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SUMMARY REPORT ABM University Health Board ND Health Board DATE: 22 MAY 2014 AGENDA ITEM: 1 (VII) Subject The Andrews Report - “Trusted to Care” – An independent Review of the Princess of Wales Hospital and Neath Port Talbot Hospital at ABMU Health Board Prepared by Joanne Davies, Trusted to Care Taskforce Leader Approved & Paul Roberts, Chief Executive Presented by Purpose To present the findings of the report “Trusted to Care” – the Decision independent review of care at Princess of Wales Hospital and Approval X Neath Port Talbot Hospital commissioned by the Minister for Health Information and Social Services in the Welsh Government to the Board and outline actions taken to date, and planned, to address issues Other raised. Corporate Objectives Excellent Excellent Sustainable Strong Excellent Effective population patient and partnerships people governance health outcomes accessible and services experience X X X X Executive Summary The report “Trusted to Care” outlines significant shortcomings in the care provided to some patients at Princess of Wales Hospital and Neath Port Talbot Hospitals, this report outlines the Health Board’s response to date and planned to ensure that care standards are improved and confidence in the Health Board’s services regained. Key Recommendations The Board is asked to: • Note the serious and concerning content of the Andrews’ Report “Trusted to Care”. • Note the actions taken to date prior to and in immediate response to the Report’s publication. • Endorse the aspects of patient care which should never happen within any of ABMU’s hospitals, as outlined in section 4 above. • Agree the detailed action plan attached as Appendix C. • Agree the reporting arrangements direct to each Board meeting on progress. 1 2 ABM University MAIN REPORT Health Board nd Health Board Date: 22 May 2014 AGENDA ITEM: 1(VII) Subject The Andrews Report “Trusted to Care” – An independent Review of the Princess of Wales Hospital and Neath Port Talbot Hospital at ABMU Health Board Prepared by Joanne Davies, Trusted to Care Taskforce Leader Approved & Paul Roberts, Chief Executive Presented by 1. PURPOSE To present the findings of the report “Trusted to Care” – the independent review into aspects of care and practice at Princess of Wales and Neath Port Talbot Hospitals commissioned by the Minister for Health and Social Services in the Welsh Government to the Board and outline actions taken to date, and planned, to address the serious issues raised. 2. INTRODUCTION In March 2013 a cluster of concerns regarding the Princess of Wales Hospitals was brought to the attention of the Board. These included a police investigation into “falsification of records”, two critical Ombudsman’s reports, relatively high (risk adjusted mortality) RAMI rates. A further serious complaint by a member of the public involving care at both Princess of Wales and Neath Port Talbot Hospitals was subsequently escalated to the Board and reported to the police. As a result the Board discussed these concerns at meetings in public and set up a quality and safety programme at Princess of Wales Hospital and commissioned an external review of safety and quality by AQuA (also being considered by the Board today). Following a meeting between the minister and one of the complainants the minister decided to commission an independent external review. The Review was undertaken between December 2013 and April 2014 by the Dementia Services Development Centre (DSDC) and The People Organisation (TPO). The “Trusted to Care” report “is about quality and patient safety. It includes a narrative and analysis of what the Review established, identifies a number of areas of concern and makes a series of recommendations for action. These recommendations largely consist of remedies which the Review Team believe are within the grasp of the local NHS leadership”. 3 The report notes that “Although the Review is specifically about two hospitals within ABMU, the Report also reflects on specific broader issues which relate more generally to the NHS in Wales, and the Report therefore also makes recommendations for action by the Welsh Government.” 3. BACKGROUND TO THE REVIEW The Review Team was led by Professor June Andrews, Director of the DMDC at the University of Stirling and Mark Butler, Director of TPO. The remit for the Review concentrated on four areas: • The culture of the care of older patients, particularly in the medical wards • The administration and recording of medicines, particularly how medicines are administered to patients who are cognitively impaired or have other challenges taking medicines orally • How professional nursing standards are protected and delivered consistently and how the Health Board responds to lapses in delivery of these standards • The response to complaints, how they are handled by the Health Board and how professionals are held to account for lapses in care identified through investigation including Protection of Vulnerable Adults (POVA) investigations. The Review Team focused on the current position in the hospital and report of previous experiences of older people in the care of ABMU over a three year period. 4. KEY FINDINGS The published report “Trusted to Care” is attached as Appendix A. It should be noted that the authors state that “The Report provides a thorough account of the work of the Review Team and is intended to be read, and engaged with, as a whole”. Therefore the recommendations have not been reproduced within this Board paper as it is felt that the Board needs to focus on the entire report content rather than just the 18 summarised recommendations (14 for action by the Health Board and four by Welsh Government – one of the latter to be commissioned via AMBU). The review found that some of the poor professional practice which was evident in the past is still happening on some of the wards of the Princess of Wales and Neath Port Talbot Hospitals today. The report states that “This is unacceptable and requires immediate concerted action, in addition to the required longer-term cultural and behavioural change. It is important to make it clear that these concerns are not of a scale to warrant action being taken by the Minister in respect of the current leadership of the Board”. It also states that “There are examples of exemplary practice throughout both hospitals.” 4 The report contains a number of quotations from patients and relatives which convey the seriousness of concerns in a way that cannot be conveyed by statistics or dry discussion about professional practice. On 13th May 2014, Mark Drakeford, Minister for Health & Social Services wrote to all Chairs and Chief Executives of Health Boards and NHS Trusts in Wales to highlight the publication of the Andrews Report “Trusted to Care”. His letter is enclosed as Appendix B. In this he states “The review team’s findings and observations will be for everyone in the NHS. I am determined that nothing of this sort will be tolerated in any hospitals, any helaht board or Trust in NHS Wales in the future”. The Minister gives each organisation a four week period (by 11th June 2014) to absorb the findings of the report and satisfy themselves that such departures from basic professional standards are not present in their organisations. In the immediate weeks after this, all district general hospitals will be visited, unannounced by a team of senior individuals to undertake a series of Ministrial “spot checks” in the following four areas of care: • In giving patients their medication; • In ensuring that patients are kept hydrated; • In the overuse of night-time sedation; and • In basic continence care. The findings will be reported directly to the Minister and Professor Andrews and her team have agreed to direct and guide this process. Sir Ian Carruthers will provide leadership to the activity. 4. ACTION TAKEN TO DATE ABMU Health Board received an ‘in-confidence’ copy of the Andrews report the week prior to publication so that it had an opportunity to respond to the findings appropriately and with urgency. As a result a statement was issued on the day the report was published by Welsh Government and this is attached as Appendix C. The Chairman and Chief Executive made strong statements on behalf of the Board both of regret and apologies to patients and families but also of the resolve to tackle these issues with determination and urgency. When issues were identified at the Princess of Wales Hospital in March last year we took immediate action. Some of these actions are already showing progress including an improvement in mortality rates, a reduction in hospital acquired infections and pressure ulcer (bed sores) rates plus 95% positive feedback via the Friends and Family Test (ward-based feedback system). 5 However, the improvements to date are still not enough and the Health Board is committed to urgently replacing any remaining pockets of poor care with consistently excellent care. We took immediate action when concerns were first raised, and we are taking immediate further action now on the issues raised in this report, particularly in relation to: • Medication • Hydration • Night-time Sedation • Continence care The report specifically asks us to develop clear standards for the care of frail older people to address some poor practice highlighted in the report. We will do this as a matter of urgency over the coming weeks with the help of external experts, patients, carers, relatives and frontline teams. However there are some issues in the report which we want to be clear are completely unacceptable and should never happen in any of our hospitals: • Patients being given prescribed medication but then not being observed taking it; • Staff signing the medicines chart to say that a patient has taken medication when they have not seen this; • Inappropriate use of sedation for “aggression”; • Patients being told to go to the toilet in bed; • In addition we must ensure that patients are appropriately hydrated.

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