Dear Mr Gittins,

REGULATION 28 RELATING TO MR ARTHUR PRICE HUGHES

I am writing further to the recent Regulation 28, Prevention of Future Deaths Notice, issued to the Health Board following the inquest touching upon the death of Mr Hughes.

I would like to begin by extending the sincere condolences and apologies of both myself and the Health Board to the family of Mr Hughes. We fully accept the findings of the inquest and we deeply regret that we did not meet the standards that we expect of ourselves. We have used the findings of the inquest to review and improve the quality and safety of our services.

Please find below our response to your concerns which I trust will provide you with assurance about how we intend to strengthen our processes to avoid a reoccurrence of the issues you have identified. We are committed to continually improve the quality and safety of our services and I hope the below conveys this.

The concerns you raised were:

Ein cyf / Our ref: INC142329 Eich cyf / Your ref: : 01978 727463 Gofynnwch am / Ask for:

E-bost / Email:

Dyddiad / Date: 04 May 2020 Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd, LL57 2PW
---------------------------------- Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk

Our response:

1. Appointment of Locum Medical Staff – Assessment of practice

A Standard Operating Procedure (SOP) had been revised and implemented previously as reported during the inquest. The SOP required clinical departments to undertake the following for all locum appointments (both fixed term contracts and agency locums).

1. Undertake a Local Induction to be completed by the end of the first shift and submitted no later than 3 days following the first shift. The Local Induction includes  Practical arrangements  Key Health Board Policies  Initial outline of expectations of the post and limitations against the role  Confirmation of minimum period of supervised practice (if applicable)

2. Undertake an Assessment of Practice and Performance – This assessment includes:  Clinical Skills  Knowledge  Attitudes  Relationships  Integrity

The SOP required retention of documentation by the clinical department.

An audit of compliance had been undertaken in relation to the two requirements above against appointments (18 placements) made following revision of the SOP in 2019.

Whilst Clinical Directors confirmed that the requirement for Local Induction had been met, not all were able to provide the documentary evidence required.

Clinical Directors also confirmed that ongoing assessment of practice and performance was undertaken and where issues were identified, these had been escalated as appropriate through the Office of the Medical Director/Responsible Officer and/or the relevant Agency provider Responsible Officer. However, the specific pro forma required by the SOP had not been completed for all placements.

Action taken to date:

i. Immediate action was taken to obtain assurance from each of the relevant Clinical Directors regarding the capability and performance of each of the 12 individuals remaining in the Health Board – this has been completed.

ii. In addition to the immediate assurance, Clinical Directors were asked to provide completed assessment forms for each of the individuals – original due date 31 March 2020;
iii. The Standard Operating Procedure (SOP) has been amended to ensure central collection and follow up of both Local Induction and Assessment of Practice and Performance pro forma – due to be implemented 01 April 2020;

iv. Locum Induction pro forma now to be submitted to the Medical Bank Service with payment not processed until received – original due date 01 April 2020;
v. Assessment of Practice and Performance pro forma required by the tenth day of placement, signed by the Clinical Director and submitted to the Medical Bank Service – original due date 10 April 2020;
vi. Compliance and action taken to remedy non-compliance with both requirements included in the monthly Medical Agency Locum Report to the Executive Director of Workforce and Organisational Development and Board Committee – original due date 28 April 2020.

The original implementation dates for the actions above have been delayed due to the activation of the Major Incident Response to COVID-19. However, revised implementation dates have been set to ensure documentary evidence requirements are in place by 31 May 2020 with reporting by 30 June 2020.

In the intervening period, Clinical Directors are required to provide verbal/email confirmation that individuals working under their supervision (accountability) are competent to do so.

We apologise for the concerns identified in our recruitment process and we are sorry that we were unable to offer greater assurance to you at the inquest. I trust the above actions demonstrate our continued commitment to improvement.

2. Reference validation

The Health Board is required to follow the NHS Employment Check Standards for both employees and Agency workers.

The NHS Employment Check Standards include the requirement to:

i. Obtain factual references covering the last 3 years employment and specifically from the current or most recent employer;
ii. Current or most recent employer reference must be from the line manager;
iii. References must be written and sent from a recognised company email address;
iv. They should include the referee’s name, job title and a main landline number.

Action taken to date:

Following the review undertaken as a result of the inquest, the following process has been developed to ensure that any issues or anomalies are addressed prior to a formal offer of employment being issued:

i. Application forms for shortlisted candidates will be screened by the central Recruitment Team prior to interview to ensure that referees provided include the current/most recent line manager;
ii. This screening will identify any irregularity with the candidate and confirm that this must be addressed prior to interview or invitation will be withdrawn;
iii. Were permission to contact referees is granted, references must be sought prior to interview and any issues, irregularities highlighted to the chair of the panel prior to interview;
iv. Chair of the panel to seek clarification from candidate either prior to interview if the matter is sensitive in nature (i.e. could be considered to be prejudicial or personally sensitive) or as part of the interview, responses for both must be recorded in writing;
v. In the event that the panel requires additional validation of information provided in relation to competence or performance, the chair of the panel may contact the referee provided either by email or telephone to seek further assurance, this information must be recorded in writing;
vi. In the event that the candidate is an agency worker, the chair of the panel may contact the Responsible Officer for the agency copying in the Health Board’s Responsible Officer.

The additional elements of this process were due to be reviewed, approved and implemented from 01 April. However, this has been delayed due to the activation of the Major Incident Response to COVID-19.

At this point the Health Board is following the temporary pre-employment check requirements set out by NHS Employers during the COVID-19 pandemic. Appropriate risk assessments are undertaken for appointments made during this period.

Subject to the continuation of these temporary standards, the Health Board would intend to implement the revised process from 01 June 2020. An audit will be carried out at 3 and 6 months post-implementation to give us assurance that this has been effectively embedded into practice.

We regret that the appropriate references were not taken up as identified at the inquest and I trust the above provides assurance that our process has been strengthened and is in accordance with NHS standards.

Conclusion:

As mentioned above, we fully accept the findings of the inquest. I would like to reiterate the condolences and apologies of the Health Board to the family of Mr Hughes. We deeply regret that there were concerns in our processes and we apologise for this. We are equally sorry for the distress that must have been caused throughout this inquest process.

We have used the findings of the inquest to improve our services and I hope that our response provides confidence to you and Mr Hughes’s family that we have acted upon your findings at. The actions above will be tracked by our Quality Assurance Department to ensure that they are completed, and this will be reported to our Board.

If you require any further information or wish to discuss this letter please do not hesitate to contact Matthew Joyes, Acting Associate Director of Quality Assurance.