel identified that the Trust had made a number of improvements since the change of leadership in 2010. There had been improvements in staff engagement and
confidence but there is further work to do. The panel also recognised that the announcement of the RRR had knocked staff confidence and morale which had resulted in
improvement projects being postponed and may have slowed the rate of improvement. The RRR panel said that they had been struck by the degree the Trust felt impaired to
act by the RRR and that putting things on hold for the review felt a negative approach when business as usual would have been a more appropriate response for staff and
patients.
The RRR Panel noted that the staff as a group were committed and enthusiastic, but there were examples where they needed better clinical leadership. The RRR identified a
number of areas of good practice, although these were applied inconsistency. The RRR Panel noted that many of the recommendations contained in the report are within the
gift of the Trust, with some joint working required within the health community on the End of Life recommendations.
The Executive team interviewed recognised the issues at the Trust and the need to increase the pace of change. The Chief Executive and Chair were clear that there is a
need to develop and embed the clinically led divisions. The panel indentified that was a lot to do within that and for which there needed to be an explicit plan (with timelines) to
ensure all staff are aware of what is important and the pace of change required.
The RRR panel also identified a number of areas of outstanding concern across all nine KLOEs. For the majority of areas a number of improvements were identified that
were either already underway at the Trust or planned actions. The Trust responded positively to the RRR process and welcomed the issues raised in the RRR. Eight areas
were identified for discussion at the risk summit. These are summarised in the following sections and are detailed within the RRR report. An action plan was agreed at the
risk summit addressing all the urgent priority actions discussed.
Next steps
As the risk summit had focused on urgent priority actions, the Trust also agreed at the risk summit to provide a detailed action plan to all outstanding concerns and
recommended actions included in the RRR report by 30 July 2013.
Follow up of the RRR and risk summit action plan will be undertaken by other organisations within the system, including CQC and GMC visits. A formal follow up will consist
of a desktop review and a targeted one day site visit to the Trust in November 2013 reviewing key areas to understand the improvements that have taken place. A report of
the follow up findings will be issued to the risk summit attendees and will consider, if there are significant remaining concerns, whether to convene a further risk summit.
5
2. Summary of Review Findings and Trust response
Introduction
The following section provides a summary of the RRR panel’s findings and the Trust’s response presented at the risk summit. The detailed findings are contained in the
Trust’s RRR Report. The Trust response was presented by Gordon Coutts, Chief Executive, supported by Sean Macdonnell, Medical Director, and Kathy French, Acting
Director of Nursing. The agreed action plan in response to the urgent priorities is included in the following section.
Overview of Trust response
The Trust welcomed the review and its findings and recognised the issues identified. The Trust accepted the report as a fair account and accepted that that although it had
improved over the last three years in relation to patient safety and mortality, further improvement is needed and it plans to continue in a sense of openness and transparency.
The Trust stated that the review confirmed the areas of concern that it was already working on and signalled the need for clearer prioritisation and communication of its plans.
The need for development of clinical leaders taking on the divisional roles was acknowledged. The Chief Executive recognised that the Trust had motivated, caring and
enthusiastic staff groups and it would need to engage with them effectively on these plans. The Trust confirmed that they would be seeking some external support and
guidance in implementing the recommendations, in particular in the development and mentoring of clinical leaders and senior clinicians.
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Summary of Review Findings
1. Quality focus still being developed
The current Executive Team and Board have developed the new clinical led divisional structure over the last three years, however there is still work to do to embed the
governance and accountability arrangements for quality governance within the new structure. The panel reviewed a Quality strategy for 2010-2012. This was extended
to early 2013 without revision and is therefore out of date, for example it does not respond to the Francis report findings. The Medical Director confirmed a new strategy
was being worked on but still some way from completion, being partially delayed by the review. Staff at all levels including the Acting Director of Nursing, were unable to
clearly articulate the key quality priorities for the Trust.
During the interview with the Medical Director, the panel understood the Quality Hub was an initiative intended to be both a resource centre to promote the development
of quality themes in the Trust. It is also a mechanism for performance managing the implementation of quality related programmes. The Acting Director of Nursing, who
is responsible for the Hub, recognised that the programme has only managed limited progress in the first year in terms of engagement or outputs. The panel considered
this needed further review to ensure it has the desired impact.
Recommendation



The Trust will need to consider how it develops a clearer focus on quality, based on transparent performance information and a tone from the top. This should
include implementation of the planned improvements and recommended actions in this report.
The Trust must increase the pace of planned change in order to develop a safe, mature organisation that provides high quality patient care. The role of the Quality
Hub needs to be reviewed to support this
The Trust needs to develop a comprehensive and clear quality strategy and ensure it is consistently applied throughout the organisation. This must include areas of
priority with defined action plans in place.
Trust response
The Trust reported that it was in the process of re-writing the quality strategy when the review was announced and is due to be completed between September and
December 2013. The Panel stated that the pace of change was slower than anticipated and that the Quality Strategy should be agreed at the September 2013 Board
meeting with key quality messages being communicated to staff prior to this. The Trust agreed this was reasonable and the timetable was amended to September 2013.
NHS England agreed to provide examples of best practice with the Trust.
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2. Clinical Leadership
During interviews with the Clinical Directors team, the panel noted that the management structure is not consistent with the structure publicised on the Trust’s website.
The panel was concerned that divisional clinical directors were reporting to the Medical Director and the Chief Executive whilst the Associate Directors report to the
Director of Operations, which may lead to an inconsistent approach for performance management and governance arrangements. The panel considered that there was
also a risk of the two leaders of each division having conflicting directions and priorities and unclear ownership of quality.
The panel heard from numerous interviews, observations and focus groups concerns regarding the lack of nurse representation at a divisional level. There is no senior
nurse leadership other than the Acting Director of Nursing and Matrons on the wards. The panel considered that this lack of the ‘nurse voice’ at a senior level
contributed to the issues with two way communication between ward level and Executive level that was reported during interviews and observations.
Recommendation


The Trust should review the management structure in place to ensure it is robust enough to support consistent clinical leadership (both medical and nursing) and
management at Divisional level.
The Trust should ensure there is clinical leadership and accountability for patient safety throughout the organisation.
Trust response
The Trust stated that they had established a clinical divisional structure but that the structure and governance process would be reviewed in August 2013. The Trust
plans to develop a fully risk assessed structure by October 2013.
The risk summit emphasised that due to the serious medical safety issues highlighted in the RRR, the Trust must focus on medical leadership. It recommended that the
values and behaviours need to be more explicit in the governance processes. The Trust was advised that the planned change to clinical leadership is a significant
undertaking that must be programme managed and may take a year to fully embed. The change to divisional clinical leadership must be run in tandem with the Quality
Strategy.
The risk summit recommended a clinical leadership development programme focussed on driving forward change which should be integrated with the Board
development programme. The risk summit recommended that the Trust should task clinicians with addressing the clinical issues raised in the Keogh Review as part of
the development programme.
The risk summit recommended to the Trust that it must consider the inclusion of nurse leadership at divisional level and include junior doctors and student nurses in
leadership development as part of succession plans.
Support was offered to the Trust by the National Leadership Academy to help it broaden its networks and share best practice. It was agreed that a meeting would be
held to outline an offer of support in the next three weeks.
The risk summit recommended that the Trust develops a strategy to develop the clinically led organisation which should be taken to the Board in October 2013.
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3. Deteriorating patients
The panel evidenced ownership amongst medical staff for deteriorating patients overnight was unclear and PAR (patient at risk) escalation was not effective.
Recommendation


The Trust should develop an action plan to improve its escalation approach for deteriorating patients. This should include engagement with clinical leadership and
frontline staff including nurses and junior doctors to understand the reasons for the inconsistent escalation of deteriorating patients and improve related
documentation.
The action plan should be monitored regularly by the Board in order to seek assurance that the issues are being addressed.
Trust response
The Trust reported that National Early Warning System (NEWS) has been trialled on three wards from March to June 2013 and will be rolled out across the Trust by
December 2013. This will include focus groups on barriers to escalation.
The risk summit told the Trust that the pace of change was not fast enough and recommended it should roll out NEWS by 1 October 2013. The Risk Summit also
recommended that as part of this work the Trust re-launches using high profile campaigns the sepsis care bundle by 1 September 2013 and the World Health
Organisation (WHO) surgical checklist, focussing on interventional radiology during July.
4. Radiology Escorts
The panel heard at the public event concerns that patients are taken to radiology without an appropriately qualified escort when required. At the unannounced visit the
panel observed a high risk patient waiting unescorted for X-ray. This issue was escalated to the Trust using the formal escalation process. CQC has requested that the
Trust provides them assurance that action has been taken on this issue.
The radiographers reported to the panel that the issue of unescorted high risk patients in X-ray awaiting assessment and diagnosis from A&E and EAU has been raised
with management on several occasions but no action had been taken.
Recommendation

The Board should obtain urgent assurance that the policy is being applied consistently. This should include working with CQC to provide them with assurance that
action has been taken and Trust staff are compliant with the policy
Trust response
The Trust has already taken the following actions:
 Investigation of the patient from A&E escalated at the unannounced visit (12 June 2013)
 Reinforce policy with staff (12 June 2013)
 Informed CQC of actions taken in response to escalation (14 June 2013).
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4. Radiology Escorts
The Trust told the risk summit that it plans to tackle the wider issue with review and re-issue of policy with training for radiology escorts between July and December
2013 which includes an audit in September 2013. The risk summit considered that the pace change was not quick enough and the Trust was recommended to
communicate to radiologists how to use the policy effectively in July 2013.
5. Communication & Engagement with Staff
The Panel met a large number of committed and enthusiastic staff who were keen to give their best for patients. The Panel heard on numerous occasions from many
sources, how the announcement of the review had severely knocked the confidence of the staff. The Panel was impressed by the staff they met and would want this
review report and the recommendations to enable continuous improvement for them as individuals to benefit the quality of care for patients.
There were a number of areas where the staff felt they were not being listened to by their managers and that there was an apparent lack of response to patient safety
concerns escalated. Important areas identified by the panel included the process for managing deteriorating patients and radiology escorts which staff identified needed
urgent action but had not seen this addressed. Further improvements in the amount of meaningful staff appraisal rates and finding a way to rapidly feed back to staff
how their concerns have been heard and addressed should be a priority.
Recommendation


The Trust should ensure it uses systematic processes to gather feedback from staff, for example focus groups, including ways to gather feedback confidentially.
The Trust should also consider how it uses the information collected to act on concerns raised by staff and how it feeds back actions taken as a result to all staff in a
consistent manner.
Trust response
The Trust outlined its plans to improve communication and engagement with staff including the development of a comprehensive Staff Engagement Plan by August
2013. The risk summit agreed with the action plan as outlined by the Trust.
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6. Staffing levels and skill mix
The panel heard a number of examples where additional permanent nursing staff were being recruited or had already arrived in order to increase the number of
registered nurses in some areas following a skill mix review. It was not possible during the visit to get all the detailed information on this and to understand the overall
increased investment that had been approved by the Board. However the panel would strongly encourage that this a staffing and skill mix review becomes a regular
process, probably twice a year, to ensure staff remain in the right place with the right skills to ensure a high quality service is delivered. A medical staffing review should
also take place to ensure that everything is being done to reduce the use of locum medical staff.
Recommendation
The Trust should urgently review staffing levels on the following wards:
 Brighlingsea
 D’Arcy
 Fordham
 Nayland.
The Trust should develop a clear and credible plan for staffing levels which sets out how the Board will ensure staffing levels and mix are safe, particularly out of hours.
The Board should assure itself that investment in additional medical and nursing staff is impacting in high risk areas. Information should be reported to the Board that
clearly triangulates staffing levels, qualified to unqualified nurses, incident rates e.g. falls, complaints and staff feedback so that it can measure the impact of additional
investment in staffing levels and ensure that staffing levels are consistently safe.
Trust response
The Trust outlined the action plan to improve staffing levels and skill mix at the hospital. This includes the triangulation of staffing levels and skill mix on specific wards
with soft intelligence and information about incidents to identify areas for improvement and assess the impact of staffing levels and skill mix on patient safety. The Trust
also plans a review of medical staffing on December 2013 with a regularly six monthly review of nursing staff levels and skill mix.
The risk summit told the Trust that the action plan for the review of medical staffing was not of sufficient granularity. The panel recommended that the Trust urgently
develops an action plan to addresses issues raised by the staff survey and by the Deanery, in addition to developing a strategy to ensure there are adequate staffing
levels in the future.
The risk summit recommended that the workforce strategy must be completed by December 2013 and include job planning, a robust appraisal process and should
focus on out of hours provision. The risk summit also asked the Trust to put in place governance arrangements to assess whether additional investment in staff is
working and that there should be Board oversight of a staffing review every six months.
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7. Complaints
The Trust should continue to develop the process for handling complaints by working with patients and staff. Many of the patient stories the panel heard had common
threads about the poor handling of the complaints process, which the Trust have been acting to improve. Some of the stories were historical in nature, but not all. There
have been changes to the complaints process and ownership for complaints is now with the clinical divisions. This needs to be further reviewed in the light of patient
feedback.
Recommendation
The Acting Director of Nursing and the PALS manager should review the handling of complaints and the processes whereby complaints can be systematically fed back
and used by staff teams to improve service delivery. This should respond to the issues identified in the RRR report.
Trust response
The Trust outlined the action plan to improve the complaints process as follows:




Revise complaints handling process to improve patient focus (by July to December 2013)
Revise Complaints and PALS process (by December 2013)
Devise mechanism for patients to help dissemination of lessons Ward to Board (September 2013)
Audit evidence of impact (November 2013)
The risk summit agreed with the Trust action plan was appropriate but challenged the pace of change. The risk summit recommended that that the revised complaints
handling process to improve patient focus should be completed by October 2013 instead of December 2013. This is a known issue to the Trust and there is an action
plan in place already being monitored by the CCG, therefore it should already be progressing the action plan.
8. End of life provision across the health community needs review
The panel heard that the Trust has identified that a high proportion of deaths occur in patients admitted at the end of their life. We heard from Trust managers that there
is a complex system, with limited joined up working. The Trust has been working with partner organisations including the CCG and has developed a Joint Mortality
Action Plan in the summer of 2012 which includes End of Life provision. All partners need to progress at pace.
Recommendation
The Trust should work with the CCG and community health providers to develop care pathways for end of life care.
A strategy should be developed through joint engagement with the CCG to review wider health system engagement to make better use of hospital beds including using
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8. End of life provision across the health community needs review
out of hospital care, preventative strategies and community care and to improve end of life provision for patients.
Trust response
The Trust described that Joint Economy Action Plan that is in place and recognised that the pace of change has not been acceptable in implementing this strategy. The
CCG agreed that the End of Life strategy needed review with the inclusion of metrics to measure performance against timed limited targets. The CCG agreed with the
Trust that this review would be completed by 1 September 2013. The risk summit accepted this plan addressed their concerns.
9. Peri-natal Mortality
The Area Team reported to the risk summit that they had received the latest Peri-natal mortality data which showed the Trust’s mortality figures had increased for the
latest quarter.
Recommendation
The risk summit recommended that the Area Team perform a deep-dive of the Peri-natal mortality data using relevant clinical expertise and develop a list of
recommendations for the Trust by the end of July 2013.
Trust response
The Trust accepted this recommendation. It was noted following the risk summit that the initial review had highlighted some data quality issues but that the area team
would continue to actively review this area with the Trust.
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3. Risk Summit Action Plan
Introduction
The risk summit development of an outline plan focused on the urgent priority actions from the RRR report. At the risk summit the Area Team reported an increase in perinatal mortality for the most recent quarter which was considered at the risk summit. The following section provides an overview of the issues discussed at the risk summit
with the developed action plan containing the agreed actions, owners, timescales and external support.
Action plan
Key issue
1. Quality Focus
Quality focus in the Trust needs
further development and an
underpinning strategy.
2. Clinical Leadership
The Trust needs to empower clinical
leadership through an improved
governance and organisational
structure, and leadership
development.
Agreed action and support required
Trust to revise Quality Strategy and produce a single prioritised
implementation plan with a given timeframe and owner for improvements.
This will include a plan to communicate key messages about patient safety
to staff.
Owner
Timescale
Trust, Medical
Director
End of September 2013 with
communication of key
messages by end of July
2013.
Trust to complete review of Quality Hub function and staffing. This is to
include a review of the following:
 serious incidents,
 complaints, and
 integrated quality measures including Datix, serious incidents and
lessons learned.
End of December 2013
NHS England to provide examples of good practice to the Trust.
End of July 2013
Produce a strategic plan to develop a clinically led and managerially
supported strategic organisation.
End of August 2013
End of August 2013
End of September 2013
Trust, Chief
Submit to Board in October
Executive Officer 2013
End of August 2013
Revisit the existing divisional strategy from January 2013 including
consideration of nurse leadership.
Appoint Deputy Divisional Clinical Director for Cancer
End of August 2013
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Key issue
3. Deteriorating Patient
Processes to recognise and escalate
deteriorating patients are not
operating effectively as they could.
Agreed action and support required
Owner
Timescale
Clarify reporting lines
End of September 2013
Full risk assessed structures including divisional single point of
accountability and staffing
End of October 2013
National Leadership Academy to discuss with Trust support required for
clinical leadership and Board development programmes.
End of July 2013
Roll out Trust wide of NEWS following trial on three wards and use to
determine care
Trust, Medical
Director
Beginning of October 2013
Re-launch sepsis bundle and escalation policy with a high profile campaign
and seek assurance that both are fully embedded at the Trust
1 September 2013
Re-launch using a high profile campaign the WHO surgical checklist, with a
focus on interventional radiology and seek assurance that both are fully
embedded at the Trust
1 July 2013
November to December
2013
Use of NEWS to hold Focus Groups of nurses and trainee doctors on
barriers to escalation
October 2013
Hold individuals to account
December 2013
Emergancy care reconfiguration implementation team to review Future
Hospital
4. Radiology Escorts
Trust investigated patient from A&E
The Trust’s policy on radiology escorts
is not being consistently applied.
Trust reinforced Policy with staff through training and communication
Trust, Medical
Director
Completed 12 June 2013
Completed 12 June 2013
Completed 14 June 13
Trust informed CQC of actions
Trust to tackle wider issue with review & re-issue of policy with training for
radiology escorts
July 2013
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Key issue
Agreed action and support required
Trust to audit impact of the changes made
5. Communication & Engagement
with Staff
Develop a comprehensive Staff Engagement Plan
The Trust needs to continue to listen
to staff.
Use Focus Groups to engage with staff
Owner
Timescale
September 2013
Trust, Director of August 2013
Human Resources
September 2013
Started
Improve the cascade process to listen to and communicate with staff
August 2013
‘Francis Listening Groups’ to present directly to Board
August 2013
Expand Clinical Area Assessment Programme (CAAP) participation
6. Staffing and Skill Mix
Nursing staffing levels and skill mix
review needs to be regularised.
Urgent review of identified wards
Review of future medical staffing requirements to support the hospital.
Develop a strategy which includes job planning, workforce plans focussing
on out of hours provision and implementing a robust appraisal process
Develop an action plan to address immediate workforce issues raised in the
Staff Survey and Deanery reports
Develop regular staffing triangulation report to include staffing, incidents and
soft intelligence
Undertake staff and skill mix reviews 6 monthly which is subject to Board
oversight
Complete recruitment of 17 nurses including sisters supervisory roles
Trust, Acting
Completed
Director of Nursing
December 2013
End of July 2013
June 2013
Repeat January 2014
October 2013
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Key issue
Agreed action and support required
7. Complaints
Revise complaints handling to improve patient focus
Complaints management processes
need urgent improvement.
Revise Complaints and PALS to include a review of skills and resource
within departments
Owner
Timescale
Trust, Acting
October 2013
Director of Nursing
December 2013
September 2013
Devise mechanism for patients to help dissemination of lessons Ward to
Board
November 2013
Audit evidence of impact on new processes
8. End of Life Care
Health community review of End of
Life Care provision has started but
needs early resolution.
Existing end of life strategy to be reviewed and performance metrics with
time limited targets need to be developed.
Trust and CCG
Develop a shared End of Life register
Trust & CEO St
Helena
Develop effective End of Life planning
Primary Care/ACE
September 2013
Review the effectiveness of the Trust’s response for patients and carers
24/7
Review and monitor unmet end of life care need
9. Peri-natal Mortality
1 September 2013
The Area Team will perform a deep dive of peri-natal mortality data using
relevant clinical expertise and make recommendations to the Trust.
September 2013
October 2013
ACE/St Helena
CCG
Area Team
January 2014
End of July 2013
The most recent mortality data for the
Trust shows an increase in peri-natal
mortality for the last quarter.
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Appendices
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Appendix I: Risk Summit Attendees
Risk summit role
Name
Risk summit chair
NHS England Regional Director (Midlands and East)
Paul Watson
RRR panel chair/ NHS England Regional Chief Nurse (South)
Liz Redfern
NHS England Area Team Director
Andrew Pike
NHS England Area Team Medical Director
NHS England, Regional Dir Ops and Delivery (Midlands and East)
NHS England, Regional Medical Director (Midlands and East)
NHS England, Regional Chief Nurse (Midlands and East)
NHS England, Regional Deputy Director of Nursing (Midlands and East)
Christine Macleod
Sarah Pinto-Duschinsky
David Levy
Ruth May
Lyn Mcintyre
Trust Chief Executive
Gordon Coutts
Trust Director of Nursing
Kathy French
Trust Medical Director
Sean Macdonnell
CCG Accountable Officer
Shane Gordon
CCG Director of Nursing
Lisa Llewelyn
CQC Regional Director
CQC Representative
Andrea Gordon
Julie Meikle
Monitor Representative
Adam Cayley
Monitor Representative
Naresh Chenani
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Risk summit role
General Medical Council Representative
Health Education England Representative
Health and Wellbeing Board
Healthwatch Essex
Regional Support (Midlands and East)
Name
Andy Lewis
Stephen Welfare
Cllr Ann Naylor
Lucy-Jane Taylor
Gareth Harry
RRR Panel Representative 1
Collette Marshall
RRR Panel Representative 2
Brigid Stacey
RRR Panel Representative 3
Chris Gordon
RRR Panel Lay Representative
Trevor Begg
Deputy Regional Medical Director (Midlands and East)
James Quinn
PwC moderator
Sarah Preston
PwC Recorder
Catherine Leith
Regional Head of Communications Lead
David Woodthorpe
Trust Chair (Observer)
Dr Sally Irvine
Trust Head of External Relations (Observer)
Mark Prentice
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