internal inquiry into the standards of care
TRANSCRIPT
1
Internal Inquiry into the standards of care
on Rowan Ward,
Withington Hospital,
Final report 5th February 2004
2
Contents Section A Background .......................................................................................................... 3 Section B Evidence considered ............................................................................................ 4 Section C Terms of Reference (August 2002) ....................................................................... 5 Section D Description of the ward environment and function................................................. 6
The building....................................................................................................................... 6 Section E Description of the Trust’s governance system ....................................................... 7
Organisational Arrangements: accountability for clinical and service governance................ 7 Professional accountability................................................................................................. 7 Risk management structure at the time of the allegations ................................................... 7
Section F Timetable of events concerning allegations............................................................ 9 Section G Nature of concerns raised ................................................................................... 11
Allegations of physical and / or emotional abuse .............................................................. 11 Standard of care plans..................................................................................................... 11 Lack of clarity about consent and related issues............................................................... 11 Poor standards of recording and investigating adverse incidents ...................................... 11 Allegations of bullying, intimidation and harassment......................................................... 11
Section H Response to questions in the Terms of Reference............................................... 12 Section I Action plan: high level themes............................................................................... 17 Section J Root cause analysis: ............................................................................................ 20
Rowan causal analysis..................................................................................................... 20
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Section A Background • Concerns about possible physical and emotional mistreatment of patients were raised in
August 2002. An internal inquiry was established in accordance with the 1994 Regional Guidance on mental health inquiries. The terms of reference were agreed with the Joint Commissioning Executive. This report presents the findings of the internal inquiry.
• The Strategic Health Authority asked the Commission for Health Improvement to carry
out an external investigation and the report was published in September 2003. • A police investigation into possible criminal acts was completed and the Crown
Prosecution Service (CPS) reviewed the files. The decision of the CPS was that criminal prosecutions would not be taken forward as there was insufficient evidence at the level of criminal proof (beyond reasonable doubt) to pursue criminal proceedings against any individuals.
• An internal disciplinary investigation was started in August 2002 but completion was
delayed until the Crown Prosecution Service decision was known. Two staff had cases presented before an executive director found that there was no case to answer against these individuals on the allegations considered. The investigating officer took a similar decision about a third member of staff on the grounds that the evidence against that person was similar to the two that had already been heard. Two members of staff had already been re-instated early in the proceedings when it became clear that there was no specific case.
• Two members of staff have left the employment of this trust and have not accepted the
offer of having cases heard against them. For those members of staff there can be no overall conclusion.
• In this report allegations are considered from the perspective of the patient. Here the
evidence about what may have happened is presented without any link to specific staff members and no conclusion should be drawn about culpability from this analysis.
• However, the analysis by patient does suggest that untoward incidents occurred and that
some may have been deliberately inflicted. • To reconcile these two apparently opposing views it should be understood that staff
members could only be implicated if there is evidence, on the balance of probabilities, relevant to specific events involving them.
• From the perspective of the patient, the burden of proof is based on what is the most
likely explanation of what happened to that individual without reference to who may have caused any particular injury.
• The internal investigation followed the national and local multi-agency “No Secrets”
policy on preventing abuse of vulnerable adults.1
1 This report should be read in conjunction with the CHI investigation report (September 2003), the trust’s CHI action plan and the interim internal inquiry report 2002.
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Section B Evidence considered The internal inquiry considered the following evidence: -
• The allegations made by staff and carers/relatives • The findings of the disciplinary investigation and the case presented
• The medical notes, care plans and nursing notes of current patients and those
relating to any other patients in respect of allegations
• Transcripts and summaries of the interviews with staff, patients and carers relatives
• Review of standards of nursing care by external nurses
• Internal review of standards of nursing care across the wards in the Older Age Service Directorate
• Review of governance procedures and reporting arrangements
• Review of educational and developmental needs of staff carried out by the lead nurse
for older age services
• There has been verbal feedback from the police investigating officer, but the trust has no access to the police files
• Files sent to CHI
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Section C Terms of Reference (August 2002) The trust and Joint Commissioning Executive agreed the terms of reference. 1) To report on the standards of care on Rowan ward:-
a) To comment on standards of nursing, medical and social care b) To comment on the environment more generally, including morale and the culture of
the multi-professional ward team with particular reference to the “culture of inquiry” about adverse events
c) To report on the experiences of patients and their carers d) To summarise the evidence of injuries to patients, emphasising the nature of injuries
or harm which on the balance of probabilities were inflicted deliberately, and injuries or harm which occurred as a result of neglect
e) To summarise the evidence of emotional harm or abuse to patients f) To summarise the pattern of interaction between patients, carers, staff and others
during this period, drawing attention to any evidence of bullying, intimidation, harassment or similar behaviour
g) To summarise the evidence regarding the ability of staff to respond to early warning signs of failures of care, to complaints and to investigate and report on adverse incidents.
2) To identify the timescale and scope of failures of care.
3) To examine the effect of environmental changes including the closure of other parts of the
mental health service at Withington Hospital 4) To examine the mechanisms used for clinical supervision, staff appraisal, and education
and training, including opportunities for continuing professional development. This will apply specifically but not exclusively to nursing and medical staff.
5) To consider whether governance, research and audit procedures were used and applied
appropriately on Rowan ward. 6) To identify any failures of management during this period that may have contributed to
deficiencies of care, or delayed detection of adverse events. 7) To link with South Manchester University Hospitals Trust and ensure their appropriate
involvement in respect of any events prior to October 2000. 8) To make recommendations on what can be learned from this series of events to improve
practice locally and beyond 9) To make recommendations to improve the likelihood of detection of failures of care, and
to improve the clinical and social care governance of the ward specifically and the Trust more generally
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Section D Description of the ward environment and function Rowan ward was part of the Healey House unit on the Withington Hospital site. Since the transfer of most clinical services to Wythenshawe Hospital in 2001, Rowan Ward had been the only remaining psychiatric in-patient unit on the Withington site (co-managed with the Brian Hore Unit, a day treatment facility for alcohol dependence), and Rowan Day Hospital, also based in Healey House. A commissioning decision was made in 1999 to re-provide the unit through Anchor Housing in a new-build facility called Monet Lodge. This unit is now open and the residents of Rowan ward were transferred there in July 2003 following a period of interim care on Cavendish ward, Laureate House, Wythenshawe Hospital. The ward had been due to close with transfer of responsibility to Anchor Housing at the time of the transfer of other services, but the Anchor housing facility was delayed. The ward is linked to a day unit that was subsequently re-provided in a separate building within the Local Authority facilities at the Minehead Centre in South Manchester. The in-patient ward dealt exclusively with patients who are highly vulnerable. Most had organic illnesses (such as Alzheimer’s, vascular and Lewy Body dementia) with varying degrees of behaviours which are difficult to manage. There was also some patients with functional disorders, mainly functional psychoses such as schizophrenia, schizoaffective disorders and bipolar disorder. There had been considerable debate about the difficulties of managing a mixed group of patients. Prior to this inquiry the Director of Older Age Services had had concerns about maintaining appropriate standards of care. The staff team needed a development programme to bring the level of skills up to best modern practice in mental health nursing for older people, particularly dementia care and the management of ‘challenging behaviour’. The building Withington was a large and complex acute hospital site until the transfer of the main hospital (including most psychiatric facilities) in 2001. The remaining site is being converted in part into a community hospital and the rest re-developed commercially. Rowan ward was in Healey House, which is an old two-storey building with large cellars. Healey House and the adjacent administrative buildings date from the time when the hospital functioned as a Poor Law Workhouse. The external environment at the time of the allegations was poor as the front of the building was next to the entrance to the main demolition site. The other entrances faced a near-empty hospital site. The interior of the ward had been redecorated, but was of an old-fashioned design with converted dormitories. The ground floor housed Rowan ward and the day hospital. The upstairs area was used for a few offices, but was otherwise not in use. There were several exits from the ward, three leading to the outside. During this Inquiry a number of incidents involving patients leaving the ward occurred and were reviewed. Various means of ensuring security (types of lock, self-closing doors, changes to observation practice etc.) were implemented. Relatives suggested CCTV observation of the corridor area. There was a plan to install an external system of CCTV covering the main exit points. Relatives were sceptical about the value of this and the ward moved before the decision about internal CCTV was finally resolved. The environment lacked personal property and the impersonal decoration and furnishing was seen as “institutional” in nature. There were new furnishings and fittings in 2000/2001 even though the unit was planned to close. There were separate nursing teams for the day hospital and in-patient ward areas. One lead consultant covered the ward, although all consultants on the South site had been involved
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with the ward at some point. There was a locality manager for older age services who covered the ward and day hospital. Section E Description of the Trust’s governance system Organisational Arrangements: accountability for clinical and service governance During 2001/2002 the Trust was in an earlier form as a Mental Health Partnership existing as an entity within the Health Authority, in partnership with the Local Authority. The overall responsibility for Governance resided with the Chief Executive of the Health Authority who delegated responsibility to the Partnership's Chief Executive. The framework for clinical governance accountability was through the Chief Executive who delegated responsibility to the Board level Medical Director who chaired the Service Governance Committee of MMHSCT. Accountability for the quality and safety of services was with the service directors delegated to individuals who were responsible for different aspects of clinical governance. Professional accountability Each professional group had its own mechanism for ensuring high performance standards. Professional accountability was co-ordinated by a lead member of each professional group who was also a member of the Service Governance Committee. Risk management structure at the time of the allegations • A Controls Assurance sub committee had been established to consider the twenty-one
Controls Assurance Standards and these areas were reported to the Audit Committee of the trust as part of the Assurance Framework.
• A Clinical Risk Management group reported to the Governance committee. • There was a Trust Serious and Untoward Incident Reporting system. Training days for
staff involved in chairing reviews had taken place on two occasions. • There was a standard report form covering
• Who was involved? • What happened? • Where did it happen? • Why did it happen? • What was done? • What could improve care in the future? • Recommendations regarding policies and procedures, educational needs, and
changes to systems • There was a Scrutiny Committee for Serious Untoward Incidents chaired by the Trust
Chair. The committee reported to the Board and looked at the quality of reviews and investigations and the main issues arising from them. At the time of the allegations only two serious untoward incidents from Rowan ward had been reported to this committee.
• Each geographical site (North, Central and South) had local Health and Safety
Committees reporting to a Trust Health and Safety Committee which reported directly to the Trust Board.
• There were three different local accident and incident reporting • At the time of the allegations the Trust did not have an electronic reporting system for all
incidents and there was no risk register. • Reports were collated manually.
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• There was one senior manager for audit across the Trust and a corporate services manager covering complaints and claims
• Education and training had a small infrastructure and there was no trust-wide structure
for appraisal or personal development plans
Multidisciplinary working • There were multi-disciplinary training programmes relevant to care planning, Mental
Health Act, in-patient environment, CMHTs, Caldicott and confidentiality issues • Multidisciplinary working was limited on older age wards by a) the separation of mental
health from social care staff, b) insufficient staff from smaller disciplines to cover all clinical areas and c) reliance on service level agreements for provision of staff of some professions
Medicines Management • A medicines management sub committee reported to the Service Governance
Committee. The group advised on prescribing and more general medicines management issues, and provided guidelines to assist in the implementation of national guidance.
Research and Development A research and development manager for the trust was only appointed recently and was not in post at the time of the allegations, although there were strong existing research programmes run jointly with the university. R&D links with service users and carers were just developing at the time of the allegations. Areas of weakness in governance Several areas of clinical and service governance were in need of development at the time of the allegations. • A unified incident reporting mechanism • systems for quality control - use of standards, guidelines, evidence-based practice,
learning from risk assessment, local audit, and reviews of adverse incidents • modernising and strengthening professional self regulation - by building on the
principles of performance review and continuing professional development, detecting and managing poor performance, with clear lines of accountability
• systems for performance management
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Section F Timetable of events concerning allegations August 2001 Ward manager left. Difficulties with recruitment November 2001 Ward becomes isolated when main hospital moves December 2002 Educational needs of team identified February 2002 Multi-disciplinary group began to plan development programme Problems with recruitment and retention of qualified staff noted Untoward incident investigations of two events Actions agreed to remedy problems identified
Disciplinary investigation into senior staff member April / May 2002 Development programme delayed Senior staff recruitment problems Dementia care educator appointed but unable to begin until August
Senior nurse appointed then decided not to accept post July 2002 Increase in incident reports noted 2nd August 2002 Concerns raised in nurses’ development group
The Director for Older Age Services and lead nurse took initial steps to ensure safety
5th August 2002 Discussion at Executive management team.
First interviews Discussion about ward closure Lead commissioner informed 6th August 2002 Advice from Vulnerable Adults expert Learning Disability Partnership Four staff suspended pending investigation
Police informed Meeting with relatives
7th August 2002 Fifth staff member suspended pending investigation
Review of incidents in July confirmed increased rate of reporting Nature of alleged incidents clarified, further witness interviews Physical examination of all patients
8th August 2002 Further meeting with police and senior staff to agree actions 9th August 2002 Meeting of directors and senior staff to review actions Agreed that Medical Director would co-ordinate internal inquiry
Agreed external inquiry would be needed in addition 10th August 2002 Sixth member of staff suspended pending investigation 12th August 2002 Terms of reference drafted with lead commissioner
Structure agreed: Medical Director to lead inquiry, Director Service Development leading investigation
Autumn 2002 Further interviews with staff members who had worked on the ward
Strategic Health Authority agreed to establish an external inquiry CHI agreed to investigate Actions taken to improve safety on wards Concerns expressed by relatives about continuing risks Police investigation started and internal investigation deferred Concerns about ward closure from relatives
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Agreed to move patients to a wing of Cavendish ward: completed Autumn 2002 contd. Opening date for Monet Lodge further delayed to Summer 2003 Interim internal inquiry completed and action plan agreed Two staff re-instated 2003 April 2003 Decision by CPS not to pursue criminal prosecutions Internal investigation re-opened Further suspension of staff member
June 2003 Patients moved to Monet Lodge without incident September 2003 CHI report released Two disciplinary hearings held: cases not upheld One disciplinary case withdrawn Two disciplinary cases outstanding:
Unable to be heard as staff had left the trust
October 2003 CHI action planning day December 2003 Agreed course of action with relatives’ group February 2004 Internal inquiry report to trust board Overarching action plan and responsibilities agreed February 2004 Detailed action plan to be agreed
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Section G Nature of concerns raised Allegations of physical and / or emotional abuse
a) assaults on patients by staff (such as slapping, hitting with a hairbrush, stamping on feet, flicking ears, squeezing lips and kicking).
b) taunting and “winding up” patients or mocking c) poor standards of care d) possible deliberate withholding of food as “punishment”. e) a member of staff ignoring care plans and possibly contributing to two significant
falls and f) care of patients which did not take proper account of the need for privacy and
dignity g) an unexplained scald injury h) unexplained bruising on several occasions including one patient with unexplained
extensive bruising to the lower body
Standard of care plans a. standard of general care planning b. failure to involve carers and relatives adequately c. failure to disseminate clear instructions d. failure to follow agreed care plans
Lack of clarity about consent and related issues
a. use of “concealed” medication b. consent for taking samples c. involvement of relatives in decisions about resuscitation
Poor standards of recording and investigating adverse incidents
a. trust wide problems in unifying reports of accidents and serious and untoward incidents
b. poor awareness of reporting procedures c. inconsistency of reporting and failure to report significant incidents centrally d. incomplete investigations with inadequate follow-through of recommendations
Allegations of bullying, intimidation and harassment
a. unqualified staff alleged that senior staff treated them with disrespect or humiliated them
b. senior staff alleged that unqualified staff threatened to make allegations of bullying when they were asked to work to reasonable standards
c. staff were thought to work in “cliques”
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Section H Response to questions in the Terms of Reference 1. To report on the standards of care on Rowan ward:
a) To comment on standards of nursing, medical and social care General standards of care • The standards of nursing care can be summarised generally as outdated and lacking
in emphasis on personal-focused care. • However, standards of hygiene, cleanliness, hydration and nutrition were generally
of a reasonable standard.2 • Some of the areas thought to requiring further development work were already being
addressed in the development programme, but the programme had been delayed. Privacy and dignity • There were aspects of nursing care that did not meet adequate standards of privacy
and dignity. Adequacy of feeding • Food was withheld from patients as a form of punishment by restricting access to
“favourite foods”. • Some patients gained weight when they moved to Cavendish ward. • Poor advice was given to unqualified staff about withholding food and fluids when
patients had diarrhoea • A separate police investigation was held into the death of one patient who had poor
hydration and had lost weight during a serious, terminal illness. Their external medical report found no cause to suspect poor practice.
Care planning • Care plans were in place for most patients • Relatives were not encouraged or given sufficient opportunity to be genuinely
involved in care planning • There was poor communication of care plans to staff • Multi-disciplinary care planning needs to be improved, but was implemented within
staffing constraints Medical care • The overall standard of medical decisions and standard of prescribing was within
good practice guidelines • Medical reporting of injuries was fragmented and early detection of patterns of injury
would have been impossible given the reporting system in place at the time • Medical staff highlighted the potential problems of isolation and recruitment
difficulties • Medical staff were aware of the potential for “elder abuse”, and were aware of
previous inquiries into failures of care in the elderly, but were not part of a “whole system” approach which could have used this information more pro-actively
Social care • The involvement of social care staff on the ward was intermittent and they were not
usually part of a multi-disciplinary approach • The separation of health and social care for older people across the whole trust may
have had an adverse impact at ward level Summary: Whilst aspects of good care were recognised by CHI and in the internal inquiry, the overall standard of care was below an acceptable standard. b) To comment on the environment more generally, including morale and the
culture of the multi-professional ward team with particular reference to the “culture of inquiry” about adverse events
Morale • Morale was generally poor and recruitment and retention were known to be
problematic before any allegations were made. 2 External report on nursing standards
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Atmosphere of intimidation • There was an atmosphere of intimidation and even fear among staff. • Staff did not feel confident that their concerns would be dealt with effectively by
senior managers • Senior managers felt intimidated when trying to introduce new procedures • There is evidence that small groups of staff worked together and actively excluded
other staff Lack of a “culture of inquiry” • There was a belief that problems coming to light should be resolved locally • Central reporting was seen as a failure and to be used only in extreme situations • There was a culture of passivity with staff feeling that everything had to be checked
by their line manager. • This delayed or even prevented significant incidents being reported on several
occasions • There was also a lack of actions on concerns raised by relatives. • Reviews of the ward function focused on external constraints and there was a lack of
“self-scrutiny” • There was a poorly developed culture of learning from adverse incidents • There was an illusion that the ward was functioning at a level of “excellence” by
some senior staff and this led to a false presumption that abuse was not happening on the ward
• This belief was re-inforced from some outside sources who commented positively about the standard of care and only identified problems with the physical environment
c) To report on the experiences of patients and their carers Lack of a personal environment • Few personal possessions were in place • Ward furnishings and decorations were impersonal despite attempts by staff to
improve the atmosphere Institutionalised patterns of care delivery • The patients were woken in the morning to fit the schedule of staff • Staff left patients with soiled or wet clothes until the next routine of changing was
due • Food preferences were often disregarded • The nursing system was based around tasks rather than patient-focused teams • Tasks were carried out in regimented ways (for example all patients being weighed
or bathed at a particular time) • Care was insufficiently based on individual care plans
Attitudes to relatives and carers • Some relatives felt that they were criticised for raising concerns • Other relatives felt they were treated in a patronising way or that their concerns were
ignored • Relatives felt that there was an expectation that they should be “grateful” for the care
offered • Relatives were told that Rowan ward was “not a bed for life” which led to them
feeling that care could be withdrawn wholly at the discretion of the staff • The confusion between the various incident reporting systems and the complaints
procedure caused distress for relatives • This confusion worsened the underlying difficulty in detecting patterns suggestive of
abuse • Relatives felt that they were treated as being unreasonably demanding when these
concerns were raised at all levels of management in the trust
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d) To summarise the evidence of injuries to patients, emphasising the nature of injuries or harm which on the balance of probabilities were inflicted deliberately, and injuries or harm which occurred as a result of neglect a) Actual assaults on patients by staff (such as slapping, hitting with a hairbrush,
stamping on feet, flicking ears, squeezing lips and kicking). b) Taunting and “winding up” patients or mocking c) Poor standards of physical care d) Deliberate withholding of food as “punishment”. e) Ignoring care plans f) Care of patients which did not take proper account of the need for privacy and
dignity g) An unexplained scald injury h) Unexplained bruising on several occasions including one patient with unexplained
extensive bruising to the lower body • The trust accepts, on the balance of probabilities, that examples of the above
occurred on at least some occasions • The scald injury and examples of injuries related to failure to follow care plans were
the result of neglect or poor standards of care • The breaches of privacy and dignity are well-documented and relate to low
expectations of the standard of personal care required e) To summarise the evidence of emotional harm or abuse to patients
a) Patients being “teased” or taunted to the point that they would retaliate. b) Taunting was often based on personal attributes or personal events in the
individual’s life.
• As with the allegations of physical harm, the trust accepts, on the balance of probabilities, that examples of the above occurred on at least some occasions
f) To summarise the pattern of interaction between patients, carers, staff and
others during this period, drawing attention to any evidence of bullying, intimidation, harassment or similar behaviour a. Care was not adequately person-focused. b. Intimidation of both senior staff and unqualified staff were reported c. Some relatives reported that they were not treated with respect and that their
concerns were not taken seriously d. The general pattern of care was institutional and insufficiently patient-centred
• The trust accepts that there were occasions when staff and carer concerns were not dealt with adequately
• The overall atmosphere was confrontational and some staff felt intimidated and unable to voice concerns
• Some of these problems were identified by managers but were not addressed effectively
• On some occasions patients were treated in an inhumane way g) To summarise the evidence regarding the ability of staff to respond to early
warning signs of failures of care, to complaints and to investigate and report on adverse incidents.
• The incident reporting system in the trust was insufficiently sensitive to detect patterns of poor care
• Staff were insufficiently aware of the reporting mechanisms of the trust • Investigations of incidents were not focused on improvements in care or prevention
of recurrence • Complaint responses were sometimes inconsistent with what relatives had been told
by ward staff 2. To identify the timescale and scope of failures of care.
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• This inquiry has confirmed a pattern of inconsistent and incomplete reporting dating back to considerably before the establishment of the Partnership and continuing through 2000 to 2002
• There was poor local reporting, compounded by failures of the management system at all levels as stated in the CHI report
• Problems with leadership, recruitment and retention of staff worsened during 2001 • Two serious untoward incidents were investigated in early 2002 • A significant scald occurred in February with no explanation to account for the injury • Other injuries were reported during early 2002 but the poor quality of incident reporting
makes it difficult to know when the pattern altered • Patients left the ward on occasions without their absence being noted, and this put
patients at significant risk of serious injury • During July of 2002 an excess of incident reports was noted on Rowan ward, but no
explanation was given for this • It is still not possible to put an exact timescale to these events
3. To examine the effect of environmental changes including the closure of other
parts of the mental health service at Withington Hospital • Delays in opening Monet Lodge compounded the isolation of the unit, • Retention problems worsened when staff were unclear whether they might have an
option of redeployment to Anchor Housing. • The physical isolation of the unit was a significant contributory factor 4. To examine the mechanisms used for clinical supervision, staff appraisal, and
education and training, including opportunities for continuing professional development.
• There are written records of some supervision having taken place • The mechanisms for staff development; appraisal, personal development plans and
continuing professional development were not well developed on Rowan ward • A large proportion of long-term and short-term agency staff compounded this. • Staff development on Rowan ward and particularly its night staff was inadequate • Staff development, education opportunities, appraisal and continuing professional
development were all under-developed in the trust during the period prior to the allegations
5. To consider whether governance, research and audit procedures were used and
applied appropriately on Rowan ward. • There were weaknesses in all of these areas in the trust generally and on Rowan ward
specifically. 6. To identify any failures of management during this period that may have
contributed to deficiencies of care, or delayed detection of adverse events. • These points were covered in detail by the CHI investigation, which reported failures at
all levels of management, including failures falling outside the trust. • The CHI report makes frequent mention of inadequate infrastructure. • A contribution may have come from the separation into two distinct Directorates, each of
which developed different cultures. • The clinical governance culture impacted less on older age services than on adult
services. 7. To link with South Manchester University Hospitals Trust and ensure their
appropriate involvement in respect of any events prior to October 2000. • The trust obtained the limited information available on incidents prior to 2000 and this
information was incorporated into the inquiry and given to CHI. 8. To make recommendations on what can be learned from this series of events to
improve practice locally and beyond • This is dealt with fully in the CHI action plan
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9. To make recommendations to improve the likelihood of detection of failures of care, and to improve the clinical and social care governance of the ward specifically and the Trust more generally The trust should
• introduce a unified reporting system for all adverse events • provide an electronic reporting system • strengthen risk management awareness and training • strengthen care planning • strengthen appraisal and personal development plans • enhance education opportunities within the trust • integrate research, audit and clinical guidelines into improved effectiveness • clarify accountability for clinical and service governance • strengthen clinical and professional leadership • improve advice on consent and resuscitation decisions • strengthen the culture of inquiry • deal effectively with the culture of intimidation
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(Bur
t Bur
ton)
Ju
ne 2
004
Dev
elop
and
intro
duce
inci
dent
repo
rting
, inv
estig
atio
n an
d re
med
y sy
stem
s M
edic
al D
irect
or (H
elen
Hob
day)
Ju
ne 2
004
Inte
grat
e re
ports
and
lear
ning
from
adv
erse
inci
dent
s, c
ompl
aint
s, c
laim
s vi
a pe
rform
ance
man
agem
ent a
rrang
emen
ts
Med
ical
Dire
ctor
(Pau
line
John
) Ju
ne 2
004.
3, 4
, 5, &
6
18
Qua
lity
of W
orkf
orce
Dev
elop
an
educ
atio
n an
d de
velo
pmen
t pro
gram
me
acro
ss th
e Tr
ust t
o en
able
in
divi
dual
s an
d te
ams
to m
eet t
he o
bjec
tives
of t
he o
rgan
isat
ion
Asso
ciat
e D
irect
or o
f HR
(Rob
ert
Stea
d)
June
200
4
D
evel
op th
e H
R fu
nctio
n in
the
Trus
t to
supp
ort m
anag
ers
in th
e de
liver
y of
the
Trus
t’s o
bjec
tives
As
soci
ate
Dire
ctor
of H
R
April
200
4
D
evel
op a
pro
gram
me
to s
treng
then
clin
ical
lead
ersh
ip in
the
Trus
t, fo
cuss
ed to
the
deliv
ery
of th
e ob
ject
ives
. C
hief
Exe
cutiv
e
June
200
4
In
crea
se th
e m
anag
eria
l cap
acity
in th
e Tr
ust t
hrou
gh d
evel
opm
ent a
nd re
crui
tmen
t C
hief
Exe
cutiv
e (S
ue H
amilt
on)
April
200
4
4 &
6
Qua
lity
of M
anag
emen
t
Rev
ise
man
agem
ent a
rrang
emen
ts a
nd re
view
por
tfolio
s N
ew E
xecu
tive
Dire
ctor
stru
ctur
e de
vise
d / i
n pl
ace
New
ope
ratio
nal a
rrang
emen
ts d
evis
ed /
in p
lace
N
ew a
rrang
emen
ts to
eng
age
clin
icia
ns a
nd m
anag
ers
in d
ecis
ion
proc
ess
Chi
ef E
xecu
tive
Chi
ef E
xecu
tive
Dire
ctor
of O
pera
tions
C
hief
Exe
cutiv
e
April
200
4 Ja
n 20
04/ A
pril
2004
. Ap
ril 2
004.
/ Ju
ne 2
004
Jan
2004
. St
reng
then
ser
vice
gov
erna
nce
arra
ngem
ents
D
evis
e an
d im
plem
ent e
duca
tion
prog
ram
me
to s
uppo
rt go
vern
ance
age
nda
Dev
ise
syst
ems
to e
nabl
e ce
ntra
l gov
erna
nce
arra
ngem
ents
to s
uppo
rt fu
nctio
nal
team
s w
ith s
ervi
ce im
prov
emen
ts.
Info
rmat
ion
Rep
orts
/ An
alys
is
Polic
y an
d pr
oced
ure
deve
lopm
ent
Med
ical
Dire
ctor
(Rob
ert S
tead
) M
edic
al D
irect
or (P
aulin
e Jo
hn
Deb
orah
Leo
nard
)
June
200
4 Ap
ril 2
004.
Impl
emen
t rob
ust p
erfo
rman
ce m
anag
emen
t fra
mew
ork
whi
ch s
uppo
rts th
e de
liver
y of
ser
vice
s an
d im
prov
emen
ts to
ser
vice
pro
visi
on.
Assi
stan
t Chi
ef E
xecu
tive
April
200
4.
D
evel
op a
com
mis
sion
ing
plan
to c
larif
y re
spon
sibi
litie
s
Hea
d of
Com
mis
sion
ing
Jan
2004
5, 6
& 7
19
Qua
lity
of C
omm
unic
atio
n
Dev
elop
and
agr
ee a
com
mun
icat
ion
stra
tegy
to a
ddre
ss in
tern
al a
nd e
xter
nal
com
mun
icat
ion
need
s to
: pr
ovid
e re
leva
nt in
form
atio
n to
a v
arie
ty o
f aud
ienc
es
enab
le th
e re
ceip
t of i
nfor
mat
ion
from
a v
arie
ty o
f sou
rces
as
sist
in th
e im
prov
emen
t of r
elat
ions
hips
with
com
mis
sion
ers
and
othe
r st
akeh
olde
rs
enge
nder
pub
lic c
onfid
ence
in th
e se
rvic
es p
rovi
ded
by th
e Tr
ust a
nd th
e N
HS
help
to c
reat
e an
atm
osph
ere
in th
e Tr
ust w
hich
dem
onst
rate
s op
enne
ss to
in
spec
tion
and
conf
iden
ce in
the
qual
ity o
f the
ser
vice
s pr
ovid
ed.
Asso
ciat
e D
irect
or o
f HR
(C
omm
unic
atio
ns M
anag
er)
May
200
4.
Dev
ise
and
intro
duce
an
effe
ctiv
e tw
o w
ay c
omm
unic
atio
n sy
stem
As
soci
ate
Dire
ctor
of H
R
(Com
mun
icat
ions
Man
ager
) M
ay 2
004
Dev
ise
repo
rting
sys
tem
s w
hich
ens
ure
that
all
issu
es w
ithin
the
Trus
t are
rais
ed in
a
timel
y fa
shio
n to
the
appr
opria
te le
vel.
M
edic
al D
irect
or (H
elen
Hob
day)
Ap
ril 2
004
4, 6
& 7
20
Sect
ion
J R
oot c
ause
ana
lysi
s:
• Th
e C
HI i
nves
tigat
ion
sum
mar
ises
man
y of
the
pred
ispo
sing
fact
ors
that
led
to th
e fa
ilure
s of
car
e.
• In
this
sec
tion
the
fact
ors
are
cons
ider
ed th
ough
a ro
ot c
ause
ana
lysi
s.
• R
oot c
ause
ana
lysi
s is
a w
ay o
f lin
king
all
of th
e co
ntrib
utor
y ca
uses
lead
ing
to a
n ad
vers
e in
cide
nt, i
n a
way
whi
ch m
akes
the
chai
n of
cau
satio
n cl
eare
r an
d al
so in
tegr
ates
diff
eren
t typ
es o
f cau
se in
to a
mea
ning
ful w
hole
. •
Des
crip
tivel
y, w
e ne
ed to
con
side
r var
ious
cla
sses
of c
ausa
l fac
tor i
nclu
ding
div
erse
issu
es s
uch
as is
olat
ion
on th
e w
ard,
sta
ff m
oral
e, th
e w
ard
cultu
re,
safe
ty a
nd re
porti
ng p
roce
dure
s, th
e m
ix o
f pat
ient
s o
n th
e w
ard,
acc
ess
to e
duca
tion,
recr
uitm
ent a
nd re
tent
ion,
and
the
lack
of a
def
initi
ve p
lan
for t
he
war
d, m
anag
emen
t cap
acity
and
com
pete
nce,
pro
fess
iona
l rel
atio
nshi
ps, a
nd w
ider
issu
es fa
cing
the
trust
whi
ch m
ay h
ave
dist
ract
ed s
enio
r man
ager
s’
atte
ntio
n.
• It
is im
porta
nt to
not
e th
at th
ese
fact
ors
(man
y of
whi
ch a
re w
ell k
now
n fro
m p
revi
ous
inqu
iries
), pr
ovid
e th
e pr
edis
posi
ng c
ondi
tions
und
er w
hich
an
inci
dent
mig
ht o
ccur
. •
They
do
not e
xpla
in w
hy a
ny s
peci
fic in
cide
nt o
ccur
red,
and
they
do
not t
ake
away
the
resp
onsi
bilit
y of
any
indi
vidu
al fo
r hi
s or
her
ow
n ac
tions
or
to
thei
r pro
fess
iona
l cod
e of
con
duct
. Ro
wan
cau
sal a
naly
sis
The
diag
ram
sum
mar
ises
the
mai
n fa
ctor
s w
hich
are
thou
ght t
o ha
ve c
ontri
bute
d to
the
even
ts o
n R
owan
war
d. T
he d
iagr
am is
com
plex
as
ther
e ar
e so
man
y in
tera
ctin
g fa
ctor
s. S
ome
of th
e m
ain
links
are
sho
wn
by a
rrow
s be
twee
n th
e bo
xes,
and
the
boxe
s th
emw
elve
s su
mm
aris
e so
me
of th
e m
ain
them
es b
roug
ht
in th
is a
nd th
e C
HI r
epor
t. To
the
right
of t
he d
iagr
am th
e va
rious
issu
es h
ave
acte
d to
geth
er to
pro
duce
a c
ultu
re in
whi
ch a
buse
took
pla
ce.
This
dia
gram
is in
tend
ed to
hel
p st
aff i
n th
is tr
ust a
nd e
lsew
here
to d
etec
t the
ear
ly s
igns
and
then
to a
ct to
pre
vent
abu
se o
ccur
ring.
21
Inci
dent
s of
ab
use
Cul
ture
of i
nstit
utio
nal c
are
Cul
ture
of b
ully
ing
and
intim
idat
ion
Unc
erta
inty
abo
ut th
e
futu
re o
f the
uni
t
Phys
ical
isol
atio
n
Lack
of a
dequ
ate
disc
iplin
ary
or in
vest
igat
ive
proc
esse
s
Pass
ive
cultu
re
Lack
of c
lear
per
son-
cent
red
valu
es
Lack
of u
nder
pinn
ing
mod
el
of c
are
Dem
oral
isat
ion Po
or s
tand
ards
and
exp
ecta
tions
of
repo
rting
inci
dent
s or
con
cern
s
Poor
sta
ndar
ds o
f ed
ucat
ion
to a
ddre
ss
conc
erns
abo
ut
stan
dard
s of
car
e
Long
-sta
ndin
g cu
lture
and
ne
gativ
e at
tribu
tions
Poor
aw
aren
ess
of
polic
ies
Poor
link
s w
ith g
over
nanc
e fu
nctio
ns in
trus
t M
anag
emen
t cap
acity
in tr
ust
stre
tche
d
Con
curre
nt p
robl
ems
of
trust
: fin
anci
al a
nd
stra
tegi
c
Lack
of d
emen
tia c
are
mod
el
Unc
lear
car
e pl
anni
ng
fram
ewor
k
Lack
of m
eani
ngfu
l car
er
invo
lvem
ent i
n w
ard
and
indi
vidu
al p
lann
ing
Poor
lead
ersh
ip
Rol
e m
odel
s la
ckin
g
Lack
of c
orre
ctiv
e ac
tions
Old
er a
ge s
ervi
ces
a “C
inde
rella
of
Cin
dere
llas”
Unc
lear
nat
iona
l pol
icy
rega
rdin
g ca
re
trust
s an
d ol
der a
ge s
ervi
ces
Row
an
caus
al
anal
ysis