338-007-001 Public Accounts Committee 338-007-002 Membership and Powers Membership and Powers

Public Accounts Committee Report on the Safety of Services Provided by Health and Social Care Trusts Together with the Minutes of Proceedings of the Committee Relating to the Report and the Minutes of Evidence Ordered by the Public Accounts Committee to be printed 27 February 2013 Report: NIA 102/11-15 (Public Accounts Committee) REPORT EMBARGOED UNTIL 00:01 AM on 17 April 2013 Mandate 2011/15 Thirteenth Report Public Accounts Committee 338-007-001 Public Accounts Committee 338-007-002 Membership and Powers Membership and Powers The Public Accounts Committee is a Standing Committee established in accordance with Standing Orders under Section 60(3) of the Northern Ireland Act 1998. It is the statutory function of the Public Accounts Committee to consider the accounts, and reports on accounts laid before the Assembly. The Public Accounts Committee is appointed under Assembly Standing Order No. 56 of the Standing Orders for the Northern Ireland Assembly. It has the power to send for persons, papers and records and to report from time to time. Neither the Chairperson nor Deputy Chairperson of the Committee shall be a member of the same political party as the Minister of Finance and Personnel or of any junior minister appointed to the Department of Finance and Personnel. The Committee has 11 members including a Chairperson and Deputy Chairperson and a quorum of 5. The membership of the Committee since 23 May 2011 has been as follows: Ms Michaela Boyle1 (Chairperson) Mr John Dallat (Deputy Chairperson) Mr Trevor Clarke2 Mr Michael Copeland Mr Sammy Douglas3 Mr Paul Girvan Mr Ross Hussey Mr Mitchel McLaughlin Mr Dathí McKay4 Mr Adrian McQuillan5 Mr Seán Rogers6 1 With effect from 2 July 2012 Ms Michaela Boyle replaced Mr Paul Maskey 2 With effect from 1 October 2012 Mr Trevor Clarke replaced Mr Alex Easton 3 With effect from 1 February 2013 Mr Sammy Douglas replaced Mr Sydney Anderson 4 With effect from 11 September 2012 Mr Daithí McKay was appointed to the Public Accounts Committee 5 With effect from 24 October 2011 Mr Adrian McQuillan replaced Mr Paul Frew 6 With effect from 10 September 2012 Mr Seán Rogers replaced Mr Joe Byrne 7 With effect from 23 January 2012 Mr Conor Murphy replaced Ms Jennifer McCann 8 With effect from 1 July 2012 Mr Conor Murphy resigned from the Public Accounts Committee i Public Accounts Committee 338-007-003 Report on the Safety of Services Provided by Health and Social Care Trusts ii Public Accounts Committee 338-007-004 Table of Contents Table of Contents List of abbreviations used in the Report iv Report Executive Summary 1 Summary of Recommendations 3 Introduction 6 The extent of harm caused by HSC providers must be measured and Information on the safety of Trust services made available to the public 8 Trusts must Completely Eliminate the Blame Culture if the Reporting of Incidents is to Improve 12 Appendix 1: Minutes of Proceedings 19 Appendix 2: Minutes of Evidence 27 Appendix 3: Correspondence 63 Appendix 4: Other Papers Submitted to the Committee but not included within the Report 159 Appendix 5: List of Witnesses Who Gave Oral Evidence to the Committee 163 iii Public Accounts Committee 338-007-005 Report on the Safety of Services Provided by Health and Social Care Trusts List of Abbreviations used in the Report the Committee Public Accounts Committee C&AG Comptroller and Auditor General the Department/DHSSPS Department of Health, Social Services and Public Safety HSC Health and Social Care NCEPOD National Confidential Enquiry into Patient Outcome and Death NRLS National Reporting Learning System RAIL Regional Adverse Incident Learning RQIA Regulation Quality and Improvement Authority SAI Serious Adverse Incident iv Public Accounts Committee 338-007-006 Executive Summary Executive Summary Introduction 1. Health and social care services affect every member of society at some stage in their lives. Each year, there are in excess of 15 million key interactions between health and social care staff and healthcare patients and social care clients. The public expects, and deserves, that services are delivered safely. However, one guarantee that the health and social care services cannot give patients and clients is that they will not be harmed by the system meant to look after them. The challenge for the health and social care services is to ensure their patient safety systems minimise the risk of harm and to take steps to maximise the competence, knowledge and skills of health and social care professionals. 2. Two recent reports1 on unsafe care at Mid Staffordshire NHS Foundation Trust in England bring into particularly sharp relief just how crucial it is that the health and social care system treats patients as human beings and is open, transparent and accountable when things do go wrong. It is important that Trusts here learn from what happened in Mid-Staffordshire to ensure nothing like the events there could possibly happen here. 3. Adverse incidents are incidents that occur in a health or social care setting that could have resulted, or do result in the harm, or even death, of the patient or client. Around 83,000 incidents are reported by the Health and Social Care Trusts each year – around 250 of these are classified as serious adverse incidents. The Department told the Committee that of the 2,084 serious adverse incidents reported between July 2004 and March 2012, 813 individuals died in circumstances related to these incidents. The Committee acknowledges that deaths reported may not be a reflection of issues with the care delivered by health and social care services: for instance 488 of the fatalities reported relate to suicides, whether proven or suspected. However, while recognising such caveats, the Committee considers that the number of deaths still suggests that the standard of care being delivered by health and social care bodies requires continued close scrutiny. 4. Patient harm arising from adverse incidents is both a systemic and a human problem. While individual responsibility for adverse incidents should not be played down, systemic solutions to the problem are needed. Patient safety systems should include effective reporting and learning systems, effective remedial mechanisms and the active dissemination and implementation of evidence-based knowledge aimed at reducing adverse incidents. 5. Some, probably a very small proportion of, patients and clients who are dissatisfied with the care or treatment they receive, seek redress either by lodging a complaint or taking legal action against the provider. The latter can have significant financial implications — in the past five years, settling health and social care negligence cases has cost the Department of Health, Social Services and Public Safety (Department) £116 million. A significant proportion of this (around 35 per cent) related to legal and administrative costs. Overall Conclusions 6. The Committee’s overall conclusion is that, despite the introduction of a number of safety policies and initiatives, there is no reliable evidence to show that people receiving health and social care are any safer today than they were a decade ago. The Department still lacks a reliable means of tracking the progress of the health and social care services in improving 1 The Mid Staffordshire NHS Foundation Trust Inquiry, Chaired by Robert Francis, 24 February 2010, HC 375, London: The Stationery Office; Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Chaired by Robert Francis QC, February 2013, HC 947, London: The Stationery Office 1 Public Accounts Committee 338-007-007 Report on the Safety of Services Provided by Health and Social Care Trusts the safety of those receiving care or in holding service providers accountable for minimising preventable harm. 7. The Committee was disappointed by the Department’s reluctance to undertake research to estimate the potential level of harm caused to patients and clients. In the absence of a robust measure of the level of patient and client harm, it will be difficult for the Department to demonstrate improvement over a period of time. The Committee considers that evidence of progress is a vital step in spurring Trusts to improve safety levels across both the health and social care sectors. 8. The Committee also considers that patients and clients must be provided with much more detail on the performance of individual Trusts. In practical terms, this will involve notifying those individuals involved in adverse incidents and routinely making sufficient information publicly available to enable comparisons of safety levels across Trusts and to create external pressure for improvement. 9. The Committee recognises that the year-on-year increases in the number of reported incidents indicate some progress in developing a more open and fair reporting culture. However, on the basis of evidence given by the Department, it considers that organisational culture does not always support reporting, while fear of the consequences in terms of job security and personal repercussions still exist. The Department told the Committee that under-reporting continues to be a widespread issue, particularly in the acute sector. On the basis of this, the Committee concludes that Trusts are not maximising the potential to learn when things go wrong. As a direct consequence of this, public trust in the extent to which Trusts are providing safe and effective care can be seriously undermined. 10. The Committee is extremely concerned that nurses within the health and social care sector have reservations about raising patient safety concerns. While the Department acknowledged that staff must feel empowered to speak up, challenge and share in the responsibility for patient safety, it confirmed that, to date, it has not actively engaged with nursing representative bodies to devise a methodology for reassuring nurses. The Committee considers that there is a strong link between the culture of an organisation and the willingness and capability of staff at all levels to report and learn from adverse incidents.

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