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.

Draft regulations for registration system in England breathe new life into clinical governance

The new registration system for health and adult social care in England is described in the post below.

Healthcare Governance Review notes that the draft regulations that will, when finalised and published, set the legal standards framework for registration, require ‘registered persons’ to have “a system of clinical governance and audit.”

According to para. 23(3) of the draft regulations, a “system of clinical governance and audit” means a framework through which the registered person endeavours continuously to -
(a) evaluate and improve the quality of the services provided; and
(b) safeguard high standards of care by creating an environment in which clinical excellence can flourish.

Download the draft regulations here.

Patients at risk from mis-management of medicines

According to a new report by the Care Quality Commission (CQC), patients could be at risk unless the management of medicines between services such as GP practices and hospitals is improved.

The report – Managing patients’ medicines after discharge from hospital – looks at how well patients’ medication is managed after patients leave hospital.

The CQC visited 12 primary care trusts (PCTs), and surveyed 280 of their GP practices and found some evidence of good practice, but also found the following concerns:

• Information shared about patients moving between GPs and hospitals is often patchy, incomplete and not shared quickly enough
• GP patient records are not  always updated by clinical staff
• Too few patients are offered discussions with their GP about managing their medication
• GPs are not consistently reporting medication incidents and errors, and PCTs are not always monitoring them.

CQC Chief Executive Cynthia Bower says: “There needs to be a change of attitude in the NHS in recognising how important it is for clinicians to pass the baton smoothly between services in order to offer person-centred, integrated care.”

Download the report Managing patients’ medicines after discharge from hospital here.

NHSLA and NICE joint statement about NICE guidance and risk management

The NHS Litigation Authority (NHSLA) and the National Institute for health and Clinical Excellence (NICE) have issued a joint statement about how compliance with NICE guidance can help trusts manage risk and optimise their resources.

Compliance with NICE guidance is the focus of criterion 5.8 of the NHSLA risk management standards. This requires organisations to have in place approved documentation (Level 1) which describes the process for ensuring that agreed best practice as defined in NICE guidance is taken into account in the context of the clinical services provided by the organisation, that is implemented (Level 2) and monitored and, where monitoring has identified deficiencies, there is evidence that recommendations and action plans have been developed and changes made accordingly (Level 3).

For higher level assessments, every year NICE will provide the NHSLA risk management assessors with a revised list of manual-specific clinical guidelines that will be assessed against during the financial year. Topics will be selected by NICE based on its assessment of those that are current, relevant and could reasonably be expected to have been discussed and implemented within the organisation. The list of clinical guidelines will be included at the back of the specific manuals so that organisations and assessors are aware of the topics selected each year. The assessor will select one clinical guideline from the relevant list to test compliance with the requirements of Criterion 5.8. For interventional procedures the organisation will be asked to indicate the interventional procedures guidance that has been implemented and the assessor will select one from those to test compliance with the requirements of Criterion 5.8.

Download the full joint NHSLA/NICE statement here.

BMJ research paper adds to evidence of increased patient mortality associated with trainee doctors

A recent Healthcare Governance Review post focused on Dr Foster’s research into the association between increased patient mortality and the August intake of new junior doctors (click here).

The British Medical Journal (BMJ) has published a research paper describing a study that sought to determine whether an increase in the rate of undesirable events occurs after care provided by anaesthetic trainees at the beginning of the academic year.

The ‘retrospective cohort’ study was carried out at the Alfred Hospital, a University affiliated hospital in Melbourne, Australia. The study used administrative and patient record data and the participants involved 19,560 patients having an anaesthetic procedure carried out by first to fifth year trainees starting work for the first time at the hospital over a period of five years (1995-2000).

The study found that “The rate of undesirable events was greater among trainees at the beginning of the academic year regardless of their level of clinical experience. This suggests that several additional factors, such as knowledge of the working environment, teamwork, and communication, may contribute to the increase.”

The study concluded that “Strategies to minimise the rate of undesirable events at the beginning of the academic year should look at improving trainees’ orientation and integration during the first weeks, by developing, for example, mandatory introductory courses, hospital settings’ visits, and interprofessional meetings and, beyond all the rest, by avoiding residents’ involvement in clinical tasks from the first day. The orientation period could also include close one to one supervision, particularly when cross cover work is done in different hospital settings. The systematic use of written documentation of standard working practices should be encouraged to minimise the loss of tacit knowledge associated with staff turnover. Crew resource management programmes such as those developed in aviation and now increasingly introduced in the healthcare environment could be used to improve team coordination and interprofessional collaboration. Finally, early training sessions in simulators could be scheduled to favour rapid improvements in junior trainees’ technical skills.”

The full research paper Rate of undesirable events at beginning of academic year: retrospective cohort study can be freely downloaded here.

NPSA publishes latest organisational incident reports…..but still no learning

The National Patient Safety Agency (NPSA) has published ‘Organisational Patient Safety Incident Reports’ for NHS organisations across England and Wales. The reports summarise incidents reported by staff that have occurred between October 2008 and March 2009, and reported to the NPSA by 30 June 2009.

The figures show that across England, 92.5 per cent of all patient safety incidents result in low or no harm to the patient, 6.2 per cent of incidents are reported as moderate harm to patients, 0.8 per cent as severe harm to patients and 0.4 per cent as contributing to patient death.

The most commonly reported incident type overall is patient accident (32.8 per cent of reports), followed by treatment/procedure (10.1 per cent) and medication (9.4 per cent).

However, as the NPSA continues to fail to collect information on contributory factors and root causes, a principal reason for its establishment back in 2001, the potential for learning from the NPSA reports is limited (see Government response to the Health Select Committee Patient Safety Report here.).

Incident reports by organisation can be downloaded here.

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.

Upcoming clinical governance and related conferences from Healthcare Events

Healthcare Events have announced the following eight clinical governance and related conferences for 2009/10:

1. Strengthened Appraisal and Revalidation  1 Dec 2009
2. Clinical Budget Ownership  8 Dec 2009
3. Patient Experience  9 Dec 2009
4. Effective Clinical Director  20 Jan 2010
5. Patient Reported Outcome Measures  21 Jan 2010
6. Quality, innovation Productivity and Prevention  21 Jan 2010
7. Developing Quality Patient Information  26 Jan 2010
8. Clinical Audit and Improvement  9/10 Feb 2010

Further details are given below.

Strengthened Appraisal and Revalidation
Date: Tuesday 1^st December 2009
Venue: Cavendish Conference Centre, London

This one day conference provides a practical guide to preparing your systems and processes for Strengthened Appraisal and Revalidation due for implementation this year.

Contact: For more information please call Hanisha on 020 8541 1399, email hanisha@healthcare-events.co.uk or visit http://www.healthcare-events.co.uk

Download Brochure:
http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=356

Clinical Budget Ownership, Reporting and Management
Date: Tuesday 8^th December 2009
Venue: 76 Portland Place, London

Through a series of presentations, this one day conference will examine Clinical Budget Ownership, ensuring clinicians are in control of their own budgets and finances in order to make improvements and build services around the needs of patients.

Contact: For more information please call Hanisha on 020 8541 1399, email hanisha@healthcare-events.co.uk or visit http://www.healthcare-events.co.uk

Download Brochure:
http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=353
 
Patient Experience
Date: Wednesday 9^th December 2009
Venue: Manchester Conference Centre, Manchester

This one day Patient Experience conference focuses on delivering High Quality Care for All, defined in the NHS as ’safe and effective care of which the patient’s whole experience is positive’. Through a series of presentations, you will hear the importance of the Patient Experience from dignity and compassion to measuring and monitoring outcomes, one of the three core components of quality identified in High Quality Care for All.

Contact: For more information please call Hanisha on 020 8541 1399, email hanisha@healthcare-events.co.uk or visit http://www.healthcare-events.co.uk

Download Brochure:
http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=365
 
Effective Clinical Director
Date: Wednesday 20^th January 2010
Venue: 76 Portland Place, London

Whether you’re currently a Clinical Director, or aspiring to be one, this event provides a unique opportunity to learn from the experience of other Clinical Directors and develop your skills as an effective Clinical Director in the current climate.

Contact: For more information please call Hanisha on 020 8541 1399, email hanisha@healthcare-events.co.uk or visit http://www.healthcare-events.co.uk

Download Brochure:
http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=374

Patient Reported Outcome Measures
Date: Thursday 21^st January 2010
Venue: Manchester Conference Centre, Manchester

This one day conference provides a practical guide to measuring and monitoring clinical outcomes using Patient Reported Outcome Measures. Through a series of presentations, you will hear from a variety of healthcare professionals on the developments in your area of practice and how we’re moving forward from the National PROMs for the new conditions.

Contact: For more information please call Hanisha on 020 8541 1399, email hanisha@healthcare-events.co.uk or visit http://www.healthcare-events.co.uk

Download Brochure:
http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=383

Quality, Innovation Productivity and Prevention
Date: Thursday 21^st January 2010
Venue: 4 Hamilton Place, London

Through a series of presentations, this one day conference will provide delegates with valuable knowledge of QIPP including: leadership for QIPP, promoting innovation and benchmarking for QIPP, lean methodology and service transformation.

Contact: For more information please call Hanisha on 020 8541 1399, email hanisha@healthcare-events.co.uk or visit http://www.healthcare-events.co.uk

Download Brochure:
http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=384

Developing Quality Patient Information
Date: Tuesday 26^th January 2010
Venue: 76 Portland Place, London

This one day conference chaired by Mark Duman President Patient Information Forum (PiF), provides an opportunity for you to learn about the latest techniques and methods for writing and developing Patient Information that is accessible, understandable and personalised to patients as individuals on a day to day basis.

Contact: For more information please call Hanisha on 020 8541 1399, email hanisha@healthcare-events.co.uk or visit http://www.healthcare-events.co.uk

Download Brochure:
http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=387

Clinical Audit and Improvement 2010
Date: Tuesday 9^th and Wednesday 10^th February 2010
Venue: Savoy Place, London

This two day Clinical Audit and Improvement conference brings together an exceptional gathering of leading practitioners, clinicians, policy makers and academics to set out the major developments, promote innovative areas of work, and debate the key challenges affecting you and your organisation – through a mix of plenary sessions, debates, panel discussions, workshops and poster presentations.

Contact: For more information please call Hanisha on 020 8541 1399, email hanisha@healthcare-events.co.uk or visit http://www.healthcare-events.co.uk

Download Brochure:
http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=367

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.

South Tees FT needs Deputy Director of Healthcare Governance and Quality: Closing date 23 Oct 2009

Following a major Trust-wide review of their Governance structures, South Tees are looking for someone to provide the strategic leadership and corporate management of Clinical Governance within the Healthcare Governance Directorate. This will involve working closely with the Medical Director and Director of Nursing and Patient Safety. It will also involve working with the Head of Corporate Affairs and the Head of Financial Governance and Control to ensure that the Trust achieves integrated governance. The successful candidate will deputise for the Executive Directors on Governance issues and be part of the Trust’s senior management team. He/she will lead a team covering a comprehensive range of associated functions: NICE and NPSA guidance, Clinical Audit, NHSLA and CQC compliance.

Educated to Masters Degree level the successful candidate will need to have significant experience of working in a senior management position in a complex organisation. He/she will possess a comprehensive understanding of clinical governance and the requirements of the External Regulators and will need to be a dynamic and transformational leader with experience of developing corporate policy, strategy and preparing and presenting Board papers.

Successful candidates will be required to attend the selection process on Monday 16 November 2009.

The post is advertised as 37.5 Hours Per Week and Agenda for Change terms and conditions Band 8D with Salary Range: £63,833 – £79,031 pa plus Pension and Staff Benefits

For informal enquiries, or to arrange a visit, please contact Sue Wooding on (01642) 854697 or email Sue.wooding@stees.nhs.uk

Closing Date: 23 October 2009

Analysis of cases referred to the National Clinical Assessment Service

A key aspect of clinical governance is dealing with poorly performing clinicians.

The National Clinical Assessment Service (NCAS) has published the largest study of medical and dental performance concerns ever carried out in the UK. The publication – NCAS casework: The first eight years – analyses nearly 5000 cases referred to NCAS since 2001.

The report identifies which groups of practitioners are more likely to be referred to NCAS and what can be learnt from these referral patterns. The report also examines episodes of suspension and exclusion of individual practitioners. And, for more than 1,400 cases dealt with by NCAS since the end of 2007, it analyses the nature of concerns which led to referral.

Some of the main findings are:

• NCAS referrals come from all parts of the UK and across all sectors, whether in hospital or in general practice;
• Two referrals in three are about clinical skills but behavioural concerns are also common, seen in more than half the cases analysed;
• The average duration of exclusions of doctors in the hospital and community sector has fallen by over a third since 2003, which directly addresses concerns raised over the past two decades about prolonged exclusion from work;
• Amongst 144 of cases where the most serious concerns had been raised, two thirds were back in work after remediation – rather than being lost to the service;
• Certain groups of practitioners are more likely than others to be referred to NCAS, for example men and older practitioners. The same groups are also more likely to experience exclusion or suspension from work.

The report also examines the part played by ethnicity and place of qualification in the likelihood of referral of practitioners in hospital and community services. It shows that non-white practitioners qualifying outside the UK are more likely to be referred to NCAS, but that neither referral nor suspension or exclusion from practice is any higher among non-white practitioners qualifying within the UK.

The report can be downloaded here.

Incidents that kill or harm patients may be subject to legal disclosure requirements

According to an article in the Guardian (27 September 2009) “The Department of Health is considering imposing a legally binding “duty of candour” on hospitals, surgeries and other healthcare providers, ensuring NHS managers admit to patients when an error has led to harm as well as explain exactly what has gone wrong and apologise.”

Read the full article here.

NPSA issues data quality standards for reporting patient safety incidents

The National Patient Safety Agency has released a ‘Data Quality Standards’ document, which they say is designed to improve the quality, accuracy and timeliness of patient safety incident data submitted to the Reporting and Learning System (RLS).

The document sets out the Data Quality Standards and provides guidance on their use. It is aimed at NHS staff (such as risk managers and governance managers) responsible for submitting their patient safety incidents to the RLS via local risk management systems (LRMS) or eform.

The National Reporting and Learning Service (NRLS), part of the National Patient Safety Agency (NPSA), recommends that all NHS healthcare organisations comply with these standards so that the NRLS receives the best quality information possible for issuing patient safety guidance.

According to the NPSA, evidence suggests that organisations that follow the Data Quality Standards, and have high reporting, also have a good safety culture and sound risk management processes (but see previous Healthcare Governance Review post here).

The NPSA asserts that the Data Quality Standards will also aid the improvement of data analysis for local organisations and ensure that they meet their obligations under the Data Protection Act (1998).

Download the new data quality standards here.

Notable quote – clinical governance

“A good clinician will make consistently good clinical decisions, but having a system of effective clinical governance means there is a structure to ensure that this is not by chance, but follows from good recruitment, continuing professional education and clinical audit. Such a system will enable good performance to be sustainable and to be spread across the organisation.”

Owens, D (2005) Good integrated govenance should start from the top and spread to every aspect of the organisation if high quality care is to be sustained. Health Service Journal 9 June 2005 pp35-37

Mutual governance in action at South Staffordshire NHS foundation trust

Readers may be interested in the South Staffordshire Healthcare NHS foundation trust’s ‘mutual governance’ approach to governance.

The trust has been implementing mutual governance since 2005 and has produced a handbook on mutual governance, which can be downloaded here.

Monitor publishes lessons learnt from Mid Staffordshire….and (re)defines clinical governance

Following the significant failings in quality of care at Mid Staffordshire NHS Foundation Trust, Monitor commissioned KPMG, its internal auditors, to consider how the way Monitor operates and works with others could be improved. The KPMG report and Monitor’s response has been published by Monitor (See below).

The KPMG report makes fourteen recommendations; all of these have been accepted by Monitor and, says Monitor, agood progress has already been made against many of these. There are two main themes:

1. The need for better sharing of information across the healthcare system. Monitor has already taken action in this area. We have agreed arrangements with the Care Quality Commission (CQC) to ensure that we are informed about concerns that they might have about the quality of care delivered by applicants to be foundation trusts and that these concerns are resolved before a decision is taken to authorise the applicant. Arrangements have also been agreed to share information about under-performing foundation trusts and to coordinate any action. These agreements are part of the Memorandum of Understanding which Monitor and the CQC have now signed and can be downloaded below.

2. The need for Monitor to focus on developing an approach to assuring itself that appropriate clinical governance is in place in applicant or existing foundation trusts. Monotor has (re)defined clinical governance as “the combination of structures and arrangements in place at, and immediately below, the Board level to manage and monitor clinical performance, plan and manage continuous improvement, identify performance that may be below standard or out of line, investigate it and take management action.”

Healthcare Governance Review feels the definition of clinical governance does nothing to bring clarity to the governance versus management debate.  The Monitor definition is a confusing ‘jumble’ of governance and management statements. Indeed, the majority of Monitor’s definition speaks to management rather than governance concerns. Monitor would have been better to adopt the Scottish definition of clinical governance, which is “Corporate accountability for clinical performance.”

Download the KPMG report, Monitor’s response and the Monitor/CQC Memorandum of Understanding here.

New book – Enhancing Patient Care: A practical guide to improving quality and safety in hospitals

This is, perhaps, THE most practical and useful book on patient safety and quality of care available today. Every hospital and anyone involved in patient care, clinical governance, quality, safety and/or risk management should have a copy. And any educational programme covering the subjects mentioned should commend this book as a key text.

Written by Australian clinicians, Associate Professor Alan Wolff, Director of Medical Services, and Sally Taylor, Clinical Risk Manager and former midwife (see photo), and formally launched by the Victoria Health Minister on 31 August 2009 (click here), this is a commonsense guide to quality improvement and risk management in hospitals. The book is based on their work, over many years, in the Wimmera Health Care Group in Victoria, Australia. Their experience at a regional hospital has led to a pragmatic framework that guides other health services through the relevant evidence and theory, down to finest details on practical quality, safety and risk management. 

Whilst the book has been described in terms of “help[ing] improve practices and patient outcomes in hospitals throughout Australia” there is little, if anything, in the book that cannot be applied internationally. Enhancing Patient Care will be of particular use to anyone who wants to set up or improve a quality improvement and risk management program, regardless of size and budget.

  

Assoc. Prof. Alan Wolff and Sally Taylor

The book contents include:

- Explanations of clinical governance, quality improvement and risk management
- How to detect adverse events and risks to patient safety
- A practical framework to prevent adverse events and reduce risks
- How to develop a quality improvement and patient safety culture
- A step-by-step guide to implementing a clinical risk management program in your health service
- How to develop a clinical risk management program in a small hospital

Interested readers can download a PDF preview of the book, which includes the detailed contents pages, a diagrammatic description of the Wimmera quality improvement and risk management model, and a Foreword by Profesor Bruce Barraclough, Chairman of the International Society of Quality in Healthcare (ISQua), here.

The book costs 50 Australian dollars (approx. 30 British pounds) and can be purchased from the bookshop of the Medical Journal of Australia, here.

NHS Governance Study day, 17 November, London

Join expert speakers for “an essential, one-stop guide to the ins and outs of NHS governance.”

The Health Service Journal is running eight key information sessions, over one study day, on 17 November 2009 in Central London.

The information sessions/speakers are: 

- Linda Hutchinson, Director of Registration at the Care Quality Commission to gain a comprehensive overview of what this new era of regulation will mean for NHS governance systems
 - Get to grips with quality assurance – hear from Lynn Betts, an Independent Consultant from Quality Governance Limited, and the first ever NHS Director of Governance
 - Gain a comprehensive understanding of clinical, corporate and information governance and examine how they interact from Stuart Emslie, Assistant Director of the Centre for Corporate Ethics at Birkbeck London University and Visiting Fellow at Loughborough University Business School
 - Join a team of board level development experts – Jay Bevington and Sai Shanmugarajah from Deloitte and Deborah Arnot and Deborah Chafer from NHS North West Leadership Academy – and hear what more can be done to support board level development in your organisation
 - Understand what good integrated governance looks like and how it works in practice. Hear from Brian Terry, Head of Integrated Governance for NHS Gloucestershire about the fundamental differences between the current and historic systems of governance
- Gain an insight into how the delicate tensions of PCT governance can be balanced and what PCT governance will look like post-divestment with a presentation from Enfield PCT
- Explore the new demands on governance systems which come with the achievement of FT status in a session devoted to securing your understanding of FT governance
 - With NHS governance systems increasingly having to transcend organisational boundaries, the systems and processes of governance between organisations have never been more important. Hear how to overcome the challenges of governance between organisations from Dr John Bullivant, Director of the Good Governance Institute

According to the HSJ, this essential day gives you the unique opportunity to really understand the ins and outs of NHS governance.

For further information on the event, and to secure your place, click here.

What patients want to know in deciding where to go for hospital treatment

According to the Patient Association, patients have been telling them for years just what sort of information they want so that they can decide where to go for treatment. They need to know essential facts like:

• Clinical outcomes of individual consultants
• Ward infection rate – not just the overall hospital’s statistics
• Nurse:patient ratio – because too few nurses endangers their care
• Mixed sex accommodation – patients should not have to share toilets and wards with members of the opposite sex
• Hospital parking charges

The Patients Association says that patients need to be satisfied that information provided is totally accurate and up to date, so that they can give proper consent and do away with the postcode lottery.

Audit of organ retention and post-mortem practices in Irish hospitals points to deficiencies in clinical and corporate governance

The Health Service Executive (HSE) in Ireland has published two reports relating to retained organs and post-mortem practices in Irish hospitals.

The first is an independent national audit of retained organs and post-mortem practices in Irish hospitals. Organs or tissues are sometimes removed and retained as part of a post-mortem examination, primarily to allow for analysis of the cause of death. In hospital post-mortem services, this follows a detailed information and consent process with families. Consent processes underwent significant change and improvement following public outrage in 1999 and 2000 about post-mortem and organ retention practices in the UK and in Ireland.

The national audit was led by Ms. Michaela Willis MBE, a former member of the Human Tissue Authority in the UK and former member of the Retained Organs Commission, which previously oversaw similar audits in England. Ms Willis conducted an independent audit of currently retained organs in the State both pre and post 2000 to assist the HSE in identifying areas of good practice and highlighting areas for improvement.

The audit found many examples of good practice in clinical governance relating to post-mortem services. In the course of the audit, however, specific issues arose at the Rotunda Hospital, Dublin, which required a separate investigation and report. This was undertaken on behalf of the HSE by a team chaired by Mr. Ian Carter, Chief Executive, St. James’s Hospital.

The Carter report found a range of issues at the hospital, which included weakness in consent policy and documentation, variations between the terms of the consent given by families and the post-mortems carried out, delays in carrying out examinations and delays in implementing family instructions for respectful burial of organs or tissues.

The report found that the issues at the hospital arose from individual professional practice, poor post-mortem systems and processes and weak management and governance oversight.

The Board of the Rotunda have assured the HSE that the clinical and corporate governance of post-mortem practice have been significantly strengthened in response to the investigation.

Download the audit and Carter reports here.