Agenda item

The Chair of Healthwatch City of London to be heard.

Members received a presentation from the Chair of Healthwatch, noting that it was from their perspective, not the NHS.   The Chair addressed the Committee, setting out her career background in holding health organisations to account and ensuring the patient safety.  The presentation sought to assist the Committee in making proportionate representations on the following matters: 

Local and Strategic Management

Patient Safety Incident Response Framework (PSIRF) – Implementation August 2023

Categorising Incidents

Near Events

Serious Incidents and Investigations

Clinical and Non-clinical incidents

Thematic Causes of Failure

What should we be encouraging and what should we be looking for

During the discussion and questions, the following points were noted:

If there is an operational culture; ie in skipping a step in procedures, then this could translate into a wider Policy failure.  Leadership would then be monitored by the ICS and possibly the Board.  In more severe cases, CQC or NHS England might produce a report.

There is a concern in that imposing fines might discourage transparency but the organisation would still come under considerable scrutiny and its leadership challenged.  A serious incident is often multi-faceted and would be brought to the attention of the Secretary of State.   A lot of litigation claims are settled by the NHS, due to their transparency.

A Member shared anecdotes of incidents whereby patients had not been fed regularly, or there had been considerably delays in administering intravenous lines.  The Chair of Healthwatch advised that the greatest reporter of incidents are nursing staff.  Healthwatch recently undertook a spot check, including those areas which had little or no reports of such incidents.

Early discharge is likely to be a worthwhile area to consider in terms of virtual wards, as suggested under the workplan item above.

A report would be made to the Health and Safety Executive, and possibly to RIDDOR, if there is an equipment failure resulting in injury or death.   An instrument left in after surgery would be categorised as a  ‘never event’ and reportable to the Secretary of State. ‘Near misses’ often involve medications.

The  Chair of Healthwatch receives ambulance statistics daily and the City performs well in this area.  However, this Committee should still challenge and seek improvements, where possible.

The officers agreed to arrange for the ICB’s Quality and Safety Team to present to a future meeting in respect of reporting ‘never events’. Although Primary Care is not obligatory in this report, the Committee can still ask the ICB about how they seek assurance.