Public Inquiry Recommendations

IHRD-1 Accepted Urgent

Hyponatraemia Inquiry (2018)

Statutory Duty of Candour

A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all …

IHRD-2 Accepted

Hyponatraemia Inquiry (2018)

Criminal Liability for Candour Breach

Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.

IHRD-3 Accepted

Hyponatraemia Inquiry (2018)

Guidance on Statutory Duty of Candour

Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.

IHRD-4 Accepted

Hyponatraemia Inquiry (2018)

Trust Awareness of Duty of Candour

Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of …

IHRD-5 Accepted

Hyponatraemia Inquiry (2018)

Employment Contracts and Duty of Candour

Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.

IHRD-6 Accepted

Hyponatraemia Inquiry (2018)

Support for Candour Compliance

Support and protection should be given to those who properly fulfil their duty of candour.

IHRD-7 Accepted

Hyponatraemia Inquiry (2018)

Monitoring Candour Compliance

Trusts should monitor compliance and take disciplinary action against breach.

IHRD-8 Accepted

Hyponatraemia Inquiry (2018)

RQIA Compliance Review Powers

Regulation and Quality Improvement Authority ('RQIA') should review overall compliance and consideration should be given to granting it the power to prosecute in cases of serial non-compliance or serious and …

IHRD-9 Accepted

Hyponatraemia Inquiry (2018)

Leadership Development

The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.

IHRD-10 Accepted

Hyponatraemia Inquiry (2018)

Age-Appropriate Hospital Settings

Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in age-appropriate hospital settings.

IHRD-11 Accepted

Hyponatraemia Inquiry (2018)

Patient Transfer Protocol

There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.

IHRD-12 Accepted

Hyponatraemia Inquiry (2018)

Senior Paediatric Responsibility

Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.

IHRD-13 Accepted

Hyponatraemia Inquiry (2018)

Foundation Doctors in Children's Wards

Foundation doctors should not be employed in children's wards.

IHRD-14 Accepted

Hyponatraemia Inquiry (2018)

Clinician Competence Assessment

The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.

IHRD-15 Accepted

Hyponatraemia Inquiry (2018)

Consultant Notification on Admission

A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept informed of the patient's condition, to ensure senior …

IHRD-16 Accepted

Hyponatraemia Inquiry (2018)

Bedside Display of Responsible Staff

The names of both the consultant responsible and the accountable nurse should be prominently displayed at the bed in order that all can know who is in charge and responsible.

IHRD-17 Accepted

Hyponatraemia Inquiry (2018)

Recording Changes in Accountability

Any change in clinical accountability should be recorded in the notes.

IHRD-18 Accepted

Hyponatraemia Inquiry (2018)

On-Call Consultant Display

The names of all on-call consultants should be prominently displayed in children's wards.

IHRD-19 Accepted

Hyponatraemia Inquiry (2018)

Senior Lead Nurse in Children's Wards

To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating …

IHRD-20 Accepted

Hyponatraemia Inquiry (2018)

Consultant-Led Ward Rounds

Children's ward rounds should be led by a consultant and occur every morning and evening.

IHRD-21 Accepted

Hyponatraemia Inquiry (2018)

Nurse Attendance at Clinical Interactions

The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.

IHRD-22 Accepted

Hyponatraemia Inquiry (2018)

Parental Knowledge in Care Plans

Clinicians should respect parental knowledge and expertise in relation to a child's care needs and incorporate the same into their care plans.

IHRD-23 Accepted

Hyponatraemia Inquiry (2018)

Care Plan Availability at Bedside

The care plan should be available at the bed and the reasons for any change in treatment should be recorded.

IHRD-24 Accepted

Hyponatraemia Inquiry (2018)

Blood Test Result Documentation

All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should …

IHRD-25 Accepted

Hyponatraemia Inquiry (2018)

Drug Prescription Documentation

All instances of drug prescription and administration should be entered into the main clinical notes and paediatric pharmacists should monitor, query and, if necessary, correct prescriptions. In the event of …

IHRD-26 Accepted

Hyponatraemia Inquiry (2018)

Recording Clinical Discussions

Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.

IHRD-27 Accepted

Hyponatraemia Inquiry (2018)

Electronic Patient Information Systems

Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.

IHRD-28 Accepted

Hyponatraemia Inquiry (2018)

Informed Consent Documentation

Consideration should be given to recording and/or emailing information and advices provided for the purpose of obtaining informed consent.

IHRD-29 Accepted

Hyponatraemia Inquiry (2018)

Record Keeping Audit

Record keeping should be subject to rigorous, routine and regular audit.

IHRD-30 Accepted

Hyponatraemia Inquiry (2018)

Confidential Reporting of Clinical Concerns

Confidential on-line opportunities for reporting clinical concerns should be developed, implemented and reviewed.

IHRD-31 Accepted

Hyponatraemia Inquiry (2018)

SAI Reporting Understanding

Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').

IHRD-32 Accepted

Hyponatraemia Inquiry (2018)

SAI Reporting as Disciplinary Offence

Failure to report an SAI should be a disciplinary offence.

IHRD-33 Accepted

Hyponatraemia Inquiry (2018)

CEO Responsibility for Investigations

Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.

IHRD-34 Accepted

Hyponatraemia Inquiry (2018)

Independent SAI Investigation

The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.

IHRD-35 Accepted

Hyponatraemia Inquiry (2018)

Non-Cooperation as Disciplinary Offence

Failure to co-operate with investigation should be a disciplinary offence.

IHRD-36 Accepted

Hyponatraemia Inquiry (2018)

Separation of Investigation and Litigation

Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.

IHRD-37 Accepted

Hyponatraemia Inquiry (2018)

Family Involvement in SAI Investigations

Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all …

IHRD-38 Accepted

Hyponatraemia Inquiry (2018)

Multi-Disciplinary Peer Review

Investigations should be subject to multi-disciplinary peer review.

IHRD-39 Accepted

Hyponatraemia Inquiry (2018)

Investigation Team Reconvening

Investigation teams should reconvene after an agreed period to assess both investigation and response.

IHRD-40 Accepted

Hyponatraemia Inquiry (2018)

SAI Learning Informing Clinical Audit

Learning and trends identified in SAI investigations should inform programmes of clinical audit.

IHRD-41 Accepted

Hyponatraemia Inquiry (2018)

Publication of External Investigation Reports

Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.

IHRD-42 Accepted

Hyponatraemia Inquiry (2018)

Sharing New Investigation Information

In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.

IHRD-43 Accepted

Hyponatraemia Inquiry (2018)

GP Notification of Death Circumstances

A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.

IHRD-44 Accepted

Hyponatraemia Inquiry (2018)

Post-Mortem Limitation Authorisation

Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of the family.

IHRD-45 Accepted

Hyponatraemia Inquiry (2018)

Post-Mortem Documentation Checklist

Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.

IHRD-46 Accepted

Hyponatraemia Inquiry (2018)

Clinician Attendance at Post-Mortem Discussions

Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.

IHRD-47 Accepted

Hyponatraemia Inquiry (2018)

Post-Mortem Reporting Standards

In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy and completeness of the information briefed them. (ii) …

IHRD-48 Accepted

Hyponatraemia Inquiry (2018)

Mortality Meeting Recording and Audit

The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.

IHRD-49 Accepted

Hyponatraemia Inquiry (2018)

Multi-Trust Mortality Meeting Engagement

Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant …

IHRD-50 Accepted

Hyponatraemia Inquiry (2018)

HSCB Notification of Inquests

The Health and Social Care ('HSCB') should be notified promptly of all forthcoming healthcare related inquests by the Chief Executive of the Trust(s) involved.