Agenda item

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 3 – undertook a formal investigation ‘through maintaining high professional standards’ process and shared broad conclusions with Ben’s parents.  The Trust’s interpretation is that there is a need to share more information on this to demonstrate that the investigation was robust but was unable to share the whole report due to a duty of care to the staff concerned.  Legal advice is pending on this.

Members Questions:

Q1.            There is acknowledgement of the apology for failure and that recommendations are being worked on but no mention of disciplinary actions.  Noted that some dates outstanding , for example recommendation 9 has no date against it.  This family has gone through a terrible tragedy, are they getting any help with their legal costs?

j.        The formal investigation previously described is a preliminary to any disciplinary action if this is required, and the Trust concluded that this was not required.  Recommendation 9 completion timescale remains open until both parties agree that as much as possible has been done, hence this attempt to reengage via a senior clinician form other area. 

k.       Question on legal advice is fair challenge – Trust didn’t anticipate that there would be a legal obstruction in terms of releasing the report mentioned at recommendation 3, but this is position the Trust is in.  Confirmed that he is determined to find a way to prove the investigation was robust.

l.        Success of reengagement depends on the Trusts ability to answer questions to the family’s satisfaction.  There are avenues for independent investigation by the family which won’t incur legal costs, but this is a consideration that could be needed at later date if warranted.

Q2.            Will they make a commitment for financial provision of legal support to family within next two months?

m.    Confirmed that they were happy to do that.

Q3.            With reference to Recommendation 30 keeping families informed and provision of opportunities to be involved in design changes.

n.      There is a review of cardiac improvements and revision of complaints provision families are involved .

Q4.            Has there been a change in practice?

o.      Current process - issues are addressed in a letter to parents.  The Trust Have strengthened the process for complex complaints to include table of issues and actions.  Under pinning this, representatives from all divisions meet so that parents can be involved in the specifics of progressing an action.  Parents have named contact for who to approach regarding further involvement.

p.      Wider PPI activity – confirmed that there are a number of complainants who want to be more involved via a Patient Public Network.

Q5.            What are the representatives from UHB and NHSE each going to do personally to ensure that what has been heard and read today won’t happen again?

q.      RW – absolutely accept his accountability for the failings in these reports.  Entirely incumbent on him to deliver recommendations in all the reports that they are taken forward at speed and done well and as far as possible are delivered with parents (if they wish) and it is done publicly with reports to board and future HOSC meetings.  Personal commitment given to do everything in power to ensure done well and at pace.

r.       LP  confirmed that in NHSE and in commissioning community the absolute commitment to ensure recommendations and actions plans are implemented.

Q6.            A personal response?

s.       VL referred to the standards document previously discussed and confirmed as clinical director that he will be working with directly with Trusts and to ensure with Trust via regular meetings that there are clear action plans in place to meet standards and read the paragraphs relating to the two specific standards i) for Level 1 units (like UHB) and the ii) palliative care and bereavement.   These are both standards that are difficult to measure but the NHSE already have a number of processes in place to draw on.  A dashboard is being developed and should include these areas.  NHSE will pursue these areas with Trusts and confirmed that he would feed back to colleagues in other areas to ensure they meet standards too.

Q7.            Recommendations  2 and 8 have completion dates against them of September this year.  Are you confident these will be met?

t.        RW – yes.

Q8.            There is a need to move forward not back.  What date should we come back?

u.      Confirmed that the Trust would comply with a timescale that the committee felt appropriate.  Suggested 3 months to can update us on action plans and the same frequency going forward to update in entirety.

Q9.            Concerned that community learning could be forgotten. How do we ensure learning is embodied going forward?

v.       RW agreed.  There is a constant struggle to demonstrate learning.  This report calls for a partnership across the NHS with patients and families which is still not embedded fully in the service.  UHB is committed to developing this partnership and that level of holding to account by the very people they serve.  Need to address concerns at time occur, driving responsiveness and learning.

Q10.        Reference to 5c Discharge planning?  Progressing repatriation policy to regional hospitals?

w.     RW confirmed strategy they have and the new congenital standards put in place.  As regional, tertiary centre have responsibility across network of hospitals to assist local hospitals to have ability to care for patients where appropriate closer to their homes and where appropriate travel to Bristol for specialist care.

Q11.        Support for bereaved families  - training and dissemination of guidance to staff?

x.       IB – a palliative care team is in place and have developed bereavement support in place.  Now trying to bring both together in comprehensive way. 

The Committee briefly discussed the appropriate timescales for an update on both reports.

The Committee agreed that the Trust return to committee in 3 months to provide a progress report on the Veritas report (Item 5) and return to committee in 6 months to provide an update for the cardiac (Item 6).

Action: Officers to facilitate dates for further meetings.

Date of Next Meeting to be confirmed

The meeting closed at 12.40pm