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MINUTES OF A MEETING OF THE PATIENT SAFETY PANEL held on 11

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					                                                             Appendix 6




MINUTES OF A MEETING OF THE PATIENT SAFETY PANEL held on
11 September 2008 at Coleg Powys, Llandrindod Wells

PRESENT: Felicity Williams (Non Executive Director and Chair)
         Mike Davies, Risk/Patient Safety Co-ordinator (North)
         Terry Eckley, Risk Manager
         Anita Griffiths, Director/NHSDW Associate Nurse
         Director
         John Huxley – Assistant Corporate Secretary
         Andrew Jenkins, Consultant Paramedic
         Steve Johnson, Risk/Patient Safety Co-ordinator
         (Central & West)
         Michael Jose, Staff Side Representative (UNISON)
         Arthur Lemin, National Modernisation Manager PCS
         Dawn Sharp, Corporate Secretary

APOLOGIES :

           Mike Cassidy, Deputy Chief Executive
           Mike Collins, Regional Director, Central & West
           Grant Gordon, Regional Director, South East
           Dafydd Jones Morris, Regional Director, North
           Keith Menzies, Staff Side Representative (GMB)
           Cliff Randall, National Staff Officer
           Bleddyn Roberts, Staff Side Representative (UNITE)

1    PROCEDURAL MATTERS

     RESOLVED: That

     (1) the appointment of the Chair and agreement of the
     membership of the Panel by the Trust Board on 22 May 2008
     be noted;

     (2) the changes to the Terms of Reference, as listed below, be
     recommended to the Board for approval:

           (a) Paragraph 3, first bullet point, should read as
           follows:-

           “Minutes reported through the Risk Management and
           Modernisation and Clinical Governance Committees to
           the Board in accordance with the structure.
                                                                Appendix 6


           (b) Paragraph 5 – Quorum

           Either one Regional Director or a Patient Safety
           Representative from a Regional Adverse Incident Group.

           (c) Paragraph 6 – Membership

           Various changes made to the membership and titles of
           existing members, including the attendance of
           representatives of POVA and Safeguarding Children as
           deemed necessary and a representative of Community
           Health Councils.

    (3) the Terms of Reference for the North Regional Adverse
    Incident Group be used to establish similar Groups in the
    Central & West and South East Regions by 31 October 2008;
    and

    (4) the discussion at the meeting about the role of the Panel be
    noted, specifically in connection with the relationship and flow
    of information between the Panel and other Groups in the
    structure and the importance of the quality of this information.

2   ROLE OF THE NPSA – A BRIEF OVERVIEW

    Mike Davies, Risk/Patient Safety Co-ordinator, North Region gave
    a brief description of the work of the National Patient Safety Agency
    (NPSA) and informed the Panel that the NPSA required the Trust to
    co-ordinate patient safety issues and supply data regularly on these
    issues and how the lessons learned were taken on board.

    A number of work streams and actions were identified for future
    discussion by the Panel and a full list of these actions was to be
    brought to the Panel at the next meeting. Some of these issues
    related to rapid response reports, alerts, practice notes and
    training.

    It was noted that a representative of the NPSA had been asked to
    attend a future meeting of the Panel to provide more information
    about its work.

    RESOLVED: That

    (1) the report be received and an action plan in relation to
    patient safety issues be presented to the next meeting of the
    Panel; and
                                                                Appendix 6


    (2) this subject be a Standing Item on the Panel’s agenda to
    include alerts and overview reports.

3   PATIENT SAFETY PANEL RISK REGISTER

    RESOLVED: That

    (1) it be acknowledged that the Patient Safety Risk Register
    will be a key theme for consideration at each meeting of the
    Panel; and

    (2) the format of future reports to identify the top 5 risks for
    detailed consideration by the Panel.

4   ST JOHN AMBULANCE – ORAL REPORT

    The Panel was informed that Mike Jenkins, was currently
    reviewing a Memorandum of Understanding, from a clinical
    perspective, in relation to use and deployment of St John
    ambulances within the Trust. The current position was outlined
    which had highlighted a number of operational/clinical governance
    issues which would need to be addressed.

    RESOLVED:

    That an update on the position be reported to the next meeting
    of the Panel.

5   SERIOUS ADVERSE INCIDENTS

    The Panel discussed in detail how serious incidents should be
    reported and what information was required at each meeting. It was
    acknowledged that consideration and subsequent action in relation
    to serious incidents was at the core of the Panel’s business and it
    was envisaged that careful consideration was required to ensure
    that other directorates were kept in the loop as to what action the
    Panel was recommending in each case.

    However, the Panel concluded that it would be too cumbersome to
    receive all of the information on all cases at each meeting. It was
    suggested therefore that the Risk/Patient Safety Co-ordinators
    would decide which cases should be brought to the Panel for
    consideration but, in order for the Panel to familiarise themselves
    with the cases, the full list should be presented to the next meeting
    on an exceptional basis.
                                                               Appendix 6


    The Panel also considered whether it should receive the NPSA
    reports when they were issued.

    RESOLVED: That

    (1) a report on all current serious incidents be presented to the
    next meeting of the Panel;

    (2) summary and update reports only be required at
    subsequent meetings; and

    (3) all reports submitted by the NPSA be presented to the
    Panel for consideration.

6   HEALTHCARE STANDARDS 15 AND 16

    Panel members were familiar with the ethos behind Healthcare
    Standards for Wales. Each and every one of the Healthcare
    Standards were aimed at continuous improvements in healthcare
    with patient safety being paramount. However, there were two
    standards in particular which focussed attention on processes and
    procedures around patient safety and more fundamentally the
    learning of lessons. These were Complaints/Feedback and patient
    safety incidents.

    The Corporate Secretary submitted a report which included
    guidance notes on the completion of the self assessment and a
    draft Healthcare Standards Improvement Plan setting out specific
    actions the Trusts intended to take.

    The report confirmed that the Panel’s role in developing the
    standards and the Trust’s response to them would be critical and
    consideration of these standards at appropriate meetings of the
    Panel would be required.

    The Panel suggested that in relation to complaints, it was important
    to acknowledge NHS Direct’s processes for considering adverse
    incidents/complaints which were currently included as part of the
    proposed role of the Regional Adverse Incident Groups. The Panel
    agreed, therefore, that these arrangements should remain in place
    for the time being whilst acknowledging the need to review
    processes as appropriate in the light of any future structural
    changes.
                                                                 Appendix 6


    -RESOLVED: That

    (1) the report be received and the actions set out in the HCSIP
    be endorsed;

    (2) the Panel acknowledges its important role in contributing
    to the organisation’s aim of improving levels of treatment and
    care to the citizens of Wales.

7   COMPLAINTS, CLAIMS AND LITIGATION

    The Corporate Secretary introduced a report containing detailed
    information on the position with the receipt and administration of
    complaints, claims and litigation. It was suggested that the ability of
    the Trust to learn lessons and improve patient safety arising from
    such instances represented a significant part of the Panel’s work.

    The Panel would, therefore, receive at each meeting an overview of
    current complaints, claims and litigation cases and refer and
    receive, as necessary, recommendations from other bodies,
    particularly the Regional Adverse Incident Groups, on the actions
    taken and lessons learned.

    It was also suggested that the Panel would consider using all
    available mechanisms eg KSF to recommend actions on identified
    issues.

    RESOLVED: That

    (1) the report on complaints, claims and litigation be received;
    and

    (2) the Panel to receive a report at each meeting on the
    outcome and recommendations in relation to complaints,
    claims and litigation to ensure that appropriate actions are
    carried out and monitored.

8   RECENT EVENTS

    This item invited the Panel to discuss any significant events that
    had occurred involving patient safety. Reference was made to the
    problems with the Mercedes ambulance vehicles, the report that
    had been requested by the Assembly Government to explain the
    Trust’s poor response times in rural areas and the issues
    surrounding driving safety within the Car Ambulance Service.
                                                          Appendix 6


    RESOLVED: That the report be received.

9   FUTURE MEETINGS (PROGRAMME OF BUSINESS AND
    FREQUENCY)

    RESOLVED: That

    (1) the Panel meet on a bi-monthly basis and a programme of
    dates to the end of 2009 be drawn up;

    (2) Regional Directors be asked to establish Regional Adverse
    Incident Groups in Central & West and the South East Regions
    to meet by the end of October and report to the next meeting
    of the Panel in mid November; and

    (3) the minutes of these Groups be submitted to the Panel at
    each meeting.

				
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Description: MINUTES OF A MEETING OF THE PATIENT SAFETY PANEL held on 11