Following concerns expressed about the response of West London Mental Health Trust (the trust) to suicides the Care Quality Commission (CQC) investigated. They published their 82 page report last month.
Whilst the CQC has acknowledged that the trust had many competing priorities and nationally-set performance targets to achieve, it highlighted that one of the fundamental things that a trust must do to ensure that services are safe and people are protected from harm is to learn the lessons from serious incidents and take action to prevent the same things happening again.
In a rather damning paragraph the CQC noted that:
“rather than being determined to be a leader in the field of mental healthcare the trust tolerated mediocre and, in some instances, low standards of care. People accessing the services were entitled to better than this.”
This report follows fast on the heels of the Healthcare Commission report into Mid Staffordshire Hospitals NHS Foundation Trust.
The report is divided into three sections:
- providing a safe environment and protecting people from harm;
- enabling good outcomes for people through high quality care; and
- governance arrangements for managing risk and scrutinising the quality of care.
The full report can be accessed here
Some of the key points highlighted were as follows:
- Staff were confused because there were several different policies in place for the reporting of and enquiries into incidents.
- Different classification systems existed for reporting incidents.
- Inconsistent information within policies and inconsistent practice in the way incidents were investigated.
- Not all investigation panels included a member of staff who had received training to undertake investigations.
- The length of time it took to complete investigations and reviews was an ongoing issue – in one case there was a delay of 23 months
- Recommendations were repeated with management of risk and care planning being the most frequently recurring themes. This implied that lessons had not been learned or put into action.
- Conflicting responses were given with regard to who was responsible for implementing action plans.
- Staff were not always informed about recommendations from investigations into incidents.
- The trust did not have a robust system to share learning and implement changes across sites and services.
- The review recognised serious problems with the environment.
- Questions were asked about how the trust was reassured that actions had been implemented. It was commented that non-executive directors should have been more challenging.
How would your trust fare if such an investigation were carried out?
If any or even all of these points are alarming you please sign up to our forthcoming training session on SUIs entitled:
Investigating serious untoward incidents: practical considerations
As readers will appreciate (and as this latest CQC report exemplifies) as the criminal and regulatory burden on NHS trusts increases, internal SUI reports are increasingly important, not only as a means of closing the risk management loop, but also to present the trust as a responsible and professional well run organisation to external bodies.
A further key point from this and other reports, is the management failure to implement and monitor the recommendations and changes to be made as a result of an investigation. First class clinical governance demands that trusts can demonstrate audit and monitoring of compliance before the CQC does it for you. However it is not just the CQC who will be reviewing such reports. Coroners, health and safety inspectors, police officers, disciplinary panels and even the media can use an internal document, produced for one purpose, to criticise a trust.
It is therefore essential that those investigating incidents are not only trained in root cause analysis but also have some understanding of the different regulatory arenas in which their final work may be exposed; that they understand the basic evidential approach they should be taking to an investigation and how they can protect an organisation even where significant problems have been found. This seminar is designed to help equip those carrying out investigations within the healthcare arena, with the necessary understanding to convert their skills of incident analysis into equally impressive incident reports that can stand up to scrutiny and positively influence external organisations.
This seminar is aimed at governance/operations directors, senior clinicians, senior managers, professionals and health and safety professionals.
The seminar will consider:
- the context of an investigation within the wider regulatory framework;
- reports and recommendations; and
- pitfalls and practical advice.
It will be held in the following locations this winter