Reports & recommendations

The Inquiry recommends:
• The Department implements and funds a bespoke, regional leadership development programme for Board members and senior leaders, co-designed with external expertise including specific training in patient safety. This will complement the recently updated Board Handbook which provides excellent guidance and, if used as intended, should provide the basis for an effective Board. Such a programme should be devised with input from Trusts and professional group leaders and be informed by the work of this and other inquiries.
The programme should:
o ensure that all staff have sufficient understanding of their role in patient safety and incident reporting. Any plan must ensure that they understand the overall aims of the health and social care system;
o ensure that each professional group is assisted as needed to develop their professional duties as individuals and also to understand how they must work together in multiprofessional teams to deliver shared aims and objectives. In practice this will require each profession to have training directly relevant to it and then for combined training with other professionals in the team;
o determine how those with leadership and management responsibility are developed to understand, develop and deliver their services as a management team at each level; and
o determine how the executive team and the Board is developed to fulfill their duties. This will require a consolidation and refresh of the leadership development programmes currently available.
• The Department should facilitate discussion and debate regarding the work done in the Trust as a result of its engagement with the External Reference Group (ERG) with a view to continuing this approach. We recommend that the discussion includes consideration of a partnership arrangement with an organisation who has successfully brought about a cultural change. This would provide the Trust with the benefit of a critical friend who could add value in a pragmatic way.
• The Trust should formulate an agreed approach to ongoing Board development for the future, including lessons from the Inquiry and the events that preceded it. This should include specific training in the field of patient safety, including best practice in this area for all Board members and senior managers.
• The Department should review current methodology for Board self-assessment and guidance on Board composition. Consideration ought to be given to greater clinical input and more service user feedback and representation on the Board.
• Each Trust should appoint a Senior Independent Director (SID) as is recommended by NHS England. A SID is a Non-Executive Director with enhanced responsibilities. The SID can function as a sounding board for Board members or others who feel they cannot raise issues through normal mechanisms. The SID provides support to the Board Chair, as required, but is a point of contact regarding any issues with the Board Chair.
• The Trust should devise its own programme of work to agree on how best to implement ongoing leadership development for all Board members and Trust senior managers. This should include clarification about how to link into specific leadership development for medical managers, or other professional groups. In addition, the connections with wider organisational development programmes and regional development programmes should be clearly described in a way that ensures that there is a clear alignment of purpose. The comments and recommendations of the Messenger Report are relevant to such a programme of work.

We recommend that:
• The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in each Trust. This involves ongoing feedback and backing for Trusts in terms of making the best use of the new framework and training staff to understand it. Departmental regional support for this training would be helpful. This could take the form of multidisciplinary working groups where illustrative case studies could be used to demonstrate best practice and to discuss queries.
• There should be shared knowledge across Trusts and greater use of inter-Trust investigation leads and other mechanisms for sharing expertise.
• The emphasis of the new framework must be on rapid learning, patient involvement, and system-wide sharing of learning rather than blame.
• The Trust should use the platform provided by the Northern Ireland framework to refresh its approach to incident management. Areas for attention include the use of the current incident reporting system, the weekly incident meeting, and the clarification of responsibilities for completing the agreed learning and actions.
• The Trust should continue to improve Board oversight of SAIs and continue thematic reporting of incidents. This reporting should be further developed to ensure that Trust-wide programmes of improvement and transformation can be supported as needed.
• The Trust should continue to develop its approach to SAIs under the leadership of the Medical Director with input from senior managers in governance.
• The Trust should ensure all staff complete a mandatory programme of training that emphasises the primacy of patient safety, as well as learning from error in a way that can be understood and maintained by all staff. While clinical staff have a clear professional duty to report risks to safety, other staff need to understand they too have such a duty.

The Inquiry recommends that:
• There must be sustained investment in leadership development for doctors at all career stages. Improvements discussed in the Medical Management and Leadership chapter should continue. The Department should establish a dedicated regional programme to strengthen medical leadership and management. This programme should focus on all aspects of medical management and leadership; aid continuous development and provide opportunities for ongoing challenge.
• The Trust should continue to develop its medical managers and leaders ensuring that roles and responsibilities are clear and there is sufficient time allocated to perform the roles.
• Within the Trust there must also be access to ongoing training and development for all medical leaders. Leadership programmes for all doctors, medical managers and clinical leaders must be developed and sustained. Such programmes should be clearly linked to wider organisational development programmes to foster shared decision making across professional boundaries.
• The work done in relation to improving understanding of the different approaches to managing doctors in difficulty and the wider training on the MHPS framework put in place at the Trust should continue.
• While the MHPS framework exists in its current form, the Trust should consolidate the work undertaken to date and develop a protocol to address the recommendations listed at the end of the MHPS chapter.
• The work relating to redevelopment of the MHPS framework in Northern Ireland carried out by the Department should continue at pace as it is long overdue. The Inquiry endorses the recommendations made by the Department's review group, advocating a completely new approach to replace the MHPS framework.
• The Department should continue to invest in and enhance regional working groups for Medical Directors and other senior medical managers. These groups should provide expertise in relation to mechanisms for dealing with doctors in difficulty and difficult doctors. The groups can share case studies and best practice. The remit of these groups should include an emphasis on the use of external resources such as Practitioner Performance Advice (PPA), as well as how to develop and use robust internal processes. Such processes must encompass the need for any necessary support for practitioners, integrate with and link to all current processes that relate to how concerns about medical staff are addressed.
• All doctors and doctors in training need to be made aware of current processes and receive mandatory training in this area.
• Doctors must be involved in the management and leadership of services and in strategic planning for the future. There must be targeted funding and oversight from the Department. In the interim the Trust must ensure its medical staff is involved in the management and leadership of its services.