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.

- HSC Trusts reported that training for clinical staff on coronial and inquest procedures had been provided (IHRD Implementation Programme, Department of Health NI, March …

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.

- HSC Trusts reported that arrangements for supporting families through inquest proceedings had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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 …

- HSC Trusts reported that processes for implementing recommendations arising from inquests had been formalised (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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.

- HSC Trusts reported that bereavement support services for families had been established across all Trusts (IHRD Implementation Programme, Department of Health NI, March 2018). …

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.

- HSC Trusts reported that training programmes for Board members on scrutiny of patient safety had been implemented (IHRD Implementation Programme, Department of Health NI, …

IHRD-56 Accepted

Hyponatraemia Inquiry (2018)

Board Member Induction Training

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

- HSC Trusts reported that Board-level governance arrangements for patient safety had been strengthened, including standing agenda items on patient safety at Board meetings (IHRD …

IHRD-57 Accepted

Hyponatraemia Inquiry (2018)

Clinical Training for Guidelines

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

- HSC Trusts reported that mandatory training for clinical staff on fluid management in children had been implemented (IHRD Implementation Programme, Department of Health NI, …

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.

- HSC Trusts reported that training on the recognition and management of the deteriorating child had been strengthened (IHRD Implementation Programme, Department of Health NI, …

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.

- HSC Trusts reported that communication skills training for clinical staff working with children and families had been enhanced (IHRD Implementation Programme, Department of Health …

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.

- HSC Trusts reported that training on open disclosure and candour principles had been provided to clinical staff (IHRD Implementation Programme, Department of Health NI, …

IHRD-61 Accepted

Hyponatraemia Inquiry (2018)

Paediatric Communication Training

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

- HSC Trusts reported that training on consent processes for paediatric care had been reviewed and updated (IHRD Implementation Programme, Department of Health NI, March …

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.

- HSC Trusts reported that training on clinical record-keeping standards had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

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.

- HSC Trusts reported that training on clinical handover procedures had been implemented (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-64 Accepted

Hyponatraemia Inquiry (2018)

Parental Involvement in Training

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

- HSC Trusts reported that training on SAI investigation processes had been delivered to relevant staff (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-65 Accepted

Hyponatraemia Inquiry (2018)

SAI Investigator Training

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

- HSC Trusts reported that training on complaints handling and family engagement had been enhanced (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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.

- HSC Trusts reported that training on governance and accountability responsibilities for senior managers had been implemented (IHRD Implementation Programme, Department of Health NI, March …

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.

- HSC Trusts reported that training on human factors and patient safety had been incorporated into staff development programmes (IHRD Implementation Programme, Department of Health …

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.

- HSC Trusts reported that multidisciplinary team training for paediatric care had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

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.

- HSC Trusts reported that risk management frameworks had been updated to incorporate patient safety incident learning (IHRD Implementation Programme, Department of Health NI, March …

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.

- HSC Trusts reported that clinical governance reporting structures had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent published …

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.

- HSC Trusts reported that quality improvement programmes had been enhanced to address patient safety themes (IHRD Implementation Programme, Department of Health NI, March 2018). …

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.

- HSC Trusts reported that medical director responsibilities for patient safety had been formally defined (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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.

- HSC Trusts reported that nursing director responsibilities for patient safety monitoring had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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.

- HSC Trusts reported that patient safety dashboards had been developed for Board-level reporting (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

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.

- HSC Trusts reported that complaint response times and quality had been improved (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

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.

- HSC Trusts reported that processes for learning from complaints had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-77 Accepted

Hyponatraemia Inquiry (2018)

Trust Compliance Officer

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

- HSC Trusts reported that patient and public involvement arrangements had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-78 Accepted

Hyponatraemia Inquiry (2018)

Clinical Guidelines Audit

Implementation of clinical guidelines should be documented and routinely audited.

- HSC Trusts reported that Non-Executive Director oversight of patient safety had been formalised (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

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.

- HSC Trusts reported that clinical audit programmes had been integrated into governance frameworks (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

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.

- HSC Trusts reported that information governance arrangements for patient safety data had been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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.

- HSC Trusts reported that performance management frameworks had been updated to include patient safety objectives (IHRD Implementation Programme, Department of Health NI, March 2018). …

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.

- HSC Trusts reported that whistleblowing and raising concerns policies had been reviewed and updated (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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.

- HSC Trusts reported that leadership development programmes for senior clinicians had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

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.

- HSC Trusts reported that succession planning for key clinical and governance roles had been formalised (IHRD Implementation Programme, Department of Health NI, March 2018). …

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.

- The Department of Health NI stated in March 2018 that the role was under consideration within departmental restructuring (IHRD Implementation Programme, Department of Health …

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 …

- The Department of Health NI stated in March 2018 that RQIA's remit and resources were under review (IHRD Implementation Programme, Department of Health NI, …

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.

- The Department of Health NI stated in March 2018 that prototypes for an Independent Medical Examiner service were progressing (IHRD Implementation Programme, Department of …

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.

- The Department of Health NI stated in March 2018 that engagement with statutory organisations on a Child Death Overview Panel was ongoing (IHRD Implementation …

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.

- The Department of Health NI stated in March 2018 that this was under consideration as part of a broader patient engagement strategy (IHRD Implementation …

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 …

- The Department of Health NI reported that protocols for departmental engagement with HSC Trusts on patient safety matters had been reviewed (IHRD Implementation Programme, …

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 …

- The Department of Health NI reported that patient safety incident reporting systems were being synchronised across the HSC (IHRD Implementation Programme, Department of Health …

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.

- The Department of Health NI reported that departmental monitoring of SAI investigation outcomes had been strengthened (IHRD Implementation Programme, Department of Health NI, March …

IHRD-93 Accepted

Hyponatraemia Inquiry (2018)

Review Trust Responses

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

- The Department of Health NI reported that arrangements for cross-departmental engagement on patient safety policy had been reviewed (IHRD Implementation Programme, Department of Health …

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 …

- The Department of Health NI stated in March 2018 that this was under consideration (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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 …

- The Department of Health NI reported that guidance on legal professional privilege in the context of SAI investigations had been reviewed (IHRD Implementation Programme, …

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.

- The Department of Health NI reported that standards for Trust engagement with clinical negligence litigation processes had been reviewed (IHRD Implementation Programme, Department of …