Another Year, Another Independent Review

As HSJ reminded us, last week marked the 5th anniversary of the publication of Robert Francis’ report into Mid Staffordshire Hospitals NHS Foundation Trust.

On 8 February 2018 Dr Bill Kirkup’s report into Liverpool Community Health NHS Trust (LCH) was published.  Click here to download the report.

His terms of reference were to:

• Review the outcomes for patients care for by the Trust and its predecessor organisation from November 2010 to December 2014, with particular reference to serious incidents during the period and the provision of Offender Health at HMP Liverpool
• To review the oversight of the Trust by regulators and commissioners
• To review the response of regulatory and commissioners
• To make findings on the action taken by and in relation to the Trust and their adequacy in safeguarding patient care
• To make recommendations on the lessons to be learnt for the wider NHS

The Foreword starts by explaining that this Review shows in stark terms what can happen if services are taken for granted and if warning signs are overlooked because of the distraction of higher profile NHS services.

Whilst thanking staff for their co-operation Dr Kirkup was disappointed to note that a small minority of individuals refused to cooperate. He clearly states that it is the duty of all NHS staff to assist as fully as they are able with investigations and reviews that are directed towards improving future services.

The Review findings are set out at pages 4 – 7. They include:

• LCH was a dysfunctional organisation from the outset
• It acted inappropriately in pursuit of FT status
• Significant unnecessary harm occurred to patients
• The Board became blind to the real concerns
• It is not clear that the CCGs or NHS E had an overall view on the cumulative impact of cost savings
• The Trust should have had clear and effective systems to manage risk
• The incidence of patient harm incidents rose but Dr Kirkup heard repeated accounts of reporting being discouraged and found investigation poor with action planning for improvement absent or invisible
• External overview failed to identify problems for at least 4 years

Points of interest within the main body of the report include:

• Many staff who faced significant and overwhelming difficulties responded to the challenges by putting in extra time, not taking days off and striving to manage excessive case loads
• The Board’s SI report dated January 2013 identified numerous safety concerns and key themes. These were the same issues reported to the Trust Board 2 years later
• Actions plans were hampered by a combination of:
  - Lack of identification of actual root causes
  - Lack of time trend analysis and thematic analysis
  - Plans based on process actions unrelated to patient outcome
  - Failure to review whether actions had been undertaken and completed
  - Lack of evaluation to ascertain whether actions had been successful
• He heard repeatedly that rather than a “just culture” staff worked in a culture of intolerance, disbelief and fear, with a clear lack of care for the workforce
• Workforce plans were considered at the same Board meeting as the implications of the Francis report and there was no apparent recognition of the inherent irony in this timing
• 6 never events of a similar nature had occurred
• A critical review of clinical audit was carried out by the Trust’s internal auditors but the changes recommended were not adopted
• The biggest area of concern based on what the Review heard was prison healthcare. The Review could come to no other conclusion than the Trust let these patients down very badly and lives were likely to have been lost unnecessarily.
• There appeared to be a lack of ownership of issues with everyone blaming somebody else

10 recommendations are set out at pages 64 and 65. These include:

• NHS E should review the arrangements for commissioning prison health services nationally to ensure that these are safe and effective
• DH should review the working of CQC’s Fit and Proper Person Test to ensure that concerns over the capability and conduct of Executive and Non-Executive Directors are definitively resolved and the outcome reflected in future appointments
• Regulators and oversight organisations should review how they work together jointly at regional and national level and implement mechanisms to improve the use of information and soft intelligence more effectively

A lot to take on board!