Attachment 5

Report to the Board of Directors 2015/16

Date 29 May 2015

Subject Response to Savile Reports

Report of Associate Director of Governance, Safety and Compliance

Author Anna Hills, Associate Director of Governance, Safety and Compliance

Previously considered Safety and Quality Governance Committee 8 May 2015 by

Board Action Required Approval X Discussion

Decision Information

Executive Summary and purpose

It has come to light that over the course of many decades abused at least 500 victims, including some as young as two, males and females, and he is said to have boasted about having sex with corpses. He used the NHS and his celebrity status to exploit and abuse vulnerable patients and staff at across the country. His association with hospitals began with an unofficial role in patient entertainment, but within a few years at some hospitals he had accommodation, a car parking place and even keys allowing him access to secure areas, including the mortuary. Savile used his status as a television personality to develop relationships with politicians, including the health secretaries, and exploited these relationships to strengthen the impression that he was in a position of authority leading to him being given access to patients, often unsupervised. His celebrity status allowed him to move around hospitals unchallenged by-passing security and safeguarding measures.

A multi-disciplinary group was convened on 12 August 2014 to review the recommendations within the reports published from the Trusts who had an association with Jimmy Savile at some point in their history. This group developed an action plan for implementing these recommendations at the Trust, as appropriate.

On 26 February 2015 a further report was published regarding the allegations made against Savile in relation to his association with Stoke Mandeville Hospital. This report identified five themes for ‘lessons for learning’ and eight recommendations. These have been cross referenced to the action plan developed by the Trust and the same multidisciplinary group will continue to review, update and take forward the outstanding actions. A further meeting was held on 1 May 2015 and the action plan was updated as presented. A formal response to Monitor regarding the actions we have taken is required by 15 June 2015.

Hence, most of the recommendations focus upon strengthening safeguarding and security measures ensuring they are equally applied to all staff and visitors, irrespective of their celebrity and/or policitical status.

Strategic Context/Objective(s) and Board Assurance Framework links Strategic aim(s) To be safe X To be effective To be caring To be responsive To be well-led Strategic 1 objective(s)

BAF reference(s) 1d

This paper provides assurance against the Trust objective(s) identified This paper is to close a gap in control/assurance in relation to the objective(s)

Legal/regulatory Safeguarding Adults and Children Monitor requirement in relation to actions taken

Equality Impact/risks: Impact Equality Delivery

System 2 – EDS2 Nov Positive Negative Neutral 2013) X

Assurance/monitoring Safeguarding Committees

29052015 Savile Anna Hills, Associate Director of Governance, Safety and Compliance pg. 2 May 2015 REP/BOD/AH1005/V1

ACTION PLAN: TO MONITOR PROGRESS FOLLOWING JIMMY SAVILE REPORTS

Dated: 10/05/2015 (V7)

Aim: The aim of this action plan is to ensure actions are taken at the Trust following the investigations at other trusts in the activities of Jimmy Savile. Content: This action plan captures all of the issues highlighted following discussions around each individual Hospital’s Report and includes responsibilities and timescales for delivery. Responsibility for delivery: Director of Nursing Monitoring and Assurance: Strategic Risk Group; Safety and Quality Governance Committee

Key for RAGBW rating of Actions: (B)lue = Ongoing monitoring to be (W)hite = Not yet started (G)reen = Completed (A)mber = In progress (R)ed = Due but not complete assured of continued achievement

ID Recommendation Comments/Current Situation Action Responsibility Timescale Progress (RAG) 1 LEEDS TEACHING HOSPITALS NHS TRUST 1.1 The Trust’s safeguarding policies To review Trust Safeguarding policy to include Deputy 31/12/14 (R12.1) extend explicitly to the care and deceased patients. Policy has been revised Director of transportation of deceased patients and it not appropriate to capture this within Nursing - Julia this policy. Action complete. Hunt 1.2 Policies and controls in place Review with Mortuary Manager i) To review Trust Mortuary policy 30th (R12.2) covering security at the mortuary, November and that these are regularly audited Electronic access limited staff group Security and 2014 has access to mortuary, suitability is Emergency reviewed by Mortuary Manager the Planning Slippage to th system can be audited as required. Manager – 30 June Keith Wilson 2015 Review with Mortuary Manager and ii) To monitor frequency of access to the Available as Local Security Manager about spot mortuary a report any checks time

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ID Recommendation Comments/Current Situation Action Responsibility Timescale Progress (RAG) iii) To assess the suitability of who should have access to the mortuary iv) To review the audit programme that 30th assesses the Mortuary policy. Spot November checks would be appropriate. 2014

Slippage to 30th June 2015 1.3 Quality of the Trust’s safeguarding  DBS audit planned 2014. i) Audit programme to include a review of Deputy 31/03/15 (R12.3) compliance in respect of adult and  Staff training audit ongoing for the safeguarding of adults and children. Director of child patients, and its duty to protect safeguarding children. Audit undertaken of Children & DBS and Nursing - Julia Slippage to th staff. Working with the Safeguarding Spot check/face to face audit of spot checks completed for Adults. Audit Hunt 30 May Boards for Children and Adults in the safeguarding children awareness programme for 2015/16 will be 2015 city, an audit programme should planned Autumn 2014. developed by Named Leads when in post. Named Nurse, include a review of the safeguarding Standards subject to review by CCG Safeguarding of adults and children in in-patient Safeguarding Lead Nurse. Observational, Children – areas; staff training; and staff interviews and reviews of Alison employment checks documentation Reypert ii) Spot check of information in clinical areas - completed

1.4 Current Disclosure and Barring DBS checks - Human Resource led To review current DBS policy to ensure it is fit Associate December Policy reviewed (R12.4) Service (DBS) checks are in place for action Rigorous checks are in place, for purpose and assess our compliance. Director of 2014 and fit for all relevant employees, volunteers policy being re-written for approval Human purpose. and, where appropriate, contractors process Resources – Slippage to Currently as a matter of urgency, and that this Ginnie 30th May undergoing position is reviewed to inform each Stevens 2015 corporate Board meeting ratification.

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ID Recommendation Comments/Current Situation Action Responsibility Timescale Progress (RAG) 1.5 Quality of the complaints system; Detailed action plan in place with (R12,5) the Board should monitor full monitoring process adherence to the recommendations of the 2013 Clwyd/Hart Review 1.6 Robustness of the Trust’s processes Whistleblowing policy has been To ensure Executives are familiar with the Associate 30/11/2014 Reports (R12.6) for staff and others to raise reviewed, updated and re-launched. issues brought up in these reports via Director of provided to SQG concerns, and on how such matters Confidential raising concerns email monitoring of this action plan by SQG. Governance – and Board are responded to and addressed. address introduced. Anna Hills Particular attention should be given to allegations of sexual impropriety 1.7 There should be a Trust-wide Current safeguarding adult’s policy To review training materials to incorporate Deputy 31/01/15 Domestic (R13) campaign to raise awareness of the does cover domestic violence etc. Jimmy Savile issues. Reference is made in Director of Violence safeguarding duty to patients across training. To further extend overall content of Nursing – Julia campaign all patient contact staff and Safeguarding training Adult/Children a review Hunt planned in volunteer groups of CLAW Day 2 is planned. This will be led by November. Named Leads for Safeguarding Adult Safeguarding training is linked to policy. 1.8 All safeguarding promotional See 1.7 See 1.7 See 1.7 See 1.7 See 1.7 (R14) material, educational material or information used in the Trust should be explicit in the inclusion of all patient contact and support services 1.9 The quality of work carried out by Our porters currently have adult and To review approach taken regarding Security and (R15) porters should include reference to children safeguarding training and appraisals, to establish who the line manager Emergency patient experience and values and behaviours training. is for the porters in the first instance. Planning safeguarding, in addition to the Manager – measurement of time to complete Peter Huttley is the line Manager Keith Wilson tasks

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ID Recommendation Comments/Current Situation Action Responsibility Timescale Progress (RAG) 1.10 Porters should receive training and Counselling is available To provide evidence of training Security and (R16) support about the transportation Emergency and handling of deceased patients. Emailed Peter Huttley – “Facilities Planning De-briefing and counselling should management have detailed list of the Manager – be available for porters who are Porters training, and can provide Keith Wilson adversely affected by carrying out evidence.” this duty 1.11 The Trust Quality Committee should To walk through the process and build a Associate 30/04/2015 Consider Board (R17) commission a specific project on the report to gain assurance on process Director of to Ward visit to care, transportation and storage of Governance, Slippage to include the the bodies of deceased patients to Safety & 30th June mortuary give wider assurance that the Compliance - 2015 matters raised by Savile’s Anna Hills association with the hospital mortuary could not happen again Director of Nursing – Liz Libiszewski 1.12 Guidance and active support on We have a VIP plan on how the Trust To review VIP patient and visitor policy and Security and 30th June In progress – (R18) interacting with VIP patients should would deal with a VIP patient as part re-launch Emergency 2015 documents be developed and issued to of the Trust Major incident and Planning reviewed and consultants and senior clinicians, Business Continuity Plans. Manager – going through and its use monitored through the Keith Wilson endorsement appraisal process process

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ID Recommendation Comments/Current Situation Action Responsibility Timescale Progress (RAG) 1.13 A sanctioned visitor policy should be See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 (R19) established and implemented across all sites of the Trust with some urgency. It should set clear boundaries regarding the role of celebrities, VIPs and media contractors in the Trust, including their access to hospital premises. This policy should include robust processes for Board assurance and information about the rules of engagement with media, celebrity visitors and other VIP or non- essential visitors to the hospital 1.14 The Trust should conduct a review to To review Trust guidance to ensure Deputy 30/11/14 (R20) ensure that the support, advice and information is available to staff. Director of care it provides to victims of sexual Note Safeguarding Policy cannot contain all Nursing - Julia assault and statutory rape are information. Many rape victims would not Hunt consistent with current best practice come under SA Adults umbrella. The existing policy already covers those that do. Safeguarding Policy cannot contain all information. Many rape victims would not come under SA Adults umbrella. The existing policy already covers those that do. Best practice advice is followed and staff know how to access support in cases of suspected or reported rape. This is through the police and Rape Crisis centre. 1.15 The Trust should conduct an audit of Do not have adults on children’s ward. Audit adherence to this policy Lead Nurse, 31/05/2015 (R21) placements of children and young 16 and 17 year olds are risk assessed in Elective people on adult in-patient areas to A&E/EADU as to where they are best Division – ensure that this no longer happens placed Tracy McLean

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ID Recommendation Comments/Current Situation Action Responsibility Timescale Progress (RAG) 1.16 The Trust should put in place a safe The Trust does currently have a (R22) and confidential counselling service counselling service in place via the for all staff, patients, visitors and Occupational Health Service provider volunteers affected by the content of this report

1.17 The Trust should establish a N/A for this Trust (R23) confidential helpline and referral service for victims of Savile, including those who have not yet come forward 1.18 Development of strategies and To develop Strategies and Actions to improve Chief Board to ward (R24) actions should continue to improve the visibility of executive and non-executive Executive – reintroduced. the visibility of executive and non- directors across the organisation Christine Execs deliver executive directors across the Allen compliments organisation received HR corporately to programme individuals director – Plan to engage Geraldine with staff to Opreshko embed fundamental standards. Plan of executive launch of ‘Raising concerns’ policy through March and April 2015.

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ID Recommendation Comments/Current Situation Action Responsibility Timescale Progress (RAG) 1.19 As part of their Board responsibility, See 1.18 See 1.18 See 1.18 See 1.18 See 1.18 (R25) directors should foster a culture of curiosity, internal scrutiny and constructive challenge, particularly on matters that have a major impact on public confidence in Trust services 1.20 The Board should develop an See 1.18 See 1.18 See 1.18 See 1.18 See 1.18 (R26) understanding of how it feels to be a patient in the Trust and identify methods of communication to share good practice and celebrate success, in addition to ensuring that concerns are addressed promptly 1.21 The Trust should review security KW – documenting what we do, to Review security policy: (R27) across all sites, including on-call ensure all restricted areas are policed. i) To ensure all restricted areas are policed. residences and decommissioned How do we assure that people using ii) To ensure that people with access to areas in its estate, to develop a these areas has necessary reason. restricted areas have a valid reason. comprehensive strategic security Grand master keys have to be signed plan. The Board should seek regular off by KW. Security and assurance that all restricted areas Emergency are secure, including high-risk areas Annual Security report submitted by Planning LSMS to board. Manager – Security updates every 2 months to Keith Wilson Health Safety and Staff Welfare committee. Daily review by LSMS of all SAFEGUARD reports. Trust Security Strategy in place Review with Peter Huttley around security patrols

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ID Recommendation Comments/Current Situation Action Responsibility Timescale Progress (RAG) 1.22 A unified HR system should be ESR as a national NHS tool is in place in To ensure work that has been commissioned HR 31st Jan 2015 (R28) established across the Trust that the Trust and its use and governance regarding ESR fulfils this requirement programme fulfils the recruitment and is currently being thoroughly reviewed director – employment requirements for all as part of a project to ensure that it is *In addition to this action will include a Geraldine employees, volunteers and fit for purpose review of carers who follow their patients Opreshko contractors in a consistent manner into the Hospital from the community* 1.23 The Trust should review its policy on Hospitality policy has been reviewed. To ensure risk based internal audit feeds into Associate Achieved – (R29) gifts and hospitality and seek next year’s plan Director of Hospitality assurance that all staff (including Risk based internal audit in place. Governance, Policy and volunteers and non-executive Safety & process directors) are aware of their Compliance - updated and responsibilities and comply with the Anna Hills communicated policy. Compliance should be reviewed at least annually by Internal Audit 1.24 The Trust should develop with some Volunteer policy currently being Review Volunteers Policy: Head of 30th June Policy updated (R30) urgency a volunteer policy. This reviewed. i) To ensure all documents include Patient 2015 cross should cover volunteers’ governors where volunteers are Experience – referencing employment checks, induction, mentioned Amanda Hood Lampard and training, access to the Trust and ii) To ensure a solid understanding of Marsden’s clarity about the boundaries of their boundaries of roles across the Trust recommendatio roles ns. Supervision of volunteers in section 7 of the Policy

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1.25 The Trust should develop a major i) Business continuity strategy in i) To review business continuity strategic Security and (R31) strategic plan for the management place Major incident strategy in plan to ensure Jimmy Savile issues have Emergency of potentially catastrophic issues place Reputational risk always been considered Planning where public confidence in the taken into consideration Manager – organisation may be at stake in the Keith Wilson light of unprecedented events. This Exec and senior manager training will enable greater clarity and around Business and Major incidents consistency in matters of communication, accountability and ii) The Communications team has ii) To ensure there is an effective Head of ii) TBC External action undertaken a major review of its communications plan in place if a Communicatio comms preparedness for a MAJAX, ahead of catastrophic event was to occur ns and Trust support the recent Exercise Boudicea, including Secretary – has been key media and social media messages Ann Filby commissio as a starting point. We already have in ned to place some key lines for regular issues. support Our e-distribution lists are up to date specific for local and national media, and our high stakeholders, to ensure effective risk/high communication is possible at short profile notice. All team members have access issues to these lists. Minor amendments will be made to our processes over the coming weeks to ensure we continue to review our preparedness for any major incident or damaging media issue affecting the reputation of the Trust.

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1.26 The Trust should work with the For discussion at Charitable funds committee Director of 30th June 2015 In (R32) Leeds Teaching Hospitals Charitable Finance – progress - Trust to develop and implement a Mark Flynn To be policy for the management of large discussed financial donors, specifically setting at out how to deal with requests for Charitable favours from them Fund Committe e in June 1.27 The Trust Dignity at Work policy has A new policy has been written, Review bullying and harassment policy HR 3oth Nov 2014 Dignity at (R33) been in place since 2011, but does including the definition of sexual programme Work not explicitly mention sexual harassment and many other forms of director – Policy harassment in its definition of what bullying. It is currently going through a Geraldine updated. constitutes harassment or unwanted consultation process with staff side Opreshko behaviour. This should be reviewed and sexual harassment clearly defined, with examples given. Following review, this policy should be audited: in particular, to gain assurance that staff who have line management responsibility for others are fully conversant with the required actions to take when faced with allegations of sexual harassment or unwanted behaviour 1.28 All policies should be reviewed to Reviewed yearly as part of IG toolkit (R34) ensure that they comply with Head of Health Records & IG – Russ statutory obligations about the Crawford retention of records 1.29 All Trust policies should extend in See 1.28 See 1.28 See 1.28 See 1.28 See 1.28 (R35) their scope to the broader community, including volunteers, non-executive directors and, where appropriate, contractors; and, in time, to governors

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1.30 The Trust should review how it seeks See 1.28 See 1.28 See 1.28 See 1.28 See 1.28 (R36) the views of a wider range of stakeholders in developing policies, and should ensure that all policies are patient centred. In doing so, it should draw best practice from other organisations within and outside the NHS 1.31 All policies should be succinct, See 1.28 See 1.28 See 1.28 See 1.28 See 1.28 (R37) clearly set out in plain language, and identify the points that people need to know in order to implement them safely 1.32 There should be mandatory See 1.28 See 1.28 See 1.28 See 1.28 See 1.28 (R38) compliance with policies designed to protect patients and staff. The role of the Trust’s Internal Audit should be reviewed as part of this 1.33 A baseline review of the range of For discussion at Charitable funds committee Director of Achieved (R39) projects supported by the Leeds Finance – via annual Teaching Hospitals Charitable Trust Mark Flynn meeting should be undertaken to assess attended consistency with the current by all priorities of the Trust Board members – next due in June 2015 1.34 The Charitable Trustees should work See 1.33 See 1.33 See 1.33 See 1.33 See 1.33 (R40) closely with the Leeds Teaching Hospitals NHS Trust Executive Team to establish priority-setting and decision-making processes that reflect the needs of the patients of the hospital and the services

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provided to them 1.35 Assurance that charitable funds are See 1.33 See 1.33 See 1.33 See 1.33 See 1.33 (R41) channelled appropriately should be gathered on a systematic and ongoing basis and reported to both the Charitable Trustees and the Trust Board Audit Committee to ensure that the mechanisms in place to do this continue to be effective 2 BROADMOOR HOSPITAL 2.1 Many celebrities make a significant See 1.4 See 1.4 See 1.4 See 1.4 See 1.4 (R1) contribution to improving patient wellbeing and help to raise charitable funds, but that does not imply that they should be exempt from standard procedures governing access to NHS patients. NHS bodies should ensure that any celebrity they may consider appointing should be subject to the suitability checks appropriate to their contact with the NHS facility and its patients, and should not be given privileged access under any circumstances. 2.2 Some celebrities may have the See 1.4 See 1.4 See 1.4 See 1.4 See 1.4 (R2) necessary qualities and the desire to contribute to the NHS in a non- executive capacity, but they should not be exempt from the usual selection process, which would include careful consideration of the benefits and risks. Celebrities should not be considered for operational or executive NHS roles – not even on a

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voluntary basis. 2.3 Security systems at Broadmoor were See 1.21 See 1.21 See 1.21 See 1.21 See 1.21 (R3) underdeveloped and potentially ineffective for much of Savile’s active involvement with the hospital, and were sometimes poorly applied in practice. Nobody but a properly trained and appropriately qualified member of staff should be in a clinical area without supervision. We believe that the much-needed overhaul has been effectively implemented, but we recommend that the way theory is put into practice should be reviewed regularly by West London Mental Health NHS Trust. 2.4 Procedures to safeguard vulnerable See 1.1 See 1.1 See 1.1 See 1.1 See 1.1 (R4) patients were poorly developed during Savile’s active involvement with Broadmoor, including the reporting and proper investigation of complaints. We believe that safeguarding has been greatly improved and that procedures are appropriate and effective, but we recommend that the way theory is put into practice should be reviewed regularly. We also recommend that the arrangement that separates local authority responsibility for safeguarding from the provision of social workers should be reviewed within the next year, and that a risk assessment and appraisal of

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alternative options should be carried out. 2.5 The closed and introspective See 1.6 See 1.6 See 1.6 See 1.6 See 1.6 (R5) institutional culture of Broadmoor failed to prevent some instances of psychological, physical and sexual abuse of patients, including those committed by Savile, and discouraged staff from reporting or taking effective action. We believe that the much-needed improvement has been achieved, principally through recruitment, induction, training, continuing education and disciplinary policies. We recommend that the effectiveness of these policies continues to be monitored regularly by the Trust’s board and by the . 2.6 In order to improve the review and Not applicable (R6) monitoring of security systems, safeguarding and organisational culture, we recommend that service commissioners should review how all three high-security hospitals share relevant comparative information. 2.7 Department of Health procedures (R7) proved inadequate in ensuring that the decision to give Savile a managerial role in 1988 was thoroughly evaluated and subject to proper scrutiny. In part, this was due to a combination of circumstances at the time that is unlikely to be

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repeated. We recommend that any decision to have the Department of Health directly manage an operational service should be exceptional and subject to thorough risk assessment. 2.8 Public officials, including senior civil This has been added to the recruiting Review Recruitment Policy to ensure it HR Completed (R8) servants, who are responsible for managers guidance includes that individuals should be involved in programme recommending the appointment of the recruitment process for someone with director – someone with whom they have a whom they have a close personal Geraldine close personal relationship, should relationship. Opreshko generally withdraw from the appointment process. At the very least, they must ensure that their judgement is subject to independent verification. We recommend that the Department of Health and NHS organisations review the relevant policies to ensure that this is made explicit. 2.9 We believe that stories of multiple Review Safeguarding policy to take account of Deputy 31/12/14 (R9) sexual relationships between senior this. Not appropriate to be in SA Policy. Director of and junior staff circulated widely However is covered by other Trust policies Nursing - Julia within and outside Broadmoor, and including the Speak up campaign/policy. Hunt were particularly corrosive. We believe this contributed to an atmosphere that was unusually tolerant of sexual relationships between staff and patients in some parts of the hospital. We recommend that NHS boards ensure that policies and systems are in place to encourage staff to report such behaviour, and make sure that the organisation can act to eradicate

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it. 2.10 We are particularly concerned that (R10) we cannot confidently exclude the possibility that an irregular payment was made to settle an impending tribunal case at which embarrassing personal allegations would have become public. We recommend that NHS Protect and the police investigate this possibility. 3 ST CATHERINE’S HOSPITAL, BIRKENHEAD 3.1 A safeguarding declaration is In place (R1) produced and put on the WCT website. 3.2 Contact names and telephone In place (R2) numbers for appropriate safeguarding staff are placed on the website to make it feel more personal and approachable. 3.3 When policies are under review a Document Review Group to discuss Associate All (R3) date is added to that policy to Director of document indicate the date by which it will be Governance – s have an complete, rather than simply Anna Hills expiry recording “under review”. date and it is expected that they will be reviewed prior to expiry. There is an escalation

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process should this not be achieved and committe es are tasked with monitorin g out of date policies. 3.4 WCT should also continue regularly (R4) to review and update its policies and procedures, benchmarking with the best. 3.5 WCT should work across the Wirral (R5) health and social care community, sharing this report with partners in acute, mental health, primary and social care, so that they may assess their current policies and procedures in the light of what happened in 1964 to ensure that patients, particularly the most vulnerable, are safeguarded at all times. 4 SAXONDALE HOSPITAL Recommendations not clear 5 PORTSMOUTH HOSPITAL 5.1 There was no policy in place that See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 governed the visits of high profile guests or celebrities; these are

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managed by the Communications Department within the Trust, which ensures that such guests are accompanied at all times whilst in the hospital. However, the Trust has now updated its existing Communications Strategy to include a section on ‘the management of visits by high profile guests’. The update to the strategy was undertaken by the Trust’s Communications Team. 6 MID YORKSHIRE HOSPITALS Unable to access report 7 HIGH ROYDS HOSPITAL 7.1 The single recommendation is that N/A for this Trust the service user, identified as X, has an open invitation to visit today’s mental health wards in order that she can see for herself the changes in environment, practice and protection offered to vulnerable service users. 8 WHEATFIELDS HOSPICE 8.1 Reinforcement of the need for Sue See 1.23 See 1.23 See 1.23 See 1.23 See 1.23 Ryder to continue to operate rigorous safeguarding and vetting procedures for staff and volunteers across all directorates and incorporating this into the Internal Audit Plan for 2013/14 8.2 Reinforcement of the importance of See 1.21 See 1.21 See 1.21 See 1.21 See 1.21 supervise ensure no uncontrolled

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access to vulnerable people is gained and to communicate this via the Hospice and Centre managers and Fundraising managers forums. 8.3 To ensure that the ability to raise a In place concern or a complaint is well advertised at both a centre level and via our website and that Sue Ryder’s Complaints Policy reflects this change. 9 CARDIFF ROYAL INFIRMARY There are no specific recommendations made in relation to the allegation made in this case. 10 GREAT ORMOND STREET HOSPITAL Although no formal recommendations have been identified through this investigation, the Trust had previously carried out an assessment based on the letter from Sir David Nicholson in November 2012 which has been added as an appendix (appendix F) to this report 11 EXETER HOSPITAL 11.1 DPT to identify learning points from (R1) the NHS investigations in relation to Jimmy Savile when published and identify recommendations within four weeks of publication of the report. 11.2 The Trust’s Safeguarding Lead to

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(R2) identify any learning points and recommendations from the NHS investigations and formulate an action plan should the need be identified within six weeks of publication of the report. Learning points and recommendations and actions planned in response (identified above) to be shared with all Trust staff within 10 weeks of publication of the report 11.3 The Trust Policy Officer under the See 1.1 See 1.1 See 1.1 See 1.1 See 1.1 (R3) supervision of the Trust’s Safeguarding Lead and in conjunction with policy leads to review existing policies to identify that they are fit for purpose and current in relation to the learning points identified from the NHS investigations within 12 weeks of publication of the report. 11.4 Any new policies identified by the (R4) process referred to above to be published and implemented within 16 weeks of publication of the report. 12 No clear recommendations 13 BARNET GENERAL HOSPITAL 13.1 The investigators recommended that See 1.24 See 1.24 See 1.24 See 1.24 See 1.24 the volunteer procedure is used to develop a policy to clarify what is

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required in order for volunteers to be recruited and permitted to work in the Trust 14 BOOTH HALL 14.1 The Trust Access to Vulnerable See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 People Group should continue working towards a suite of policies and guidance to manage visiting celebrities to all areas of the Trust. 14.2 The Safeguarding Team, on behalf of See 1.3 See 1.3 See 1.3 See 1.3 See 1.3 the Trust, should continue to regularly review and audit safeguarding practice to ensure the high standard of safeguarding practice continues 14.3 It has been proposed that a system  Staff aware of who cannot visit. Children’s Safeguarding Lead to investigate Child 31st July Nicola will be developed to provide a daily  High turnover so logistically this. Safeguarding 2015 Lovett to account of resident parents/carers complex to use I.D. badge/band. Lead Nurse review and to provide visitors with name  Locked door system in place. lanyards for badges/bands. This should be  Family centred care environment. families and progressed. The Head of Nursing for  Visiting celebrities have planned visitors to the Children’s Hospital has been visits and always escorted. ward allocated to this programme of work Outside agencies – SLA’s in place. 10/11/NNU and it is anticipated it will be complete by December 2014. 15 DE LA POLE HOSPITAL The investigation team did not make any recommendations in relation to this alleged incident and subsequent review of the findings. However it has concluded that following a review of the current Policies, Practices and Procedures that there

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is a need to develop a specific policy to address the management of Visitors and VIP’s who attend Trust premises. 16 DRYBURN HOSPITAL 16.1 The Board should commission a further review by the Senior Associate Director of Assurance and Compliance of all of the above policies in the light of the wider lessons learned from investigations throughout the NHS into Jimmy Savile, following the publication of Kate Lampard’s independent, overall ‘Lessons Learned’ report. One aspect of the current policies to be considered as part of this review should be the frequency of supervision of volunteers following their initial induction, depending upon their areas of work. The policy currently requires a quarterly supervision meeting (Lead Officer: Senior Associate Director of Assurance and Compliance; Deadline: 30th September 2014). 16.2 The Board should commission, Internal Audit programme should include a Associate 30/04/2015 To be through the Trust Board Audit review of the volunteers policy. Director of discussed at Committee, internal audits of Governance – Slippage to Audit compliance with those policies not Anna Hills 30th May Committee covered by recent internal audits or 2015 to include in independent assessments, 2015/16 specifically the ‘Volunteer Policy’ programme (which includes sanctioned visits) and the policies on conduct and To be

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discipline and standards of business discussed at conduct (Lead Officer: Senior Audit Associate Director of Assurance and Committee Compliance; Deadline: 31st October in May 2014). 16.3 The Trust should review its See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 procedures for supervision of celebrity and similar visitors to make clear that the visitor’s interactions with patients (including by telephone) and with staff should be closely monitored, mindful of their impact on the patient experience, or staff welfare, and ultimately on the Trust itself. Supervising officers should have sufficient standing and authority to challenge any inappropriate behaviour by such visitors. These procedures should be documented in detail within a separate policy which should supersede the current policy statements set out within the ‘Volunteer Policy’ (Lead Officers: Senior Associate Director of Assurance and Compliance and Associate Director of Nursing, Patient Experience and Safeguarding; Deadline 31st May 2014). 17 HAMMERSMITH HOSPITAL No recommendations are considered necessary in light of the investigating team’s findings

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18 LEAVESDEN SECURE MENTAL HEALTH HOSPITAL 18.1 Amendment to the HPFT Charitable See 1.26 See 1.26 See 1.26 See 1.26 See 1.26 Funds Policy 19 MARSDEN HOSPITAL 19.1 To consider any learning coming from other organisations in relation to ‘the NHS investigations into matters relating to Jimmy Savile’ to continue to ensure that patients, visitors and staff are protected at all times when associated with the Trust 20 MAUDSLEY HOSPITAL 20.1 The Trust’s Head of Communications should review its Communication and Media Handling policy to ensure that standards and expectations on the management of celebrity and VIP visits to Trust services are explicit, robust and consistent 21 ODSTOCK HOSPITAL 21.1 Whilst the investigation team did See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 not find evidence to establish any wrongdoing by JS at Odstock, we recommend that a Visitor/ VIP Policy is developed, preferably with input at a national level by way of guidance from the DH. This policy would be intended to guide Trust process around celebrity requests, escorted tours and access to staff and patients.

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By: Director of Nursing When: September 2014 21.2 Feedback investigation to SFT staff, the timing of which to be aligned with the report publication locally, and the wider learning to be disseminated centrally via the DH By: Director of Nursing When: September 2014 21.3 Feedback investigation findings and See 1.26 See 1.26 See 1.26 See 1.26 See 1.26 learning to all the charities associated with SFT, especially relating to ‘VIP/ Celebrity’ links with the organisation. Again, whilst this investigation has not revealed any evidence of harm to patients by virtue of JS’s presence within Odstock or the Spinal Treatment Centre, the Investigation team considered that charitable associations with celebrities ought to be subject to a greater level of scrutiny than was the case in the 1980s. By: Director of Nursing When: September 2014 21.4 Review staff support/ tolerance of Director of Could this be unwanted contact from patients, Nursing – Liz included in visitors and celebrities, on Trust Libiszewski Board to Ward premises questions? By: Director of Nursing When: September 2014

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22 PRESTWICH The investigation does not have the power to impose disciplinary sanctions or make findings as to criminal or civil liability. Where evidence is obtained of conduct that indicates the potential commission of criminal offences, the police will be informed. Where such evidence indicates the potential commission of disciplinary offences, the relevant employers will be informed. 23 QUEEN VICTORIA HOSPITAL, EAST GRINSTEAD 23.1 QVH to feedback to staff the See 1.7 See 1.7 See 1.7 See 1.7 See 1.7 outcome of this investigation and to remind them of their role and responsibility in raising concerns about any inappropriate behaviour by staff, patients or visitors. This will be included within the trust's face to face paediatric and adult safeguarding training during the next year. 23.2 Complete the update of the trust’s See 1.6 See 1.6 See 1.6 See 1.6 See 1.6 whistleblowing policy. 23.3 Complete the update of the Review Complaints Policy Complaints 31/03/15 Policy complaints policy in line with the Investigator – updated in publication, ‘Putting Patients Back in Tracey Slippage line with the Picture’ (October 2013). Noakes to 30th requirements May 2015 and recommendati ons, currently

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awaiting ratification 23.4 Complete and publish the See 1.24 See 1.24 See 1.24 See 1.24 See 1.24 recruitment and management of volunteer’s policy 24 ROYAL VICTORIA INFIRMARY 24.1 The Trust to develop a ‘’Celebrity’’ See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 Visitor Policy/framework to replicate and formalise the local guidance in place in the Great North Children’s Hospital and reflect the good practice and Trust central co- ordination of Celebrity visitors. 24.2 The findings and recommendations of this report will be shared with the Trust Safeguarding Committees and Newcastle Safeguarding Children’s and Adult Boards to provide assurance and ensure responsibility for on-going action. 24.3 Any further allegations received shall be thoroughly investigated with the same rigour. 25 QUEEN MARY’S HOSPITAL 25.1 To include a process for planned and See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 unannounced VIP/Celebrity attempts to access ward areas into the Security Policy and a new Policy to manage planned celebrity, VIP visits and events.

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25.1 To update existing Safeguarding See 1.7 See 1.7 See 1.7 See 1.7 See 1.7 Adults and Children’s training to ensure that staff are aware of the continued need for vigilance, especially with regard to unannounced VIP visits and include this in future Listening Events, as part of planned staff engagement events regarding quality and risk. 26 WHITBY MEMORIAL HOSPITAL 26.1 As a result of the investigation the See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 Trusts guidelines on External Communications and Media Handling are to be reviewed and a Policy will be developed which will clearly identify the steps to be taken when dealing with celebrities or any other visiting individual. This will be undertaken by the Head of Communications and completed by October 2014. 27 WYTHENSHAWE HOSPITAL 27.1 That all policies identified as having Document Review Group and process passed their formal review date in place should be reviewed and ratified. 27.2 A specific, stand-alone policy for See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 Volunteers and Visitors to the Trust should be developed to consolidate current processes, protocols and guidance

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28 WOODHOUSE EAVES CHILDREN’S CONVALESCENT HOME 28.1 Put in place a policy for See 1.12 See 1.12 See 1.12 See 1.12 See 1.12 VIP/Celebrity visits to Trust premises, to include unannounced visits. This policy should be properly publicised to Trust staff and embedded in every day practice 28.2 Update the existing Safeguarding See 1.7 See 1.7 See 1.7 See 1.7 See 1.7 Adults and Children’s training to ensure that staff are aware of the new policy in relation to VIP and Celebrity visits 28.3 Put in place a separate Recruitment Policy in place and Retention Policy 28.4 Put in place a supervision policy as Develop a supervision policy for volunteers. Volunteers 30/04/2015 Section part of the volunteers pack Coordinator – regarding Amanda Hood Slippage to supervision of 30th June volunteers 2015 included within new policy. 29 STOKEMANDEVILLE HOSPITAL 29.1 The Trust should: See 1.24 See 1.24 and ensure the Volunteers Policy Volunteers 30/04/2015 Achieved includes all of the aspects described. Coordinator – Ensure that the register of all Amanda Hood Slippage to voluntary services within the Trust is th 30 June complete, accurate and able to 2015 confirm: how many volunteers are deployed across the organisation and in what capacity; how many volunteers are currently

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subject to a DBS check; the current risks in relation to unsupervised contact between volunteers (in all occupations) and children and vulnerable adults; whether there are voluntary service roles that are currently not put forward for a DBS check but should be in the future; the supervisory arrangements that currently exist for volunteer roles; whether any additional supervisory arrangements need to be in place for volunteers who may have unsupervised access to patients and the general public and who do not meet the DBS criteria.

The Trust should then agree the frequency of ongoing audit checking of this volunteer services register. 29.2 The Trust should: See 1.12 and 1.13 by the time of publication, have amended and made available its current volunteer and visiting policy to include procedures to take into account all celebrities and VIPs (including politicians) who may visit the organisation. It should become a tenet of basic Trust policy that every individual, regardless of their status, will be treated in the same rigorous manner as all other visitors to the Trust; set out clear celebrity and fundraiser

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guidance regarding access, conduct and supervision which will be given to each visitor; ensure that a senior officer of the Trust will be nominated as being both responsible and accountable for each celebrity or fundraising visitor; audit this policy six months after the publication of this report, to review the application of the new procedures for effectiveness and safety.

The Trust should establish the ongoing frequency of future audits of the effectiveness and consistent application of the volunteer and visiting policy. 29.3 The Trust should: Audit programme in place Develop robust audit programme to cover all Adult and 30th May aspects of safeguarding practice. Child 2015 Ensure that an audit is conducted Safeguarding which: Lead Nurse Slippage to st tests the consistency of application and Doctor 31 July of current safeguarding policies and 2015 procedures regarding children and vulnerable adults in all accident and emergency contexts; confirms and provides disaggregated accident and emergency safeguarding data; confirms and provides training and supervision records for accident and emergency staff; confirms and provides detailed

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information about all safeguarding concerns raised regarding both children and vulnerable adults over the past 18 months; confirms that adequate information exists to track each individual case to ensure that all correct processes were followed (for example, reporting to the Local Authority Designated Officer); • confirms and provides detailed information about staffing levels; • confirms and provides detailed information about the safeguarding complaints raised by patients and the subsequent actions taken to ensure resolution and ongoing service improvement. The ongoing frequency of the accident and emergency services audit will be agreed by the Trust in conjunction with its commissioners. 29.4 The Trust should: Patient Experience and Engagement Deliver Patient Experience and Engagement Head of 31/03/2016 Strategy developed. Strategy. Patient Conduct a series of events in order Experience to understand in detail any barriers Raising Concerns Policy refreshed and and that may prevent either patients or programme of awareness raising Engagement staff reporting complaints, concerns underway. and incidents. This will be achieved Deliver ‘Speaking Up’ strategy. Director of 30/04/2015 by: Workforce conducting both a staff and patient and Corporate survey to establish levels of Affairs confidence in reporting systems and to provide feedback regarding the Trust culture (both barriers to

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openness and positive factors); holding regular focus events within local patient advocacy groups; holding regular focus events with chaplaincy and occupational health (as these are the mechanisms through which staff concerns are often routed when whistleblowing processes fail); holding regular focus events with staff, to include junior doctors particularly at the end of their training.

29.5 The Trust should: Conduct review and audit of complaints Amanda Hood 31/03/2016 processes. – Head of Conduct an audit of its current Patient complaints processes to ensure that: Experience current Trust policies and and procedures have been amended to Engagement take into account the expectations and recommendations set out in the above review; • Trust induction and staff training events are reviewed to take into account the expectations and recommendations set out in the review; • patient and visitor information is amended to take into account the expectations and recommendations set out in the review; • all relevant policy documents and training materials provide explicit detail regarding how to support and protect vulnerable adults when

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making complaints about NHS services; • opportunities to learn and subsequent action taken are clearly visible to all in the Trust and extensively presented to encourage an improving culture of openness.

29.6 During the course of the Approach to be discussed at Quality Contract Associate 30/04/2015 To discuss at Investigation, work has been meeting. Director of Quality undertaken to ensure the safety and Governance – Slippage to meeting in support of the victims of Savile’s Anna Hills 30th May May sexual abuse. Buckinghamshire 2015 Healthcare NHS Trust, the Local Authority, Buckinghamshire Clinical Commissioning Group and Oxford Health NHS Foundation Trust should review local circumstances to ensure that support can be offered to other victims of sexual abuse in the future. 29.7 The Trust should: Corporate records storage and archiving Trust 30th systems and processes to be reviewed and Secretary September Conduct a review of its current updated as required. 2015 document archiving and destruction processes to ensure that:  no Trust documents are stored in ‘unofficial’ locations such as loft spaces;  consideration is taken as to whether some documents should be scanned and stored electronically when hard copies are destroyed (such as clinical records, outdated policies and procedures etc.);

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 a formal catalogue is created detailing exactly where documentation is stored.

29.8 The Trust should: Stakeholder events to be held to present findings from these reports and the actions  arrange a focus event with key being taken by the Trust. This could local stakeholders (for example, commence with Leadership Brief and then be staff groups, patient groups and cascaded. commissioning bodies) to ensure there is a wide understanding of Speaking out events led by Executive team to Executive 30th May the findings in the report, the include specific reference to Savile report Team 2015 recommendations and the findings. actions that the Trust is undertaking; Patient focus groups commencing in May Head of 30th May  ensure that, in conjunction with 2015 will also include discussions around Patient 2015 stakeholders, enduring and fit- Savile report findings. Experience for-purpose systems are put into and place to guarantee that the Engagement lessons for learning from this report are understood and lead to service improvement. To include issues around Savile report in Safeguarding 30th May Safeguarding Adults and Children Mandatory Leads 2015 training around Lessons for Learning from Stoke Mandeville 29.9 During the course of the Complaints Policy is clear that patient’s Investigation, several victims and raising concerns will not affect their their families stated that they did care or treatment either now or in the not complain about the sexual abuse future. experienced during encounters with Savile because they were afraid that the care and treatment provided to them, or to their loved ones, would be compromised.

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29.10 It is tempting to sometimes regard legislation, policy and procedure as ‘red tape’ or bureaucracy. It was evident that the people who gave Savile his access, permissions and privileges thought they were being innovative and courageous by doing things differently. It is a significant lesson for learning that a person like Savile was able to exploit his position of trust so entirely because he had been placed outside of the regulatory processes designed to prevent such abuses of power. This is a lesson which still has resonance for present-day public services.

29.11 Where informal cultures exist in Complaints and incidents are copied to conjunction with invisible and senior divisional management. confused leadership delineations, Themes are discussed and responded circumstances are created in which to via Divisional Governance meeting complaints, incidents and and reported through the Trust’s safeguarding breaches remain governance processes up to the Board undetected by the organisation at meeting in public. large and go unmanaged. This made a significant contribution to Savile’s Strategic Risk Group, an entirely sexual abuse behaviours going executive group, is in place to undetected over time. Clear rigorously review investigations and leadership structures which are ensure actions from recommendations embedded into complaints, are taken. incidents and safeguarding procedures are essential if patient safety is to be maintained and managed effectively.

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29.12 Those who did report the abuse Raising Concerns Policy is clear that staff can Safeguarding 31st July contemporaneously were either raise concerns without fear of ridicule or Leads 2015 ‘told off,’ ‘warned off’ or ignored. retribution. Ensure Safeguarding policies are Many of those who did not report reviewed. the abuse at the time chose not to because they thought they would not be believed.

29.13 Guidance needs to be put into place See previous actions and to ensure that the same abuses of recommendations power as are identified with Savile could not happen again. The lessons learned from the Investigation are clear: celebrity fundraisers and VIP ‘good cause’ champions should be subject to regulation and clear lines of accountability.

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