Public Inquiry Recommendations

IHRD-51 Accepted

Hyponatraemia Inquiry (2018)

Independence of Coroner Witness Statements

Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-52 Accepted

Hyponatraemia Inquiry (2018)

Inquest Duties Protocol

Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-53 Accepted

Hyponatraemia Inquiry (2018)

Legal Privilege Disclosure to Coroner

In the event of a Trust asserting entitlement to legal privilege in respect of an expert report or other document relevant to the proceedings of an inquest, it should inform …

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-54 Accepted

Hyponatraemia Inquiry (2018)

Bereavement Counselling Services

Professional bereavement counselling for families should be made available and should fully co-ordinate bereavement information, follow-up service and facilitated access to family support groups.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-55 Accepted

Hyponatraemia Inquiry (2018)

Board Member Training on Patient Safety

Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-56 Accepted

Hyponatraemia Inquiry (2018)

Board Member Induction Training

All Trust Board Members should receive induction training in their statutory duties.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-57 Accepted

Hyponatraemia Inquiry (2018)

Clinical Training for Guidelines

Specific clinical training should always accompany the implementation of important clinical guidelines.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-58 Accepted

Hyponatraemia Inquiry (2018)

Paediatric Fluid Management Training

HSC Trusts should ensure that all nurses caring for children have facilitated access to e-learning on paediatric fluid management and hyponatraemia.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-59 Accepted

Hyponatraemia Inquiry (2018)

Post-Mortem Request Form Training

There should be training in the completion of the post-mortem examination request form.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-60 Accepted

Hyponatraemia Inquiry (2018)

Coroner Communication Training

There should be training in the communication of appropriate information and documentation to the Coroner's office.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-61 Accepted

Hyponatraemia Inquiry (2018)

Paediatric Communication Training

Clinicians caring for children should be trained in effective communication with both parents and children.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-62 Accepted

Hyponatraemia Inquiry (2018)

Adverse Incident Communication Training

Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-63 Accepted

Hyponatraemia Inquiry (2018)

Evaluation of Parental Involvement

The practice of involving parents in care and the experience of parents and families should be routinely evaluated and the information used to inform training and improvement.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-64 Accepted

Hyponatraemia Inquiry (2018)

Parental Involvement in Training

Parents should be involved in the preparation and provision of any such training programme.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-65 Accepted

Hyponatraemia Inquiry (2018)

SAI Investigator Training

Training in SAI investigation methods and procedures should be provided to those employed to investigate.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-66 Accepted

Hyponatraemia Inquiry (2018)

Time for SAI Learning

Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-67 Accepted

Hyponatraemia Inquiry (2018)

Informing Teaching Authorities

Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-68 Accepted

Hyponatraemia Inquiry (2018)

Using Investigations for Training

Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-69 Accepted

Hyponatraemia Inquiry (2018)

Executive Director Responsibilities

Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI related patient deaths.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-70 Accepted

Hyponatraemia Inquiry (2018)

Board Meeting Minutes Preservation

Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-71 Accepted

Hyponatraemia Inquiry (2018)

Children's Healthcare Governance

All Trust Boards should ensure that appropriate governance mechanisms are in place to assure the quality and safety of the healthcare services provided for children and young people.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-72 Accepted

Hyponatraemia Inquiry (2018)

Candour in Trust Communications

All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a nominated non-executive Director.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-73 Accepted

Hyponatraemia Inquiry (2018)

GMC Code in Employment Contracts

General Medical Council ('GMC') 'Good Medical Practice' Code requirements should be incorporated into contracts of employment for doctors.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-74 Accepted

Hyponatraemia Inquiry (2018)

Professional Codes in Employment Contracts

Likewise, professional codes governing nurses and other healthcare professionals should be incorporated into contracts of employment.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-75 Accepted

Hyponatraemia Inquiry (2018)

Independent Disciplinary Action

Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-76 Accepted

Hyponatraemia Inquiry (2018)

Publication of Clinical Standards

Clinical standards of care, such as patients might reasonably expect, should be published and made subject to regular audit.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-77 Accepted

Hyponatraemia Inquiry (2018)

Trust Compliance Officer

Trusts should appoint a compliance officer to ensure compliance with protocol and direction.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-78 Accepted

Hyponatraemia Inquiry (2018)

Clinical Guidelines Audit

Implementation of clinical guidelines should be documented and routinely audited.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-79 Accepted

Hyponatraemia Inquiry (2018)

Reporting Clinical Practice Changes

Trusts should bring significant changes in clinical practice to the attention of the HSCB with expedition.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-80 Accepted

Hyponatraemia Inquiry (2018)

Healthcare Data Analysis

Trusts should ensure health care data is expertly analysed for patterns of poor performance and issues of patient safety.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-81 Accepted

Hyponatraemia Inquiry (2018)

Board Awareness of SAI Reports

Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-82 Accepted

Hyponatraemia Inquiry (2018)

Policy on Learning from SAI Deaths

Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-83 Accepted

Hyponatraemia Inquiry (2018)

SAI Deaths in Annual Reports

Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-84 Accepted

Hyponatraemia Inquiry (2018)

Trust Board Review of IHRD Report

All Trust Boards should consider the findings and recommendations of this Report and where appropriate amend practice and procedure.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-85 Accepted

Hyponatraemia Inquiry (2018)

Deputy CMO for Children's Healthcare

The Department should appoint a Deputy Chief Medical Officer with specific responsibility for children's healthcare.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-86 Accepted

Hyponatraemia Inquiry (2018)

Expand RQIA Remit and Resources

The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the SAI process (ii) be strengthened in its capacity …

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-87 Accepted

Hyponatraemia Inquiry (2018)

Independent Medical Examiner

The Department should now institute the office of Independent Medical Examiner to scrutinise those hospital deaths not referred to the Coroner.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-88 Accepted

Hyponatraemia Inquiry (2018)

Child Death Overview Panel

The Department should engage with other interested statutory organisations to review the merits of introducing a Child Death Overview Panel.

Government response: Accepted. Implementation status based on Department of Health NI Implementation Programme updates.. No independent verification has been carried out.

IHRD-89 Accepted

Hyponatraemia Inquiry (2018)

Patient Concern Organisation

The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-90 Accepted

Hyponatraemia Inquiry (2018)

Clinical Guidance Dissemination Protocol

The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals fixed with responsibility for implementation and audit to …

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-91 Accepted

Hyponatraemia Inquiry (2018)

Synchronise Patient Safety Systems

The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional …

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-92 Accepted

Hyponatraemia Inquiry (2018)

Review Healthcare Standards

The Department should review healthcare standards in light of the findings and recommendations of this report and make such changes as are necessary.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-93 Accepted

Hyponatraemia Inquiry (2018)

Review Trust Responses

The Department should review Trust responses to the findings and recommendations of this Report.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-94 Accepted in Part

Hyponatraemia Inquiry (2018)

Clinical Negligence Litigation Reform

The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical …

Government response: Accepted in Part. Implementation status based on Department of Health NI Implementation Programme updates.. No independent verification has been carried out.

IHRD-95 Accepted

Hyponatraemia Inquiry (2018)

Legal Privilege Protocol

Given that the public is entitled to expect appropriate transparency from a publically funded service, the Department should bring forward protocol governing how and when legal privilege entitlement might properly …

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.

IHRD-96 Accepted

Hyponatraemia Inquiry (2018)

Healthcare Litigation Standards

The Department should provide clear standards to govern the management of healthcare litigation by Trusts and the work of Trust employees and legal advisors in this connection should be audited.

Government response: Accepted. Last substantive update was January 2024. No recent public evidence of further progress.