1. Safeguarding Children SUI reporting & performance management London Safeguarding Children Board Conference 9 th December 2009 B. Ladbury and Karen Green NHS London

2. Independent reviews 2009 Forty four cases audited, many fell below an acceptable quality standard. Named and Designated Professionals confused about role, responsibilities, authority and accountability Very few reports demonstrated skills in structured investigation, root cause analysis or meaningful report writing. Crossed borough boundaries confused NHS agencies about responsibility for ensuring that health recommendations were implemented Similar issues emerged in NHSL internal independent Post Baby P incident report

3. Recommendations NHSL to monitor serious incidents and the SCR process more effectively (work with GOL) PCTs and provider Trusts to inform NHSL of the progress of SCRs, and ensure that the final reports are of high quality and signed off at Board level. PCTs and NHS Trusts to submit their SCR Individual Management Reports and action plans to NHSL as well as to the Local Safeguarding Children Board. SCR action plans require performance management, and tracking until full implementation (will be audited). Lessons must be learned and embedded into practice.

4. Working Together 2006 Chapter 7 – Child Death Review (CDR) Rapid Response and Overview Panel Chapter 8 – Serious Case Reviews (SCR) Defines Role of SHA SHA is member of LSCB SHA must manage performance against core and developmental standards and Trusts implementation of child protection SCR action plans 2.43 LSCBs should ensure that the SHA is briefed about SCRs so they in turn can fulfil their responsibility with regards to briefing the DH of emerging issues 8.83 Defines operational structures for NHS 2.58 – 2.96 Designated and Named Professional Role 2.58 – 2-65 Outlines Health responsibilities for CDR & SCR Designated Professionals have key responsibility 8.18 Rewrite has taken into account role of SHA Will clarify accountabilities

5. Issues for NHS action All child deaths 0-18 Child Dies anticipated Child Dies Unexpected Child Dies Unexpected ??? circumstances Unknown: need more information Child protection circumstances identified No suspicious circumstances Rapid Response Referred to Child Death Overview Panel Concerns Identified No concerns identified LSCB SCR Panel decision to undertake SCR YES NO SUI

6. LSCB SCR Panel Decisions LSCB full multi-agency Serious Case Review under Chapter 8 of WT LSCB commissioned Multi-agency Internal Management Review LSCB commissioned Single Agency Individual Management Review One or more NHS services All use systems approaches including structured investigation and RCA principles

7. PCT SUI system for all NHS incidents Incident = notification via STEIS system Structured investigation (RCA) Specific time line (NB parallel but not the same as for SCR) Analysis using RCA Report (NB parallel format, but not the same as SCR) Recommendations Action Plan Tracking system Follow up on quality, actions and embedding learning

8. SCR and SUI Processes Incident – initial SUI notification Feedback SCR decision to SHA PCT notify as SUI/SCR (reminder sent from SHA one month following incident) 60 day reminder – Feedback to SHA on progress IMRs to PCT Designated Lead to produce PCT Overview. Reports to Overview writer 6 months PCT Overview, chronology, all IMRs and all action plans to SHA Incident notified to GOL SCR panel meets to decide / SCR is triggered SCR panel meetings and multi- agency discussions 5 months – all SCR Individual Management Review reports to independent overview writer 6 months SCR completed 1 2 3 4 5 Timelines can be extended in exceptional circumstances, by Ofsted 6 SUI SCR

9. SCR Process summary Defined in Working Together Child deaths & Serious Injuries Further guidance in London CP procedures Local Authority LSCB lead on process but are not accountable for NHS actions, NHS delivery or performance management – PCTs & SHA hold this function SCR coordinated by Independent Chair of SCR panel Health components coordinated by Designated Professional (doctor or nurse) Regulated by Ofsted and CQC Can become a Public Enquiry Parallels to SUI process – with some variations !!

10. What is RCA? Root cause analysis is a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened. Seven Steps to Patient Safety 2004

11. Basic elements of a good RCA investigation WHAT happened HOW it happened WHY it happened Unsafe Act (CDP/SDP) Human Behaviour Contributory Factors Solution Development & Feedback

12. How do accidents happen? 2. Prior conditions - contributory factors 3. Unsafe acts, errors & omissions 4. Multiple defences/ controls/ barriers Patient Safety Incident 1. Organisation and process deficiencies

13. Service Delivery Problem (SDP) Latent failure Arises from weaknesses in the organisation or environment Distant from direct patient care e.g. failure to undertake an environmental risk assessment in a ward

14. Care Delivery Problem (CDP) Active failure Arises in process of direct patient care Act or omission by member of staff e.g. failure to undertake 15min observations of patient

15. Contributory factors Patient factors Individual factors Task factors Communication factors Team & social factors Education & training factors Equipment and resource factors Working condition factors Organisational & management factors

16. What are contributory factors? Influencing or causal factors that contributed to the incident. May vary in the significance of impact on the CDP/SDP. May have a negative or a positive impact.

17. Care/Service Delivery Problem Education & Training Organisational & Strategic Factors Working Conditions Team Factors Individual (staff) Factors Task Factors Patient Factors Fishbone Diagram

18. Five whys Simple tool that helps you look underneath each problem (CDP/SDP). Best suited to simple and non-complex problems. Quick and easy to teach 3 – 5 – 7 whys?

19. What is a root cause? A fundamental contributory factor One which had the greatest impact on the system failure. One which, if resolved, will minimise the likelihood of recurrence across the organisation. Rarely is there ever just one root cause, usually there are several.

20. Process Gathering Data / Info Mapping Data / Info Identify Care / Service Delivery Problems Analyse the Problem / Identify Root Causes Develop Targeted Recommendations Write Report