“Quality [of care] starts at the governance level”

An article in the Otago Daily Times (New Zealand) quotes the Chief Executive of Otago District Health Board, Brian Rousseau, as saying “The Otago District Health Board does not understand the role it will need to take in leading from the top to improve quality of health care if it is to catch up on the rest of the world………I think quality starts at the governance level. The boards need to understand their role in quality and I don’t think they do.”

Mr Rousseau was talking to the Otago Daily Times following a trip to the Institute for Healthcare Improvement’s annual conference in the USA in early December. Following his return from the conference he says “If I take a look at what is happening [in patient safety and quality of care] in the rest of the world, we have slipped behind in New Zealand.”

Mr Rousseau took home a message from the conference that every board member should be asking questions about patient safety, such as "do we really have an open and fair culture?" and "are we always open when things go wrong?" 

While change was needed at board level, Mr Rousseau was also critical of his own performance. As chief executive, it was his role to lead a change of culture in the organisation to a culture focused on quality, he said.

"Probably the biggest problem is lack of time. The reality of a chief executive’s job is there are a lot of other things we deal with. "It is about finding the time to get out of the office and spending time walking around the organisation, talking to people. Finding out more about their roles is a vital step. "I don’t do that enough and it is one of the things I have got to change."

Read the full Otago Daily Times article here.

Women in the boardroom and their impact on governance and performance

In October, Healthcare Governance Review reported that Harriet Harman, minister for Women and Equality, has told the Treasury Select Committee that the Britain’s boardrooms must have more women on them (click here).

Speaking on Tuesday 20 October in relation to how boards of City firms could improve Britain’s economic performance through boardroom diversity, she told the Committee “If you want to make sure you don’t have the nightmare of men-only boards, you actually have to change the terms on which men and women participate, you have to change the culture and working practices because the greater good you are aiming for is to make sure you have diverse boards and a proper meritocratic approach.”

Healthcare Governance Review has come across an interesting academic paper Women in the boardroom and their impact on governance and performance by Renee Adams (Australia) and Daniel Ferreria (London).

Adams and Ferreira, in a study of US corporate firms, state that “Many proposals for governance reform explicitly stress the importance of gender diversity in the boardroom. In the UK, the Higgs (2003) report, commissioned by the British Department of Trade and Industry, argues that diversity could enhance board effectiveness and specifically recommends that firms draw more actively from professional groups in which women are better represented. If companies do not voluntarily reserve a minimum of 25% of their board seats for female directors, Sweden has threatened to make gender diversity a legal requirement ………The most extreme promotion of gender diversity occurs in Norway, where since January 2008 all listed companies must abide by a 40% gender quota for female directors or face dissolution.”

In their paper, Adams and Ferreira say they provide new evidence that is relevant to the ‘women on boards’ debate by investigating the hypothesis that gender diversity in the boardroom affects governance in meaningful ways. In particular, they ask the following questions. First, do measures of board inputs (director attendance and committee assignments) vary with gender diversity? Second, does the gender composition of the board affect measures of governance, such as chief executive officer (CEO) turnover and compensation? Finally, does the effect of gender diversity on governance matter sufficiently to affect corporate performance?

The researchers found that gender diversity in boards has significant effects on board inputs. Women are less likely to have attendance problems than men. Furthermore, the greater the fraction of women on the board is, the better is the attendance behaviour of male directors. Holding other director characteristics constant, female directors are also more likely to sit on monitoring-related committees than male directors. In particular, women are more likely to be assigned to audit, nominating, and corporate governance committees, although they are less likely to sit on compensation committees than men are.

Women also appear to have a significant impact on board governance. The researchers found direct evidence that more diverse boards are more likely to hold CEOs accountable for poor performance.

The evidence on the relation between gender diversity on boards and firm performance was more difficult to interpret. The researchers found that firms perform worse the greater is the gender diversity of the board. This result is consistent, they say, with the argument that too much board monitoring can decrease shareholder value. Thus, they conclude, it is possible that gender diversity only increases value when additional board monitoring would enhance firm value.

If the key findings of Adam’s and Ferreira’s research can be extrapolated to the case of NHS boards, who tend to ‘fail’ because of a lack of sound monitoring of management, we might reasonably conclude that more diverse boards would be more likely to hold the CEO accountable for poor performance and, in general, would enhance board monitoring of management.

The full academic paper Women in the boardroom and their impact on governance and performance by Renee Adams and Daniel Ferreira can be downloaded here.

Notable quote – board accountability

Most readers will be well aware of the recent furore regarding mortality rates and NHS regulation. According to an article in the Health Service Journal (HSJ – 3 December 2009) NHS Confederation policy director Nigel Edwards said “Inspection is hugely burdensome. Regulation should be a backstop – the foundation stone is board and professional accountability.”

Read the HSJ article here (registration may be required).

Monitor removes Chair of Colchester Hospital University NHS foundation trust

Monitor, the independent regulator of NHS foundation trusts, has used its regulatory powers to remove Mr Richard Bourne as Chair of the Trust with immediate effect and appoint Sir Peter Dixon as interim Chair of Colchester Hospital University NHS Foundation Trust with effect from Monday 30 November 2009.

The decision to intervene was taken by Monitor’s Board at its monthly meeting at which the Board found the Trust in significant breach of its Authorisation.

Regulatory action has been prompted by the Trust’s failure to comply with healthcare standards; its failure to exercise its functions effectively, efficiently and economically; and serious and wide ranging concerns as to overall governance and leadership at the Trust.

Having given full consideration to these issues, and the various options for regulatory action, Monitor decided a change in Board leadership was most likely to assist in a rapid and sustained return to compliance with the terms of its Authorisation. Monitor’s Board has therefore taken action to ensure that the Trust has the Board-level leadership capacity to secure on an ongoing basis safe, high quality care for its patients.

Commenting on the intervention, Monitor’s Executive Chairman, William Moyes said:

“We have taken this decision to ensure the Trust has the Board leadership capacity to address our concerns. Ultimately this is about making sure the Trust is in a position to identify risks and challenges that affect patient services and then deliver an effective response.

“Sir Peter Dixon is a highly experienced Chair of a successful foundation trust that has successfully addressed challenges of its own. I am confident his leadership will benefit Colchester Hospital University by providing strategic board-level leadership.”

Sir Peter Dixon’s term as interim Chair will conclude when the Trust has demonstrated that it can return to compliance with its Authorisation and at that time we will expect the Trust’s governors to commence a permanent appointment to the role.

Read Monitor’s full statement on this matter here.

Boards that don’t receive patient safety information are “irresponsible”

A Health Service Journal (HSJ) article outlines survey findings by Dr Foster that indicate one in 10 hospital trusts do not regularly reporting patient safety and outcomes at board level. This finding comes more than a year after Lord Darzi’s next stage review said care quality should be “at the heart of the NHS”.

"Luton and Dunstable Hospital Foundation Trust chief executive Stephen Ramsden, who is director of the National Patient Safety Campaign for England, described the findings as “astonishing”. Boards not receiving such information were “irresponsible”, he said.

The results, released to HSJ early, will be published on the Dr Foster website on 30 November along with the high profile hospital standardised mortality ratio for each trust.

Read the full HSJ article here.

Monitor questions board effectiveness following poor inspection report at Basildon and Thurrock NHS foundation trust

The Care Quality Commission (CQC) recently rated Basildon and Thurrock NHS foundation trust “Good” for quality of services and “Excellent” on use of resources. But a few weeks after publication of these performance figures, an inspection by CQC inspectors found:

• blood-splattered equipment;
• blood stains on floors and curtains and badly soiled mattresses in the A&E department with stains soaked through;
• equipment being used repeatedly that should only be used once;
• resuscitation room equipment past its use-by date;
• blood pressure cuffs stained with blood, suction machines contaminated with fluid inside and out and evidence of mould;
• inadequate arrangements to treat children, with few specialist paediatric staff;
• the mortality rate in 2008 for all emergency admissions was 6.1% compared to the national average of 4.4%; and
• the trust’s own analysis also showed that between 18 and 20 patients per 1,000 had evidence of pressure sores, compared with a national average of 11 per 1,000 patients.

In a statement issued by Monitor, regulator of NHS foundation trusts, Dr Bill Moyes, executive chairman, said “Our concerns about board effectiveness, together with the concerns that the CQC has raised about quality of care, mean that we are placing a requirement on the trust to take action with immediate effect to resolve these issues.”

Patients Association director Katherine Murphy reportedly called for board members of Basildon and Thurrock University Hospitals NHS Foundation Trust to step down. She said “The board should most certainly resign – I would say the entire board……..If there was one member of the board who had any concern, they should have been raising that over the past couple of years.”

The Monitor statement can be found here.

Dr Foster and Salford Royal NHS foundation trust event – ‘An intelligent NHS: leadership, delivery and safer hospitals’

Dr Foster and Salford Royal NHS Foundation Trust worked together to build an exciting programme around leadership, delivery and safer hospitals. Quality was the theme of the day and some excellent keynote presentations delivered by a group of national and international speakers including Stephanie Peditto, Director of Innovation, Johns Hopkins Hospital, Baltimore and Joe Rafferty, Chief Executive, NHS Central Lancashire.

The event was attended by over 150 delegates comprising of NHS, Chief Executives, Medical Directors, Directors of Governance and those involved in delivering quality.

Delegates were invited  to attend breakout sessions providing a unique opportunity to listen to presentations around specific issues including measuring patient experience, quality, patient safety, clinical leadership, board reporting and handling the media and to ask questions and debate the issues.

Copies of presentation slides together with summaries of various discussions are provided by Dr Foster on their website. These should be of interest to many concerned with healthcare governance matters. Click here for further information.

House of Commons Health Committee ‘Special Report’ on Patient Safety

The Health Committee has published a ‘special report’ on patient safety relating to the Committee’s patient safety report published in July 2009 (click here).

The Government responded to the patient safety report on 13 October (click here).

This special report sets out the responses to the patient safety report  by the Care Quality Commission and Monitor. It also contains a response by Professor Sir Ian Kennedy (formerly chair of the Healthcare Commission) and a reply to his response from the chairman of the Health Committee.

Of particular interest in the report is Monitor’s responses to various issues around boards highlighted in the original patient safety report.

Download the 27 page ‘special report’ Patient Safety: Care Quality Commission, Monitor, and Professor Sir Ian Kennedy’s Responses to the Committee’s Sixth Report of Session 2008-09 here.

“Assessing board effectiveness should be a required component of the annual work programme for all NHS boards”

The Department of Health has published the summary findings of Neil Goodwin’s review of allegations of bullying and harassment of the United Lincolnshire Hospitals NHS trust by the East Midlands Strategic Health Authority (see previous post here).

The review found “no evidence” to support the claims against East Midlands Strategic Health Authority (SHA). However, concerns have been raised about the independence of Neil Goodwin, a former SHA chief executive (click here).

According to Mr Goodwin “Given the increasing pressures on NHS leadership and management that will result from the impact of the economic downturn on public services there is the possibility of firm performance management being interpreted as bullying or harassment.”

Key recommendations made by Mr Goodwin’s relate to improving the performance of board members and boards. In particular, he recommends that “Assessing board effectiveness should be a required component of the annual work programme for all NHS boards and the results included in performance management and regulatory assessments.”

Read the summary findings of Mr Goodwin’s report, along with NHS chief executive David Nicholson’s response here.

Charity Commission disputes Department of Health ruling on NHS charities’ accounts

According to an article in ThirdSector (27 October 2009), The Charity Commission appears to be heading for a showdown with the Department of Health (DH) over accounting procedures for NHS charities in England and Wales.

Senior Department of Health official Janet Perry has told health authorities that any NHS body that is the sole trustee of a charity must move that charity’s assets onto its own balance sheet.

Her position relies on a recently introduced international public accounting standard that says public sector bodies must consolidate the accounts of any organisations they control that have an income above a certain level. The DH estimates this to be about 30 of the 282 NHS charities that have NHS bodies as sole corporate trustees.

But the Commission is planning to write to the health authorities telling them they must not consolidate NHS charities’ accounts. Its official guidance says it is “wholly inappropriate” that charitable funds should ever appear on the balance sheets of public sector organisations, because it gives the impression that charitable assets are controlled by government.

Nick Brooks, head of not-for-profit at accountancy firm Kingston Smith, called the DH position “accounting dogma gone barking mad”. He said: “Consolidation should occur only if there is ownership. If you would not own the funds if the other organisation was wound up, you should not consolidate those funds into your own accounts.”

Jonathan Brinsden, a partner at specialist charity law company Bircham Dyson Bell, said he believed the commission was right to take a stand against the DH, but that corporate trustees would now be left in an invidious position.

“If I was in this situation, it would be impossible to know which authority to listen to,” he said. “Nor do I know how this conflict can be managed.”

A spokeswoman for the Commission said: “We don’t agree with the interpretation in the Department of Health’s letter. We will be following up with the Department of Health on this issue accordingly, and will also be writing to strategic health authority directors of finance to make our position clear.”

Source: ThirdSector – click here.

NHS governance related courses from ICSA

The Institute of Chartered Secretaries and Administrators (ICSA) is running three governance related one day courses for NHS participants during November 2009. Detailed are as follows. ICSA says if all three courses are booked you save 20% on total price – a saving of £237.

The NHS Trust Secretary

Price: £395 Date and location: 10 November, London CPD: 6 hours

Click here to view a detailed programme

Understanding Finance in an NHS Trust

Price: £395 Date and location: 17 November, London CPD: 6 hours

Click here to view a detailed programme

Effective Governance in an NHS Trust

Price: £395 Date and location: 24 November, London CPD: 6 hours

Click here to view a detailed programme

Note: This post is provided for information only. Unless specifically indicated to the contrary, Healthcare Governance Review does not endorse advertised training events.

The Government response to the Health Select Committee Report ‘Patient Safety’

The Department of Health has published the Government’s response to the Health Select Committee Report ‘Patient Safety.’

National Reporting and Learning System (NRLS)

The Health Select Committee stated that “After the expenditure of much effort and funding on the National Reporting and Learning System…….we are concerned that the NRLS is nevertheless still limited in its effectiveness.”

Healthcare Governance Review is particularly concerned that despite the ongoing failure of the NPSA to establish a national reporting system in line with Building a Safer NHS for patients, published in 2001, the Department of Health nevertheless contends that “The NRLS is one of the most comprehensive patient safety reporting and learning systems in the world.” We wonder how this statement can be justified given that the Health Committee states that “The [NRLS] currently amasses a good deal of summary data of doubtful usefulness [and] unlike reporting systems in other safety critical industries, and in other healthcare systems, it does not systematically gather in-depth (root-cause analysis) data on serious and sentinel events.”

Managers and Boards

Managers and boards came in for significant criticism from the Health Committee. In particular, the Committee felt that:

1. There was disturbing evidence of catastrophic failure on the part of some Boards in cases such as Maidstone and Tunbridge Wells Trust and Mid-Staffordshire Trust.
2. Boards too often address governance and regulatory issues, believing that they are thereby discharging their responsibilities in respect of patient safety—when what they should actually be doing is promoting tangible improvements in services.
3. Many managers and non-executive members of Boards with responsibility for patient safety seem to have little or no grounding in the subject.
4. Patient safety is not currently, but must become the top priority of Boards.
5. No Board in the NHS should always be meeting behind closed doors.

The Government appears to have largely accepted the Committee’s finding in relation to management and boards and their responses can be found in the Government’s response document at paras. 49-57, inclusive.

Download the Government response to the Health Committee report on Patient Safety, together with the original patient safety report, here.

Lessons from a review of five London hospital fires and their management

NHS London has published  a review of five significant fires during 2008/09 at NHS sites in London, which required the evacuation of part or whole of the building. Any evacuation of a large commercial building is difficult – coping with a facility as complex as an NHS site, complete with sick and recovering patients, staff and visitors presents further challenges.

The events of 2008/09 proved that with good teamwork, leadership and planning, a safe, successful evacuation of a healthcare facility is achievable. NHS London states that it is imperative that every NHS organisation in London has tried and tested full site evacuation plans.

London’s experiences during 2008/09 demonstrate the critical importance of being prepared for emergencies. The report shares lessons learned from the five significant sires to support colleagues in the wider NHS when developing local plans.

The detailed lessons identified from the five events detailed in the report are clearly laid out in Appendix 2 to provide a checklist for planners and managers across the health service. The report will help to inform the ongoing development of the Department of Health guidance – planning for the evacuation and shelter of people in healthcare settings.

Healthcare Governance Review suggests that NHS boards assure themselves that management in their organisations are well prepared for emergencies and, in particular, have tried and tested full site evacuation plans in place.

Download the report Review of five London hospital fires and their management here.

Credit: Thanks to Peter Aldridge, fire safety manager at Leeds Teaching Hospitals NHS Trust, for bringing this report to our attention.

Governing the NHS 2010 and beyond – consultants appointed to write the new guidance

Readers may recall that the 2003 Department of Health guidance Governing the NHS: Guidance for boards is being ‘refreshed’ (see the following post).

According to Elisabeth Buggins, Chair of NHS West Midlands and the Board Development lead for the National Leadership Council “The National Leadership Council has recognised the critical role boards play in addressing the challenges of the modern NHS and I want to make sure that the whole board will benefit from up to-date guidance on governance issues.”

Working with the Appointments Commission and other partners including Monitor, the NHS Confederation and the NHS Institute, Elisabeth has established a vision that the new guidance will be ‘compelling not compulsory’.

Foresight Partnership in association with the King’s Patient Safety and Service Quality Research Centre have been appointed to develop the new guidance. According to Adrienne Fresko of Foresight Partnership “We will be looking at the extensive literature on governance to underpin the guidance but we are also keen to make sure that we are responding to the issues that Boards sometimes find difficult.”

Adrienne and her colleagues are working to a tight deadline as the new guidance will be launched at the Chairs Conference organised by the Appointments Commission on 23 February in Central London.

According to Elizabeth Buggins “We hope that the final document will assist boards in reaching the highest standards of governance, which we know is so important in achieving world class commissioning and excellent service delivery.”

Healthcare Governance Review endorses Elizabeth’s hopes and looks forward to reviewing the new guidance when it is published early in 2010.

Further information can be found in the autumn 2009 edition of Bulletin – News from the Appointments Commission, downloadable here.

Governance of health and safety – the need to ensure safe systems of operation and to carry out risk assessments

David Halcki MBE (David.Halicki@btinternet.com), independent health and safety consultant and former NHS safety professional, believes that NHS boards and managers should learn lessons from the following industrial laundry incident. In particular, he is urging boards to ensure that NHS organisations have safe systems of operation in place and carry out risk assessments both in relation to any laundry services they might have, and in relation to wider organisational health and safety matters.

The Health and Safety Executive (HSE) is urging laundry companies to ensure that they have safe systems of operation in place and carry out risk assessments after a worker was left in a coma, following an incident at a factory in Balham, Wandsworth. This follows the successful prosecution (Thursday 24 September) of a major UK laundry company at Southwark Crown Court, following an incident in October 2007. OCS Group UK Limited of Limpsfield Road, Sanderstead in Surrey was fined £80,000 and ordered to pay costs of £33,059, after pleading guilty to breaching section 2(1) of the Health and Safety at Work etc Act 1974, after Joseph Pathmananthan, a worker at the site, was injured in a serious incident.

OCS Group UK Limited provides commercial laundry services at industrial processing plants across the UK, including Balham. This plant had approximately 150 workers. 

On 2 October 2007, Mr Pathmananthan, a 61 year-old employee from Sutton in London, was working at the company’s Boundaries Road site in Balham. He was repairing the hopper unit which loads roller towels into the top of a continuous batch washer, which is an industrial washing machine costing more than one million pounds. The hopper unit needed repairing after a towel had become entangled in a lifting belt. After several different methods had been used by Mr Pathmananthan and four other colleagues to dislodge the towel, he entered the hoist’s protective cage to continue to try to remove the towel. Mr Pathmananthan was standing underneath the suspended large steel hopper. As the towel became free the hopper fell two meters onto the victim, crushing him. He suffered from multiple broken bones and internal injures and was in a coma for 19 days.  He stayed in hospital for three months and has not been able to return to work for two years since the incident.

OCS Group UK Ltd carried out an internal investigation into the incident and almost all the blame fell on a number of employees on the Balham site, including the victim who was disciplined. Despite the HSE subsequently prosecuting OCS, the company’s own internal investigation made little criticism of the company’s policies or of senior management. The HSE investigation showed that OCS Group UK Ltd did not have a sufficiently effective system for ensuring the machinery was safe to be operated and maintained, and that there were no checks on the machinery after its repair.  Also, the Balham site engineering team had not been provided with a manual which would have clearly shown how to raise the hopper safely for someone to work beneath it.  The court heard that two years prior to the incident, an HSE Inspector had attended the site and had identified that Mr Pathmananthan needed more support.

The HSE gave direction on necessary improvements including the need to risk assess the continuous batch washer, but there was no evidence this had been followed by OCS Group UK.  The HSE also found the site had inadequate controls in place to stop people slipping and tripping and that the movement of vehicles at the busy site was disorganised and dangerous.

While sentencing the company, Judge Taylor criticised OCS Group UK Ltd for what she said was a systemic failure and its complacency during monitoring. If the company had not pleaded guilty at the earliest opportunity Judge Taylor, said the fine would have been £40,000 more. Andrew Verrall-Withers, Health and Safety Inspector, said: “I was pleased the company co-operated with the investigation and made good efforts to improve after the incident, but I was surprised and disappointed that their own internal investigation failed to identify so much of what the company had got wrong.  “I hope this case sends out a message to other companies, including large ones, that it is vital they make sure that they are protecting their employees effectively. It is no good to anyone if problems are only found after it is too late.”

Healthcare Inspectorate Wales publishes 2008-09 Healthcare Standards Reports

In May 2005 the Welsh Assembly Government published Healthcare Standards for Wales, setting out a common framework to support the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings. The standards are focused on improving the experience of patients and service users and placing them at the centre of the way in which services are planned and delivered, thus providing a basis for continuous improvement. The 32 standards include 15 concerned with ‘healthcare governance.’

This is the third year in which each of the Welsh Local Health Boards and NHS trusts, together with Health Commission Wales has been required to self assess its progress in delivering the highest level of performance against each of the 32 standards and to submit its assessments to Healthcare Inspectorate Wales (HIW) for testing and validation.

All of the Healthcare Standards reports for 2008/09, together with archived reports for the past two years, can be downloaded here.

Developing an effective, forward-looking NHS board to drive the organisation to success

One of the presentations at the Health Service Journal’s (HSJ) Leadership Forum 2009 (30 November in Central London) is titled Board level leadership: Developing an effective, forward-looking board to drive the organisation to success

Led by Elisabeth Buggins, Chair NHS West Midlands, and Mike Cooke, Chief Executive, Nottinghamshire Healthcare NHS Trust, the presentation will aim to:

1. level leaders to look out at the commercial landscape, and not up;

2. examine the role of executive coaching, and understand where it adds value; and

3. Empowering board members to understand what information they require to respond to the needs of their trust and the community

For further information on the HSJ Leadership Forum 2009, click here.

 

Mid Staffs – “It is the job of boards and board members to make choices and balance priorities”

The Health Service Journal (HSJ – 8 October 2009) has reported on the publication by Mid Staffordshire Foundation Trust of a report into the conduct and performance of its previous chief executive Martin Yeates. Mr Yates resigned in May this year after the Mid Staffs board received the report.

According to the HSJ, the report says leadership and management of the trust had improved after Mr Yeates arrived, but confirms the massive failures reported by the Healthcare Commission.

It says: “….we have not seen or heard evidence to subvert the [Healthcare Commission’s] findings that there were significant failures in the leadership and management of the trust over the period of care, and these contributed to poor clinical care.”

The report further states that “Safety and quality of care are clearly of paramount importance in any NHS trust and would therefore need to be given priority in any consideration of the conduct and performance of a chief executive. They are not, however, the only measure of performance and the trust appears to have performed well against some other targets and priorities in recent years and we make reference to some of these later in the report. But performance in one area cannot be at the expense of performance in another, especially where patient care is concerned. It is the job of boards and board members to make choices and balance priorities.”

Readers can download the report on the HSJ’s website here.

Liverpool trust fined £48k for legionella ‘complacency’

The Liverpool Heart and Chest Hospital NHS Trust was ordered to pay nearly £48,000 following an HSE investigation at the NHS Trust’s hospital on Thomas Drive, Liverpool.

The investigation found unsafe levels of legionella in the water supply system for the showers, baths and sinks at the hospital. But it was not able to conclude whether two patients, who both contracted legionnaires’ disease before their deaths in early 2007, were infected at the hospital or elsewhere.

Liverpool Magistrates’ Court heard that the NHS Trust had stopped testing the water supply for legionella, despite high levels of the bacteria being found in the Audrey Leigh wing in May 2002.

HSE criticised the NHS Trust for failing to put suitable control measures in place, and senior management for failing to take responsibility for overseeing the control of the bacteria.

The NHS Trust pleaded guilty to breaching Sections 2(1) and 3(1) of the Health and Safety at Work etc Act 1974 by putting employees and the public at risk. It was fined £35,000 and ordered to pay costs of £12,862 at Liverpool Magistrates Court on 8 October 2009.

HSE Inspector Kevin Jones said:

“It is almost beyond comprehension that Liverpool Heart and Chest Hospitals NHS Trust became so complacent about legionella in the water supply system. We were astonished to discover that the NHS Trust’s management team took a decision to stop testing for the bacteria. The hospital’s water supply system was clearly at risk from legionella and so regular tests should have been carried out.

“The NHS Trust ignored the recommendations it had been given by a specialist contractor to control the levels of legionella in the water system. No one took, or was given, responsibility for managing the bacteria, and suitable control measures were not in place.

“Hospital patients are at more risk than most of being infected with legionnaires’ disease. It’s therefore vital that NHS Trusts treat the risks seriously to help prevent deaths in the future.”

Audit Commission ‘High Performing Board’ events for existing and aspirant foundation trusts

Following the success of their high performing board seminars in 2007 and 2008, the Audit Commission is holding a series of seminars between 22 October and 26 November dedicated to foundation trusts and aspiring foundation trusts across England.

Continuing the theme of the high performing board while focusing upon quality, the seminar will support executive and non-executive directors to enhance their understanding of the right level of information required to discharge their duties.

The seminar will focus on three themes:

Quality Improvement

This presentation will enable you to learn from others by sharing the experience of delivering quality improvements in patient care and re-shaping local health services to respond to the needs of the local community.

Quality and Costs

This presentation will explore how boards ensure that they can safely reduce costs and advance quality at the same time. It will also explore successful NHS productivity and efficiency schemes.

Quality NHS leadership

This presentation will discuss and explore the benefits of creating and embedding a quality leadership culture. The seminar will allow for presentations, time for discussion and reflection. It will enable you to meet and network with colleagues working in diverse roles across the health economy.

For further information, including dates, venues, speakers and booking form, click here.