Public Inquiry Recommendations

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 …

- HSC Trusts reported that laboratory turnaround times for urgent paediatric blood tests have been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). …

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.

- HSC Trusts reported that clinical audit programmes for paediatric care have been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

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.

- The Department of Health NI stated in March 2018 that electronic care record programmes were progressing (IHRD Implementation Programme, Department of Health NI, March …

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.

- HSC Trusts reported that clinical communication systems between primary and secondary care for paediatric patients have been reviewed (IHRD Implementation Programme, Department of Health …

IHRD-29 Accepted

Hyponatraemia Inquiry (2018)

Record Keeping Audit

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

- HSC Trusts reported that arrangements for transfer of children between hospitals have been formalised with standardised protocols (IHRD Implementation Programme, Department of Health NI, …

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.

- The Department of Health NI reported that confidential reporting mechanisms had been established (IHRD Implementation Programme, Department of Health NI, March 2018). - A …

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').

- The Department of Health NI reported that work to improve staff understanding of SAI processes and their purpose had been taken forward (IHRD Implementation …

IHRD-32 Accepted

Hyponatraemia Inquiry (2018)

SAI Reporting as Disciplinary Offence

Failure to report an SAI should be a disciplinary offence.

- The Department of Health NI reported that the SAI process had been redesigned to separate learning and improvement from disciplinary procedures (IHRD Implementation Programme, …

IHRD-33 Accepted

Hyponatraemia Inquiry (2018)

CEO Responsibility for Investigations

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

- The Department of Health NI reported that CEO accountability for SAI investigation quality and timeliness had been strengthened in revised SAI procedures (IHRD Implementation …

IHRD-34 Accepted in Part

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.

- The Department of Health NI stated in March 2018 that independent investigation arrangements had been strengthened (IHRD Implementation Programme, Department of Health NI, March …

IHRD-35 Accepted

Hyponatraemia Inquiry (2018)

Non-Cooperation as Disciplinary Offence

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

- The Department of Health NI reported that SAI investigation teams now include members with appropriate clinical expertise for the incident under review (IHRD Implementation …

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.

- The Department of Health NI reported that SAI investigation training for panel members had been developed and delivered (IHRD Implementation Programme, Department of Health …

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 …

- The Department of Health NI reported that standardised terms of reference for SAI investigations had been developed (IHRD Implementation Programme, Department of Health NI, …

IHRD-38 Accepted

Hyponatraemia Inquiry (2018)

Multi-Disciplinary Peer Review

Investigations should be subject to multi-disciplinary peer review.

- The Department of Health NI reported that timescales for completion of SAI investigations had been set and were being monitored (IHRD Implementation Programme, Department …

IHRD-39 Accepted

Hyponatraemia Inquiry (2018)

Investigation Team Reconvening

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

- The Department of Health NI reported that family engagement in the SAI process had been formalised through the SAI Engagement Platform (IHRD Implementation Programme, …

IHRD-40 Accepted

Hyponatraemia Inquiry (2018)

SAI Learning Informing Clinical Audit

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

- The Department of Health NI reported that SAI investigation reports are now shared with families in a timely manner (IHRD Implementation Programme, Department of …

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.

- The Department of Health NI reported that arrangements for families to provide input to SAI investigations had been strengthened (IHRD Implementation Programme, Department of …

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.

- The Department of Health NI reported that mechanisms for tracking implementation of SAI recommendations had been established (IHRD Implementation Programme, Department of Health NI, …

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.

- The Department of Health NI reported that arrangements for sharing learning from SAI investigations across the HSC had been improved (IHRD Implementation Programme, Department …

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.

- HSC Trusts reported that post-mortem communication procedures with families had been updated (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

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.

- HSC Trusts reported that consent processes for post-mortem examinations had been reviewed and strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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.

- HSC Trusts reported that mortality review processes for child deaths had been formalised (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

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) …

- HSC Trusts reported that arrangements for paediatric pathology services had been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

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.

- HSC Trusts reported that processes for timely completion of death certificates for children had been reviewed (IHRD Implementation Programme, Department of Health NI, March …

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 …

- HSC Trusts reported that quality standards for post-mortem reports had been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

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.

- HSC Trusts reported that procedures for engagement with the coronial process had been updated (IHRD Implementation Programme, Department of Health NI, March 2018). - …

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 …