Safeguarding Children

SUI reporting & performance

management

London Safeguarding Children Board Conference9th December 2009

B. Ladbury and Karen Green NHS London

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

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.

• PCT’s 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.

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

Issues for NHS action

• All child deaths 0-18

Child Diesanticipated

Child DiesUnexpected

Child Dies Unexpected

??? circumstancesUnknown: need more

information

Child protectioncircumstances

identified

No suspiciouscircumstances

Rapid Response

Referred to Child

Death Overview Panel

ConcernsIdentified

No concernsidentified

LSCB SCR Panel decision to

undertake SCR

YESNO

SUI

LSCB SCR Panel Decisions

LSCB full multi-agency Serious Case Review

under Chapter 8 of WT

LSCB commissionedMulti-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

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

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

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 !!

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

Basic elements of a good RCA investigation

WHAThappened

HOW ithappened

WHY ithappened

Unsafe Act (CDP/SDP)

Human Behaviour

Contributory Factors

Solution Development & Feedback

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

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

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

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

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.

Care/Service Delivery Problem

Education & Training

Organisational & Strategic

Factors

Working Conditions

Team Factors

Individual (staff)

Factors

Task Factors

Patient Factors

Fishbone Diagram

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?

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.

Process

Gathering Data / InfoGathering Data / Info

Mapping Data / InfoMapping Data / Info

Identify Care / Service Delivery ProblemsIdentify Care / Service Delivery Problems

Analyse the Problem / Identify Root CausesAnalyse the Problem / Identify Root Causes

Develop Targeted RecommendationsDevelop Targeted Recommendations

Write ReportWrite Report