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Corporate Risk Register 2009 - Walsall Teaching Primary Care Trust

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Corporate Risk Register 2009 - Walsall Teaching Primary Care Trust Powered By Docstoc
					1. Corporate Risk Register - STAYING HEALTHY
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress)

Appendix 1
Links to other strategies /documents/st andards
Risk Score Lead Director

What has to be achieved

What could prevent this What controls/systems objective being we have in place to assist achieved in securing delivery of our objective Minimal narrowing or widening of the gap

Where we are failing to put controls/systems in place?. - Where are we failing in making them effective?

We have evidence that shows we are reasonably managing our risks and objectives are being delivered

What actions are to be put in place to address the Gaps? What progress has been made? Implementation of strategy, the gap is reducing numbers particularly amongst women. Life Expectancy Group to be established Aug 09. Introduction of Vascular check July 09. Implementation of fuel poverty programme Aug 09. Introduction of Tariff for smoking cessation September 09 Revision of Obesity Strategy Aug 09. Development of child care pathway July 09

Conseq uence x Impact = Risk Score WCC1 3x3= Objective WCC 9 Strategy JSNA. Vital sign. WCC2 2x4= Objective WCC 8 Strategy. Vital sign. Dr Sam Ramaiah

1.1

Narrow the gap between the poorest and most affluent areas

1.2

Reduce by 10% the Minimal narrowing or gap between the widening of the gap fifth of areas with the lowest life expectancy at birth & the population as a whole by 2010

Walsall Partnership Health Target variation and Joint Walsall Inequalities Group to lack of comprehensive Inequalities commence monitoring of appraoch Strategyendorsed by target Local Authority, NHS Walsall and Partnerships Walsall Partnership Health Life expectancy Monitoring system is in and wellbeing group will variation in the place. monitor. Infant mortality borough. Good report recommendation progess in women. implemented.

Dr Sam Ramaiah

1.3

Reduce the Increase rather than average BMI - 5% decrease reduction by 2010

Number of people Encouraging positive accessing level 2 to level response for Walsall 4 of over weight and people obesity care pathway.% of adults on GP register with a BMI recorded in last 15 months

Multifunctional approach undertaken. Some very positive responses

WCC5 2x4= Objective. WCC 8 Strategy. Vital Sign.

Dr Sam Ramaiah

Corporate Risk Register Version 1 July 2009

2. Corporate Risk register - CHILDREN AND FAMILIES
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk Lead Director strategies Score /documents/st andards Children NSF 4x3 =12 Yvonne Thomas LIT Working Together Strategy WCC Strategy

2.1

Implementation of Safeguarding throughout NHS Walsall

GPs not all trained in safeguarding procedures

Action plan in place agreed at NHS Board and PEC . Support in General Practice to train GPs

Changing workforce skills and Competencies need assessing of training

Audit if 115 HCC questions evidence in place, and action plan in place monitored by Ops group of WLCSB

working with WLCSB, to monitor and implement action plan all GPs have been sent Walsall Child Protection protocol as in working together

2.2

Implementation of Workforce to deliver key Children & Young Peoples every child matters agenda not fully in place Plan in Place 200911agreed with the partnership Comprehensive Agreeing with Mental CAMHS service in Partnership to provide place 24 hour cover Commission comprehensive immunisation programme Capacity within community services to provide the service

2.3

2.4

Working with Children's Area Partnership to develop commissioning competencies Reduction in CAMHS Lack of 24 hour cover Recent review from TAMHS project in waiting times. CAMHS across CAMHS and SHA deemed good place to deliver Tier Strategy in place , needs clarity over contracting 1 services a assessment complete process prevention model in schools Achievement of all Lack of clarity around Walsall's Performance Working with immunisation rates community contracting above average for the Children Centres to Included in Childrens NSF West Midlands deliver the LIT programme, programme Performance monitored across the partnership

Changing workforce skills and Competencies need assessing

Annual Performance Assessment at Level 3. Children's and Young Peoples Plan in place

Children NSF 2x3=6 LIT Working Together Strategy WCC Strategy C&YPP 200911 National Priority

Yvonne Thomas

5x3=15 Yvonne Thomas

National 2x3=6 Priority In C& YPP Plan 200911 and NSF LIT

Yvonne Thomas

Corporate Risk Register Version 1 July 2009

3. Corporate Risk Register - MATERNITY AND NEWBORNS
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk Lead Director strategies Score /documents/st andards Children NSF 5x3=15 Yvonne Thomas LIT Working Together Strategy WCC Strategy

3.1

Reduce the rate of Not achieving target infant and perinatal deaths to 4.8 per 1000

Data reporting to Perinatal Institute Data entry clerk dedicated to ensuring information captured Programme in place for reduction of target Inequalities strategy in place IfH project 2 c linked NSF LIT monitoring the FNP and C&YP Partnership signed up to the programme

Collection system at the Perinatal Institute has changed due to CEMACH collection stopped

A multi-agency Infant Mortality Reduction Steering Group has been established, chaired by the Chief Executive of NHS Walsall, to oversee progress in this area. Birbeck University monitoring FNP, and Cardiff University monitoring RCT

3.2

3.3

Continued expansion in FNP to provide enhanced support to new mothers in areas of greatest Achieve higher specified standard for 12 week assessment of needs, risks and choice

Recruiting 150 families as approval from Ethics committee has slowed down recruitment

Commissioning of Genetic Counselling Service in Walsall Maternal and baby Obesity reduction programme in place (IfH project 2C) Baby friendly in the community stage 1 Recruited two nurses, training in place and commenced recruiting families

Children NSF 4x3 =12 Yvonne Thomas LIT Working Together Strategy WCC Strategy Children NSF 4x3 =12 Yvonne Thomas LIT Working Together Strategy WCC Strategy

Community Midwifery Service specification not increased with developed for delivery of workforce changes midwifery services agreed by NHS Walsall

Changes to the DOH Vital signs targets and Collection system at the Perinatal Institute

Performance measured through the C&YPP and NHS Board. LIG in place and increase in information in Community pharmacies to enable women earlier access

Corporate Risk Register Version 1 July 2009

4. Corporate Risk Register - UNSCHEDULED CARE
Risk Key deliverable Number Principle Risk Key Controls Links to other Risk Lead Director strategies Score /documents/st andards Lack of control over Procurement plan in Progress report to WCC strategy. 2 x 4 = Anne Baines delays in construction. place. Emergency care Emergency Care Net Emergency 8 Unsure of avaiable network health and work quartly. care strategy. resources. social care and external Emergency Care National partners strategy to be Targets. Vital developed. Produce signs affordable plan/model Lack of clarity around Transition plan in place Develop wrkforce community contracting availability to negotiate plan WCC Strategy 1 x 4 = 4 WCC Strategy 2 x 4 = National 8 targets. Vital sign trajectory Anne Baines Gaps in Control Positive Assurance Assurance Plan (Progress)

4.1

Redesign of UCC Availability of facilities Achievement of 4 hour and OOH services. on hospital site. Design wait target. Reduce A&E not fit for purpose. attendances by 35% Model unaffordable in current climate

4.2

Rapid response service in community

Capacity within community services to provide the service

Reduction in numbers of emergency admissions

4.3

Timely transfer of Lack of standardised care from hospital criteria for discharge to most appropriate place of discharge

Reduction of LoS by 15%. Lack of 7 day extended Both main Providers Working together on Reduction in excess bed working across all currently undergoing pathway days organisations management of change development process

Anne Baines

Corporate Risk Register Version 1 July 2009

5. Corporate Risk Register - PLANNED CARE
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards National priority. Vital Sign. WCC Strategy 1x5= 5 Lead Director

5.1

18-week RTT (% 18 week targets not pathways achieved. completed within 18 weeks) – Admitted Patients 18-week RTT (% pathways completed within 18 weeks) – NonAdmitted Patients

18 week targets and systems and processes are in place to ensure weekly PTL reporting and performance management of targets. Issues concerning performance and risk management will be addressed via the contract management process.

The 18 week programme board is still in place and will remain so for 2009/10. It currently monitors 18 weeks performance at Walsall Manor, identifies areas for concern and oversees service developments required to deliver sustainable 18 week pathways.

The development of the ‘Patient Navigation Team’, which is a new approach to the operational management of outpatient/diagnostic and inpatient booking services. It aims to ensure capacity is matched to demand by centralising booking services with more efficient and effective means of appointing patients for outpatient appointments, diagnostic tests or inpatient stays. Review rectification plan

Anne Baines

5.2

95% of patients are Rectification plan not seen at GUM clinic working with 48hours Improved Tier 1& 2 service for sexual health through the introduction of a LES Slippage on implementation due to issues raising form negotiation with GPs. Lack of project plan. Lack of resource.

Routine reporting via performance monitoring report

Level of escalation needs to be reviewed

5.3

Appropriate monitoring of TBD LES. Effective negotiation with Primary Care.

Sexual Health Planning Group. Monitored at Contract Performance meetings Sexual Health Planning Group

Need to produce project plan. Negotiate effective LES outcomes.

Vital sign . NHS Contract. Sexual Health Strategy WCC Strategy. Sexual Health Strategy.

4x4= 16

Anne Baines

2x2= 4

Anne Baines

Corporate Risk Register Version 1 July 2009

5. Corporate Risk Register - PLANNED CARE
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Sexual Health 3 x 3 = Strategy. 9 WCC Strategy. Lead Director

5.4

Specification and Lack of implementation Service specification Organisational commissioning of a of Integrated Service developed with outcomes structure not clear. Integrated Sexual Model by Providers. clearly specified. Health and Reproduction Service

Sexual Health Planning Negotiations with Group. Contract providers meetings Integrated service operational

Anne Baines

Corporate Risk Register Version 1 July 2009

6. Corporate Risk Register - LONG TERM CONDITIONS
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Lead Director

6.1

Fully implement currently commissioned services to targeted levels - Walsall Own Health - Tunstall - Met Office Schemes - Expert Patient Programme CT Brain Scans with 24 hours for stroke patients

Low uptake by patients Maintenance of all targets Timeliness of data on and lack of support from up date is poor. GPs. Resources unknown. Shortage of available resources.

Long Term Conditions Programme Board.

Self Care WCC Strategy 2 x 2 = 4 Anne Baines Management 3x4= Strategy needs to be 12 developed. Phase implementation in line with available resources.

6.2

Milestones and WCC Outcome not achieved. Issues with data collection.

The following improvements are required as part of the CQUIN agreements 61%April 2009 75%June 2009 85%Sept 2009 95%Dec 2009

Knowledge of data collection.

Monitoring as part of the contract via Clinical Quality Review meetings. Part of contract monitoring process. CQUIN.

Baseline agreed. Regular reporting., Cardiac Network develop data guidance.

WCC outcome. 3 x 4 = WCC Strategy. 12 Vital Sign.

Anne Baines

Corporate Risk Register Version 1 July 2009

7. Corporate Risk Register - MENTAL HEALTH / LEARNING DISABILITIES / DEMENTIA
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Lead Director

7.1

Commissioning Plan for Mental Health in place.

No cost and volume contract.

Clinical Quality Review and Contract monitoring.

Financial modelling.

7.2

A range of services No targeted service and Commissioning plan. Long for people with LD. no health inequality gap term financial model. target. Needs assessment projection. Implement National No local strategy in Contract monitoring Dementia Strategy. place. Delayed start performance meetings. date for new appointee.

No gaps in control.

Block contract MH intentions, MH Strategy. Work stream identified in the commissioner for Mental Health work programme. Responsible to LD Programme Board

Additional support to WCC Strategy. 1 x 5 = Commissioning MH 5 Manager. Commissioning Plan.

Yvonne Thomas

Develop strategy for Joint 1 x 2 = 2 Yvonne Thomas out of area residents. Commissioning Plan WCC Strategy. 3 x 5 = Joint 15 Commissioning Plan. WCC Outcome. Vital Yvonne Thomas

Not currently applying Appointed member of Develop Strategy needs assessment staff for Dementia Care data. to develop pathway.

7.3

Corporate Risk Register Version 1 July 2009

8. Corporate Risk Register - SAFETY / QUALITY
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Vital Sign . 3x4= NHS Contract. 12 CQC Registration. Infection control and prevention strategy Lead Director

8.1

Reducing MRSA rates across the health economy

National target not achieved

8.2

Implementation of same sex wards

National target not achieved. Areas such as ITU Day, Day Surgery.

Monthly reports to Trust Board. Issues concerning performance and risk management are addressed via the contract management process. Health economy wide HCAI steering group chaired by CEO Annual CQC patient Capacity issues whilst Health economy wide survey. Patient experience work is taking place. group. Monies received surveys included in from SHA to address contract as part of CQUIN. single sex ward issues DoH Assessment process.

100% pre 48 cases reviewed jointly 100% Activity screened (monthly reports) 100% Activity screened (monthly report)

Implementation of screening in residential and care home screening

Commissioning of ‘MRSA’ Busting screening programme fpr nursing / residential homes

Dr Sam Ramaiah

8.3

Reduction of CQC ratings are significant untoward reduced. incidents causing harm.

Monthly reports to CQR meetings

Baseline not agreed

The PCT will specifically ask that views from patients concerning mixed sex accommodation are gathered and reported and that demonstrable action is taken to address those areas where achievement does not match with expectation. Monthly review at CQR Need to agree base meetings as part of line and reduction contractual against the baseline agreements. Montly reports to Board

National target. 3 x 4 = DoH guidance. 12 NHS Contract.

Anne Baines

NHS Contract. 4 x 3 = CQC. RMST 12

Yvette Sheward

Corporate Risk Register Version 1 July 2009

8. Corporate Risk Register - SAFETY / QUALITY
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Lead Director

8.4

Effective implementation of NICE Guidance

Not meeting CQC standards

All main contractors are required to audit and report on implementation of NICE Guidance. % of TAGs and guidelines implemented and audited

Process for Monthly review at CQR dissemination of meetings as part of guidance but no formal contractual agreements process for monitoring implementation by Independent contractors

Develop audit plan to NHS Contract. 4 x 3 = monitor compliance CQC.NICE 12 with NICE guidance Policy by independent contractors

Yvette Sheward

8.5

Local population WCC Competency not agree that the local met NHS is improving services

All main providers have CQUINS do not include Monthly review at CQR signed up to undertake independent meetings as part of and improve on results of contractors contractual agreements Patient surveys as part of CQUIN programme. All providers have complaints policy in place

Develop programme WCC for measuring competency. patient and public PPI Strategy satisfaction of independent contractors services

4x3= 12

Yvette Sheward

Corporate Risk Register Version 1 July 2009

9. Corporate Risk Register - PATIENT, PUBLIC INVOLVEMENT
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Lead director

9.1

Building capacity of Training not accessed commissioners by commissioners.

Audit check list is being developed.

No clear links to programme structure.

Training Plan

9.2

MyNHS Walsall increasing membership.

Membership does not reach target

Active marketing programme using multi media approach for recruitment.

No reporting to the Board.

Monthly monitoring of membership uptake. Quartrly report to the Board.

WCC Strategy. 4 x 2 = Yvonne Thomas WCC 8 Competency. WCC OD Plan. Reporting developed WCC Strategy. 2 x 3 = 6 Yvonne Thomas for September 2009 WCC onwards. Competency. WCC OD Plan.

E Cycle model training for commissioners

Corporate Risk Register Version 1 July 2009

10. Corporate Risk Register - STAFF EXPERIENCE AND ENGAGEMENT
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Staff survey. NHS Walsall. HR policies. 4x3 =12 Lead director

10.1

Improve staff survey results

10.2

Robust workforce development plan and strategy in place.

Poor Staff survey results. % of staff reporting work related stress does not reduce Lack of mentoring and shadowing opportunities Poor response to elearning Failure to engage with lead partners including Primary Care. Lack of robust timely data.

Stress Management training is mandatory for Managers

Develop process to ensure all managers are aware of and attend stress management program. ESR will assist in more timely reporting. Head of Workforce Lack of engagement Representation at Local Workforce Development in post. around Workforce Stakeholder Board Development group ESR provides timely data development in Primary ESR Board in place. to be established. HR KPIs included in main care Black country workforce Workforce strategy to provider contacts. planning programme be developed.

Not all managers attend training. No formal programme for mentoring or shadowing. Poor response to elearning oprtunities

HCC staff survey results reported to Board. Actions Plans / response by main providers Survey monitored by part of CQR meeting

Yvette Sheward

WCC Strategy. 1 x 3 = 3 Anne Baines WCC OD Plan. CQC standards. CQC Staff survey. Investing for Health /workforce strategy

Corporate Risk Register Version 1 July 2009

11. Corporate Risk Register - ORGANISATIONAL DEVELOPMENT
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards WCC 3x4= competencies. 12 WCC Strategy. WCC OD Plan. Lead director

11.1

Meaningful clinical engagement. Informing strategy and driving quality and service design and reosurce allocation. Revigoration of Practice Based Commissioning

Unable to ensure active clinical leadership. Orgnaisatoinal structures do not facilitate clinical quality assurance and innovation. Action Plan not delivered.

11.1

Newly formed PEC. Darzi Leads in place. All committees have appropriate clinical engagement and memebership. Accreditation of providers committee functioning. Regular monitoring of actoin plan through PBC Governance Committee.

New committee membership not agreed. Darzi leads linked to programme boards to be established.

TOR for new committees and programme boards.

Clinical Engagement. Framework developed. Review of clinical engagement.

Pam Skinner

Independent nature of New Governnance PC practitioners. Framework. Progress reported against actoin plan.

11.2

11.3

Corporate intelligence strategy and framework in place Strategic Approach to market management

WCC Competency gap In development. NED not addressed. sponsor effective.

Time and resource to progress quickly.

WCC Strategy. Reinvigoration action plan. PBC Governance. WCC Assurance. Regular report to Develop intelligence WCC stratgy. Intelligence Executive. strategy Intelligence Strategy. Regular reporting via OD progress report.

Develop and implement governance for Practice Based Commissioning

2x5= 10

Anne Baines

3x4= 12

Anne Baines

Insufficient resource to deliver to timetable.

Development of effective No Plan in place. project plan.

11.4

Board Architecture Committee structure Scheme of Delegation in reviewed and does not facilitate board place. agreed assurance

Strategy to be agreed. Market assessment for transforming community services Board Architecture Board committee paper Review roles and information flows NED July 2009 responsibilities. roles need to be Review information agreed flows. Review Board committee structure.

WCC Strategy. 3 x 4 = WCC OD Plan. 12 WCC competencies. WCC Strategy. 4 x 4 = WCC OD Plan. 16 WCC competencies.

Anne Baines

Yvette Sheward

Corporate Risk Register Version 1 July 2009

11. Corporate Risk Register - ORGANISATIONAL DEVELOPMENT
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards NHS Contracts. 3 x 3 = WCC 9 competencies. OD Plan. WCC strategy. Lead director

11.5

Robust Procurement process in place

Contracts not robust. Contracts not viable. Lack of clarity between provider and commissioner.

Team in place. No formal procurement NHS Contracts developed procedures in place. for all main providers.A structured procurement process is followed. Procurement Policy agreed.

Contracts, Regulation Formal procurement and Governance procedures to be Committee regular developed. reports. Monthly contract meetings with Providers. Accreditatoin Committee.

Robert Mackie

Corporate Risk Register Version 1 July 2009

12. Corporate Risk Register - Primary Care
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Lead director

12.1

12.2

Improving access Lack of patients taking Mobilisation plan in place. to all new GP up new services at any Regular meeting with Practices mobilised of the new practices practices. Trajectories agreed and monitored. Improving access Lack of patients taking Mobilisation plan in place. to NHS dentistry up new services at any Regular meeting with through new of the new practices practice. Trajectory practice developed agreed and monitored. in East of Borough

Potential slippage on trajectory numbers.

Regular reports to Primary Care Contracting team. Regular reports to Primary Care Contracting team.

Quarterly WCC Strategy. 4 x 3 = performance reports. National Target. 12

Robert Mackie

Potential slippage on trajectory numbers.

Monthly performance WCC Strategy. 4 x 3 = reports. National Target. 12 WCC Competency.

Robert Mackie

Corporate Risk Register Version 1 July 2009

13. Corporate Risk Register - End of Life
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Primary Care 4 x 5 = Strategy. WCC 20 Strategy. Lead director

13.1

Palliative Care Centre for Walsall by 2010.

Business realisation Full business case. plan not achieved. Monitoring service Progress on Partnership specification. delayed. Shortfall in revenue resources.

Contribution of partners. No service specification in place.

Board reports. Develop service Partnership with Walsall specification. Hospice Charity. Partnership Agreement.

Anne Baines

Corporate Risk Register Version 1 July 2009

14. Corporate Risk Register - Finance Plan
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards Lead director

14.1

Achieving Financial Minimal risk of not Monthly financial reports Balance meeting statutory break to the Board. even.

None identified

Board reports. Audit committee reports. External and internal audit.

LTFP

WCC strategy. 2 x 4 = 8 Robert Mackie WCC Competencies. WCC finance.

Corporate Risk Register Version 1 July 2009

15. Corporate Risk Register - IM & T
Risk Key deliverable Number Principle Risk Key Controls Gaps in Control Positive Assurance Assurance Plan (Progress) Links to other Risk strategies Score /documents/st andards CQC. Information Governance Toolkit. Corporate Business Continuity Plans. CQC. Information Governance Toolkit. 4x3= 12 Lead director

15.1

Robust Business Loss of business critical Business Continuity plans Continuity Plan and IT systems - Business developed for the Impact Analysis in Continuity corporate patient systems place

15.2

Robust Disaster Recovery Plan in place

Departments need to consider the risks associated with any of their systems failing and determine what the fall back procedure is. The organisation is currently undertaking a major assessment of their BCPs. Loss of business critical Disaster Recovery plans Reliance on BT. Also IT systems - Disaster in place. Contracts cover there is no Diaster Recovery Plan - IT rapid repairs. Recovery in place for issues Maintenance contracts in Email and File Printing place. Suitably qualified servers. This is being staff. assessed and quotations being sought to provide.

Need to test the plans, either through unplugging the systems or through a desk top exercise.

Review of continuity plans to be undertaken for systems other than corporate patient systems.

Steve Darkes and all Directors who have corporate systems within their departments

Need to test the plans, Review of either through contingency plans to unplugging the systems be undertaken or through a desk top exercise.

4x3= 12

Steve Darkes

Corporate Risk Register Version 1 July 2009


				
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