Agenda and draft minutes

This Commission will meet with the South Gloucestershire Health Scrutiny Commission to discuss the item set out on this Agenda, People Scrutiny Commission - Friday, 12th August, 2016 10.00 am

Venue: The Council Chamber - City Hall, College Green, Bristol, BS1 5TR. View directions

Contact: Claudette Campbell  0117 92 22324

No. Item


Welcome, Introduction and Safety Information pdf icon PDF 91 KB

Chairing Arrangements:

In accordance with previously agreed arrangements, Councillor Brenda Massey will act as Chair for the duration of the Meeting and Councillor Toby Savage, South Gloucestershire, will act as Vice-Chair.


In accordance with previously agreed arrangements, Councillor Brenda Massey, (Bristol), took the role of Chair and Councillor Toby Savage (South Gloucestershire), took the role of Vice-Chair.


The Chair led welcome and introductions and outlined the Health Scrutiny requirement and Meeting in Common powers in full as outlined in the agenda papers.


Apologies for Absence


Apologies for absence were received from, Councillor Jos Clark, Councillor Mark Brain, Councillor Celia Phipps, Councillor Ruth Pickersgill, Councillor Sarah Pomfret, Bryony Strachan – UHB Clinical Chair, Division Women’s and Childrens, Mark Pietroni, Erica Wiiliams,  and Gloria Steven.



Declarations of Interest

To note any declaration of interest from the Councillors.  They are asked to indiciate the relevant agenda item, the nature of the interest and in particular whether it is a disclosable pecuniary interest.


Any declarations of interest made at the meeting which is not on the register of interests should be notified to the Monitoring Officer for inclusion.




There were no declarations of interest.


Public Forum

Up to 30 minutes is allowed for this item.


Any member of the public or Councillor may participate in Public Forum.  The detailed arrangements for so doing are set out in the Public Information Sheet at the back of this agenda.  Public Forum items must be emailed to and please note that the following deadlines will apply in relation to this meeting:-


Questions – written questions must be received 3 clear working days prior to the meeting.  For this meeting, this means that your question(s) must be received in this office at the latest by 5pm on 8th August 2016.


Petitions and Statements – Petitions and Statements must be received on the working day prior to the meeting.  For this meeting this means that your submission must be received in this office at the latest by 12.00 noon on 11th August 2016.


The Committee considered the public forum statements received as follows with Daphne Havercroft and Allyn Condon in attendance:


Statement 1

Yolanda and Steve Turner

The Bristol Review into Cardiac Services at Bristol Royal Hospital for Children 2010-2014

Statement 2

Daphne Havercroft

Childrens Cardiac Services – Risk Management

Statement 3

Allyn Condon

UH Bristol Trust Progress of the Verita recommendations

Statement 4

Katharine Tylko

The Bristol Review – improvements in the safety of childrens congenital heart surgery nationwide



Independent Reports Relating to the Bristol Royal Hospital for Children, 2016 pdf icon PDF 467 KB

Report presented by:

·       Robert Woolley, Chief Executive University Hospitals Bristol NHS Foundation Trust


Accompanied by:

·       Sean O’Kelly, Medical Director

·       Carolyn Mills, Chief Nurse

·       Bryony Strachan, Clinical Chair, Division of Women’s and Children’s

Additional documents:


The Committee considered the report presented by Robert Woolley, Chief Executive University Hospitals Bristol NHS Foundation Trust, accompanied by Sean O’Kelly, Medical Director, Carolyn Mills, Chief Nurse, Bryony Strachan, Clinical Chair, Division of Women’s and Children’s.


Which set out the Trust’s response, to the Independent Review of Children’s Cardiac Services in Bristol and the Trust’s response to the two independent reports published on 30 June 2016, namely the report of the Independent Review of Children's Cardiac Services in Bristol and a Review of pre-operative, peri-operative and postoperative care in cardiac surgical services at Bristol Royal Hospital for Children. And presented the University Hospitals Bristol NHS Foundation Trust's

Cardiac Review Action Plan.


Robert Woolley (RW) summarised the UHB response to failings identified in the report and made the following points.


a.        Clarified that the CQC have stayed involved and have carried out random sample cases with audits targeting most complex cases.  Separate independent clinical experts have been used to analyse case notes.  EG had sight of the findings before she concluded her review. CQC did a comprehensive inspection in September 2014 with 70 inspectors.  Review found services for CYP at UHB in 2014 were good overall, specifically good for safety.

b.        In April 2016, NICOR published audit of all specialised children’s cardiac centres and found outcomes and standards of care were comparable with standards in other UK centres.

c.         In 2016 new a national congenital heart disease review announced results of assessments of all units against the new standards.  Announced intention to cease commissioning from three units in England.  UHB was not one of these and would receive support to comply with all commissioning standards (which came in from April 16).

RW read out the independent review conclusions and CQC conclusions and concluded with the following points:


d.        Recognition that UHB fully accept findings, got things wrong in a number of ways.  Care feel below acceptable standards, did not respond to parents concerns, apologised unreservedly and repeat this today.

e.        Pleased that upon review standards now found acceptable, but must get it right for every parent every time.  Have already taken number of actions and will describe significant improvements in response to questions later.

f.          Referred to Chapter 14 which set out actions already taken and Appendix A3 which sets out the action plan against recommendations.  Thirty-two recommendations apply in the main to the Trust and also to NHSE and DoH.

g.        Issue of consent is one area that is being looked at – how can parents know exactly what they are consenting to; the way that incidents are dealt with. Grieving parents should not be expected to navigate the system of complaints handling– CDR, CQC, ombudsman, etc.

h.        The result has been a confusing picture for all, UHB was inefficient in communications.

i.          Staffing is major theme and paediatric cardiac intensive care provision across country needs to be addressed.

j.          Failings in the report are not ones that persist now.  Great deal of external assurance in place.  Acknowledged  ...  view the full minutes text for item 5.


Verita Report - University Hospital Bristol Trust Response Appendix B pdf icon PDF 145 KB

Additional documents:


The Committee considered a report presented by Robert Woolley on the Independent investigation into the management response to allegations about staff behaviours related to the death of a baby at Bristol Children’s Hospital.


The points below were noted in the question and answer session that followed:


Summarised the key points that triggered the Veritas investigation and management response to the conclusion’s detailed in the Veritas summarised as follows:


a.      Staff behaviour;  a meeting where parents were given inaccurate information about the timing of tests; an episode in a CDR feedback meeting, (during a recess the consultants continued to discuss matters after parents left the room and when they realised they were still being recorded, one suggested it be deleted). The Trust investigated this and as stated p297.

b.      An allegation in an email from a parent about a cover up by staff which linked to a deeper allegation that clinical staff had been responsible for Ben’s death on IC unit.  That is why Verita was commissioned to do the investigation into the management response to the allegations.

c.       The Trust were keen that Ben’s family was able to influence the Terms of reference for the investigation and feed their concerns into the investigation.

d.      The Report is the management response to staff behaviour subsequent to Ben’s death.  Confirmed that that there had been a formal inquest a few weeks ago, it did not find that failings in the care given to Ben, had caused Ben’s death.  Confirmed that Ben’s family do not accept this finding and there are differences in opinion.

e.      Acknowledged that Ben’s family feel consultant staff have lied, but this was not the conclusion of the Trust.  Nonetheless the investigation shows that the Trust has let Ben’s family down in a number of ways. The Trust missed a number of opportunities to engage proactively and candidly with Ben’s family.  Delays in complaints being investigated, contributed to a sense of mistrust and suspicion.  The senior management team failed to get a grip of the complaint at first, and then subsequently the complexity of the investigation and response required.

f.        Veritas report states that the Trust hadn’t explained sufficiently what they had found. Thereby the Trust’s responses have compounded the issue with its poor responses and communications.

g.      The Trust had begun to deliver the 9 recommendations, p300, the action plan demonstrates the progress made.  This was shared with Ben’s parents, who disputed the contents, before it went to the Trust’s Board.  This was discussed openly in a Board meeting.  In response to recommendation 9 the Board agreed to identification of a senior clinician within the Trust from a different division to meet with Ben’s parents and to understand the outstanding concerns and endeavour to agree a plan to answer those concerns.  So it is a work in progress.

h.      Ben’s father has raised concern that the Trust is trying to lump in other matters to Reccommendation 9 but this is not the intent. 

i.        With reference to Reccomendation  ...  view the full minutes text for item 6.