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.